Open Source Health Care

Okay, call me a geek.

Or a nerd.

Just don't call me late for dinner.

I've been noodling something new:

As regular readers of IB have no doubt ascertained, I'm an enthusiastic supporter of Consumer Driven Health Care. The basic premise of CDH is that, when consumers have "skin in the game," they're more likely to make informed, rational, effective health care decisions.

My friend Dmitriy Kruglyak, editor of Trusted.MD, proposes an alternative: People Powered Health(care).

Okay, freeze-frame.

Recently, I had the privilege of addressing a large group of local medical practice managers (and some of the doctors whose practices they manage). Since my reputation as an expert in CDH preceded me, that's the subject on which I spent the most time. As I was researching my presentation, though, something began to bother me:

Is that all there is?

Okay, I admit it: I am a geek. Whenever family members or friends need help fixing their PC's, I'm the first one they call. And I've begun learning about things like Linux, which is part of a (relatively) new movement collectively known as "Open Source Software."

OS Software is defined as "a development method for software that harnesses the power of distributed peer review and transparency of process. The promise of open source is better quality, higher reliability, more flexibility, lower cost, and an end to predatory vendor lock-in."

The more I consider this, the more applicable it seems to become to the future of health care (and the financing thereof). What if, instead of focusing on "consumer driven" or "people powered" health care, we turned our efforts instead to "Open Source Health Care?"

So what would OSHC look like?

I'm not really sure. But it seems to me that it would encompass all that's "good" about CDH (consumer empowerment, personal responsibility, transparency and outcomes) and what Dimitry likes about PPHC (peer-to-peer support networks, emphasis on wellness programs, online resources) while encouraging personal responsibility and provider (and carrier) information management.

Not bad, but how would it work?

Well, let’s start with some basic premises:

1) I have a visceral distrust of gummint-run health care systems. OTOH, my own industry has to be pulled, kicking and screaming, into making things "work."

2) As much as I advocate CDH, it's slow in "taking off." Part of that is our cultural reluctance to take personal responsibility, but a part is also that we lack both the tools and the incentive to empower ourselves.

3) Dimitry's PPH relies on tech & wellness programs, but seems to emphasize the provider angle.

4) What we need is a catalyst: something to drive us forward, to give people an incentive to make changes in lifestyle, care delivery AND funding (insurance) choices.

5) It occurs to me that we're using outdated models for all of these things. We should be looking at what's currently driving our economy and society: information. And how do we access that information? Computers. But it's not about Windows and Mac's. The real action is in the Open Source community.

Why? Because there's a synergy there: folks share info and code, try out new ideas (some of which flame out, but some of which stick). The bottom line is, they're driving information delivery tech forward.

What’s appealing about Open Source Software is that emphasis on sharing: new ideas, new tech, new code. Seems to me, Open Source Health Care could emphasize sharing, too: resources, information, outcomes and pricing. The culture of OS is one which embraces and encourages change, not for its own sake, but for a specific purpose.

Could we co-opt that culture, and apply it to health care delivery (docs, hospitals, pharma, etc) and funding (insurance)? You’ll have noticed that I’m not proposing any specific ways in which this could be implemented; right now I’m primarily interested in whether the concept makes any sense.

Well, dear readers?

Not so great HIX news: SEP edition

So by now, most folks understand that it's quite the challenge to buy ObamaPlans outside the regular Open Enrollment season; that one requires a Special Enrollment Period trigger (losing group coverage, getting married or having a baby, etc) to do so. Well, the process just got a bit more onerous.

From email from our Betters in DC©:

"Special enrollment periods (SEPs) provide an opportunity to consumers who experience certain qualifying events to enroll in or change their health coverage outside of the annual Open Enrollment period.

Beginning in early 2019, Marketplace consumers may need to choose a plan in the same metal tier category (instead of from all available categories) during their SEP window. [emphasis in original]

 This impacts consumers when they:

•Currently have a Marketplace plan,
•Experience most SEP-qualifying life events, and
•Want to change from their current plan.You can help consumers understand that their plan choices after Open Enrollment will likely be limited later in the year, even if they qualify for an SEP and want to change plans. You can encourage them to choose a plan that will meet their needs and their family’s needs until the next Open Enrollment period."

Oh goody.

Did I mention that I'm aware of precisely zero carriers paying commissions on plans outside of the regularly scheduled Open Enrollment? How come no one seems to care (since they don't reduce the premiums to reflect that fact)?

Failure to Resuscitate

A couple weeks back we shared the news that Obamacare enrollment was flatlining. However, there were still four weeks left in open enrollment which gave hope to resuscitation.

Yesterday HHS released another data set with two additional weeks of open enrollment. The prognosis is now dire and indications are showing a failure to resuscitate. The enrollment figures released show only 63,190 new plan selections since January 1st. This is compared to the 2016 open enrollment when 153,631 plan selections were made during roughly the same time period. Overall enrollment is slightly lower by 10,557.

Comparing the press releases from 2016 and 2017 is quite somber. Note the tone (and figures) used by HHS.

2016

Since Open Enrollment began on November 1, about 8.8 million consumers signed-up for health coverage through the HealthCare.gov platform or had their coverage automatically renewed. This week’s snapshot includes weekly and cumulative data for enrollment through HealthCare.gov, a breakdown of cumulative data for 38 states using the HealthCare.gov platform, and cumulative data for local markets.

“As expected, consumer interest is beginning to increase again as we near the deadline for 2016 coverage,” HHS Secretary Sylvia Burwell said. “We know we have more work to do and as we count down to the January 31 final deadline, we’re focused on making sure consumers understand that they must act soon to find affordable health coverage and avoid the fee for choosing to not have health insurance in 2016. Consumers should know that we’re here to help 24 hours a day, 7 days a week.”

2017

More than 8.8 million Americans were signed up for 2017 coverage through HealthCare.gov as of January 14, 2017. This compares to about 8.7 million sign-ups as of January 14 last year, as Americans continue to demonstrate strong demand for 2017 Marketplace coverage.

“With almost 9 million people signed up for 2017 coverage just in HealthCare.gov states, it’s clear that Marketplace coverage is a product Americans want and need,” said Secretary Sylvia M. Burwell. “Strong demand is especially striking in light of the unique headwinds created by discouraging rhetoric from ACA opponents. More than 40,000 people have contacted our call center expressing concerns about whether they should sign up for coverage, with a sharp uptick in these questions last weekend. My answer is a resounding yes: in fact, I’ll be signing up for Marketplace coverage myself by the end of the month. If you still need coverage for 2017, visit HealthCare.gov or your state Marketplace before January 31, and join me and millions of other Americans in purchasing affordable, quality coverage.”

Today’s report covers the period from January 1 through January 14, 2017. Enrollment weeks are measured Sunday through Saturday. Since this year Open Enrollment began on a Tuesday, the totals reported in this snapshot reflect two fewer days than in last year’s published Week 11 snapshot. Measured over the equivalent time period, plan selections this year are almost 100,000 higher than last year.

Not surprisingly, the government still isn't giving up hope. But based on the enrollment my guess is that many of the insurance companies playing in the market are even closer to issuing DNR orders.

More ObamaPlan Anecdata

So, two (more) examples:

■ Email from Betty:

"Don't know if you'll remember me, but in April/May 2016 you had helped me evaluate health insurance for me with my husband retiring.  It ended up that going through his COBRA was the best option for me at the time.  Well, I'm now coming to the close of that (have coverage through Jan. 2018), but I know sign up for the ACA is Nov. 1. - Dec. 15 so I need to start the process again.  Are you still available to help me?"

In reply, I told her about my decision to hand these off to trusted partner Cornerstone.

She responded:

"I'm sorry, but I really don't understand your response.  This sounds different from they way things were when we sat down and talked before.  At that time you had looked into different insurance companies to see what they offered, etc.  Now are you saying you know of someone else who would do this for me?  You had helped me search out options instead of me going on the ACA website myself."

So I sent her the link to my post last year on why I've decided to sit out (for the most part) Open Enrollment.

I wasn't terribly surprised to receive this:

"Per your blog, I would like to talk to the folks at Cornerstone.  Please forward my info to them for referral.  Thanks!"

And of course I will.

■ A few days later, Sheila called me about her health insurance needs. She immediately launched into a request for a detailed description of the various companies we represent, as well as plan options and costs.

I cut her off as quickly as I could, telling her "no, I can't do that."

There was a moment of stunned silence, and she asked "Why not? I work at a schoold and they've always provided that to me." I explained that they're a rather large organization that can afford to do that, and that I no longer sell plans in between Open Enrollment (she and her children seem to qualify for a Special Open Enrollment).

She immediately understood, and asked if  could refer her to another agent. I told her that I don't know of any other local agents still selling health insurance outside of Open Enrollment. She took that in, and then asked "well, what can I do?"

I didn't want to leave this poor lady just twisting in the wind, so I directed her to the 404Care.gov site, and gave her some pointers about navigating it (SWIDT?).

Thus life under ObamaCare.

In-and-Out Info

So, some ObamaTax news from different ends of the spectrum:

OUT - So you don't want to buy a health insurance plan, but you also don't want to pay the fine penalty tax surcharge; what to do?

Well, you could apply for an exemption. Ms Shecantbeserious and her helpful minions have made available a downloadable guide to the ins-and-outs of qualifying for a get outta jail free card.

Your tax dollars at work.

IN - On the other hand, you decide that yeah, it'd be a good idea to buy a plan after all, but the next Open Enrollment Period is still months away. Isn't there some way to open up one's own little enrollment period?

Indeed there is (or may be); Aetna helpfully emailed with a reminder that there are several different events that could "trigger" a Special Open Enrollment, including:

Permanent Move - this one may be tricky: you'll need to provide proof of both prior and new residence locations.

Employer's Bankruptcy - this is aimed specifically at retirees who were covered by a former employer's retiree health plan.

Birth - this would trigger a Special Open Enrollment Period for the entire family. But beware of timing!

Can I get fries with that?

O frabjous day!

Well, it's that time of year again, when agents must decide whether or not to participate in ObamaCare Open Enrollment (this year: v6.0). For most folks, this year's festivities run from November 1 through December 15 for a January 1, 2019 effective date.

I say "most folks" because DC and Golden State citizens have their own, quirky schedules:

"California has enacted legislation that permanently establishes different enrollment dates within the state, both on and off-exchange. From now on, open enrollment in California will begin on October 15, and end on January 15. So for 2019 coverage, California residents will be able to enroll starting on October 15, 2018, and will have until January 15, 2019 to enroll."

Californians who sign up after December 15 will have February '19 effective dates.

"[O]open enrollment in DC will begin November 1, 2018, and will continue until January 31, 2019. DC residents who enroll between December 16 and January 15 will have coverage effective February 1, while those who enroll in the second half of January will have coverage effective March 1."

Everyone got that?

Good!

Adding a little fuel to the fire is the fact that folks in DC will get their own insurance mandate:

"[T]he District of Columbia City Council approved a requirement for all DC residents to purchase health insurance ... The D.C. mandate contains three elements that make it just as bad as, if not worse than, the federal mandate it is intended to replace."

Sweet!

(Click on through for the details)

As for my part? Well, regular readers know that I've long since bailed from actively engaging in the Open Enrollment circus process, but that I continue to do the online training necessary should I change my mind (or, as in recent years, be available to help folks out from the sidelines). This week, I got email from CMS announcing that:

"Marketplace agent and broker registration and training for plan year 2019 is now live!"

I can choose the free (no Continuing Education credit) version from CMS itself, or pay for the training (which includes CE for most folks) from their preferred vendor, AHIP.

Not an AHIP fan, and don't need the CE. So: hard pass.

Not So Open Enrollment

I've been working with a referral over the past few days. This young man works for a regional retail store, and thought he'd enrolled for the group health insurance during their most recent Open Enrollment period (he was a relatively new hire at the time), but found out unexpectedly (at the provider, natch) that he had not, and was currently uninsured.

So he went to HR to try to get back on-board, but his appeal was denied. Ken was told that he'd have to find another health insurance plan, "any plan," in fact, and then cancel it to be eligible (yeah, didn't track for me, either, but there it was).

Over the course of several emails and phone calls, Ken shared with me this little tidbit that seemed to confirm what he was being told:

[click to embiggen]

Eagle-eyed readers will note the two rather glaring problems here. First, does no one use spell-check any longer? Second - even more egregiously - as I pointed out to Ken, "Credible" coverage would mean any ID card I successfully PhotoShopped together. And it's not like "Creditable" coverage is a new term, it's been around for at least 20 years.

In the event, we still had to get him something for a month, but with ObamaCare's Open Enrollment in the rear-view, and no Special Open Enrollment triggers available, what to do?

Of course, this is a perfect use of Short Term Medical (I mean, how much shorter of a term could there be?), so we got Ken signed up for March, and we'll cancel it at the end of the month so he can qualify for group coverage.

What's that? "Playing chicken, you say?"

Yup:

My concern is that we'll get to the end of the month, cancel the STM, and then find out that it wasn't "Credible" coverage, after all. All we could do then, of course, would be to look at another STM, or perhaps explore other options for the balance of the year.

I'm not happy about this, but at least we've bought him some time.

Gaming the system: We *may* have a winner

Last month, FoIB Dr Stuart Fickler posed a challenge:

"It appears to me that a system as complex as Obamacare is vulnerable to a vast range of gaming.  To be clear, I am not referring to just the computer aspects of the system, but the entire system, from applying to delivery of the care itself ...  if they don't want to take the risk of "second class medical treatment", they can switch over to the "marketplace" insurance."

I was skeptical that this would be a viable strategy, asking "what if the diagnosis came, and treatment was scheduled to begin, between regularly scheduled Open Enrollment periods?" There was also the challenge in finding a suitable "Special Open Enrollment period [SOE]."

While perusing another blog, I noticed that someone observed that simply moving to another state would be sufficient to trigger such an event. Again skeptical, I began researching to see if this might be the elusive "viable strategy."

And it appears that it just may be. According to Ms Shecantbeserious:

"Outside open enrollment, you can enroll in a private insurance plan through the Marketplace only if you have certain life events that give you a special enrollment period ... "Permanently moving to a new area that offers different health plan options"

Now this would seem to indicate that a SOE period is triggered simply by moving to (for example) a different state (notwithstanding the difficulties inherent in this if one is incapacitated).

I'm not entirely convinced that this is a "winning" strategy, for a number of reasons:

1 - From a strictly practical viewpoint, how likely is it that you'll find an oncologist who's taking new patients?

2 - I'm concerned about the "offers different health plan options" verbiage: it seems to imply that one is already insured, but that one's current carrier doesn't have a presence in the state to which one is moving (or has moved). On the other hand, it is in the "Special" open enrollment category, which defines circumstances under which someone who is not currently insured may buy coverage.

To quote Jamie and Adam, I'll call this one "Plausible."

[Hat Tip: Ace of Spades]

Not my monkeys... [UPDATED]

[Please scroll down for update]

As regular readers know, I elected to "sit out" the past Open Enrollment season:

"Due to the significant changes carriers have made to their compensation schedules (aka commissions), I don’t believe that I can continue to offer the kind of comprehensive service to which I, and you, have become accustomed."

Of course, I'm far from the only agent to have pulled that particular trigger. And next year's circus Open Enrollment season promises to be even more stressful:

"CMS Officially Shortens 2018 Individual Health Enrollment Period ... will move the end of the open enrollment period for 2018 individual major medical coverage to Dec. 15 [,2017], from Jan. 31, 2018."

Thus lopping off a month and-a-half, or roughly 50%.

I can see no way that could possibly go south.

(UPDATE) HEH: FoIB Holly R send us this relevant announcement from the D'Unh! Department:

"UnitedHealth beats earnings forecasts as it pulls out of Obamacare markets"

Imagine that.

We Get (e)Mail!

Recently, reader Brad F wrote to us with a dilemna:

"First of all, I enjoy your site [ed: /blushes].

I think other readers (and employees of your clients) may face the same issue I now face. Later this year, I am getting married. After the wedding, we planned to consolidate our health coverage with her employer. Unfortunately, my HR department just informed me I will face “tax consequences” if I leave my high-deductible plan for her PPO before the end of 2008. Although I can avoid the penalty by staying with my plan for a few extra months, it was a definite unexpected surprise."

In general, if one leaves an HSA/HDHP (Health Savings Account/High Deductible Health Plan) mid-year, one has a number of issues. From a coverage standpoint, there's a new deductible to satisfy. Although it's likely to be (much) lower than the High Deductible plan's, it does start at "$0 met" on the first day of coverage, previous HDHP-covered expenses notwithstanding.

From a tax standpoint, there are also some speedbumps:

1) You can't make any more contributions (dunh!)

2) You may well have overfunded the account. This is kinda screwy: if you start an HSA mid-year, the contributions aren't pro-rated (that is, you can still fund the max, if you want). But it doesn't work in reverse: you'll have to withdraw the excess contributions, and there are some taxes to be paid on those.

Curiously, you can still use the HSA to pay for qualified medical expenses. That is, even though the underlying plan isn't HSA-qualified, you can still use the account itself to pay for most medical expenses, with no tax or other penalties.

But I wasn't the only one who responded to Reader Brad. Co-blogger Mike Feehan offered a different perspective:

I don't see this as a now-or-never choice. (I)t appears to me that the basic amount at stake here is

(a) the difference (presumably a savings) between the payroll deduction in his own plan and the dependent deduction in his new wife's plan vs.

(b) the "tax consequence" (i.e., a cost) for dropping his employer's plan before year end.

So it boils down to the customary question: is the savings bigger than the cost?

First of all, I think the correspondent should ask his employer to tell him, in dollars and cents, exactly what the "tax consequence" will be to him in 2008. He can then judge whether it's better for him to disenroll before year-end and eat the tax consequence, or stay in his own plan until the end of the year and pay his own premium contribution for those few months.

No matter what, he [should] be able to enroll in his new wife's plan effective January 1, if he wants to, during the open enrollment period later this year.

What is the tax consequence anyway? I've understood that IRS allows certain tax advantages in group "cafeteria" plans - - subject to certain conditions, one of which is that there can be only one benefit election or open enrollment for any taxable year. To the insured person, the tax advantage is that premiums are paid or deducted from payroll on a pre-tax basis, which reduces one's taxable income. So from IRS' standpoint, you've agreed to a tax deal when you enroll in a cafeteria plan, and breaking the terms of the tax deal forfeits the tax benefit. You point out that the tax deal includes the employee's own contributions to the HSA (which also reduce one's taxable income) so those contributions would also become subject to tax if one were to drop out mid-year.

An employee who chooses not to enroll during the open enrollment, can enroll later but only under certain circumstances permitted by IRS. An employee who enrolls but then later decides to drop out can do that, too, but in that case the cost is forfeiture of the tax advantages for that taxable year. (The forfeitures don't apply to employees who "drop out" because of retirement, or termination of employment, or death.)

I may not have all the details 100% but I think this is pretty close.

PS - I certainly hope we are not getting to the point where our choice of wedding day is influenced by the tax treatment of our medical insurance premiums!

So there you have it! Thanks to Brad F for the great email, and to Mike for his help in answering it.

More March (Open Enrollment) Madness

As we noted a few weeks ago, Our Betters in DC© have (illegally) extended Open Enrollment season for those who flaunted the (evil) Individual Mandate last year:

"The Centers for Medicare & Medicaid Services (CMS) announced today a special enrollment period (SEP) for individuals and families who did not have health coverage in 2014 and are subject to the fee or “shared responsibility payment”

Aetna has emailed a helpful "message for the brokers" to let us know that "[t]his Special Enrollment Period is for on-exchange business only and all applications must go through the Marketplace." That's actually a helpful bit of info: it means that one can only satisfy the requirement this way by going to the buggy, security-challenged Exchange.

The carrier also "expects premiums to be paid prior to the member’s specified due date. Exchange rules require a payment grace period. Although this is not a new term, the grace period for Exchange premium payments will differ between non-subsidized and subsidized members."

Which is a rather long-winded way of saying that some insureds are more equal than others. You'll also note that they don't specify exactly how some are more equal, presumably to avoid giving folks any ideas about gaming the system (heh). The bottom line is that, if you're eligible for and take a subsidy, your grace period is 3 times greater than the rest of us proles.

Isn't that special.

Oh, and ICYMI, only those who meet these criteria are eligible at all:

• Are not already enrolled in a 2015 plan.
• Were unaware or did not understand the implications of the fee for not enrolling for 2014 until after the end of open enrollment (February 15, 2015).
• Owe a fee for not having coverage in 2014

Pre-65 Medicare Health Insurance

It's currently Open Enrollment season for both ObamaPlans and Medicare Supplements. The former has been a bit frustrating (the only non-Medicaid carrier available in this market has a *very* narrow network) and I've been referring the latter out for many years.

But it got me to thinking that perhaps it's time to reprise another of my former Answers.com gig's posts:

For millions of younger Americans with health problems, Medicare may be available to cover medical expenses. This would include those with long-term disabilities or who have been diagnosed with specific diseases or health conditions, such as amyotrophic lateral sclerosis (ALS) or end-stage renal disease. As with those who qualify due to their age, though, Medicare itself doesn't cover everything, and some form of supplemental coverage may be desirable.

What's the problem?

During surgery, a client's adult daughter was deprived of oxygen for many minutes, resulting in brain damage that left he unable to support herself. She was eligible for Social Security Disability, and thus for pre-65 Medicare health coverage. The challenge is that there are deductibles and co-payments that add to her out-of-pocket costs. A Medicare Supplement policy might be able to pay for most of them. Unfortunately, many people don't know that these plans exist.

What's available?

In some states, one can purchase a standardized Medicare Supplement policy from a licensed carrier. These plans, which are usually available only to those 65 and older, are made available to those who qualify for pre-65 Medicare. They can be expensive, but in many cases the coverage they provide far exceeds the monthly premium.

Medicare Advantage Plans may also be an option, depending on one's residence.

How does Medicare Advantage work for pre-65 beneficiaries?

There are several benefits to an Advantage Plan. First, it caps one's maximum out-of-pocket in case there are a lot of claims (or one very big one). Second, many plans are available at little or no cost to the consumer. This can save thousands of dollars a year in premiums over a standardized Medicare Supplement policy.

The downside to Advantage plans is that one is limited to certain providers for health care, and not all of one's medications may be covered.

What about Open Enrollment?

One challenge with switching to a Medicare Advantage plan is that this can generally only be done during Open Enrollment. Fortunately, my client's daughter was also participating in Social Security's "Extra Help" program. Extra Help enables qualifying Medicare beneficiaries to purchase their meds at greatly reduced prices, with the government picking up the cost. According to the Social Security Administration (which oversees the program), Extra Help "[is estimated to be worth about $4,000 per year]( ttp://www.ssa.gov/prescriptionhelp/)." 

What about an Exchange Plan?

One of the alternatives we explored was whether or not an ACA-compliant Exchange plan would be appropriate. This was quickly discarded because, according to the Centers for Medicare and Medicaid, "it’s against the law for someone who knows that you have Medicare to sell you a Marketplace plan".

And people who do choose to reject Medicare and end up buying a plan from the Exchange are ineligible to receive any subsidy.

And so?

Americans who are on Medicare due to serious health conditions have limited health insurance choices. For many, a Medicare Advantage plan may be the most efficient means to supplement their Medicare coverage.

Medicare for Young Folks: A Case Study (Part 2)

In Part 1, we met a young lady who suffered a tragic medical setback, and is now unable to live on her own, and whose medical care is paid for by Medicare. We also began to learn about what alternatives or supplements might be available to her and her family to help fund her care.

The Medicare Advantage plan seemed promising. One immediate challenge is that the most recent regular Open Enrollment period ended last month, and the next one doesn't start until the Fall. The good news, according to my personal Medicare Advantage guru Roger D, is that folks on the Extra Help program are pretty much always in Open Enrollment, so she may be able to hop on to an Advantage Plan.

So we'd now identified 3 potential avenues: an Exchange plan, her father's retirement medical plan, or a Medicare Advantage plan. It was now time to do a little more digging, and then to meet to review the results:

As it turns out, folks on Medicare can not (easily) buy an ACA Exchange policy. As the folks at CMS explain:

"It’s against the law for someone who knows that you have Medicare to sell you a Marketplace plan."

But what if you really, really want one?

Well:

"[T]here are some situations where you can choose Marketplace coverage instead of Medicare ... if you’re eligible for Medicare but haven’t enrolled in it ... If you’re paying a premium for Part A, you can drop your Part A and Part B coverage and get a Marketplace plan"

Oh. Well, our young lady is already enrolled, so the first "out" won't work. And the second alternative didn't seem very promising, since she wouldn't be eligible for a subsidy.

So much for that.

Adding her to my friend's plan has some attraction: it's a known quantity (and is itself a Medicare Advantage plan with some great benefits) and offers the convenience of having one plan (and carrier) for both.

I had, however, a concern: what happens if/when my friend passes away - can his daughter stay on the plan? After poring over the written materials he had brought with him, and several frustrating phone calls to the carrier, we still don't have a definitive answer. This is troubling, but not necessarily a deal-killer.

So we called Roger (my guru) and had a very frank and helpful discussion about a separate Medicare Advantage plan for the daughter. First, we confirmed that she is, in fact, an Extra Help participant, so the Open Enrollment issue is moot. Second, we learned that there are several $0-premium Advantage plans available here, saving my friend several thousands of dollars in extra premiums. These plans also cap her out-of-pocket exposure to about $4,000 a year, which is well within my friend's means to cover.

One thing that still needs to be done before a final decision is made is to confirm that her doctors and other providers are in-network, and to check her meds against the carriers' formulary lists.

My friend was delighted that a good plan is available at a very affordable cost ("free"), and was very impressed with Roger's depth of knowledge about not just the Advantage plans but also the Extra Help and other programs. He even suggested some other places for my friend and his daughter to look for additional resources and help.

It's such a blessing to have access to folks on whom I can call to ask for help and advice, and who I know will take care of my clients. It makes me look good (no mean feat in itself), and they get quality advice and service.

And there's this: I try to learn from every interaction I have, whether or not I make a sale. There is no doubt that I'll have the opportunity to use what I've learned on this case down the road. And that, too, is no small thing.

Web (in)Security

Yesterday,  I received the following from CoveredCA: 

New!  iPad Online Application:  Replace "HTTPS" with "HTTP" in URL Address

If you are using your iPad for enrollment and already have an URL saved to get to the open enrollment online application, you will need to update the URL Hyper Text Transfer Protocol Secure (HTTPS) address by removing the “S” from the “HTTPS” in the URL address so you can access the open enrollment online application. 

Seriously?   HTTPS is the secure protocol for transmitting information over the internet. HTTP is open text that's readable by anybody who intercepts the transmission.  Nobody should EVER use HTTP for any kind of sensitive work...even Facebook uses HTTPS:

Frustrating Circumstances

I originally thought this would be another in our series of either Stupid Government or Frustrating Carrier Tricks. But it's really about how "life happens."

So we know that HHS has been cracking down on off-season ("Special Open") enrollments, leading carriers to be particularly stringent on what documentation they'll accept, and adhering tightly to the 60-day open window.

But sometimes, even having all the documentation one thinks is necessary just isn't enough, and it's not the fault of the proposed insured, the carrier, or the government.

Here's the story:

Bill was covered under his wife's health insurance policy until their divorce this summer. The divorce was actually finalized on July 13th, but Bill's ex told him that her boss had promised to keep him on the plan through the end of the month (that would be July 31st, for those following along at home). Divorce is one of the Special Open Enrollment triggers, as is involuntary loss of group coverage. Typically, the clock starts ticking the day the divorce is finalized, or when the coverage ended.

Because we believed that Bill was covered until July 31, we presumed that the clock started then, and we had 60 days to obtain new coverage. Bill didn't contact me until early this month, so we knew that clock was ticking, but believed we'd be clear for an October 1 effective date.

We submitted the application and supporting documents (well, those we knew about), one of which was the Proof of Coverage from the group plan. It said that coverage ended July 1, but since we'd been assured by Bill's ex that this wasn't the case, we pushed forward.

As the 60 day window continued to close, I asked Bill for more documentation to prove that we'd gotten in under the wire.

This is what I got in  email this morning:

"It was not supposed to end until Augus! I found out yesterday that it was cancelled July 1, and my ex's was cancelled August 1. She has left that position and is suing the guy she was working for. I have not been able to reach this former employer. Calls not being returned. I really don't know what to do at this point."

So basically, the carrier was correct that we'd missed the deadline, and will be refunding Bill's initial payment shortly. On the bright side, I was able to come up with a pretty nifty solution to Bill's coverage and ACA problem (but that's another post).

The moral of this little [ed: "little‽"] story is that sometimes one can dot all the right i's and cross all the right t's, and still come up short.

VERY Stupid Agent Tricks

On the one hand, having an agent help you "navigate" (heh)  the 404care.gov site is essential. Having one who actually knows what he/she is talking about is equally so.

Witness the power of this fully operational StupidStar:

"Yes, you can still get health insurance after Obamacare open enrollment ends."

In a glaring - and unprofessional - attempt to correct herself, "The Goddess" has completely revamped her original post, without leaving the original post intact, as if actual professionals didn't already save her egregious misrepresentations.

Here's what her post originally said:

“Yes, you can still get health insurance after Obamacare open enrollment ends.

Obamacare has NO bearing when health insurance is available for purchase. It’s available year-round- like it’s always been."

And she actually doubled down on The Stupid in her comments section:

"I stand by my statement, but perhaps my explanation in the post was unclear. Here's another try: Health insurance is available year-round- but in two different ways- inside the Marketplace and outside the Marketplace"

The fact is that, without an officially sanctioned "Qualifying Event," one may not purchase a new plan "year 'round," on or "off" the Exchange.

Rather than acknowledging and then correcting her mistake, "The Goddess" simply dumped her original post "down the memory hole" and attempted to shift the blame for her stupidity onto some nameless carrier.

The fact of the matter is that, if she truly underwent (and understood) the FFM training, then she would have known that what she posted was wrong. And if this is the quality of her "advice," then Heaven help her poor clients.

Now you may be thinking "hey Henry, why the attitude? She owned up, 'fessed up and apologized. What's the big deal?"

Except:

Except she didn't, really. What she did is throw the original post "down the memory hole" and (attempt to) blame some anonymous carrier rep. Even if this rep had claimed that Open Enrollment applied only to On-Exchange plans (about which there is some dispute), "The Goddess' - alone - was responsible for vetting this information before posting it. And it was easy to do, as anyone who had taken (and passed) the FFM certification course could attest.

Again, we all make mistakes, but responsible folks acknowledge and correct them, and responsible bloggers make sure to keep the original post intact (or, perhaps grayed out, to indicate something's amiss) so that others could see the error and understand the correction.

"The Goddess" did neither.

And that's the reason for "the attitude."

Not Ready for (Sub-)Prime Time

So I spent a great deal of yesterday afternoon on the phone with the friendly - if hapless - folks at 404Care.gov. Turns out, one of my "Grandmothered" Anthem clients may be eligible for a subsidy, which means the (dreaded) Marketplace. We'd already picked out a plan, now we needed to enroll her.

Since her December renewal triggers a Special Open Enrollment, we were looking for a December 1 effective date. She's actually pretty fortunate: as I explained to her, it's not yet Open Enrollment season (that starts this coming Saturday), so there were likely only hundreds, perhaps thousands of folks vying for coverage at any given time today. Come the weekend, and especially next Monday, that will swell into the millions.

And yet, well, what you see at the top of this post is what we encountered multiple times. So we took their advice and called the toll-free number.

And spent the next two hours (really!) speaking with a delightful young lady named Destiny (last name withheld because she isn't the problem). Like us, she was unable to successfully access the system; in fact, she had to ask for my client's information several times as the system gobbled it up and spat out error message after error message. If it spat out anything at all (she was experiencing more hang-time than Michael Jordan).

Ultimately, we had to bag it (my client had another appointment, as did I) and we'll pick up again in the morning. We did ask Destiny if there was a better time to call, and she assured us that the call center is open 24/7, and one time's as good useless as any other.

And remember: this is the off season - still think they'll be up for the real deal?

I'll let you know how it goes today...

Weird Caller Tricks

So I get a phone call this past Friday from "Pam," who's looking for help with "personal health insurance." Turns out her husband's "idiot boss" had neglected to pay the group health insurance premiums, and as a result that plan had lapsed. At which point her "idiot husband" went on the Exchange (during Open Enrollment) and signed them up for a plan with Molina, to the tune of $2,100 per month (you know, 'affordable'). Pam was unhappy with both of these events (no kidding), and wanted to make some changes.

In the meantime, she had signed up for a UHC short term plan that will expire on the 20th.,

It should also be noted that Pam has a pre-existing shoulder injury for which she receives periodic treatment, and her "idiot husband" was recently diagnosed with a (thus far benign) thyroid nodule.

Hunh.

I explained that there really weren't a lot of insurance options here: since we're outside Open Enrollment, and I don't see any Special Open Enrollment triggers in her situation, there's not much we can do with ACA-compliant plans. Nor would another Short Term plan be advisable, since both her shoulder and now her "idiot husband's" thyroid condition would be pre-existing and thus excluded.

I then turned to some non-insurance (but ACA-compliant) options, and asked if she was familiar with Health Care Sharing arrangements; she was not. So I explained to her that, although I don't write these myself, I do know that there are a lot of folks who think they're pretty good (and also a lot who think they're a rip-off, of course). I also asked if she knew about Direct Primary Care (DPC) and, unsurprisingly, she did not. And so I explained how DPC worked, and how to use the DPC Frontier site to see if there's a nearby practice.

I also explained that many folks combine these two plans, and why that is often effective.

Keep in mind that I've now spent about 45 minutes with her answering questions and offering advice, and that since I wouldn't be selling her anything myself, this was completely uncompensated. On the other hand, The Sticker pretty much dictates this course of action.

At the end of the conversation, I asked if she had any other questions, and she said "no, I'm going to call the Exchange number and get my plan changed." And then she hung up.

Gee, Pam, you're quite welcome.

And rotsa ruck with that.

Interesting (and sad) case

Had a call the other day from an acquaintance whose 30-something daughter had been experiencing severe and debilitating health issues for the past two or so years. She had lost significant weight (and she was hardly exactly 'zaftig' to begin with), and had begun seeking non-traditional, "alternative medical" treatments, to the tune of tens of thousands of dollars.

My acquaintance called because he knew I dabbled in the health insurance field, and hoped I could give his family some advice and insight on what options might be available.

Oh, there's an interesting twist, which may play an integral part: the daughter, who had never given up her US citizenship, had nonetheless spent the past few years living abroad, and had moved back here just before she became ill.

This is important, because one of the Special Open Enrollment triggers is "Changed your primary place of living." Now, it actually gets more specific:

"Moves that may qualify you for a Special Open Enrollment Period [include] ... To the US from a foreign county."

Which seems a slam dunk, but then there's this caveat:

"Important: To qualify for an SEP, you must prove you had qualifying health coverage for at least one day during the 60 days before your move except moves from a foreign country)." [emphasis in original]

This is crucial because it seems to be referring to the so-called "60-day rule;" that is, you must exercise your SEP opportunity within 60 days of becoming eligible for it. I think she's missed that window, but I'm not entirely sure, and so I urged my acquaintance to call the nice folks at the Marketplace to confirm, and also to see if the daughter might be eligible for a subsidy.

We then looked at what plans and carriers were available in their area, to get an idea of costs and benefits. The less expensive Bronze level plans were, of course, very affordable even without the subsidy, but the out-of-pockets were pretty hefty. The other issue is that, at least in Ohio in 2019, all plans are built on an HMO chassis, which means basically zero out-of-network coverage, which might be an issue (or maybe not: after all, she doesn't have insurance now).

Okay, that's the insurance side, but maybe there's another line of attack open to us?

And indeed there may well be:

I then suggested that they also consider other options. For one thing, a call to the local Medicaid office might be helpful: those folks have access to information on all kinds of medical financing options.

I also asked if he was aware of Direct Primary Care. I explained that these practices worked like a gym membership, with monthly dues granting 24/7 access to a physician. They also often have big-ticket diagnostic equipment in the office, saving even more (eg: MRI's costing hundreds of dollars, not thousands), as well as discounted prices on meds. They are also very helpful in referring patients to fellow cash-only-type providers in the area for non-primary care services.

I promised to send him the link to the latest directory of DPC practices, but I also cautioned him to beware that they aren't much help with catastrophic medical issues, and that's something to consider, as well.

Looking forward to seeing how this plays out and, of course, always happy to help.

An Embarrassment of (Link) Riches

The Inbox is filling up with interesting linkage: many of interest, few really blogworthy on their own.

So, in no particular order, some (hopefully) interest-piquing links:

■ "By February, CMS had spent an average of about $92 per HHS exchange QHP enrollee"

That is, they'd spent almost $100 per (successful?) ObamaPlan victim enrollee. That may not seem like much, but if the numbers HHS is touting are true [ed: uh-hunh], then we're talking hundreds of millions of IT dollars.

■ Does the ObamaTax actually contain wording that contains the seeds of its own destruction?

"The Patient Protection and Affordable Care Act (PPACA) contains a provision — Section 1332 — that states can use to turn it inside outside"

The little-known Section 1332 allows state Departments of Insurance the opportunity to solicit waivers for certain plan provisions, including Qualified Health Plan requirements. Something to keep in mind, though:

The verbiage in question is actually called "Sec. 1332. Waiver for State innovation," and allows states to "apply to the [HHS] Secretary for the waiver of all or any requirements described in paragraph."

But it's not open-ended; rather, it's an opportunity for a given state to experiment a bit, while requiring of the state a "10-year budget plan for such plan that is budget neutral for the Federal Government."

Sweet deal for the Feds.

■ As if confirmation was needed that the ObamaTax has lead to provider shortages, and at least a suspicion that rationing is just around the corner (if not already here):

"5 ways insurers can limit care access in this brave new world ... Insurers are not sitting back with open arms and welcoming all of the poorest, sickest and most costly patients"

No kidding. When increased demand (in the form of newly insured, both on ObamaPlans and Medicaid) meets static (or perhaps even shrinking) supply, something's gotta give. 

■ Here's a new twist on the ol' Three R's: reinsurance, risk corridor and risk-adjustment. These also happen to comprise some underlying reasons why insurers' own financial health may face some challenges.

According to Steve Zaharuk, a senior vice president at Moody’s Investors, "although exchange qualified health plan (QHP) enrollment has been strong, insurers have given few details about QHP underwriting results ... At best insurers were predicting a break-even scenario, but most were anticipating losing money on the business for the full year.”

Not a great long-term business strategy. Which actually ties in nicely with... 

■ FoIB Jeff M tips us to this news out of The Tarheel State:

"Carolinas HealthCare System has eliminated roughly 100 jobs and is looking to cut its 2015 budget by $110 million"

Which seems to me to be a combination of the four previous links. One wonders how many more such reductions we'll see as we enter the next Open Enrollment season, and even more folks jump in (or don't).