More on CMS (Moron CMS?)

In case you were under any illusion that The DC Rocket Surgeons© have gained a single clue lo these past 6 years, well let's just disabuse ourselves of that notion.

Readers may recall that I did my annual Marketplace re-certification a few weeks ago, at which time I received a certificate (suitable for framing!) so attesting. You may imagine my surprise - my dismay - to then receive this in email this morning:

"Our records show you have not completed Marketplace registration and training for plan year 2019. To avoid losing your Marketplace access for Open Enrollment beginning on November 1, you must complete plan year 2019 registration by October 31."

What???

After a frantic phone call to the Exchange folks, including a 30+ minute time on hold, I was assured that this was an error on their part, and the nice man could only confirm that a blast-email with this misinformation was generated last evening.

Thankfully, I received this helpful update a few minutes ago:

"You may have recently received a message entitled “One Day Left Before You Lose Your Marketplace Access,” which stated that you had not completed Marketplace registration and training for plan year 2019. This message was sent in error." [emphasis in original]

One wonders, though, how many senior agents are still recovering from heart attacks caused by the message "sent in error."

ObamaCare Auto-Reminder

Heads' up, courtesy of the CMS in email this morning:

"If your clients do not update their Marketplace application and enroll in a plan November 1-December 15, they may be automatically enrolled in a 2019 plan."

If you're okay with that, then no need to take action. On the other hand, if you'd like to see what's "new and improved" out on the market [Spoiler Alert: pretty much zilch], then starting tomorrow you can get a quote for a new plan, preferably through the services of a local, professional, independent agent.

Oh, and if you don't, and you'd like to keep your plan as-is? Well, that may not be possible:

"Individuals currently enrolled in plans through issuers that will not be participating in the Marketplace for 2019. These consumers will be matched with an alternate plan from a different issuer."

Seems like there was some kind of explicit promise made, back in the day.

Oh, yeah.

Quite Novel Medical Tourism Idea

Wow:

A Utah insurer is offering plane tickets to San Diego, transportation to Tijuana, and a $500 cash payout to patients who need certain pricey drugs for multiple sclerosis, cancer, and autoimmune disorders. https://t.co/oAZtKWsYtX

— Rebecca Robbins (@RebeccaDRobbins) October 29, 2018

CanuckCare© FTW

Surprise!

This woman spent 47 hours waiting for surgery in the Sunnybrook ER, with shattered wrists, a broken elbow, cracked ribs and internal bleeding. An investigation into the overcrowding of Toronto ERs..https://t.co/by2dxBLjLO pic.twitter.com/5m0oyaDELC

— Dutch Rojas (@DutchRojas) October 28, 2018

Money quote:

"There was a curtain, but no switch to turn off the lights at night. That location would be Yerxa’s home for the next 19 hours—and her predicament would get worse from there."

But hey: Free!

It's Your Birthday

Medicare states with special rules.

Most states follow CMS guidelines about when one can enroll in a Medicare supplement (Medigap) plan and whether or not you can be medically underwritten.

But a few states follow their own rules.

[click to enlarge]

Birthday rules.

Anniversary rules.

Rule rules.

Here is a sampling of what you can expect.


In New York and Connecticut, Medigap plans are guaranteed issue year-round.

California and Oregon both have “birthday rules” that allow Medigap enrollees a 30 day window following their birthday each year when they can switch, without medical underwriting, to another Medigap plan with the same or lesser benefits.

In Maine, Medigap enrollees can switch to a different Medigap plan with the same or lesser benefits at any time during the year, and all carriers must designate one month each year when Medigap Plan A is available on a guaranteed issue basis to all enrollees.

Missouri has an Anniversary Guaranteed Issue Period; anyone with a Medigap plan has a 60-day window around their plan anniversary each year during which they can switch to the same plan from any other carrier, guaranteed issue. - Medicare Resources

While most states allow the current 10 standardized Medigap plans, if you live in MA, MN or WI you will be offered plans that differ from the standardized plans in other states.

And in case you are wondering, Obamacare prohibitions on underwriting pre-existing conditions does not apply to Medicare plans.

You have questions, we have answers.

How Original Medicare Works Video - No Networks

MyChoice: Part 2

Last Friday, we posted on a new product being rolled out by Blue Cross/Blue Shield of North Carolina (BX):

"MyChoice is a less expensive option for families and small businesses who may not be able to afford other, higher-priced ACA plans"

The product's "hook" is that, instead of paying negotiated rates (as in PPO and HMO models), the plan reimburses "up to" 140% of what Medicare would pay. So, for example, if the doctor charges $100, and Medicare would have paid $60, MyChoice would reimburse $84 (leaving $16 as a potential balance to be billed). Now it's possible, given the "up to" wording, that the carrier may, in fact, send a check for (substantially?) less than this.

But it gets even more interesting: I had at first taken this to be a plan for small employers, but BX is also offering it on the individual market for 2019. Note, though, that even though it's ACA-compliant, it's not going to be offered on the Exchange, and therefore it's not subsidy-eligible (which makes sense, given it's already bare-bones pricing). On the other hand, it does include ACA-required EHB's and no exclusions for pre-existing conditions. And, of course, no extra charge for folks with those conditions.

So Henry, you may ask, how can they offer ObamaPlans with premiums discounted by up to 30%?

Well therein lies a rather interesting tale: while pretty much all carriers are now moving to narrower networks and abandoning PPO-style plans, MyChoice eschews the network model altogether, and, in fact tosses out UCR (usual, customary and reasonable), as well. Instead, you go to any doc you choose, and the plan will pay up to that pre-arranged number. And this is the case with both the individual and group models.

Patrick and I have some questions about this, and have reached out to the carrier for clarification (which we'll share in a future post providing they reply). But in the meantime here's my takeaway:

On those individual plans, the anti-choicers went ballistic over the new, expended Short Term Medical plan rules; one can only imagine the paroxysms they'll have on these.

And what about employers: will they be able to explain the potential balance billing nightmares to their employees? The carrier provides at least a partial answer:

"Blue Cross NC encourages myChoice customers to talk with their provider before any appointment or procedure to make sure they will accept the benefit payments that are provided, or find providers who will."

Now again, this touches on the Holy Grail of transparency, but as I alluded to in the previous post, who shops for the cheapest brain surgeon?

Patrick was concerned about how prescriptions would be handled in these plans, and now we know:

"The plan has a contracted network of pharmacies with agreed-to prices. There is no balance billing if a member goes to an in-network pharmacy."

And they're also HSA-compliant, which may help mitigate some of the balance billing concerns (or no).

Patrick also noted that these plans aren't available state-wide:

"BCBSNC is only offering the product in counties where they couldn't leverage providers."

Which makes sense, in a macabre way. Again, this is ripe for balance billing.

Will be interesting to see how this fares.

Looking forward to reporting on BX's answers.

Something old, something new [UPDATED]

[Scroll down for Update]

So back in April, we blogged on a medical insurance reimbursement model called reference-based pricing:

"Briefly, this is where an employer enters directly into a contract with a hospital (or other health care provider, one supposes, including DPC) ... but can carry additional risks, as well, namely balance billing"

In that post, I really defined the concept way too narrowly, because it doesn't have to be contractual with the provider. Indeed, as FoB Jeff M alerts us, it can be in relationship with one's insurance company:

"MyChoice is a less expensive option for families and small businesses who may not be able to afford other, higher-priced ACA plans ... This isn't a reduced-coverage plan, however. The cost savings are achieved through reference-based pricing. The plan reimburses customers directly for medical procedures at rates that are up to 40 percent higher than what the doctor or hospital would receive for providing the exact same services to a patient on Medicare."

Which seems fair, and also touches the sacred Price Transparency button. The challenge, of course, is two-fold (at least):

As noted in our April post, this opens up the very real possibility of balance-billing; that is, it's not a network issue, so the provider is free to charge more than the reimbursement value. Which leads to the second, related issue: sure, this may be great for non-emergency services, but who's shopping for the cheapest ER when having chest pains?

And the balance billing issue on this could be huge. remember last month's post on the $100,000 heart attack? A key passage notes:

"His insurance did what it was supposed to do, it made a fair and reasonable offer for the care received."

Kinda like 140% of Medicare pricing?

And how did that work out?

"St. David's stuck to their guns and refused to budge."

So, is this the future?

UPDATE: Co-blogger Patrick explains how this will work in practice:

"Essentially the member gets reimbursed for the cost of the service at 140% of the Medicare rate, so if a doctor charges $100 the member pays $100. If Medicare contract says the provider gets $40 then BCBSNC will reimburse the member at $56 (140% of $40).

If that isn't enough reimbursement for the doctor then they can balance bill the difference [ed: as noted]. Think about how much of a nightmare this will be for members: Every code has a different charge and reimbursement. If you have ten codes from your ER visit then you could be balance billed for each line item. Aspirin at $8 Medicare pays $0.20. 140% of $0.20 is $0.28. Does the hospital balance bill the difference of $7.72 or do they eat it? How ticked is the member if they have to pay $7.72 for an aspirin?"

Indeed. Thanks, Patrick!

Careful What You Wish For Dept: VA edition

A bit of foreshadowing for all those folks out there clamoring for Medicare4All (aka socialized health "care"):

This is enraging. A veteran who had spinal fusion surgery was in great pain, oozing blood, and his leg went numb. But he needed Department of Veterans Affairs’ approval to call an ambulance. 😡 God bless Jimmy John’s. https://t.co/WYm5vgiBnE

— Allison Reynolds (@chim0m) October 24, 2018

(Great sammiches, BTW)

Interesting HSA Marketing

So this shows up on my Facebook feed:

[click to embiggen]

I reached out to the vendor to confirm that these are, in fact, legit HSA expenses, and was assured that they were:

"Yes, they are. All of them are available for HSA purchase."

But you know me, ever skeptical, so I also reached out to our Gurus of HSA, FlexBank, for confirmation, which they happily provided:

[click to embiggen]

Hunh.

So there you have it: a unique and potentially life-saving use for your HSA.

Cool.

Let's Talk Scope

We've talked before about the true number of folks who, prior to ObamaCare, were medically ineligible for individual health insurance, most recently here:

"ObamaCare has failed patients with pre-existing conditions ... Estimates suggest that less than one percent of all people covered by private insurance have medically uninsurable conditions that would make them ineligible for medically underwritten coverage."

But that was then, and this is now, and we have this helpful video:

About how many Americans faced barriers to health insurance coverage due to a pre-existing condition before the Affordable Care Act? Keep watching. You might be surprised by the answer. https://t.co/zK7dIl3f4B #healthcare #IWhc #PreExistingConditions pic.twitter.com/TCLOPOyxTw

— IWV (@IWV) October 22, 2018

(I couldn't find a version on YouTube)

[Hat Tip: @spongeworthy2]

Where can I find the BEST Georgia Medicare plan supplement rates?

Tuesday Link RoundUp

■ First up, from co-blogger Bob, we learn that the rocket surgeons in charge of 404Caregov have apparently learned nothing:

"[Last] week, CMS staff detected anomalous activity in the Federally Facilitated Exchanges, or FFE’s Direct Enrollment pathway for agents and brokers ... At this time, we believe that approximately 75,000 individuals’ files were accessed"

Quick, let's put them in charge of health care for all!

■ Short Term Disability plans are generally a very affordable way to help keep food on the table and a roof over one's head. And employers also often provide Family Leave benefits that include salary continuation. What happens, though, when these collide?

Well, FoIB Allison  Bell reports that new IRS regs may put the kibosh on those Short Term DI pans:

"The regulations could push many kinds of eligibility restrictions, including pre-existing condition exclusions, out of group short-term disability plans."

And what would that do? Well, as we've seen from the ObamaCare debacle, this will of course increase rates for these plans, perhaps rendering them unaffordable, especially for smaller employers.

Behold the Law of Unintended(?) Consequences.

■ And finally, thanks to FoIB Steve Downey, we get some helpful ObamaCare news:

"Trump administration makes it easier to avoid Obamacare tax penalty ... The new policy allows hardship exemptions to be claimed without "the documentary evidence or written explanation generally required."

What does this mean? Well, think "Epstein's Mom."

Making Strides Against Breast Cancer: Thank You!!

Thanks in large part to our readers, Saturday's Strides Against Breast Cancer was a huge success. Personally, yours truly ended up at the #6 spot on the Individual Leader Board, and my team (Love, Hope and Faith) was #4 out of over 450!

Altogether, our Walk raised almost $200,000 - Fantastic!

You can still donate to this very worthy cause.

Thank You!!!

Premium Financing: A Primer (From the P&C Files)

So the other day, I saw an interesting thread on Twitter about “Premium Financing.” It piqued my interest, and since we’ve never blogged on the subject, I asked the gentleman whose thread I was reading if he would mind explaining for our readers what it is and how it works.

Tim Randle is a Certified Financial Planner with 16 years’ experience in the financial services industry. He’s also an insurance agent, registered representative, and investment advisor representative, and lives in Alabama, with his wife, 2 kids, and 2 larger than expected dogs.

Take it away, Tim:

■ What is Premium Finance?

As a small business owner, I may suffer from being a bit of a control freak. Ever happen to you? With a financial planning firm that out of necessity grew its own insurance agency, we found using the available premium finance companies to be expensive and restrictive. How could we pick? Could we start our own? What were the rules on both?

To start, what is a Premium Finance Company (PFC)? At its root it’s a niche loan company that provides funding for businesses (and sometimes individuals) to purchase their larger commercial (business) insurance policies. If you’ve never purchased a commercial policy, you may be wondering “Why don’t they just select the monthly payment option like my auto insurance company offers?” Unfortunately, most commercial insurers don’t offer a periodic payment plan—and with premiums that can range from thousands of dollars to tens of thousands, it doesn’t always work well to put it on your credit card. On top of that, many companies don’t even take credit cards either…our recent investigation showed that it’s pretty typical for merchant services to cost 10 to 25 cents per transaction, plus up to about 2% of the amount charged. I guess they don’t mind paying the quarter, but the 2% of a $12,000 premium is painful! This is where premium finance companies (PFC) come in.

A PFC works by inserting themselves between the agent and the customer (insured). The customer typically pays 25% of the premium and all of the taxes and fees up front to the PFC. The PFC then pays any fees or taxes to whomever those monies are due, as well as paying the entire premium to the insurance company. The insured then pays back the PFC, typically in 8 payments starting the next month. If the customer doesn’t make their payment, the PFC has the right to contact the insurance company to cancel the policy. The PFC is hoping that the payments the customer has made plus the refund from the insurance company is enough to prevent a loss.

■ How to select a PFC:

As a customer, you want to take that one line that says ‘Fees, Taxes, Surcharges’ and see what’s buried there. Does the PFC charge a fee? Ok, that makes sense, I paid a mortgage origination fee…but is it a reasonable number? Does your agent charge a fee, and is it reasonable? What else is buried in there? If your agent waves his hand and says ‘taxes’ you should ask what the tax rate is and how it’s applied. Finally, there’s the service charge or the interest that the customer will be charged on the loan. Typically the larger the loan the lower the rate. High teens isn’t abnormal for low amounts, and I’ve seen as low as 8.5% on very large amounts. Some may be negotiable, some may not—a great piece of advice here is WORK EARLY. Some insurance companies give discounts for quoting policies several days before they go into effect. And if you decided you want to try a different agent or PFC, you may need a week or more to do it.

I hope that this helped you understand a little more about financing insurance premiums on the commercial side, and what impact the PFC is able to have on for both customers and agents.

Thanks, Tim!

Boo! October's spooky (and wonderful) Health Wonk Review

Catch it over at Joe Paduda's place. Lots of good info on Open Enrollment, mental health and Big Pharma.

From the Annals of the MVNHS©: Part 2,736

As UK NHS #SinglePayer crisis deepens, private care surges 53%. Latest NHS rationing move: making patients suffer uncontrolled intense pain for 6 months before getting hip surgery. #SinglePayerIsInhumane
https://t.co/AZGI06pKPZ

— Obamacare TruthSquad (@ObamacreTrthSqd) October 15, 2018

Price Transparency

Some people make a big deal about price transparency in health care.

Others don't.

It seems the US may be bending to the will of the people and will move towards some kind of drug transparency, price regulation, or both.

The federal government said Monday that it wants to force drugmakers to disclose prices for prescription medicines in their TV commercials.

The drug industry's main trade group said drug companies are only willing to disclose the prices on their websites, not in commercials, and they'll start doing that next spring. - KYW

Almost every time DC tries to "help" they make things worse.

Less competition.

Higher prices.

Fewer choices.

The most feared words in the English language, "I am from the government and I am here to help you".

Regarding drug price transparency, Medicare prescription drug pricing has full disclosure. Cost reports for the Part D coverage illustrate the full retail price as well as the copay.

Drugs on the formulary are priced to the consumer at a discount.

Those not on the formulary are not.

I have a client that uses Xarelto and refills in 90 day increments. The retail cost is listed at $1200 for 90 pills. The medication is on most plan formulary's.

For the first 2 refills she has a $0 copay. By the time she get's to her third refill she is entering the donut hole and will pay $130. Her last refill for the year is $380.

Yesterday she complained about having to "pay so much" later in the year and wanted a better plan. She completely ignored the fact she is getting $5,000 worth of medication for less than $500 per year.

Price transparency.

And yet, she still complains.

How to succeed at Obamacare Without, Well...

So I did my Marketplace re-certification this morning, enabling me to sell ObamaPlans in the upcoming Open Enrollment v6.0. I anticipate that comp will continue to be less than generous, but at least we have some choices this year. As part of the re-cert curriculum, I learned that CMS has a Circle of Champions" award package, which includes "a letter, badge, and access to a certificate" presumably suitable for framing. All for selling (IIRC) 20 or more plans during this Open Enrollment season.

But seems like someone may have found a short-cut. Thanks to co-blogger Bob V, we learn about this enterprising family:

"A father and son from California have pleaded guilty for their roles in a scheme that defrauded more than $27 million from Affordable Care Act programs in at least 12 states ...  the Whites fraudulently enrolled people in ACA plans in states where those people did not live."

They then signed these folks up for (expensive?) substance abuse programs and pocketed the reimbursement fees.

One wonders if they signed up enough folks to earn that sweet CMS swag.

2,000 Words

First, from FoIB Jeff M:

[click to embiggen]

Second, from Google:

Singer Quits, Medical Tourism Wins

Longtime entertainer and 4-time Grammy Award winner Michael Buble, whose hits include "Haven't Met You Yet" and "It's a Beautiful Day" has put his career on hold to care for his liver cancer-stricken son, Noah:

"Going through this with Noah, I didn’t question who I was, I just questioned everything else. Why are we here? 'Is this all there is? Because if this is all there is, there has to be something bigger."

A selfless act by a successful musician. Yasher koach, and may Noah experience a full recovery.

Which is all very noble, Henry, but what the heck does it have to do with insurance, let alone medical tourism?"

Well, as regular readers know, we have pointed out many times over the years that CanuckCare© may be free, but that doesn't mean it's terribly good. And how do we know this? Because folks with the resources to do so choose American health care when lives are at stake:

"Both he and Luisana put their careers on hold to be there for their son - they jetted to the US so Noah could undergo treatment for hepatoblastoma." [emphasis added]

Of course, with a $46 million a year income, he and his family can afford to do so. But what about average Joe Poutine?

Gives one pause, no?

[Hat Tip: FoIB Michael Bertaut]

Making Strides Against Breast Cancer: v2018

Once again, I'm raising money with my team: Love, Hope and Faith. Our walk is coming up so quickly - this coming Saturday, October 20th - and I'd really like to break the $1,800 mark.

Will you please help out by making a donation - Any amount helps.

Thank You!!

CanuckCare©/Medicare4All: A study

Shot:

My discussion with a friend who grew up in Canada, cautioning about single payer healthcare. There those who think Canda’s socialized healthcare works well, this will dissuade you. pic.twitter.com/qeKH5LIKoa

— Naomi Levin (@NaomiLevinNY) October 10, 2018

Chaser:

"On a Slippery Slope, Canadian Hospital Unveils Physician-Assisted Suicide Plan for ‘Sick Kids’"

Hat Tip: FoIB The Political Hat

If it's too good to be true....

There's an old retailer's trick where one marks up the merchandise 75% (or more!), then announces a 50% off sale. It's tried and true, and coming to an ObamaPlan for you. From our friend Holly R:

"Obamacare premiums are going down for first time"

Oh frabjous day!

That's right, standard-bearer Silver level plans are set to go down a bit when Open Enrollment v6.0 takes off next month.

By about 1.5%. Which is nice, but then comes the not-so-fine print:

"[T]he decline comes after a 37% spike for this year's benchmark silver plan."

Which means that average $6 per month savings pales in comparison to the $1,200+ increase they ate last year, and will continue to pay even now.

Such a deal!

Something new

So, we've discussed Direct Primary Care (DPC) for quite a while here at IB; some pro, some con. On balance, I think the idea has a lot of merit, and certainly potential.

But as Yoda says, "there is another:"

I've been reading a lot about Virtual Primary Care (VPC). Like DPC, it's usually a subscription-based model, offering direct access to a (presumably qualified) physician who can diagnose what ails ye, and even prescribe meds. One advantage to VPC is that, unlike your friendly neighborhood Direct Primary Care doc, it's available 24/7. Of course, you give up the inherent advantage of actual person-to-person direct access, but how often is that actually necessary?

The other appeal to VPC is its low price, often much lower than DPC (caveat: be mindful of "you get what you pay for"). It seems to me that these plans would work well with so-called "high-deductible plans" (scare quotes because true "cat plans" are illegal under ObamaCare), especially those with limited or no office visit co-pays.

We've arranged to offer one such plan to IB readers - the subscription fee is a modest $20 a month (regardless of whether it's just you, or a family). You can get all the gory details in the "Teledoc [NEW]" link in the side-bar.

The cost of compliance

First off, I realize that anecdote ≠ evidence, but this seems like a really simple, effective and meaningful way to describe the impact of full ACA-compliance on small group plans:

Both Employers A and B are insured with the same carrier, are about the same size and with similar plan designs, and boast a January 1 renewal date. Employer A's plan is Grandmothered (doesn't fully comply with all ObamaCare requirements), Employer B's is not.

Yesterday, I received both renewals.

Company A's premium actually decreased (by pennies, but still...). I haven't seen that for many, many years.

Company B's premium increased by about 17%. Now, I've seen worse, but it's not as if they can now just go out and raise their service rates by almost 20% to cover that difference. And that 17% is, basically, the cost of ACA compliance.

The more you know...

What happened?

How could this be?

Back to healthcare

While the country has been playing Whack-A-Judge, Kaiser Permanente released their 2018 Employer Health Benefits Survey.
https://t.co/I0gfWe1EWL

— Rich Weinstein (@phillyrich1) October 8, 2018

'Tis a poser.

Monday Round-Up

■ We noted last month that surprise medical bills, primarily from out-of-network providers, continue to be a plague and a menace. As a result, there's at least one legislative effort to curtail them, but will the cure be worse than the disease?

Our friends at Health Agents for America tipped us to this article that offers a clue:

"Legislation limiting a provider’s ability to negotiate prices could ultimately result in reduced access to care for consumers"

One step forward....

■ Short Term Medical plans continue to be a popular ObamaPlan alternative, offering lower premiums and greater flexibility. But so-called Blue States seem to have a problem with choice. Our friends at Inside Health Policy pointed out this handy info:

"A federal judge in DC on Tuesday (Oct. 2) scheduled a hearing for Oct. 26 on stakeholders' motion to immediately suspend the administration's short-term health plan rule."

Will be interesting to see the outcome.

■ Regular readers know about the zeroing-out of the (Evil) Mandate/Tax for the 2019 plan year (assuming there's no drastic change due to next month's mid-term's). But what most of us likely didn't know was just what burden that tax levied on those least able to afford it:

“The silver lining of the zeroing out of the individual mandate in the Tax Cuts and Jobs Act, though, is that a $43 billion tax -- essentially a poverty tax -- has been thrown into the dustbin of history.” https://t.co/uGiDJTIxFT

— Kris Held,MD (@kksheld) October 4, 2018

■ Finally, a bonus. Via email from the folks at All Health PR:

"Sperm Counts Drop Across U.S. - Except New York"

According to new research, the sperm counts of male residents of six major US cities went down over the past ten years, except for those in New York City.

Yeah, I don't believe that, either.

Pot, Kettle, LifeLock©

So this happened:

[click to embiggen]

This in email from a Mr Ed Sutton at Symantec. His proposed solution?

"If employees are not enrolled in LifeLock, this is a good reminder for them to do so now."

Really, Ed?

Here was my reply:

"Hunh.

That the same LifeLock that exposed millions of its own customers' data?

That LifeLock?

What. A. Joke."

Odds on him responding?

Yeah, no.

An Unspoken ObamaCare Shanda: Bye, Bye PPO

As we mentioned a few weeks ago, Anthem is diving back into the individual major medical market for Open Enrollment '19; although there's no official word yet on product details, it's a safe bet that they'll be using the ubiquitous (and problematic) HMO model. And we've just recently learned that Medical Mutual is also re-joining the Ohio market, and they've confirmed that theirs is, indeed, an HMO product.

So what's the big deal, Henry? Shouldn't you be grateful that (at least) two more options will exist for your fellow Buckeyes? And isn't this incentive enough to dive back in yourself?

If only it were that simple. Yes, I suppose it's gratifying to see carriers dipping their toes back into the individual medical pool. But it's disheartening - if completely understandable - that all of the choices available for the upcoming season are HMO's, with zero PPO options even available.

Ok, but you still haven't answered the question: So. What?

Back in the day, the PPO (Preferred Provider Organization) was dominant: under this model, one got the "biggest bang for the buck" by accessing care in-network, but there was always this safety net, or out-of-pocket cap, on non-network services. Sure, it stung a little more, but at least one wasn't footing the entire bill.

Under the HMO model, there is essentially zero coverage for non-life-threatening situations outside of the (now even narrower) network. This means that unless one is basically bleeding out on the front steps of the out-of-network facility, there's likely to be no coverage.

This is a major issue for folks with significant and/or chronic health issues: what if your oncologist isn't in your plan's network? Yeah, a problem. And it's a direct result of ObamaCare rules which leave carriers with few options to rein in costs. Of course I'm not holding them entirely blameless, but this is really the only rational choice.

Sigh.

Phrasing: An LTCi story

Recently, I had an interesting Twitter conversation about Long Term Care insurance. It all started when our friend Allison Bell tweeted:

"While a lot of insurers are hiding from stand-alone long-term care insurance... National Guardian Life is out there getting its product Partnership program approvals."

[ed: Partnership-compliant plans have special powers]

I replied:

"Good for them! Challenge: They still use Service Days for Elimination Period."

And that's when things got interesting.

A Twitter friend responded "Educate us please... What is that, and why bad?"

So I explained:

"Long Term Care insurance (LTCi) plans have a "deductible" in the form of waiting periods until benefits begin. Some (most?) are based on *calendar* days; that is, I've been eligible for benefits for 90 days now, go ahead and send those checks.

NGL, though, uses service days; that is "I've been eligible for benefits for 90 days, but have only had care for 60 of those, so I still have 30 more days receiving care before I'm eligible.

It's not good/bad, just different, but I much prefer calendar to service. Often get benefits much quicker."

Our friend Scott Olson (a recognized LTCi guru) chimed in:

"My relative had a home health aide come to the house everyday for 90 days... just a short visit of a few hours. That satisfied the service day elimination period in only 90 calendar days and it didn't cost much."

I replied that I had nothing against service day plans, but that I preferred calendar-based ones. I then pointed out that home health care is not free; around here, it runs about $20 an hour. Based on a 90 day elimination period (by far the most popular option), that would cost about $3,600 just to access the claims process.

Scott agreed, but suggested that this could be offset by lower premiums on service day plans. My experience has been that this is rare (I've actually never seen it happen 'in real life.'). Still, worth considering.

Tuesday Linkage

■ Hey Ohio Gov John "The Mailman's Son" Kasich:

"There is evidence from Arizona that expanding Medicaid increased the prices of services to both privately insured and uninsured patients, and strained the medical system, especially in rural areas," https://t.co/lB68dTccA7

— AssocAmerPhys&Surg (@AAPSonline) October 1, 2018

Ooops.

■ Britain's Much Vaunted National Health System© still hates young people:

"A Teesside school choir has created a hit record - to raise much-needed funds for an Eaglescliffe teenager."

Recently graduated Evie Whittaker has been fighting an uphill battle against cancer, complicated by a stroke. She's still unable to sit up, and has been told by the caring, compassionate government bureauweenies who run the MVNHS© that she's no longer eligible for that awesome free health "care." As a result, her friends and family are trying to raise money to get her to Germany for treatment.

Consider the irony of that.

[Hat Tip: @flintbedrock]

■ Finally, our friend Shari G tips us to a summary of who's really to blame for the train-wreck that is Obamacare, and this singularly explosive (not to mention dead-on accurate) assessment:

"The individual market comprises just 7% of the total insurance market. And of those, only a much smaller fraction had ever been denied coverage due to pre-existing conditions before ObamaCare"

Baby, bathwater: Indeed.

More from The Standard

The innovative folks at The Standard strike again. Readers may recall our post last month about the carrier's Family Care Benefit:

"[H]elp your client take time for caregiving. This benefit provides cash to replace lost income due to working fewer hours and earning less income to care of a family member."

I could see that as a sort of Long Term Care insurance supplement, as well.

Anyway, they have a new bennie available that seems like it could be very helpful for folks with college debt. Via email this morning:

"With the Student Loan Rider, if you become totally disabled ... we'll reimburse all or a a portion of your student loan payments so you don't fall behind."

I could see this as particularly helpful for attorneys and physicians, who can rack up big student loan bills and take a while to start earning enough to begin chipping away at the debt.

Very cool!

[Hat Tip: Diversified Brokerage]