Good News from UHC

United Healthcare is expanding its Cancer Support Program for many if its insureds:

"The Cancer Support Program helps save clients money associated with treatment costs, while improving health outcomes and providing support to members facing cancer."

More info available here.

And there are new preventive screening benefits, too, with zero out-of-pocket (well, other than premiums) for maternity health, hepatitis B, skin cancer prevention and others.

Interesting news from HHS

Via email this morning:

"[On Friday], July 27, the Centers for Medicare & Medicaid Services (CMS) [began] implementing a new policy that allows consumers to request same day Marketplace coverage termination (i.e., the termination takes effect on the date of their request) instead of the previous requirement to give 14 days prior notice."

This is actually very helpful, since sometime folk can't know two weeks out whether or not their coverage really will take effect.

For example, you start a new job, and your coverage is set to take effect on August 1. Previously, a Marketplace insured would have had to have cancelled their ObamaPlan mid-July. But what if something came up - such as being fired or quitting - and one needed that Marketplace plan, after all?

And on the other side of this coin:

 "Consumers can also set their Marketplace coverage end date to a day in the future."

Sort of post-dating a cancellation. As  noted above, I'd be less inclined to advise this course of action.

These new rules are definitely more consumer-friendly, and a welcome change.

Details, shmetails

Oh:

The combined net worth of all US billionaires is $2.7 trillion.

That means if you were to tax billionaires at 100% AND send in agents to forcibly seize and liquidate all their property assets, you couldn't even fund it for one year. https://t.co/HzkvQAEf2D

— Donny Ferguson 🗽 (@DonnyFerguson) July 30, 2018

But hey, "free" healthcare!

What to make of this?

I've wondered for a while now about how the life insurance industry is going to handle the inevitable case of a transgendered male requesting (lower) female rates.

Or transgendered females asking for (lower) male disability income insurance rates.

(And my apologies if I have the nomenclature backwards)

As I discussed with a life field rep friend a while back, the life company is likely to decline the case altogether because of the increased suicide risk. Assuming, of course, that the situation is disclosed. If not, well, the misstatement of age/sex clause in life policies would come into play, no?

As they say, a can of worms.

Which a Canadian national just opened, bigly:

"Alberta man changes gender on government IDs for cheaper car insurance ... I just basically asked for it and told them that I identify as a woman, or I'd like to identify as a woman, and he wrote me the letter I wanted."

Now, the gentleman doesn't actually identify as a woman (NTTAWWT), he's simply playing the game by the rules the government has laid out. By claiming to so identify, he got his birth certificate and driver's license changed, and was able to save almost $100 a month on his car insurance.

Sweet.

[Hat Tip: FoIB Brian D]

Coverage ≠ Care: MVNHS© Anecdata

One of our most oft-repeated mantras here at IB is that health insurance is not health care. Now, that may seem self-evident, but far too many people conflate the two.

Well, the Much Vaunted National Health Service© provides today's lesson:

NHS increasingly desperate for nurses and midwives as applications continue to fall via @Telegraph https://t.co/NOSkxSFChh pic.twitter.com/uSbB0hmSf2

— Sally Pipes (@sallypipes) July 27, 2018

That is, the Brits may have free health insurance, but rotsa ruck obtaining care.

Good Intentions, Awful Execution

So to all the alphabet soup that is modern American heath care, we can add QSEHRA (Qualified Small Employer Health Reimbursement Arrangement):

"This new legislation specifically "enable[s] small employers with fewer than 50 full-time employees to fund qualified stand-alone HRAs. Employees may use the HRA to pay for qualified out-of-pocket medical expenses, including individual polices purchased through the public exchanges."

So far, so good: I've long been a big fan of the "defined contribution" model. That is, instead of a "one size fits all" small group health insurance plan, employees are given a budget to pay for a plan of their own choosing (or forgo a plan altogether). Call it a "health insurance gift card" that's good both on- and off-Exchange.

What's not to love, right?

So, I reached out to our gurus of all things Alphabet Soup (HSA, HRA, etc) for their take.

Turns out, they've been offering to help set these up for a while now, going so far as to sponsor Continuing Education classes for agents to help sell the concept to their small group clients. The response from agents was tremendous: a great deal of enthusiasm both for the free CE and the plans themselves. Which is fine, but far from the most important metric: what about their clients?

Their reaction, once learning about the caveats and limitations, has been a resounding /crickets.

But why is that? After all, it only takes a pretty simple (and inexpensive) set of documents to be up and running, and then each employee can go choose whatever plan best suits him or her (or, again, none at all).

Aye, there's the rub: yes, the setting one up part is pretty low-cost and straightforward, but the devil truly is in the details. For one thing, there are all kinds of non-discrimination rules (for example, one can't give managers more than those they manage), and you can't have any group-type plan at all (like dental or vision) in place. Even though these are what we call "non-medical," if they're group you're outta luck. And there are other speedbumps, as well. From our gurus:

"When we receive calls inquiring about the QSEHRA plans, we explain to the employer that it is like peeling back the layers of an onion to determine if they meet the requirements to offer the QSEHRA.  Below are the peels that we go through that usually become the challenges:

• They are a subsidiary of another company.

• Corporation Type:  Sole proprietors, partners within a partnership, owners of an LLC (filing as a S or partnership), owners of an LLP and more than 2% owners of an S Corporation are prohibited from participating in the plan and the rules of attribution apply to more than 2% S Owners, thus owner’s spouses, parents, children and grandparents cannot participate. – In the majority of the calls the corporation type is what puts a “STOP” in the peeling process.

• They offer some type of other group plan including dental and/or vision.  Even if it is voluntary it disqualifies them from being eligible to offer the QSEHRA.

• If they are considering offering the QSEHRA to include eligible out-of-pocket medical expenses, they are surprised and often not thrilled that they have to offer it to all employees (even those on spouses plan).

• Impact on the subsidies if an employees is receiving a subsidy of tax credit.  Many employers who contact us have employees with plans that do receive the subsidy of tax credit."

So what happens is that the initial enthusiasm gives way to reality, and thus very few (if, indeed, any) of these actually get implemented. Which is a shame, since the concept holds such promise.

Leave it to the DC Rocket Surgeons to mess up a (potentially) good thing.

Oh! One more thing: it seems that neither DPC fees nor Sharing Ministry "dues" are QSEHRA-eligible since they don't include Minimum Essential Coverage (MEC) requirements (list of acceptable individual plans here). Which is a bummer, since both are otherwise ACA-compliant (just like on- and off-Exchange plans are).

In a nutshell: Medicare-4-All

Truth bomb:

A good time to remember that if I created a health insurance product that exactly mirrored Medicare Parts A+B+D it would be illegal to sell on https://t.co/7PqS2kBKZf. Not rich enough to be called a Qualified Health Plan.https://t.co/RUif0knyAl

— Michael Bertaut (@MikeBertaut) July 26, 2018

That's *not* how this works

So this comes across my timeline:

Some life settlement companies have responded to universal life cost-of-insurance increases by suing the life insurers that issued the policies. https://t.co/kAwxq15hWA

— ThinkAdv Life/Health (@TA_LifeHealth) July 20, 2018

A little over 2 years ago we blogged on a similar suit against TransAmerica Life:

"Universal life insurance policyholders behind a multimillion-dollar class action are asking a Miami federal judge to stop Transamerica Life Insurance Co. from drastically raising their monthly charges."

In brief: Universal Life (UL) policies are made up of two components, the death benefit and the cash value. When one pays a premium, part of that premium goes into the cash value and part pays the Cost of Insurance. That cost of insurance is basically an annual renewable term policy, the cost of which increases each year as one ages. The policy contains language limiting the absolute maximum the carrier may charge, but I've never heard of one actually doing so. Generally, companies charge the "current" rate, which is based primarily on their own mortality experience (how many of their insureds passed away last year). If a company has a bad year, then it can choose to increase the internal cost of insurance.

In no case, however, can a specific policy or policyholder be singled out for such an increase (after all, that person is still on this side of the grass). Which is what the Life Settlement folks want us to believe is happening to them. Now, it's certainly conceivable (although unlikely) that carriers could track which policies have been sold off in this manner, but there is absolutely no mechanism for them to raise the internal rates for those plans, and those plans alone.

I call BS.

Let's be Franc about health care costs

Almost two years ago, we reported that Belgium's then-new regs permitting "assisted suicide" for minors was up and, er, running:

"The first child to be killed by “assisted suicide” since Belgium legalized the practice for minors has had his life snuffed out."

[ed: and how is it that minors are able to give consent for this "assistance?"]

But that was then, and this is now, right?

Oh:

Three Children Die After Belgium Approves Measure Allowing Doctors to Euthanize Childrenhttps://t.co/doTfuxpWjx

— Þe Political Hat with "Ralph" The Wonder Llama (@ThePoliticalHat) July 20, 2018

Yay for cost containment strategies?

Southwest Ohio Heads' Up

From our friends at Cornerstone:

"Ohio Department of Insurance Director Jillian Froment reported Monday about an insurance fraud scam involving individuals posing as representatives of Dayton-based Premier Health Plan"

Premier health has long since opted out of the health insurance market, but apparently not everyone's gotten the word. As a result, folks are forking over hard-earned dollars for, well, nothing:

"Ohioans need to know that Premier Heath Plan is not selling health insurance products in Ohio. The individuals behind the scam want to steal consumers’ bank account information and money, and have no intention of providing health insurance.”

Check out the link for valuable tips on how to avoid becoming another victim.

Hey buddy, can you spare a hip op?

Shot:

Pay £15,000 to jump the queue for a hip operation on the NHS https://t.co/tvdUNBb05a via @DailyMailUK pic.twitter.com/dRAJBNb7ut

— Sally Pipes (@sallypipes) July 22, 2018

Chaser:

"Patients are being allowed to jump growing NHS queues by paying up to £15,000 for a hip replacement."

Now I personally have no problem with this as a matter of practice. After all, Americans with million dollar homes get care at the Mayo Clinic, and those in Section 8 have the free clinic (yes, I am that cynical). The difference is that we don't pretend otherwise. A (nominally) free market-based system such as ours is going to have this result.

But in a government-run system like the Much Vaunted National Health Service©, everyone is supposed to be treated equally. So while it doesn't surprise me that folks who can afford better care get it, it beautifully illustrates the hypocrisy of that system's proponents (and, of course, those who agitate for it here).

Now there was one intriguing item in the linked article, which was quickly elided over, but which I think may hold some promise here:

"Many hospitals offer all-inclusive packages that work out significantly cheaper than charging separate fees for the operating theatre time, the consultant and occupying a hospital bed."

So-called "bundled billing" may well be a pipe dream, but seems to me to be a worthwhile goal.

What's up with West Coast Life?

Readers may recall this story from last summer:

"[T]he application was apparently written in Ohio, but the applicant chose to have the exam done in Texas. I'm thinking that right there's a red flag, but apparently WCL wasn't bothered by it (or perhaps, they became retrospectively concerned). In the event, a person claiming to be the applicant shows up, all 176 pounds of her."

Which would have been fine, except that the actual applicant clocked in at over 200% of that. And of course, come claim time, WCL finally thought it maybe oughta take a look into these ... unusual ... circumstances, and at that point determined that they'd been had.

Well, it turns out that the case actually happened right down the road from us, and thanks to FoIB Holly R, we have new news:

"Mason family who faked life insurance policies, bought Bentley convertible, pleads guilty"

On the one hand: Bentley. Kudos to the Stevenson's for enthusiastically embracing the concept of "go big or go home."

On the other hand: Every few years, I'm required to take an industry-approved anti-money-laundering course (which one of our field reps refers to, unironically, as "a how-to course"). We still don't know who actually wrote this case, although it's certainly not the accused  who, in an ironic twist that defies disbelief, "operated Lego Demolition out of the family’s home."

I bet.

On the gripping hand: how is it that a well-known and financially strong (AM Best rating A+ Superior) carrier can be so easily duped? There is no way that death benefit gets "EZ Issue" underwriting.

Methinks some West Coast Life heads will roll.

Oy, Canada - Part 7,285

Previously on Oy, Canada:

"Patients also experience significant waiting times for various diagnostic technologies."

And that's just to be seen and treated. But what happens next? Often, the provider prescribes a med (or meds) to help treat the issue.

That's the easy part:

I'm Canadian. I have universal healthcare. My oncologist prescribed Xeloda, an oral chemotherapy, to try to extend my life. In Ontario, oral chemotherapy isn't covered.

My insurance has been dragging their heels and just today declined coverage. #ThisDoesntSeemUniversal

— Katie Davidson (@LovlyKatieLumps) July 19, 2018

That's right: in at least one province CanuckCare© doesn't cover oral cancer treatment.

And if one follows the comments, one is reminded of this dirty little CanuckCare© secret:

"[P]rivate insurance is responsible for oral chemo (different from province to province"

That's right, our Neighbors to the North© recognize the devastating limitations of "free" health care, and have developed (and market) supplements, much like our own government-run health care system (Medicare).

The more you know....

The MVNHS© very strange fixation on Medical Tourism

Specifically, enforced medical tourism.

For example, just a week or so ago we learned of a teeneager with a heart condition that the Brits' "free" health care was unable to treat, thus forcing his parents to seek help from the much-maligned American health care system:

"'Teen 'not sick enough' for NHS heart transplant has urgent op in US'"

And, of course, the Much Vaunted National Health Service© is (in)famous for its gleeful slaughter of the most vulnerable:

"UK Supreme Court declines appeal from parents of ill toddler"

But sometimes, the bureauweenies lose, and the patient wins:

After U.K. Doctors Said His Heart Couldn’t Be Fixed, U.S. Saves Baby Oliver https://t.co/zM8camyCoy pic.twitter.com/JA64ZPpYpK

— The Daily Signal (@DailySignal) July 19, 2018

Turns out, little Baby Oliver was born with a rare heart problem that the "free" British health "care" system was unable to treat. So, of course, the compassionate and warm-hearted government-run service denied care doomed the baby to death. The parents, understandably, demurred, and successfully sought treatment in the United States.

Specifically, the Boston Children's Hospital, which, unlike its counterparts in the UK, boasts a 100% success rate.

Okay, that's not fair, allow me to clarify:

Boston's Children's Hospital, unlike the MVNHS©, boasts a 100% survival rate.,

Ah, that's better.

Check's in the mail

Well, it's that time of year again, when the temps soar, folks head to the beach and the pool, and insurance companies announce when they'll be cutting checks to comply with ObamaCare's Medical Loss Ration (MLR):

"Final Medical Loss Ratio (MLR) rebate reports for UnitedHealthcare customers will be available on the broker portal the week of Sept. 15, and customers will receive their rebate payments in the mail at the end of September."

In case you didn't know, the ACA requires carriers to pay out (at least) 80% of premiums collected in claims. For large groups, that requirement is 85%. Anything less and they have to send the difference to their insureds.

By the way, that MLR check's no bargain for insureds. As co-blogger Patrick pointed out a few years ago:

"MLR was designed to leverage insurance company profits and administrative expenses. Reality is all we have seen from MLR is an increase in profits and expenses."

True then, true now.

A million here, a million there...

Over the years, we've reported on a number of health insurance claims that hit (and/or exceeded) the magic $1 million mark. These have always been rare, partly because, even in today's inflated medical expense environment, it takes a lot of medical care to reach that summit:

"Olive-McCoy, 44, has hereditary angioedema (HAE), a life-threatening disease so rare that many doctors have only read about it ... the price of just one of Olive-McCoy’s drugs will be about $600,000 this year ... she has received hospital bills for more than $1 million"

But this is apparently changing:

"The number of million-dollar medical claims has nearly doubled, with cancer care remaining the most costly health condition"

Cancers of various types accounted for almost $800 million in health insurance reimbursements fro 2014 through last year. And the total number of million dollar patients nearly doubled: from 104 in 2014 to almost 200 in 2017.

What's also interesting  to me  is that cancer was the #1 culprit: I would have guessed that the opioid crisis would have been to blame, but that doesn't seem to even register on the radar. Granted, these are from a study of self-funded plans from one carrier, but still; it's not as if employees and their dependents are immune.

What wasn't a surprise is the low percentage of folks who experienced these claims:

"Patients with claims of more than $1 million represented only 2% of the total number of stop-loss claims from 2014 to 2017."

But that low number comprised almost one-fifth of the total dollars paid out.

So, 2% ate up 20%. Interesting.

La plus ca change

That was then (early 2016):

"So we have one woman who went from the AFL-CIO to AHIP to EmblemHealth.

But who replaced her?

Well, that would be the lovely and talented Marilyn Tavenner, who came to AHIP directly from her previous gig as Administrator of the Centers for Medicare and Medicaid Services, which is part of the bureaucracy tasked with implementing ObamaCare."

And this is now:

Burwell named board director at Florida Blues https://t.co/F47g3NrS9I

— LifeInsuranceLarry (@lifeinslarry) June 11, 2018

Seems like the womenfolk in the highest echelons of the health "care" industry do very well for themselves.

[Hat Tip: Life Insurance Larry]

Health Care Currying favor?

India faces an interesting challenge: how to provide health care to its most vulnerable (ie poorest) citizens. Currently, health care financing and delivery models are left up to the individual states (not necessarily a terrible idea, but that's for another post). The country's federal government has been tasked with rolling out private health insurance to some 500,000 of its citizens, which is proving - as one might imagine - quite a challenge:

"Almost five months after announcing the ambitious program, the government is still working to lock in hospitals and insurance companies in time for its planned August launch."

One challenge is infrastructure: "Although ... the IT infrastructure has been put in place, the involvement of hospitals — public and private — and insurance companies was still to be finalized." Sounds familiar.

The other problem is something we also face: how to provide care to an ever-expanding population with a shrinking supply of providers?

"It will not be possible for health care providers to respond to such a huge expansion of coverage without substantial investment in medical facilities and manpower,” said Owen O’Donnell, associate professor at the Rotterdam-based Erasmus School of Economics. “Without that, the extension of coverage risks being nominal rather than real.”

I bet. And again, similar to what we see here with, specifically, expansion of Medicaid "coverage" with narrower and narrower networks from which to obtain actual care. Wonder if our Indian friends will be more successful.

At least they're trying a privatized alternative, even as we plunge headlong toward single payer. What do they know that we don't?

[Hat Tip: FoIB Allison Bell]

Health Care Economics 1201

■ Case Study #1, The Much Vaunted National Health Service©:

Nurses quit NHS to work in Lidl because pay, hours and benefits better via @LondonEconomic https://t.co/1WbEc4BR91 pic.twitter.com/j80uwwAmCk

— Sally Pipes (@sallypipes) July 6, 2018

As we've previously noted, MVNHS© docs aren't doing much better:

"A "talented" junior doctor who had spoken about the pressures of working in an A&E department has been found dead at her home."

So, low pay, horrendous workload, "free" health care. What's not to love?

■ Case Study #2, Direct Primary Care Fees:

So who gets to decide the single price and unit measure? If I sell my services as a doctor to a patient who is happy with the price and service, why do you get to choose what I price my service at? #FreeMarket #DPC

— Jackson Hole DPC, Jonathan Figg MD (@JacksonHoleDPC) July 9, 2018

As regular readers know, we've been longtime fans of the DPC model, while acknowledging its (substantial) limitations. But this is something that's been under our radar, and bears consideration. That is, DPC practices are, by definition, independent, and free to set their own fee schedules and rates. But this also means that it's currently kind of a "wild west" in terms of defining what is - and is not - a true DPC office. For better or worse, there doesn't seem to be a nationally recognized "DPC Association" that offers some kind of consistency across various practices. Now, I kinda like that, but it also means major 'caveat emptor' warning should apply.

■ Case Study #3, Medicaid as Flawed Model

'Dozens of Studies Demonstrate Failure of Medicaid' via @RealClearHealth. Why do people want to expand Medicaid, again? https://t.co/oa2DNtPORa pic.twitter.com/XYcbqsvAJi

— Sally Pipes (@sallypipes) July 12, 2018

This one stands pretty much on its own, I'll add only that a better question might be "Why would people want Medicaid-For-All, again?"

Artwork Liability Update

Last month, we reported on the strange case of the child versus the glass sculpture:

"[T]he young lad, attending a wedding reception replete with expensive (and apparently fragile) art work, who (apparently accidentally) knocked over a priceless glass statue."

Well, maybe not "priceless:"

"A Kansas mother says an insurance company wants her family to pay $132,000"

Now, if you're wondering about how that seemingly-arbitrary value was assigned, well, it appears to have been the sales price of said sculpture [ed: notwithstanding that "asking price" isn't necessarily "what someone ultimately pays"]. In the event, there was some dispute about whether or not the child actually touched, let alone knocked over, the piece.

The good news is that this is now settled:

Surveillance video shows the child wrapping his arms around it and then struggling to hold it up as it fell https://t.co/ITQnKZKSat

— New York Post (@nypost) July 10, 2018

 

So, that's that, and we appreciate the tip from FoIB NARNfan who also asks (one presumes rhetorically) "How much would you get if you stole it and fenced it?"

The world may never know.

From the P&C Files: Heads' up, Campers!

[Hat Tip: SoIB Gail S]

New Claims Tech

If you're fortunate enough to (still) have a PPO-type health insurance plan (coverage for both in- and out-of-network expenses), then you probably know the frustration of actually filing those OON claims. What if there was a simple, inexpensive way to get them paid with little or no hassle?

Well, as you might have guessed, there's an app for that:

"Reimbursify’s smart dashboard manages your claims, helping you to make new claims, and keep track of pending reimbursements."

There's even a feature that helps if your claim is denied.

There's also a "Provider Pro" version for doc offices; this waives the $2 per-claim filing fee. And the folks behind the app promise to keep your personal health info as safe as possible.

The app itself is free, and available for both Apple and Android devices.

Oh, and it may be especially useful for folks who choose both insurance and Direct Primary Care (since DPC folks are by definition out-of-network).

Cool.

[Hat Tip: Vatsal G. Thakkar MD]

Hot Summer 'Review

Our good friend Peggy Salvatore hosts the July Health Wonk Review. As she notes, it's "short, sweet and HOT!"

Posts include Joe Paduda's take on high deductible plans, and Tom Lynch's on new Medicaid work rules in the Bluegrass State.

Check it out!

MVNHS© vs Medical Tourism

Heh:

I'm just surprised that the #NHS didn't forcibly tie the kid down and starve him and withhold water from him. https://t.co/u3bXTL6W0Q

— Þe Political Hat with "Ralph" The Wonder Llama (@ThePoliticalHat) July 11, 2018

On Risk Adjustment

The only permanent "R" of Obamacare's 3R's, Risk Adjustment, was implemented in 2014 with the impression that it would keep insurers from cherry picking the healthy risk versus the unhealthy risk. Using an actuarial formula insurers would predict health care costs based on a variety of factors.

In a nutshell, the program would take money from insurers who had lower risk members and provide funding to insurers who disproportionately attracted higher risk members. There were two goals: minimize adverse selection and stabilize premiums.

So what happened?

A handful of mainly small insurers got clobbered. The most heavily hit were Obamacare's newly created CO-OP's. Many of these start ups underfunded premiums to be competitive. They took in a large portion of good risk and had priced for it. But when Risk Adjustment (RA) was factored in they had to pay huge amounts of their premiums to other insurers who had higher risk scores.

Three CO-OPs - Minuteman, Evergreen, and New Mexico Health Connections, challenged parts of the formula laid out in HHS annual payment and parameter regulations. These lawsuits were filed in the summer of 2016 against the Obama Administration's HHS and CMS. One of the main points of contention was HHS's use of statewide average premiums instead of each plan's premiums when creating its risk adjustment formula. HHS adopted this based on the assumption that the program must be budget neutral.

Evergreen went in to receivership right after it was ordered to pay $24.2 million dollars into the RA fund in August of 2016. If they wouldn't have had to pay the RA funds they would have seen a profit of $2 million for the year. Minuteman saw their lawsuit upheld in early 2018 so no changes were required to the original HHS/CMS guidelines.

New Mexico however, received a somewhat positive outcome. In their case the judge ruled in favor of NMHC on payments being based on plans and not the state's average premium. All other claims in the suit were dismissed and lawsuit was completed at the end of February of 2018.

Which leads us to now. Without clarity the Trump Administration has temporarily suspended all payments and collections of RA until the lawsuit is resolved. Once it is resolved payments and collections will resume. Further, because the Trump Administration issued relevant guidance in the 2018 Notice of Benefit and Payment Parameters this shouldn't happen again in the future.

Trump is not "sabotaging" Obamacare. In fact this is something that could have been avoided and fixed by the prior administration. I'm not sure why they didn't fix it and I haven't seen anyone suggest or explain why Andy Slavitt and Sylvia Burwell lacked a game plan back then.

They could have issued interim rules to circumvent the problem. They could have adjusted the 2017 Notice of Benefit and Payment Parameters that were rushed through in late 2016 to mitigate the problem too.

But they didn't. So now - for at least the next news cycle - we will be stuck hearing about a small but substantial piece of the insurance payment system gone awry. Albeit those complaining are the ones who implemented it but didn't fix it.

Medicare Drug Plan Deductible - How Does It Work?

How do Medicare Part D prescription drug plans work? Why do some have a deductible? Am I required to pay the deductible up front before I can have a copay? Does the copay apply to all drugs? Isn’t a plan without a deductible less expensive?

In 2018 Georgia has 24 different prescription drug plans. Some #PartD plans have a deductible, others do not.

In many cases your drugs may have a lower #copay and lower annual out of pocket cost when you choose a plan with a #deductible. Premiums are usually less as well when compared to plans that do not have a deductible.

Roughly 6% of Medicare beneficiaries will ever enter the #donuthole. Many people can actively monitor their drug plan and avoid the donut hole completely.

Every #drugplan has a #formulary. The formulary let’s you know which drugs are covered by the plan, which are not.

The formulary also determines your copay.

Every Part D plan is approved by Medicare and each one is required to cover roughly 600 different drugs.

You have questions. We have answers.

Additional reading
https://www.medicare.gov/part-d/coverage/part-d-coverage.html

https://www.medicare.gov/Pubs/pdf/11136-Pharmacies-Formularies-Coverage-Rules.pdf

https://www.ncoa.org/wp-content/uploads/part-d-drug-coverage-rules.pdf

Words. Fail. Mandate. Lives.

While we've never been fans of the (Evil) Individual Mandate, we've recognized that it's limited in how draconian its enforcement is allowed to be. Worst case scenario, a big check to Uncle Sam (and even that's difficult to actually enforce).

But as terrible as the (Evil) ObamaCare Mandate is, it pales in comparison to the new iteration recently passed by the Rocket Surgeons in the District of Columbia:

"DC Passes Law Requiring People To Buy Health Insurance Or Have Their Property Seized"

So, "nice house you've got there, be a shame if something happened to it because you passed on buying health insurance."

Worse yet, it doesn't appear that there's a carve-out for Direct Primary Care or Health Care Sharing Ministries (as there is in the ACA).

Yikes, indeed.

Darned if you do...

We try not to get too political here at IB, so I want to be careful in how I characterize the subject of this post. First, one needs to know that the Cost Sharing Reduction (CSR) mechanism was designed to help offset the higher claims anticipated as a result of implementing ObamaCare. There's some dispute as to their legality (or, rather, how they were actually paid for). Regardless, carriers counted on them when determining rates, and for "cleaning up" their books at the end of a given plan year.

These funds have now been cut off by the folks in charge (ie President Trump's CMS). Now, whether or not this is a good idea is, of course, debatable. What's not at issue, it seems, is the effect this will have on premiums going forward. As FoIB Michael Bertaut has noted, carriers have been counting on these reimbursements (from the 2017 plan year) in their 2019 rate calculations. Absent these funds, rates are going to go even higher.

On the other hand, FoIB Jeanne Bodine calls them "insurance company bailouts."

Contrariwise, co-blogger Patrick says that they're not bailouts, but promises to carriers.

I think that there's room here for everyone, and that the most accurate description is "bribes."

So, you may ask, what's the difference between a "bailout" and a "bribe?"

Well, a bailout is something that occurs after an event, whereas a bribe is an inducement towards a given behavior or action. And there is zero doubt that insurance companies were big proponents of the idea of ACA (hey, the government's going to make people buy my product? Count me in!) but not so much fans of the promise of guaranteed issue and immediate coverage of pre-existing conditions. The CSR's were a bribe to get (and keep) carriers "on board;" if they go away, what then?

Well, it's not as if there's currently a plethora of carriers available, so look for even more market tightening.

And, since there aren't a lot of variables left for carriers to rein in costs, look for narrower networks and more restrictions on prescription drug coverage.

Oh, and the idea that this some kind of "sabotage" by the Trump administration?

Well, not so fast there. As Christopher Jacobs (CEO of a well-regarded policy consulting firm) notes, this actually lies at the feet of one Andrew Slavitt, also well-known but hardly someone to be admired. Mr Jacobs writes:

"The Trump administration took actions to comply with a federal court order that vacated rules promulgated by the Obama administration—including rules CMS issued when Slavitt ran the agency. If Slavitt wants to denounce the supposed “sabotage” of Obamacare, he need look no further than the nearest mirror."

In other words, Mr Trump was simply following the law.

Not that there's anything wrong with that.

ACA Tweet of the Day

Pitch perfect:

Disagree. Why can't savvy shoppers be allowed to manage their own level of risk? This is INSURANCE after all, not healthcare. We let them manage their own auto risk, homeowners risk, death risk. Why not healthcare risk? Afraid of market forces in healthcare? Hmmm..... https://t.co/gUizCBhmPv

— Michael Bertaut (@MikeBertaut) July 5, 2018

Perhaps doubly so, given the similarity between auto/home insurance and health insurance (or, rather, what health insurance used to be),

From the ACA Bargain Bin

At an acquisition cost of $200,000 per enrollee? https://t.co/f68fBEM0QC

— John Chamberlain (@misterchambo) July 4, 2018

This is a great point: imagine how much more efficient and effective health care financing and delivery could be if instead of throwing all this cash at a few, selected carriers offering "one size fits all" (or none) policies, folks could choose the plan they want (if any), including Direct Primary Care and other options like true catastrophic pans.

One wonders, though, what one would call this system?

I'd voucher for it, though!

Travel Medical Insurance: Why it's important

First, our heartfelt condolences to Stefanie Schaffer, a young woman who recently lost both legs in a tragic boating accident while on a cruise in the Bahamas when the boat she was on exploded.

To make matters worse, Ms Schaffer was an aspiring dancer.

And to pile on, she apparently had neglected (declined?) to purchase travel medical insurance. Assuming this was a week-long cruise, a $1million dollar plan with a $1,000 deductible from our friends at Global Underwriters would have set her back a measly $15.

A small price to pay in comparison to the $50,000 she's hoping to raise through GoFundMe.

A painful, and expensive, lesson learned.

More Nationalized Healthcare #Winning

First, from our Neighbors to the North (ie CanuckCare©). Our friend Holly R tips us to this interesting tidbit:

"Ontario’s government will no longer offer free prescriptions to kids and young adults with private coverage"

Wait, what??

Government-run health care is free in Canada, so what's this about "private coverage?" Well, regular IB readers already know that dirty little secret. As we pointed out 13 years ago:

"The Supreme Court on Thursday struck down a Quebec law banning private medical insurance"

In the event, Canadians savvy enough to buy their own coverage, and also forced to pay for the gummint-run one, can no longer benefit from the latter. Actually, this isn't all that different from ObamaPlans, where men are forced to pay for women's health care with no corresponding coverage for themselves.

Next up, Across the Pond to the Much Vaunted National Health System© where, thanks to Sally Pipes, we learn that:

"Tens of thousands of protesters [took] to the streets of London [yesterday] as they mark the 70th anniversary of the National Health Service by marching to Downing Street."

Wait, we've been constantly reminded about what a great deal the MVNHS© represents. How can this be?

Well:

"The march is part of a larger movement of pressure on the government for increased funding and staffing for the NHS, as well as a protest against privatisation."

Heh.

So again, if it's such a rousing success, why is it losing money hand-over-fist, and why do its advocates feel so threatened by alternatives?

(To be fair, one could ask the same of ObamaCare proponents here in the US)

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