Tuesday, June 25, 2019

Trump Executive Order and HSA's

One of the bullet points in yesterday's order focused on the use of HSA's for Direct Primary Care and Health Sharing Ministries. To those in these types of arrangements, you might want to dial back your enthusiasm.

Why do we say this?

One first must remember the requirements to fund an actual Health Savings Account. Straight from the IRS website...

To be an eligible individual and qualify for an HSA, you must meet the following requirements.
  • You are covered under a high deductible health plan (HDHP), described later, on the first day of the month.

So, to fund an HSA to pay for DPC or HSM you must pay premiums and purchase an insurance plan. Nothing like paying premiums for insurance so that you can set up an account to draw funds from said account to pay for more "insurance."


Via FoIB Holly R, this latest from the rascals at the MVNHS©:

"Coroner demands NHS 111 changes after six-year-old Sebastian Hibberd's death "

And what, you may ask, is the context here?


"Sebastian Hibberd died after staff failed to spot warning signs that part of his bowel had collapsed."

After which he experienced cardiac arrest while, and sit down for this, he awaited medical attention.

You don't say?

But what could possibly have led to this tragic outcome?

Would you believe ... math?

"[C]all handlers were not being "adequately assisted" by the algorithm used to assess patients over the phone."

Those darned algorithms will get you every time.

Cannot wait for us to implement that here.


Monday, June 24, 2019

What is the Medicare Hospital Benefit?

Medicare Hospital benefit Part A covers medically necessary inpatient charges incurred and billed by the hospital. GA Medicare expert Bob Vineyard explains.

Original Medicare has a PER ADMISSION deductible. In 2019 the amount is $1364. Charges incurred during the next 60 days are covered by Medicare.

Most Medicare supplement plans, also known as Medigap, pay that deductible for you.

You may also incur OUTPATIENT charges in the ER and treatment or consult by medical personnel who are not on staff. These charges are applied to your Medicare Part B coverage.

Howdy Gramps, great to see ya!

We've written before about (so-called) Grandfathered Plans, most recently here:

"... as frustrating as it is, their current policy is the least bad alternative (at least until the next Open Enrollment period)."

A good blog-friend of mine recently wrote about her experience with her own grandfathered plan. She's a long-time MS patient, and had this to say:

"I finally received the hospital bill for my Feb 4th Rituxan infusion. That was my 36th infusion since Nov 2009. At first we tried stretching out the time between infusions, but I was still relapsing. After a relapse in Nov 2011, we went to the every-6-month schedule. I didn't relapse again until Feb 2016.

That's amazing!

So back to the bills. I'm a number cruncher and keep track of all sorts of things. For those 36 infusions, the hospitals have charged $539K in total. More than half a million dollars, folks! Insurance okayed charges of $458K of which $399K was for the Rituxan itself. Because of having a grandfathered individual insurance policy, my copay for infusions/drug has been limited to $22,857.24.

This is what I need to remember to appreciate my current monthly insurance premiums of $1028 (which will certainly go up again after my annual renewal in September). So from 2009-2019 (11 years), I will have paid at least $87,732 in insurance premiums, BUT my out-of-pocket maximum has been limited to $27,500, the most of which has been allotted to Rituxan infusions. (Vision, dental, and other prescriptions not included.)

So..... for $115,232, I have received half a million dollars worth of medical care for a single pharmaceutical treatment and have spent only about $5000 OOP for doctors, MRIs, or ER visits.


That's my gratitude thought of the day. The same day I worked outside in the yard for at least 4.5 hours this morning and experienced difficulty walking and gripping at times and really only want to sleep right now. Stable does not mean no symptoms or never any problems

Well first: Baruch HaShem that she's not getting worse (which is always a danger with MS).

It also puts into perspective something that doesn't always get much play regarding ACA plans: not only do they tend to have very narrow provider networks, they also typically include restrictive formulary benefits for meds. As we've long noted:

"The stated reason for this business model is that it helps carriers to rein in the cost of medications, which make up a disproportionate percentage of claims."

But it presents a major challenge to folks with, for example, MS (let alone cancer or diabetes).

My friend continues:

"I'm very fortunate that my current treatment is an infusion therapy, otherwise it would be a very different story.

It does support the extra cost of keeping that grandfathered PPO plan tight within my grasp for as long as possible. The $100 deductible, 10% co-insurance, and $2500/year OOP max (for med coverage) are priceless. Good thing I'm not taking any expensive oral or self-injectable drugs; $1500 max coverage for pharmacy drugs doesn't go very far. All generics for me

Bottom line: keep that legacy plan for as long as you can.

Friday, June 21, 2019

Rx Heads' Up

If you have an ACA plan and take prescription meds, you'll want to be careful about using those now ubiquitous manufacturers' coupons:

The key is whether there's a generic equivalent available. The problem here, it seems to me, is that this ruling doesn't seem to take into account folks for whom the generic just doesn't work.

Caveat emptor.

Thursday, June 20, 2019

From the P&C Files: Every step you take, every mile you drive....

Hard to believe but we first wrote about driver tracking and insurance over a decade ago:

"A high-tech monitoring device makes it possible to reduce insurance premiums for drivers who avoid jackrabbit starts and slam-on-the-brakes stops...The catch? Bad drivers who take a chance on the program may wind up paying a surcharge instead."

So a reasonable, if potentially risky, trade-off. But that was then, and this is now (11 years on). Surely we've mined collected enough data to determine the efficacy of these programs and devices, no?

Well, thanks to FoIB tsrlbke, the results are in, and they're (generally) positive:

"[A] new business study involving Washington University in St. Louis provides analytical theories showing that such driver-monitoring technology can not only prove beneficial to the bottom lines of some consumers, but also to insurance companies by alleviating moral hazards that affect the risks of accidents."

Which makes sense: careful driving motivated by potential insurance savings is obviously more likely to result in fewer accidents and tickets.

On the other hand, privacy-minded folks might want to take heed of this:

"They install it in your car, and it records all your driving patterns: Where you have been?"

Talk about trade-offs....

Wednesday, June 19, 2019

Sunshine State Health Insurance Anecdata

So recently, had a client move to Orlando, and asked for a referral to a local health insurance agent (since I'm not licensed for Florida). I reached out to some folks who might be of help, including a couple relatives. One very helpful kin had this to say about the state of individual medical plans there:

"We don't have an agent. About 2 yrs ago Florida Blue, the only insurance provider in our area, drastically cut commissions so independent agents are almost non existent. Do you know where he is moving? Basically the way I approach it is to find the insurance company with the best network (in Florida there are only two main cancer centers - Shands and Moffett). If you get in a narrow network you could end up in trouble if you have an unusual health problem since the local expertise may not be that good.

I think Florida hospital is pretty good in Orlando but if you have something unusual you may need to go to Moffett in Tampa. I would just be sure the network includes Moffett. Florida Blue likely has plans in Orlando and basically you buy a policy from them using salaried agents on their staff. I would caution them against getting a narrow network plan that does not include Moffett or Shands. It will be cheaper but they could end up with a bad outcome from not having the right expertise on your side. With [your sister's] illness dealing with Shands was a pleasure. Not just the quality of care but no financial hanky panky which is common in Florida

I mentioned that salaried carrier sales folks makes sense, since The Blues are (apparently) the only game in town, and got this reply:

"What happened is that they cut commissions to such a low level most agents quit selling health policies including mine."

Ah, yes, we're quite familiar with the concept.

Interesting, no?

Tuesday, June 18, 2019

CBD Oil: An Update

Regular readers may recall our post from last month on insurance and CBD oil:

I had an interesting conversation with a doc who specializes in pain management and is a big fan of CBD oil and its pain-reducing abilities. He also claimed that taken topically (ointment) or even orally, one would likely not get flagged on a drug test."

Well, I recently received this in email from one of my group clients:

"Hi Hank!

Brought to my attention and I didn't know:

CBD oil/salves for anxiety/depression/pain management?

Has anyone asked you about these for HSA write offs?

Which is a great question.

I did some research, and thought I'd found the answer:

"CBD products are probably not considered HSA- or FSA-eligible, though there hasn't been any formal guidance from the IRS on the matter. This is similar to medical marijuana, which is also not HSA or FSA-eligible even if you're taking it for a diagnosed disorder or to reduce the effects of chemotherapy"

But just in case, I also reached out to our own gurus of all things HSA/FSA/HRA. Their answer surprised me:

"Although we have received no official guidance, it’s seem reasonable that with the passing of the 2018 Farm Bill it can be reimbursed through FSA and HSA’s with a doctor’s note prescribing it for a specific diagnosis."

So there you have it: the key is in that little script fom the doc.


Monday, June 17, 2019

When is a QSEHRA *not* a QSEHRA?

Regular readers may recall our post last year on the debacle that was Qualified Small Employer Health Reimbursement Arrangements (QSEHRAs):

"Their reaction, once learning about the caveats and limitations, has been a resounding /crickets ... the devil truly is in the details."

In other words: a dud.

But that was then, and this is now:

"The Health and Human Services, Labor and Treasury Departments joined forces on a new initiative intended to provide affordable health careOpens a New Window.  coverage ... The legislation will expand the use health reimbursement arrangements (HRAs), allowing employees use pre-tax health arrangements to buy insurance."

First impressions:

This sounds great on paper (maybe), but what differentiates this new effort from last year's failed version?

I reached out to our gurus of all thing FSA/HRA/HSA for their initial take, asking if this was just a QSEHRA re-hash. They graciously responded that it is not last year's iteration, but a new alphabet soup, almost 500 pages long, with a lot of details. They also pointed out that the original QSEHRA was a flop because of all of the rules, and that this version may be as well.

I would add something else that seems to have slipped under the radar in both instances:

Group plans have participation requirements; that is, a minimum percentage of employees must be on the group plan or it will go away (I've had this happen, and it's not pretty). To be fair, it's not usually enforced that rigidly, but I suspect that would change if carriers saw their groups suddenly shedding participants willy-nilly.

Now, as one who would ultimately like to see health insurance de-coupled from employment, this is not unappealing. But as a realist, I think this is playing a little too close to the edge of the envelope.

And there's this: pretty much all group plans are built on the PPO model (coverage in- and out-of-network). But all of the individual plans I've seen the past two cycles (and I have no reason to think this won't continue to be the case) are HMO's, meaning that there is essentially zero OON coverage.

What's that worth?

Oh, and one more thing: if your employer offers a group plan, then you likely won't qualify for a subsidy on that individual major med. And since ACA plans include pretty much all the things that make group coverage so expensive (guaranteed issue, pre-ex and maternity cover, for example) plus often (usually?) have much higher out-of-pocket limits, not seeing the savings.

Time will tell.