Time's running out: HRA edition

Our friends at FlexBank (now Flexbank/Navia) have a timely reminder for employers with Health Reimbursement Accounts (HRA's):

"Don't forget! The HRA PCORI fee is due by July 31, 2020"

As in: tomorrow.

This year's fee is about two-and-a-half bucks per participant, and it's due no later than tomorrow (July 31).

Oh, and just what is this fee?

"[T]he Patient-Centered Outcomes Research Institute, which "funds studies that can help patients and those who care for them make better-informed healthcare choices."

Okay, thanks for clearing that up.

Timing & LTCi

A few years back, I ran into a colleague at the grocery. She had recently been licensed to sell Long Term Care insurance, and wanted to "talk shop."

Okay, I’m all ears.

Turns out, she had been trained (??) to advise her clients to put off filing a claim for as long as possible, on the theory that using their own funds would allow the insurance dollars to last longer.

I nodded and said "well, that’s interesting," and we went our separate ways.

It was not, in fact, "interesting,” it was stupid.

Whoa there, Henry them's sharp words. Care to 'splain’ yourself?

Sure.

Last Fall, my mother-in-law was in a pretty nasty car wreck, and ended up in a very nice  Assisted Living facility. She had long ago bought a Long Term Care insurance policy through an affiliate program that her husband's employer offered. Since she had multiple physical issues as a result of the accident, she qualified for benefits under the policy, and they began rolling in a few months later.

Unfortunately, she passed away recently, which is what prompted this post.

The most important aspect of the claims issue is that we don't know how long that person will live, and had we listened to my colleague's advice, we may well have left significant "money on the table." Here's why:

She needed help with activities of daily living, and part of the claims process is an evaluation by a company representative (usually a nurse or service that they contract with) to make that assessment. If we had waited, there would have been no way for that evaluation to have taken place, and the claims process would have been very messy (or just straight-out declined). There was absolutely no upside to waiting, but significant potential (more likely, probable) downside.

Alternatively, had she been cleared for claims up-front and we had simply waited before filing the claim (which is another way to have interpreted my colleague's idea), we would not have been reimbursed until later. Yes, we would likely have still received the funds (this was a reimbursement-type plan) but why would we have given up the interest (this was a fairly decent amount)? After all, money is fungible, and using the carrier's funds instead of Mom's meant her money was able to keep earning interest.

Take heed.

COVID & BI: One more time...

We last discussed this issue a couple months ago:

"It's going to perhaps send a false sense of hope and promise to a community of folks who need action and relief now."

That was in response to a threat by DC Council-critters to force carriers to pay Business Overhead (BI) claims for quarantined businesses. Regular readers know that this coverage does not extend in that circumstance.

Fast forward a bit, and we get this in email:

"The ruling reaffirms that BI policies only cover physical damage."

That is, the closing of a business due solely to government mandate, with no actual physical loss, is not a covered BI expense.

This is important because it's one more nail in the proverbial BI/COVID coffin.

Click on through for the gory details.

Kind of Off-Topic, but...

This is pretty amazing:

"2nd baby is born from dead donor's transplanted womb at Cleveland Clinic"

Most of us are familiar with posthumous organ donation (heck, there's even a checkbox on drivers' licenses), but I daresay that likely includes corneas and kidneys, hearts and lungs, that kind of thing. I've even heard of harvesting sperm from a dying father.

But this one is new to me. And it gets even more interesting:

"It's the second child in the hospital system to be born from a dead donor's transplanted womb." [emphasis added]

Wow - And Mazel tov to Mom!

[Hat Tip: Holly R]

From the folks in DC

Comes this helpful video on how to report federal pandemic unemployment compensation. Although it's geared for agents, seems perfectly suitable (and informative) for consumers, as well:



In case you're debating whether or not to watch, the video covers how folks can:

• Update their income information due to unemployment
• Add in unemployment benefits to their income
• Determine what types of unemployment benefits should be counted as income
• Accurately estimate their yearly income

And heck, it's less than 6 minutes long.

The Kickstarter clock is ticking...

Just a few more days left for our friends at Fat Dragon Games' latest project.

For RPG fans and 3D printing aficionados.

Our good friends at Fat Dragon Games have launched their latest KickStarter, and it's a doozy:

"VALLIS MORTIS, the valley of the dead, is the campaign world created by Fat Dragon Games founder Tom Tullis over 35 years ago. Starting with this Kickstarter, and continuing with future campaigns, locations in this setting will be brought to life as richly detailed 3D printable models, and an accompanying campaign setting pdf will feature information on each location as it is released."

There are some incredible stretch rewards, lighted terrain options, and even detailed miniatures that rival the most intricate store-bought models.

And the world of 3D printing keeps getting more and more affordable, with decent printers starting at about $220.

So what are you waiting for?

This is Weird: Revisited

The other day, Hank posted on the difficulty he was having reconciling why a given person's group health insurance rate changed depending on whether they were the employee or the employee's spouse. That post, and some back-and-forth in the comments, sparked my curiosity. 

Hank said

"up until about age 40, the male spouse rate is actually lower than the male employee rate. And at age 35,female employees are actually more expensive than their(presumably) stay-at-home counterparts."

So I graphed the data based on the original post.

1.  Male employee vs male spouse
2.  Female employee vs female spouse

Graph #1 addresses the first reference above (click to enlarge):

The premium rates differ in specific amounts, but the differences are not material below age 50.  After age 50 the spouse rate rises above the employee rate.  This insurance company apparently has data that support the higher cost for older male spouses vs older male employees.  I’m guessing that older male spouses tend to have more health conditions that prevent them from working.  That would show up in the experience of the pool, and its effect would likely grow as the individuals age.

Graph #2 addresses the second reference:

The main difference in this graph vs. Graph #1, is seen in ages under 35.  My guess is that the female spouse rate is higher than the female employee rate through these younger ages because of marginally higher maternity liability.  That difference then closes rapidly.   After age 54 the female spouse again appears to be more costly.  Again, I don't dispute that the insurer’s cost data support the differences.  After taking maternity into account, the result observed in Graph #2 is consistent with the result observed in Graph #1.   It may well have the same origin i.e., that older female spouses tend to have more health conditions than older female employees, that prevent them from working.

Another possibility is that this insurance company’s pool includes marginally more male spouses who are employed (under age 50, anyway), and therefore represent a lesser liability to the female employee's plan because of COB (Coordination of Benefits).

Whatever, and aside from the actual dollars-and-cents differences in rates, the shapes of the lines on the graphs seem to me consistent.

I think the actuarial correspondent is correct about the beneficial effect of selection for employees vs spouses.  It’s visible in the premium rate relativities in all the other premium rate graphs I created.   I'm surprised he did not mention (or maybe he did?) the cost of maternity for younger females, regardless whether working or not.  That’s visible in the graphs, too.

In each of the questions you’ve raised, I’m not claiming I have a full explanation.  While I think my guesses may be a good part of the explanation, we’re still left with questions.

"We started with one question, and ended up with many questions."  One of my profs in college (philosophy, not mathematics) often made that remark at the end of his lectures - and then always concluded by saying "What a marvelous bargain!"    I still think that insight was worth the whole semester's tuition.  At least for his class.  (In 1965, the undergraduate tuition at my school for a 3-hour class was only about $150).

Which means - - this exercise was a bargain!

A Win for Private Medical Practices

The news for privately held medical practices of late has been bad. Revenue cuts from insurance companies, continuing competition from Hospital Based Groups, the continued selling of practices to Hospitals or simply closing business due to lack of funds.

Friday July 17, Private Practices were given a win by a federal appeals court:

“A federal appeals court ruled the federal government has the authority to cut Medicare payments to off-campus clinics to bring them in line with independent physician practices, reversing a lower court’s decision.
 

The goal of the rule is to reduce a disparity in Medicare payments where hospital-affiliated clinics get paid more than physician offices for the same services. Some critics have said the gap has helped fuel a race towards hospital-physician consolidation.”

So dear readers, this does sound confusing. If you are a provider practicing in the same locality, doing the same work, and billing the same CPT codes to Medicare, why are Hospital-owned providers paid more than non-hospital (private) providers? The answer lies in the place of service:

When a provider bills for your appointment, there are several key pieces of information sent to your insurance carrier so that they'll know both what happened and how to pay. One of those pieces of information is the 'place of service' code. This code lets the insurance carrier know if the facility is an office, a hospital, an ASC (Ambulatory Service Center), or a myriad of other facilities where medical care is rendered. Depending on the place of service, the payment for the same procedure can be more than the standard payment. Hospitals are one facility where the payment is higher.

This affected private practice owners because hospital-owned providers, who worked in a hospital or in a Medical Building next to the hospital, billed the facility code as a hospital instead of as an office. Thus, hospital-owned providers would receive higher compensation for an office visit than would a private practice provider.

So in the end, is this a turnaround for private practices or a little too little, a little too late?

Math is hard

Especially in these difficult times. On the plus side, I recently received this news in email from the Feds:

"Helping consumers calculate their income can be challenging, especially for those who are self-employed or have income that is difficult to predict. The Centers for Medicare & Medicaid Services (CMS) has released a new tool to make this process easier!

The new income calculation tool allows consumers to add previous income, unemployment benefits (including federal pandemic unemployment compensation), and expected future income to calculate their income."

They've even supplied a helpful video:



Feeling frisky? Well then, click here to test drive the new tool itself.

So this is weird

Working on a new group quote, finally noticed something I suppose I've know all along, but just never 'paid any attention to.

Take a look:

[click to embiggen]

It's never really "clicked" for me until the other day that at any given age, the rates are different for employees versus spouses. That is, a male employee's rate is always different than that same age male spouse, and same for females.

Why?

After all, that person is the same risk regardless of whether he or she is the employee or the spouse. Or is he (or she)?

So I reached out to FoIB (and actuary) Gregg Fann for his insights, and he replied that it likely has to do with the "actively at work" clause in group plans. That is, dependents (spouses) aren't necessarily that healthy.

And I can see that, but it still doesn't wash, because, well, up until about age 40, the male spouse rate is actually lower than the male employee rate. And at age 35, female employees are actually more expensive than their m(presumably) stay-at-home counterparts.

I realize that in the grand scheme of things this is really not a huge deal, but it's been bugging me for a few days now: why the difference?

Any thoughts on this?

Another great idea

This reminds me somewhat of the Sesamecare site which "takes the reduced-fee, cash only model and expands it to include primary care and dental visits, eye exams and MRIs, and other services." So there's precedence:

"I’m building a network of cash friendly medical providers in the DC Metro area."

This is from FoIB Sheron Sidbury, an agent in Virginia, who's expanding her menu of client services in a very meaningful way. She's taken a clue from our friends in the DPC and cash-provider worlds, and then gone a step further:

"[M]y goal is to help people in our local area find cash pay and other non-insurance methods to take care of their healthcare needs."

I love this.

Why?

Well, as we've noted ad nauseum, coverage ≠ care, and with today's emphasis on both higher deductibles and health care pricing transparency, this seems like a wonderful opportunity to help her clients. This effort is still in the embryonic stages, but I expect that it will grow quickly as more and more providers learn about it and hop aboard. Hopefully, this can continue to expand to other markets, as well.

So, fingers crossed hopefully.

Rx for Shanda

Shanda being Yiddish for scandal. And boy, this one appears to be a doozy:

Express Scripts "egregiously charged for services it didn't deliver," that has cost Ohioans millions. " We want our money back," says @OhioAG Dave Yost. https://t.co/AYFF0UnCQn via @healthcaredive

— AssocAmerPhys&Surg (@AAPSonline) July 15, 2020

At the linked story we learn that the vendor (allegedly) overcharged The Buckeye State's Highway Patrol Retirement System. Looks like they're going to be getting quite the ticket.

Express Scripts is a Pharmacy Benefits Manager (PBM); we've written about these before:

"PBM's are (allegedly) a cost-efficient way for carriers to offload the administrative functions of filling prescriptions."

But wait, there's more:

"While the concept seems innocuous enough, it's apparently become a major source of tension in the health care community, and is frequently cited as a major driver of increasing health care costs."

Oh.

Timing is Everything (Still!)

Working on an interesting case, and thought readers would be, um, interested:

Sally called yesterday about individual medical insurance. Her husband had retired and is on Medicare, she still has a couple years to go until she's 65. In the meantime, her COBRA plan is due to run out in November, and she's trying to figure out her options.

There are a bunch of issues here, and we discussed them at length (she's my favorite kind of client, interested and engaged, asking really good, helpful questions). I'll cover just a few of them in this post.

First is timing: if she rides out her COBRA until November she's going to end up squarely in "regular" Open Enrollment Season at the very same time that she's eligible for her own Special Enrollment opportunity. Which means she'll be shopping for a 2-month-long 2020 ACA plan (if she goes that route) and a 2021 version. Which also means that she's going to have 3 annual deductibles in about 60 days (2020 COBRA, 2020 ACA, and 2021 ACA). Not a great place to be, but as I explained to her, pretty common when we're looking at plans this late in the year.

It turns out that she's met very little of her 2020 COBRA deductible, so she might be better served cancelling that sooner rather than later; that way, any expenses that crop up would go towards the 2020 ACA (or other) plan. On the other hand, her COBRA plan is pretty decent, and is a PPO, unlike current ACA plans that are built on the HMO model with pretty much in-network coverage only.

Another option we're exploring is a Short Term Medical plan, which offers better coverage and lower rates than ACA plans, but are underwritten and don't cover pre-existing conditions. That latter isn't really a problem, she's in good health now, but some years ago she had a cancer scare, and we're looking to see if that's going to rule out the STM option.

This is the kind of case I most enjoy: challenging issues, an attentive, engaged client, and the opportunity to look at some outside-the-bun options.

Grateful!

Fighting For the Children

It seems the L.A. Teachers Union has issued a manifesto to create safe schools . . . for the children.

The UTLA has decreed that Los Angeles Unified District schools effectively cannot reopen unless certain conditions are met.

And those conditions are?

• Charter schools should be closed
• Medicare-For-All ("free health care) is to be legislated
• Tax the rich with a state "wealth" tax
• Fund housing for the homeless
• "Financial support" for illegal aliens

Perhaps I missed it, but how does this benefit the children?

And here is an interesting tidbit.

Many private schools and charter schools didn’t miss a beat when Gov. Gavin Newsom ordered schools across the state to close down due to coronavirus. Within one week, most were already up and running with online learning programs, while public schools took as long as 6 weeks to even start to prepare online learning. And private and charter schools have been preparing to reopen for in-class teaching once again.

So how does CLOSING private and charter schools BENEFIT students?

All this begs the question.

Is Marxism taught in L.A. public schools?

Asking for a friend . . .

CV-19 Claims Another

If you've ever bought a life insurance policy, you've probably (although not necessarily) had what we in the biz call a paramed exam. These usually consist of a nurse (or NP, etc) who takes your pulse, height, weight and samples of various bodily fluids, and then transmits these to the carrier. It's not really a big deal, but on any given day thousands (hundreds of thousands?) of folks undergo this process.

One of the more successful such vendors is - was - EMSI. I say 'was' because, well:

"COVID-19 has disrupted families, communities and businesses ... As a result, all company operations ceased on Friday July 3, 2020."

Yikes.

So what does this mean to the average person? Well, unless you were an employee or recently applied for life insurance, not much. If the latter, then expect to see underwriting delays while the carriers sort this out. I understand that at least one major company expects this to add at least two more weeks to the underwriting process.

Co-blogger Bob wonders if this may lead to more carriers adopting some kind of simplified issue process,and I think that may be correct: one of our carriers recently (well, within the past couple of years) introduced a product, in conjunction with its sister P&C company, to offer auto/home clients plans which require no application, exams or even paperwork. Pretty cool. So, it can be done, will be interesting to see if it will be.

[Hat Tip: Co-blogger Bob V and FoIB Brian D]

Dodged a Bullet: A Close Call Non-Client Story

So got a call from Sam, inquiring about possible health insurance options.

Sam has a policy he bought from a company that doesn't, in fact, sell insurance, but is some kind of pre-paid, limited benefit type plan with a $2,000 deductible and $30 co-pays and costs about $300 a month (keep in mind that Sam's in his mid-50's and in good health). Problem is, no one accepts this insurance, and he's not satisfied.

That's typical of these types of plans, which sound really great, until you have to actually use them. But, lesson learned (maybe), one supposes, and I'm happy to offer an alternative.

Since we're out of Open Enrollment season, and he didn't appear to qualify for a Special Open Enrollment exemption, I turned to Short Term Medical plan options. One of my primary STM vendors recently got rid of their (obnoxious, but apparently industry-standard) application fee, and offers a $2 million lifetime maximum on their plan (unlike pretty much everyone else's $1 million max). I found several alternatives priced competitively with his (actual junk) plan, albeit with slightly higher deductibles.

I had also asked him if he was, perhaps, self-employed, and when he told me that he was, I began researching whether he might be eligible for one of those new-fangled Chamber Plans.

So, I called him back with my good news.

And, surprise, he told me that since my STM offerings weren't going to save him any premium dollars, his current deductible was so much lower, he wasn't interested. Okay, but...

And he further informed me that, after speaking with a local hospital admin, and his current carrier, he'd been assured that if he was hospitalized the facility would have to treat him and the insurance would have to cover that.

Of course, that's NOT how EMTALA works.

So he's told me at least one lie, and who knows how many others, and all I can see is "Red Flag Ahead." I immediately cut the conversation short, and thank him for the opportunity to have at least tried to help him. He replied that he understood but was only rejecting the Short Term plan ... No thank you, and best of luck!

(Whew!)

 This was definitely not the type of customer (let alone client) that I'd want to take on.

Revisiting the MVNHS©

It's been a while since we last looked in on Britain's Much Vaunted National Health Service©:

"A doctor said pressures at a Bangor hospital in January left staff in a "very deep hole"

But that was then, and this is, well:

"NHS must apologise for dismissing pelvic mesh and anti-epilepsy drug patients' suffering."

How's that?

When we as patients raise concern about our treatment with those providing it, it's only right that they at least consider what we're telling them. But apparently that's not how it works in one of the world's pre-eminent government-run health "care" systems:

"Since the review launched in 2018, more than 700 families from across the UK have given "harrowing details of their damaged lives ... fought for decades to "achieve acknowledgement" of their suffering."

Turns out, they've actually lost count of how many.

But hey: Free.

#Medicaid4All

[Hat Tip: Holly R]

Who Was That (Un)Masked Man?

An un-named insurance agent has been fired after a COVID-related confrontation at Costco. A video of the dust up surfaced on social media and the termination followed shortly thereafter.

 In the video post on Twitter, the man screams an expletive-ridden tirade telling the woman and a man who appears to be defending her to back up and stop harassing him and his family after he was asked to put on a mask and stay 6 feet away.

"You're harassing me?" the man says as he clenches his fists, to which the other man replies, "I'm not harassing you, you're coming close to me."

The man continues to approach the pair, yelling, "I feel threatened, I feel threatened! Back up! Threaten me again! Back the f--- up, put your f---ing phone down." - Yahoo News

Some folks just aren't meant to be in the insurance business.

No word on whether Costco revoked his membership

#COVID19Mask #Costco

Double dipping and CV-19

It's not just George Costanza:

$42,000 bill from a “not for profit” Hospital for a Covid patient placed on a vent. (recovered and back to work) I inform them I know they’re getting $39K from the fed gov’t and the self-funded health plan won’t be participating in their double dipping. 💰🏨

— Rachel Means 🇺🇸✌🏼🇺🇸 (@rachel_means) July 7, 2020

Nicely done!

Now, how to get the word out to even *more* folks?

Felonious Consumer Tricks

Or, more precisely, murderous consumer tricks:

"Florida woman had hitman kill stepfather to collect on life insurance"

Which is actually kind of refreshing after the ubiquitous "Florida Man" memes of late.

Still, beyond the actual tragedy lies a fascinating, if horrifying, detail:

"Stepdad was killed two weeks after the insurance policy was changed from $25[thousand] to $750[thousand]." [emphasis added]

There's a lot to unpack here, starting with the obvious question of how,exactly, one might go about increasing one's life insurance (let alone someone else's)  by 30-fold without some kind of underwriting?

But of course, the MSM can't be bothered to report that little piece of info; too much trouble, one supposes. So I reached out to three reporters who covered the story, and Eli Witek of The West Volusia Beacon was kind enough to share the charging document with me (Thanks, Eli!). It's a bit confusing, but it appears that the the policy was, in fact, an accidental  death plan with a $750,000 face amount. My favorite part, though, is when Ms Williams says to the Mutual of Omaha rep "life insurance is not trying to kill somebody."

What's that word?

Oh, yeah.

In the meantime, we have other questions.

The investigation revealed that Williams’ motive was an insurance policy, which she recently had increased the value in the event of Mr. Gibson’s death."

Well, yeah, three quarters of a million dollars would be classified as a decent motive for murder (even by Angela Lansbury's criteria).

As we've noted previously, it's generally considered illegal (and, of course, poor sportspersonship) to profit from ones' crime, but we also know that this isn't always the case:

"Judge rules Denver man who 'killed his wife' can use up to $500,000 from her life insurance to pay for his defense"

Be interesting to see if Ms Williams can tap that $750,000 policy's proceeds for her legal fees.

Let's talk about those "Non-Existent" Death Panels

Our friend Holly R tipped us to this post at Hot Air:

"Disabled man with COVID-19 left to die of starvation in Texas over “quality of life” judgment?"

Michael Hickson, a 46 year old Lone Star State citizen, was diagnosed with COVID.

He was also paralyzed with a brain injury.

Certainly not a likely candidate for a long, healthy life.

But: he seemed to be recovering, kinda:

"[H]e was moved out of the ICU, was stable and breathing on his own, and that hospice care would be calling her. "

Why hospice?

Well, because shut up, explained the doc and "the state."

And that's where it gets, well, fuzzy:



Pay special attention to the doc at 3:21, where he explicitly says "at this point, we are going to do what we feel is best for him, along with the state." [emphasis added]

So first, who is this we you're referring to, Doc, and what do you mean by "the state?"

The closest explanation of the latter that I could find was that the patient victim had been appointed a guardian 'ad litem' as the result of an intra-family dispute. But it seems a stretch to go from guardian "only for the duration of a legal action" to agent of the state, replete with the power of life and death (but mostly death).

And let's circle back to that initial statement, itself particularly chilling:

"This is a calculated decision, we feel like this is what is going to be best for him."

Who thinks this is best for him? Hickson certainly didn't seem to think that:

"He was still responsive, puckering his lips when she said “Can I get a kiss?” and answering that he would like her to pray with him."

Well, now we know.

And there's this: there is perhaps an argument to be made for withholding life support for someone in, say, an irreversible coma (although even that presents challenges). But Mr Hickson was certainly awake and cognizant of what what was happening, and from what we can tell was not asking for a referral to Dr Kevorkian.

This case has an overwhelming stench to it.

Happy (And Safe!) 4th of July

Our friends at the Cincinnati Insurance Company's blog have some tips for enjoying the holiday weekend, especially in this modern era of social distancing:

• Read your grill's/smoker's instructions and owner’s manual.

• Place the grill well away from the home, deck railings and out from under eaves and overhanging branches.

• Keep the grill clean and check for grease and fat in the drip pans before firing up the grill [ed: especially important when using gas grills/smokers]

• Use only charcoal starter fluid to start a charcoal fire – never gasoline [ed: better yet, use lump hardwood and a chimney]

And more at the link.

Enjoy!

Off Topic: Unemployment Comp

While this isn't really in our wheelhouse, the Fed's have provided us with this helpful video, "to better assist you help consumers impacted by COVID-19."

On second thought, it is, after all, unemployment insurance, the "premium" for which every employee pays.


Oookay:

Medicare (Re-)Certification: Are you kidding me?

Got this in email:

"Things to pay attention to when doing your recertification:

New Kids- plan to do one section a day over a course of days cause it’s REALLY boring! It will take you about 12-14 hours to complete including the exam.

Recerts- it will take you 4-6 hours approx. You will need to click into EACH section to download the slides and then you are required to take the quizzes at the end of each section."

■ Well first, up to 14 hours? That's ridiculous. And keep in mind that, unless one pays an additional fee, they don't count toward one's Continuing Education requirements (TBF: Same with ACA certification/re-certification).

■ If this does nothing else, it should definitely discourage lay people from trying to DIY their supplemental Medicare coverage.

■ Finally, because we so value the 1st Amendment:

"Section 4 has more and better examples plus clarification on what you can do/not do on social media."

Or else, what?

#Overreach

[Hat Tip: Amanda B]