"Has anyone addressed the Pre-x issue concerning the new law. For example it seems that an employee could be involuntary terminated without paying the premium for 5 months, then come back on the plan by paying 35% of one months premium, have both knees replaced with no pre-x conditions because the creditable coverage period does not apply.
If the participant discontinues coverage after one month the adverse carrier risk is brutal to say the least."
Unfortunately (for the carrier, at least), this is correct. ARRA defines a "late-electing person" as one who had previously been offered, and rejected, COBRA extension, and who subsequently became eligible under the new rules [ed: new "rules?" Are they really "rules" if they can be changed on a whim?]. Such a person could, indeed hop back on the plan by simply paying their portion of one month's premium, have such a procedure, then bail.
As a practical matter, though, I'm not convinced that this will be a common occurrence. For one thing, they'll still have their deductible and co-insurance, and the pre-cert requirements may well take longer than the person would have under this one-month scenario. Also, any such procudure is likely to require follow-up care, not to mention rehab, which would also take at least a few months.
■ Aetna/Humana: FoIB Rick emails that this is more likely to be a distraction than a certainty; it seems that there's more happening under the radar than in plain sight:
Rick explains that "Availity is working towards -- and in testing in selected Florida markets has actually achieved -- real-time claims adjudication, the Holy Grail of claims processing." One of the challenges of Consumer Driven Health Plans (e.g. HSA) is lack of hard data at time of service. Since there's no co-pay, and the provider generally has no real idea of what that claim will really cost (after repricing and depending on deductible and/or co-insurance), most folks leave the office parting with no cash. The doc then has to wait for the claim to be processed for payment to be received, from either the insured or the carrier (or some combination of the two).
A system that allows the provider to immediately know how much to collect from a patient, and the patient immediately knows what the service will cost, is a major step towards more transparent health care delivery. This is a good thing.
In related news, however, Rick reports that the aforementioned partnership now adds up to almost 50 million "medical lives, not counting Part D standalone or Med supp members, from the first, fourth, seventh and thirteenth largest insurers in the country. Hmmm. The words "too big to fail" come to mind, and not necessarily in a good way."
A year ago, I would have pooh-poohed such sentiments, but based on the AIG and Big 3 fiascos, I'm not so quick to dismiss this concern. On the other hand, there's not much we can do about it (even if we wanted to) except to hope for the best.
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