MidWeek LinkFest

■ Medical Mutual of Ohio is enhancing its autism coverage for many of its insureds "on the spectrum." I've already reached out to one client that I know of who's likely to benefit from this.

Coverage enhancements include speech, language and occupational therapy, as well as screening and diagnosis benefits.

Yasher koach.

■ Last time we looked at the burgeoning Life Settlements industry, I mentioned my own uneasiness with the concept:

"It's not that I have any particular ethical qualms; after all, it's my client's policy, so why should I care? It just feels ... weird to bring this up."

But our friend Allison Bell reports from that industry's annual convention that they're facing an equally difficult challenge:

"Life insurers and life settlement firms are struggling to comply with new tax reporting rules without an official tax form, a draft tax form, or a clear idea of what the Internal Revenue Service might like to see."

Turns out, even though viaticals have been deemed 'kosher' for some 20 years, their fraternal twin Life Settlements are facing different tax treatment (which makes sense, one supposes), and the IRS still hasn't gotten around to providing a fix.

Whether or not that will prove an insurmountable obstacle remains to be seen.

■ And speaking of relatively new, burgeoning industries, I've been spending a lot of time lately educating folks on the Direct Primary Care model (since I no longer sell ACA-compliant health plans, and still want to provide some service to clients). The challenge is that I really didn't know where to send folks for local DPC practices.

Now, thanks to FoIB John Chamberlain, I've been clued in to this helpful site which offers an interactive map of nearby DPC's.

Nice!

Tomayto, tomahto

Via The Banana News Network (courtesy FoIB Holly R):

"About 9 million fewer Americans will have health insurance next year thanks to the Trump administration and Republicans in Congress, a new report estimates"

Translated:

“About 9 million more Americans will have the choice of finding lower priced, better coverage ACA alternatives, thanks to Donny Two Scoops” 

Related:

"20 states sue Trump administration to end Obamacare after mandate repeal"

The logic seems to be that deleting the tax fine penalty somehow "invalidates the mandate and all of Obamacare."

Interesting.

The MVNHS© continues swirling

Another day, another chapter in the on-going train-wreck we lovingly call the Much Vaunted National Health System©:

"NHS crisis: Patients face delays for vital treatment amid 'staggering increase' in cancelled operations"

Well no wonder. I'm old enough to remember this (from last month):

"Every hospital in the country has been ordered to cancel all non-urgent surgery until at least February in an unprecedented step by NHS officials."

Things (obviously) haven't gotten any better, with the Independent reporting that:

"Nearly 1,000 urgent operations have been cut so far this winter for patients with life-threatening illnesses due to pressures on hospital resources ... It’s unsurprising that urgent operations have come to be cancelled at a greater rate over these years of spending restrictions and increasing demands on services."

No kidding.

But remember kids, national health care schemes are proven to reduce costs and provide excellent, timely care.

Plus: Free!

[Hat Tip: FoIB Michael Bertaut]

Dunkin' (Medicare) Donuts

We first blogged on the (so-called) Donut Hole in Medicare over a dozen years ago:

"The donut-hole comes into play whenever a covered person (“beneficiary” in Medicare parlance) reaches a specific threshold, and leaves that person without prescription drug cover until another threshold is reached."

And it's a big problem for seniors, since that demographic tends to use a lot of meds.

Recently, our friends at Cornerstone alerted us that:

"For Medicare Part D beneficiaries with high prescription drug expenses, the “Doughnut Hole” means they pay more for their medicine once costs reach a certain threshold. Narrowing each year since the Affordable Care Act was passed in 2010, the gap was scheduled to close in 2020. With the 2/16 budget deal, the doughnut hole will now close in 2019."

So, good news, right?

Well, maybe not. As co-blogger Bob V explains:

"Medicare drug donut hole to close in 2020 as part of Obamacare. Trump closed a year earlier in latest budget deal. Carriers are unhappy because they will have to pay more for drugs. Also CMS trying to shift expensive drugs currently covered under Part B to Part D."

To which I (who should have known better), replied:

"Ah. Well too bad for the carriers, but seems like okay for insureds?"

(Yeah, dumb)

Bob put it to rest:

"Rule #1. Carriers don't pay for higher costs.

Consumers do.Higher premiums, copay's, deductibles, OOP [out-of-pocket]"

Yup.

"I'm from the government..."

Tacos, Tequila and (Medical) Tourism

Medical Tourism has been a frequent topic here at IB, so this tweet from FoIB Dr Kris Held caught my eye:

Yesterday I saw a precious lady patient who suffers with severe pain from rheumatoid arthritis.She told me she had to seek care just across the border in Mexico recently, because she could not find a rheumatologist who could see her before July! Unreal. @AAPSonline @SeemaCMS

— Kris Held,MD (@kksheld) February 20, 2018

Perhaps not-so-coincidentally, I recently received this in email:

[click here for full graphic]

There are, of course, downsides to traveling to foreign lands for health care, and one wonders how (or even if) such care is covered under one's insurance. But there's no question that actually receiving timely care seems to be a lot more important than owning an insurance ID card that doesn't actually provide it.

[Hat Tip: Lisa B]

"Skimpy" Insurance

Tomayto, tomahto. From CMS Secretary Seema Verma:

Our proposed STLD rule would allow insurers to sell a flexible and short-term insurance product to consumers and extend coverage up to 12 months. The current allowance is no more than three months. We know this will help people left behind by #obamacare.

— Administrator Seema Verma (@SeemaCMS) February 20, 2018

And Reuters' more, um, progressive take:

"U.S. to extend skimpy health insurance outside of Obamacare"

Well first, no one's "extending" anything: Short Term Medical plans have been around for a long, long time.

And let's talk about that rather loaded term: "skimpy"

Most STM's offer deductibles as low as $500 (or lower), with out-of-pocket exposure (MOOP) limited to a few thousand dollars.

Contrast that to typical ObamaPlans with deductibles over $7,000 a person, and MOOPs in the tens of thousands. But yeah, the STMs are "skimpy."

All this particular ruling does is restore the maximum policy length to the status quo ante, before the previous administration unilaterally (and illegally) cut those short.

So which one's "skimpy," skippy?

[Reuters Hat Tip: FoIB Holly R]

Monday Morning LinkFest

■ Interesting story about the (perhaps not so precious) Much Vaunted National Health System©, courtesy of co-blogger Mike:

"[Prime Minister Teresa] May spoke of the importance of “taking a balanced approach to government spending, so we get our debt falling but can also invest in the things that matter -- our schools, our police and our precious NHS.”

The article's author points out that this is a rather odd description of a government bureaucracy, and he goes on to explain why it's rather troubling.

■ It's been a while since we've posted on Alzheimer's; last May we noted that "[m]aple syrup isn't just delicious, it could also cure Alzheimer's disease."

Now, thanks to FoIB Holly R, we learn that "scientists have successfully reversed Alzheimer's in a middle-aged lab mouse."

That's the (potentially) good news.

The bad news is that the day before this breakthrough was announced, another clinical trial of the med was called off "due to safety fears."

Hopefully they can get those resolved.

■ A Lone Star state mother appears to have chosen poorly:

"A Texas mother of two died Sunday from flu complications after reportedly deciding that the $116 medication to treat the virus was too costly."

As FoIB Jeff M (who tipped us to this sad story) observed, "the funeral is likely to cost even more."

Her widower defended her decision thusly:

"She wouldn't go get medicine because she's a mama. Mamas are tough ...  I don't think she is being irresponsible. I don't think she thought she was that sick. It happened so quick."

The truly tragic part is that her husband actually picked up the drugs for her, but by then it was too late.

Tragic, but easily preventable.

STCi: Revisited

It's been a while since we talked about Short Term Care insurance coverage:

"Short-term care (also known as Recovery Care or “LTC Lite”) is not a new product but it has been gaining ground in the last 2 years ... With its shorter underwriting cycle, high-issue rates, and low premiums it’s becoming increasing popular"

As may be, but contra this take, we really haven't seen much discussion of this product in the intervening five-and-a-half years, so one wonders about its appeal.

On the other hand, there must be something positive about it; we recently received this educational video on a related plan from our friends at Guarantee Trust Life:


GTL's Short-Term Home Health Care Insurance from Guarantee Trust Life Insurance on Vimeo.


Thanks, GTL!

Post-Valentine's Health Wonk Review

Steve Anderson hosts this month's eclectic collection of health care wonkery, with a decidedly Olympian effort.

Do check it out!

Celebrating Obamacare's Exchange "Success"

Last week a new report came out - albeit not from CMS - showing Obamacare's enrollment results for 2018. The headlines make the case that enrollment is "stable", that the law "isn't dead". Another headline by the AP's Ricardo Alonzo-Zaldivar portrays it as a success "despite efforts to dismantle the ACA" by the Trump Administration. Fast Company's headline goes as far as to say Obamacare is "still pretty popular" despite attempts to "kill it."

These stories are total spin showing media are nothing more than fairweather fans. The truth is, since 2015, Obamacare's exchange enrollment figures show that Team Obama hasn't been able to move the football down the field. What has changed, is in eight years of Obamacare we have seen goalposts moved. This allowed Team Obama to spike the football on a field that is less than half the size of what they originally were playing on.

In the original CBO score enrollment in the exchange was supposed to be 21 million in 2016, 23 million in 2017, and 24 million in 2018. By 2016 CBO set new goal posts hoping to break 13 million. Cutting the field in half was the only way Obamacare supporters could claim that insurance exchanges are working. You can see here how bad the exchanges have actually performed.

The chart is nothing to celebrate. This is not a success. This is a football team that is entrenched in mediocrity. The team has struggled to move the ball because the offense being run doesn't work. Instead of being open to a new offense, fairweather fans jumped on the bandwagon embracing changes to the rules of the game. When that didn't work they started blaming losses on the new coach who inherited a mediocre team from his predecessor.

Sidebar Update News

FoIB Roger Downey has launched a new health news aggregating site, and it's quite interesting:

"My Healthcare Report is the healthcare version of the Drudge Report without the politics. There is nothing else like it on the internet: I select the top story and populate the three columns below with links to the latest healthcare stories."

I like the minimalist, easy to navigate design, and there are a lot of interesting news items. We've added it to our sidebar ("Blogs of Interest").

Do check it out.

About That Individual Mandate...

For the last few months we have been hearing President Trump touting his "repeal of the individual mandate" as a huge opportunity for people to not be penalized for going without health insurance. On the Democratic side Nancy, Chuck, and their minions have been scolding Republicans for kicking 13 million people off of insurance.

This game of rhetoric is confusing to the general public. Well, never fear, here at IB we are all about educating the public as to what the reality of the latest partisan divide actually means.

First, let's get the "people are going to die/kicked off insurance" fallacy out of the way.

Democrats were quick to point out that CBO is showing that in 2026 (8 years away!) 13 million more people will be uninsured through their scoring system. In telling the story democrats have used language that insinuates people are going to be kicked off of their plans. This is a blatant lie. 

The CBO report notes that 5 million people will drop off of Medicaid, 2 million will not stay on their employer sponsored plan, and 5 million people will not buy insurance in the individual market. Note that none of these people are being forced to lose insurance. Rather they are electing not to participate. That's a huge difference.

So, what is the truth about "repealing the individual mandate"?

Quite simply put, the mandate still exists. It's still in the law. What has changed is the penalty for not purchasing health insurance has been zeroed out in the new tax law. More important, the zero doesn't begin until 2019. So not only is the mandate alive it still has teeth (alright maybe only a single tooth) for this year. Here's the actual language from the tax bill Trump signed:

PART VIII—INDIVIDUAL MANDATE

SEC. 11081. ELIMINATION OF SHARED RESPONSIBILITY PAYMENT FOR INDIVIDUALS FAILING TO MAINTAIN MINIMUM ESSENTIAL COVERAGE.

(a) In General.—Section 5000A(c) is amended—

(1) in paragraph (2)(B)(iii), by striking “2.5 percent” and inserting “Zero percent”, and

(2) in paragraph (3)—

(A) by striking “$695” in subparagraph (A) and inserting “$0”, and

(B) by striking subparagraph (D).

(b) Effective Date.—The amendments made by this section shall apply to months beginning after December 31, 2018.

A swing in the political pendulum could bring the penalty for not having insurance back. Changes in congress could reopen these discussions. Striking "Zero percent" and inserting "2.5 percent" could happen. Republican's aren't telling you this.

Honesty is a lost attribute for politicians these days. Yet CNN, Fox News, and countless other media continue to promote what the inner beltway folks tell them as if it is gospel. This is why we are in the political environment we are today. Honesty doesn't get you reelected. And the best stories are the ones that are the most egregious.

Fortunately for IB readers, we aren't politicians or journalists. Instead we are insurance professionals. You know, the guys who politicians think are one step below ambulance chasers and one grade above used car salesman. 

#Fake ObamaCare News

Uh-oh, looks like someone misspelled 3000% rate decrease:

"Health care premiums for the skimpiest Obamacare plans in the District of Columbia are skyrocketing in 2018."

Rates for Bronze-level plans are supposed to be among the lowest (with concomitantly higher out-of-pocket exposure). The article cites the example of Daniel Turner, "a single healthy guy in Washington, D.C., with no dependents." His Bronze plan shot up almost 36%, to over $4,400 a year. Couple that with his deductible and co-insurance and he's out over $10 grand before the plan pays a nickel.

Oh, wait, he does get a "free" colonoscopy, which is worth at least a few hundred, right?

Condolences - And Here is Your Rate Increase

Some forms of insurance offer multiple policy discounts, family discounts, household discounts, etc as a marketing incentive. The thought process is, if you get a discount for buying more insurance from the carrier you are more likely to select that carrier over one who does not have discounts.

It might also encourage you to not only buy your coverage there but could be an incentive to leave all or part of your business with the same carrier.

But it turns out there is a dark side to the discount game. One I discovered quite by accident.

Many carriers that write Medicare supplement coverage will discount your premiums as much as 12% when there are multiple policies involved. A few will even discount premiums if you live with someone over the age of 18.

Seems there might be some benefit to having and adult child still living under your roof.

But I digress . . .

You can lose your discount if your spouse divorces or switches their coverage to a different carrier.

Makes sense.

But you can also lose the discount if your spouse DIES.

Spotted this on another blog that seems to be devoted to excoriating insurance carriers.

The agent told me that he had a homeowners insurance policy covering a husband and wife. Recently, the husband died. At the widow’s request, the agency sent a change request to the insurance company (which will also remain anonymous), asking it to remove the deceased husband’s name from the policy. The company issued an endorsement to the policy, along with a bill for an additional $26 in premium. Like any good agent, our member called the company to ask why the widow was being charged $26 for taking her late husband’s name off the policy. The answer: The company ran a check on her credit score and found that it was not as good as her husband’s. Under the company’s pricing system, this knowledge generated a higher premium.

 This insurance company charged a new widow $26 because she was more of a credit risk now that her husband was gone. - Insurance Commentary

Let that one sink in.

Your spouse dies. Insurance carrier acknowledges and greets you with "here is your new, higher premium".

Wonder if this carrier would REDUCE her premium if the now deceased husband was a deadbeat credit risk while she had sterling credit?

Nah. That would require the carrier to have a heart.

#InsuranceDiscount

Monday Afternoon LinkFest

■ First up, via FoIB Holly R, is news that the Much Vaunted National Health System© continues to circle the drain:

"[E]xpenses have forced 40% of walk-in health centers to close, all elective surgery in January [had] to be cancelled, and primary care has been decimated"

But hey: Free.

This is, of course, rationing by government fiat, and it's how nationalized health "care" works. Which is why it's not likely to take hold here (and the apparent rollback of the ACA Death Panel helps nail this particular coffin shut).

■ Down the road, FoIB Jeff M tips us to this Tale of Two Exchanges:

"Most states that operate their own ObamaCare exchanges saw more people sign up in 2018 than last year, while 29 of the 34 states that rely on the federal government to promote enrollment saw their sign-ups fall."

Overall enrollments continue to free fall; last year saw a year-over-year falloff of almost 4%.

Of course, the article attempts to lay the blame on the Trump administration, despite the fact that we've seen enrollments decline pretty much the whole run of the HC.gov debacle.

■ Readers may recall our post a few weeks about mudslide coverage for our Golden State friends:

"We wondered if (and/or how) one would be covered if one's house (literally) went downhill."

Co-blogger Bob alerts us that the state's Insurance Commissioner has chimed in:

"The notice acknowledges that homeowners’ and certain commercial property insurance policies frequently have exclusions for losses from mudflow, debris flow, mudslide, landslide or other similar events."

Okay, so far so good.

"Under California insurance law, the exclusions are not enforceable if the facts establish that the wildfire, which is a covered peril, was the “efficient proximate cause.”

Oh, frabjous day. Let's just wave the ol' magic wand and conjure up coverage.

WooHoo!

Another Timely Reminder

That health insurance ≠ health care. As FoIB David Fluker points out:

A lot of them won't accept Covered CA plans either. https://t.co/KXEWVxvUJd

— Dave Fluker (@FlukerDavid) February 9, 2018

To which I replied:

"We have same issues here in OH with CareSource, Molina, etc"

In my market, and in fact in most counties in the United States, there are only a few "choices" when it comes to ACA-compliant health insurance plans. Here in Montgomery county, the only such carriers are all primarily known for their Medicaid business (for lack of a better term, since Medicaid isn't insurance) that have jumped in to the ACA marketplace. And with very narrow networks (since most doc's don't want any part of Medicaid-level reimbursements), insureds are finding that their purchase may have saved them from the penalty tax fine, but is of little other value (well, except for that free birth control, er, convenience items).

So if one can't actuality use the plan, what's the point in paying for it?

Co-blogger Patrick also jumped in to the fray, pointing out that "Centene is already at the center of a lawsuit for insufficient network adequacy."

Thing is, suing for a desired result doesn't guarantee that result; the question becomes "how does one force a carrier to add non-willing providers?"

I wouldn't be counting any chickens just yet.

Happy (Belated) Blogiversary

Well! I certainly don't understand how that happened: We recently (January 31st) marked our 15th (!!) blogiversary, but failed to note it. Still amazed that a decade-and-a-half later we're still going strong, with the best co-bloggers on the internet.

Thank you, dear readers, for for your continuing support and interest!

Breaking: Is the Death Panel gone?

It would appear so:

Senate budget deal would repeal "ObamaCare’s Independent Payment Advisory Board" aka IPAB." https://t.co/ZLSYXdzByD

— AssocAmerPhys&Surg (@AAPSonline) February 8, 2018

Winter Olympics Heads' Up

Our friends at GeoBlue inform us that:

"Leading up to the event, there have been concerns due to the proximity of the games to the North Korean border. Recent dialogue initiated by North Korean leader Kim Jong Un with South Korean President Moon Jae-in have reduced tension and threat concerns however, there are safety precautions that members should consider prior to and while traveling in this region to ensure a safe and healthy experience."

So if you're headed to The Games, make sure you're adequately insured, too.

Medicare Changes 2019

Just 37 days into the new year and already looking ahead to 2019. My, how time flies.

The folks at CMS are working overtime to find ways to shift the financial burden to insurance carriers and Medicare beneficiaries. To wit . . .

CMS is redefining health-related supplemental benefits to include services that increase health and improve quality of life, including coverage of non-skilled in-home supports, portable wheelchair ramps and other assistive devices and modifications when patients need them. - CMS

The items addressed above are not currently covered by original Medicare, and these changes won't happen until the 2019 Advantage plans are released.

Although the above press release does not specifically mention original Medicare, one would presume these same new benefits will also apply to Medicare beneficiaries.

So why is covering things that are not medically necessary a bad thing?

Premiums will rise for everyone. Covered DME supplies will be folded into the competitive bidding process. What's wrong with that? Isn't competitive bidding a good thing?

One would think.

But rather than relying on a free market to set pricing the government decides winners (those who will be picked to participate) and losers. Historically, once an item is covered by insurance, prices increase rather than decrease.

Laser surgery to correct vision impairment is not covered in most cases. Over time the cost of laser surgery has come down while the quality has increased.

Contrast that with the price of prescription medications.

When commercial insurance plans introduced drug copay's drugs became MORE expensive, not less. This trend exploded immediately before Medicare Part D was implemented in 2006.

Statista shows drug expenditures rising from $121 billion in 2000 to $205 billion in 2005 and then $253 billion in 2010. By 2017 the annual cost of prescription drugs were $360 billion.

Insulin priced at $17 in 1997 is $138 in 2016.

Back to DME changes for 2019.

All this is not necessarily a bad thing. People who have disabilities that impact mobility would normally be covering home modifications out of pocket. Ramps, hospital beds, slings and other mechanical devices often accompany some medical conditions.

How far will this go?

Handrails, elevators, door modifications to accomodate wheel chairs . . . the list is almost endless.

How much will prices for these items rise over the next few years once they are covered by insurance? Beyond the insurance angle, how much will prices rise for the same items when purchased by those who do not have insurance?

Stay tuned.

#MedicareAdvantage #HomeHealthCare

From the Mailbag: A Toughie

This one seems to be a real poser:

"I am hoping you can answer some questions I have. I've been looking at my marketplace application and it asks about dependents and whether or not you claim them on your taxes. My divorce decree is written so that I can claim 2 kids one year while my ex claims 1. The next year it switches. So for the purposes of getting insurance through the marketplace, can I only claim each year which children I will be claiming that tax year? My ex says when he claims the children he cannot get the child tax credit because they do not live with him. So all of this is confusing to me. I will have to pay even more for insurance if I do not claim them all. They live with me full time and their father pays child support.

As things stand now, I am court ordered to carry them on insurance. However when I fill out the application it asks me if they have access to private health insurance. Technically they do through their father but I do not have the power to force him to carry them without seeking a court order. If I answer that question as they do not have access, is that technically correct since I can’t make him without a court order? My plan is to get the order changed anyway but I have considered carrying them if it makes the premium cheaper. However, I do not know if I legally can. I would like to know what my options are in regards to this.

I have asked a few attorneys I know about this and none of them even an answer. If you cannot answer me, do you know of someone who can answer?

Thank you so much! I know that is a lot of craziness."

I replied:

"I’ve gone round and round on this, and the challenge is that these are really closer to legality/tax questions than I’m comfortable answering (since I don’t play either a lawyer or*an accountant on TV).

Two thoughts:

1 – I’d call the .gov hotline (800-318-2596) and see what they have to say.

2 – I’ll also make this offer: We would be happy to post this in our “From the Mailbag” series (anonymously, of course), see if that produces anything helpful.

Just let me know.

I’m so sorry I can’t be of more help."

She responded:

"Unfortunately none of my lawyer buddies know the answer to this but none of them specialize in tax law. I will try the government hotline as soon as I can. If you want to post it on your blog that is fine with me as well. I can’t be the only one with this problem."

Which is more than a fair cop.

Please feel free to share your thoughts in the comments, or drop us a line in email if you'd prefer.

NB: For now, this is strictly about coverage, not subsidies.

Thank you!

Conjunction Junction: 'And' vs 'Or'

Individual disability policies are one of the two most complicated products in our portfolio (the other being Long Term Care insurance). There are a lot of moving parts, and determining whether or not one is truly "disabled" is a function of the policy's definition of that term.

We're privileged today to bring you a guest post from our friends at Diversified Brokerage which I think does a fantastic job of explaining the nuances of how these definitions differ, and why that matters:

One word in the definition of disability in a disability contract can  dramatically change how a claim is paid.

That word is either "or" or "and." You must pay special attention to this when reviewing the definition of disability.

If the definition of disability has the "and" word in the definition of disability, then a professional or employee would have to have a loss of time or duties AND a loss of income.

If the definition of disability has the "or" word in the definition of disability, then a professional or employee would have to have a loss of time or duties OR a loss of income.

It's important to ensure that your plan has the "or" language; with it, a professional could be back to work full-time and still be eligible for benefits as long as there is a loss of income from the disability.  It also means that a professional could be receiving 100% of his/her income (delayed receivables or profits) and still be eligible for benefits as long as there is a loss of time or duties.

Most folks aren't aware of the impact of this one word in their Disability Insurance contract, so here's your heads' up to make sure yours is an OR definition.

I'll just add that I often I often say “it’s the difference between you being disabled versus your wallet being disabled.”

Special IB Thanks to DB's Shaun M for his help on this post.