Yom Kippur 5781 / 2020

Today, September 27, 2020 is Yom Kippur. Normally Hank would proudly share information about this high holy day. Sadly and regrettably, he is not here so I will attempt to fill his giant shoes.

This shall be a statute forever for you: In the seventh month, on the tenth day of the month, you shall afflict your souls, and do no work at all, whether a native of your own country or a stranger who dwells among you. For on that day the priest shall make atonement for you, to cleanse you, that you may be clean from all your sins before the Lord” (Leviticus 16: 29-30). - Townhall

The linked article appeared in my daily newsfeed and comes from a conservative newsletter. Some may find it odd that a "political" source has religious information but readers may be surprised to find all kinds of topics. 

Below is a partial summary of the article followed by an invitation to read more if you so choose. The author is Myra Kahn Adams, born and raised Jewish in the "Bagel Belt" (her words, not mine). She continues . . .

Decades later, I learned the reason why our neighborhood in the Boston suburb of Needham was overwhelmingly Jewish when Jews were a small minority in the town. My mother said that in the 1950s post-war exodus from the city, Jews looking to reside in Needham were only allowed to buy homes in newly built neighborhoods.

I grew up in the 50's and attended school with two Jewish children who were my age. There may have been more but they were the only two I knew. I have no idea where the temple was but there must have been at least one in Knoxville, Tennessee.

Myra Kahn Adams, born a Jew who later converted to Christianity. Her story about Yom Kippur and the Messianic "connection" continues.

“Yom Kippur is simply known as Yoma, ‘the day’ in rabbinic literature. On that sacred day, two goats were central to Israel’s atonement system. The first was put to death for the sins of the nation while the second was sent into the wilderness, carrying away Israel’s sins. Yeshua [Jesus] fulfills these two roles, dying for our sins and carrying them away. In Him, we are forgiven and free.”

You may want to read the complete article or not. If so the link is here.

L'shanah tovah

#HenryStern #YomKippur #MyraKahnAdams

NFIB v Sebelius

Five people said it was OK for the government to REQUIRE you to buy something you may not have wanted. Most folks found the new plan was NOT AFFORDABLE. They also said what you currently owned was dangerous and MUST be replaced with a new plan designed by the GOVERNMENT.

Those 5 people changed the course of commerce, and in so doing DICTATED what businesses could and could not sell to the public.

Those 5 individuals who exercised their power over 100 million people have names. Chief Justice John Roberts and joined by Justices Ruth Bader Ginsburg, Stephen G. Breyer, Sonia Sotomayor, and Elena Kagan.

How to Compare Medicare Plans

Medicare plan premiums are only PART of the story. If you don't look at out of pocket cost you made a big mistake. No premium or low premium plans are attractive but they are also a TRAP!

Compare Medicare plans. Premiums are PART of the story. If you don't look at out of pocket cost you made a big mistake. No premium or low premium plans are attractive but they are also a TRAP!

Get more Medicare tips here

https://www.youtube.com/c/georgiamedicareplans

More on Our Dear Friend Henry G. (Hank) Stern

In reviewing comments in last weeks "tribute" post to Hank I noticed one with a link. Often "link" comments are suspect as spam, but this one definitely is not.

Following the excerpt you will see a link to Greg Fann's original post. I suggest you read the post, along with the comments. Hank touched the lives of so many people in different ways. It seems impossible there was enough of him to go around, but apparently there was just barely enough.

The Loss of an ACA Voice: A Tribute to Henry Stern

“Your cold, hard facts frighten and confuse me”, he would often respond. I always took those words as an approving “job well done” complement, and presumed they were a recognition of objective truth being transparently communicated in a sea of contrary opinion narratives intended to confuse the masses; just as he liked it. Most of our correspondence was about improving the dynamics in the individual health insurance market. We shared a passion of making insurance markets work and advocating for transparency and optimal options for consumers. We encouraged each other and made each other better. We exchanged a few emails and introduced some business connections, but most of our relationship was over Twitter. We never met or spoke on the phone, but Henry was a friend.

Read more here . . .

https://www.linkedin.com/pulse/loss-aca-voice-tribute-henry-stern-greg-fann/

I leave you with one of Hank's recent FB posts. A good illustration of his sometimes off-the-wall sense of humor.

If you don't get it, use ASL to ask someone to explain it to you.

Medicare Open Enrollment - Understanding the Claim Process

If you are looking at Medicare Advantage plans you really need to consider the way they pay claims.

More Medicare tips on my YouTube channel

https://www.youtube.com/c/georgiamedicareplans

Tribute to Henry G. Stern

Henry G. Stern, Hank, was my friend, mentor and an all around good guy. We have known each other for a dozen years, perhaps longer. Our connection was a consumer forum run by a local (Atlanta) radio personality. We quickly discovered many things in common and some areas where we were opposites.

A Bit of History

My home is in Atlanta, his in Dayton. He is Jewish, I am Christian. Our insurance careers have spanned 35+ years (mine a little longer). Both of us are "students" of the industry and share a strong desire to help others navigate the insurance maze.

He referred to me as a mensch.

I had to look it up. 

That in itself is not unusual. Many of his posts included words known only to a handful of people in the world. I would often chide him for salting his blogposts with 25 cent words, Yiddish and acronyms that would confound a cryptologist. He just laughed.

I failed to appreciate the humor.

In some ways we were the odd couple, but that's OK.

He was Felix Unger to my Oscar Madison.

We only met physically once, perhaps half a dozen years ago, when Hank, Gail and Hannah (or Sara, but I think it was Hannah) traveled through Atlanta on their way back home from Florida. We met on "neutral ground", a restaurant favorite that my wife Rachel and I enjoy.

Good food. Good wine. Good company.

Legacy

InsureBlog was Hank's "baby". He fancied himself as a journo and the blog was his hobby, helping him fulfill a passion for writing.

Hank invited me to join him initially as an occasional contributor and eventually promoted to co-editor.

However the pay remained the same.

Zero.

Going forward, InsureBlog will change but the commitment to providing insurance related information will remain. The focus may shift away from individual and group health insurance and toward Medicare, which is my focus. It just depends on how many of the other contributors choose to stay connected.

Some weeks may only see one or two new posts. Other weeks perhaps more. And a few weeks could be barren.

My wife once asked "Does anyone other than you and Hank read that thing?". I guess we will find out.

The reading audience will decide how long this blog survives.

Hank left us unexpectedly on Thursday, September 3, 2020. He left behind Gail, his wife of 38 years, and two daughters, Hannah and Sara.

Hank adored Gail, Hannah and Sara. What better tribute than to say he loved his family? He will be missed by all.

Life has challenges but God gives us the ability to move forward, even when we stumble.

Hank has slipped the surly bonds of earth, and put out his hand to touch the face of God.

Rest in peace, Hank. Rest in peace. L'chaim.

Accept my apology if my Yiddish was used inappropriately. I learned it from the movies.

A Beneficial Conundrum

Well, actually a Beneficiary poser: Long time life insurance client needs to change/update his beneficiaries, which is normally the most mundane thing we do (other than maybe address changes). But, there a twist: he has four (4!) primaries listed, including a trust for one of his adult children.

Of note: my client named zero (0) contingent beneficiaries. Typically, these are folks "second in line" in case the primary predeceases the insured. Not required, or even typically critical, but kinda comes into play here.

Okay, so far not really a big deal, but then he throws me a curve-ball:

"Question, in the unfortunate event that [spouse] and I should pass away together, would her portion automatically go to [son]? How does that work and how do I make sure there is some sort of waterfall to protect my money and those beneficiaries I have listed?"

Hunh.

So, I had a thought, but really not very certain of its validity. So I reached out to our carrier rep, who also had an opinion, but wasn' very confient oin that, either. ZSo, he bumpled it up to the Vice President of Claims, who (very) helpfully replied:

"The rules vary by state and are usually called the Simultaneous Death Act (or similar).

In Ohio, the statute says this:

Except as provided in section 2105.36 of the Revised Code, an individual who is not established by clear and convincing evidence to have survived an event by one hundred twenty hours is deemed to have predeceased the event for purposes of a provision of a governing instrument that relates to the individual surviving an event, including the death of another individual.

So, what that means is that, if the husband and wife die in the same accident, then it would be assumed that the insured died first, unless there is clear and convincing evidence that the beneficiary survived for 120 hours after the accident.   The contingent beneficiary would receive the proceeds.  If no contingent, then it would go to the policyowner’s estate.

If the spouses die two days apart, then it would still be the same scenario, since the beneficiary did not survive for 120 hours.  If it is six days apart, and we have clear and convincing evidence of such, then the proceeds would go to the Estate of the beneficiary, because they survived the insured by more than 120 hours."

Hunh!

So the bottom line is that, if they're both hit by a bus and die simultabeously, the wife's portion of the policy would be paid into my client's estate. Which is I think what he was trying to ascertain.

Regarldess, I was told that the carrier would even be using this as part of a training module. Cool beans!

Also, #LearnedSomethingNew.

[Hat Tip: FoIB Brian D]

Re-thinking transparency

We first blogged on transparency in health care pricing and consumer-centric health care in 2005:

"One of these tools is the pilot transparency program."

So yes, we've long been advocates of what I called the McDonald's Model:

[click to pic to embiggen]

But FoIB Bob Graboyes of the Mercatus Institute offers a contrarian's take:

HEALTHCARE TRANSPARENCY MANDATES — FIRST, DO NO HARM: Op-ed on a point that Jessie McBirney and made in a recent @mercatus paper: why broad-brush healthcare price transparency mandates can paradoxically REDUCE competition and INCREASE prices. https://t.co/o2X1YoAYoQ

— Robert Graboyes (@Robert_Graboyes) August 31, 2020

Interesting.

Teacher's Pet?

This isn't necessarily huge, but it was kinda heartwarming:

Earlier this week, got a call from a nice lady, referred to me by another client (always a nice warm fuzzy), who had a dilemna:

She had just retired from teaching, and was trying to decide between taking the State Teacher's Retirement (STRS) health insurance plan, which was quite extensive, and quite expensive or opting for a short term plan (she wasn't interested in even discussing an ACA-compliant plan). Better still, she had to decide literally that day, because she had to let the STRS folks know by the following morning.

And yeah, I wondered why she'd let such a potentially financially impactful decision go 'til the last last minute, but I could sense the distress in her voice, so I simply said:

"Look, if you can swing the STRS premium for a month or two, then pull that trigger. Doesn't mean you're married to it, just gives us space to find other alternatives."

I could literally hear the sigh of relief as she took that in. She thanked me profusely, and said she'd be in touch.

I really like my job, and sometimes I really love it.

Spoiled baby food

This in from FoIB Jeff M:

"The [North Carolina insurance] department says an examination of 300 claims from over seven years revealed many violations with Gerber Life’s accidental death and dismemberment policies."

Ooops!

The carrier, primarily known for its "$1 for the first 6 months" juvenile life insurance plans, has been ordered to pay over $3.5 million in fines, recoveries and interest.

Not a good look there, folks.

Interesting HSA query

Recently, one of my clients had occasion to interview a potential new hire, and to explain how their benefits include both an HSA-compliant health insurance plan and that the employer contributed a non-trivial amount into it.

The potential new hire replied that he was a big believer in HSA's, and already had an established one. My client reached out to me to see if that would pose any issues.

I, of course, reached out to our gurus at FlexBank/Navia, who replied:

"As long as he hasn’t fully contributed, the employer can contribute into his already established HSA."

Nice!

Fom the P&C Files: Flo meets Darth

 

Medical Kidnapping. Wait. What?

You may have read about a young teenager named Justina Pelletier, from West Hartford, CT. In 2013 Justina was kidnapped by a hospital where she had been admitted for treatment.   Her kidnapping and other similar incidents have given rise to the term "medical kidnapping".  Medical Kidnapping is a growing phenomenon that bears watching.  

I think there is not a more accurate term for what happened to Justina Pelletier than kidnap.  Justina’s ordeal, and that of her family, is described here and here.  Her story is worth reading.  Fair warning:  The story will upset you, especially if you are a parent or a medical care professional

 

The accounts are comprehensive so I’ll add only the following observations of my own. 

 

 (a)  the core issue in the Pelletier case seems to be a scientific and clinical fight about whether mitochondrial disease is actually a physical ailment or primarily psychological.   This type of issue may be present in other cases where there is overlap between the physical and the psychological. Connection with insurance = Do insurers consider a diagnosis of mitochondrial disease consistently as either medical or psychological? 

 

(b)  It is clear that cases of Medical Kidnapping are on the rise. See here and here and here and here.   You can search for yourself by entering Medical Kidnapping and just start reading 

 

 Connection with insurance = How might insurance for mitochondrial disease change as the incidence of the disease rises?  

(c)  Justina’s parents sued Boston Children’s Hospital charging medical malpractice.  Nearly 7 years after Justina’s 2013 admission to BCH, a jury took fewer than 6 hours find BCH not guilty.

Connection to insurance = How might hospital and professional liability insurance coverage/ limits  be affected as the incidence of this diagnosis continues to rise?  

(d)  I have been unable to find any account of specific reasons behind the jury verdict.  For whatever reasons, the jury believed the hospital not the parents.  But consider.  Boston Children’s Hospital is widely thought to be America’s #1 pediatric hospital.  Its teaching affiliate is Harvard Medical School. BCH is also a primary source of professional expertise in child abuse cases before the Massachusetts Department of Children and Families.  No doubt there are many strong ties among BCH officials and physicians; influential Harvard officials and alumni; and DCF officials regarding medical care, politics and even the courts. Especially in Boston.  The influence of these ties naturally extends over the general public, from which jury members are selected.  One can appreciate how difficult it is for anyone not inside that circle of influence, to prevail when taking action against it.

I suppose a teaching hospital anywhere has similarly widespread influence within its community and can be similarly immunized from scrutiny and full accountability - as appears true regarding BCH and the Justina Pelletier experience.  

 

Connection to insurance = Same as in (c).

 

(e)  Aside from medical and insurance issues, the growing number of medical kidnap cases is a social problem, increasingly encountered in the care of minor children.  The Pelletier case illustrates the kinds of problems encountered.  Here are a few that stand out to me, there must be others:

 

1.  Significant differences of opinion among physicians treating minor children

2.  Scientific disagreement over the nature of some condition(s) affecting minor children

3.  Legislative flaws e.g., do States' children & family services bureaucracies abuse their authority? 

4.  Inadequate consultation among attending physicians

5.  Inconsistencies among insurers over terms of coverage for medical & legal liabilities

6.  HIPAA protections of minor children’s patient privacy can be used to keep parents from knowing what treatment their minor children are receiving.  This can effectively remove parents from participation in decisions involving their own minor children’s care.  

7.  Growing influence of the regulatory state, in which persons accused of regulatory violations are presumed guilty, and have the burden of proving themselves innocent.  This negates the presumption of innocence historically imbedded in our legal system.

Don't Make These Common Medicare Mistakes

You are turning 65. For most of your life your health insurance came from an employer group health plan. The next 20 years or so will be different. Why?

You will be enrolling in MEDICARE.

If you are a year away from your 65th birthday you are already being bombarded with junk mail and robocalls from folks who want to "help" you navigate the Medicare maze.

Be careful! That first step and be a doozy.

All your friends are giving advice. "You need what I have. No premiums. Small copay's. Free annual exam. Dental, vision and even a gym membership."

"Did I mention there is no premium to pay?"

Others will tell you to stick with tried and true original Medicare with the red, white and blue card. You can never go wrong with a plan that has been around over 50 years.

Whatever you do, CHOOSE WISELY. The decision you make could be one you will have to live with for a long time. Not everyone will have an option to change and many can only change plans when Medicare allows you to do so.

Let me offer a few words of advice.

Medicare is not as simple as it looks. There are a lot of moving parts.

Medicare Part D looks like a Rube Goldberg contraption. Just when you think you have figured it out things change. New rules. New preferred pharmacy's. New copay's.

And then there is the mystical Donut Hole. It should be called the Black Hole. The few people that figured it out have never been seen again.

Medicare Annual Open Enrollment

But wait! There is always the annual Open Enrollment. I can take a Mulligan and start over. I don't have to keep the plan I bought. Open Enrollment is like a Get Out of Jail Free card.

Hold on there Skippy. Not so fast. Open Enrollment is by invitation only. Some folks can attend. Some can't.

If you have a Medicare Advantage Plan, come on in. You can window shop for a new plan or keep the one you have. Changing plans is easy. 

Almost.

Just make sure you can keep your doctors and all your medications are covered. If the plan you want is an HMO be especially certain you understand the rules. This isn't Kansas anymore.

If you have a stand alone Part D plan, you are also invited to the annual Open Enrollment. Change plans or keep what you have. Don't forget to compare costs and preferred pharmacy's against your EXISTING plan before taking the leap.

Medicare Supplement Plans Open Enrollment

If you currently have a Medicare supplement plan and want to TRADE IT IN for one of those shiny no premium Advantage plans, you can join the party.

There are NO HEALTH QUESTIONS. Come one, come all. In the past ESRD patients were excluded but that will change in 2021.

But if you LIKE having a Medigap plan, but want to change to a different plan, you will have to get in a different line. Changing supplement plans means proving you are healthy enough to be accepted by a new Medigap carrier. If you are in good health, you can change plans. If not you stay where you are.

Even if you ARE healthy, Open Enrollment is the WORST time to change plans. You can change ANYTIME during the year. Pick any time OTHER THAN October, November or December.

You have Medicare questions, I have answers. Take advantage of my "offer you can't refuse".

You can find Bob Vineyard here on YouTube

#MedicareAnnualOpenEnrollment

Fallout From a Political Pandemic?

In the movie "Something's Got To Give" one of Jack Nicholson's lines is "I have never lied to you. I have always told some version of the truth."

#COVID19, #coronavirus, #WuhanFlu . . . no matter what you call it, the disease is still the same. It is deadly, but how much MORE lethal than earlier influenza strains that originated in Asia?

But how can a disease be political?

The disease isn't political, but the way the INFORMATION about COVID perhaps was politicized.

When did the CCP (Chinese Communist Party) know about the seriousness of the disease and when did they tell WHO (World Health Organization)? How many other organizations in the information chain withheld or minimized details of the illness that would rapidly become a pandemic?

Paraphrasing Sen. Howard Baker, "What did these people know, and when did they know it?".

ER physician Dr. Dan Erickson is quoted. "We decided to keep people at home and isolate them, even though everything we’ve studied about quarantine…[says] you quarantine the sick. When someone has measles you quarantine them. We’ve never…[taken] those without disease and without symptoms and lock[ed] them in [their] homes. So, some of these things [given] what we’ve studied from immunology and microbiology aren’t really meshing with what we know as people of science… - RedState

Readers may say this is new information. Something they have never heard or read before.

What if social media, main stream media and others have FILTERED the news to hide the real truth? This would not be the first time it happened.

Social media is relatively new, but consider this opening line from the Washington Post. Until 1968, Walter Cronkite believed what his government told him about the Vietnam War. He was an old-school journalist, a patriot, a man who came of age covering World War II as a wire-service reporter and then taking over as the anchor of “The CBS Evening News” at the height of the Cold War. Like most journalists of his generation, he embraced the fight against communism and understood why the United States had intervened in the war raging in Vietnam.

The news media and the public have been played before. What if it has happened again?

Dr. Erickson continues. "Was the lockdown successful? I say yes very successful. Successful in things like this. Anxiety hotline calls up 1000 percent. Child abuse both sexual and non up. Financially, emotional distress, Suicide. Alcohol. 150,000 Americans a month not receiving cancer screening. It’s been effective alright, in all the wrong metrics — in all the areas we didn’t want it to be effective. Delay in medical care. We talked about that. Orthopedics, nonessential. Suicide calls up 600 percent. Suicide calls. We heard other doctors mention this. So was the lockdown effective? If that’s the effect you were going for, then yes."

Has the COVID pandemic been mishandled? Is the long term economic and psychological impact of the disease worse than the illness?

Is the "cure" worse than the disease?

What if we have only been told some version of the truth?

Where do we go to get our world back?

Bob Vineyard administers Medicare advice on his YouTube channel

Someday Your Health Will Change

No one PLANS on being sick. If you have been blessed with good health most of your life that is wonderful.

But things can change, often when you least expect it.

Donna (not her true name) has been a client a little over 3 years. She never cared much for insurance carriers or agents. We have never met. I believe she found me on Facebook, or maybe one of my clients gave her my name.

I don't hear from her very much. That's probably a good thing. Clients call for one of two reasons.

Their rates are increasing, or their health has changed.

Donna did not call, but she did send an email. Here is her story, in her own words:

Well life is interesting. I’m only sending this to thank you for pointing me in the correct direction years back.

Within the last 3 weeks I was fine felt like I was having a gall bladder attack and ended up having a laparoscopic hysterectomy.

I’m recovering but absolutely fine.

I went to the best doctors and the top gynecologist oncologist.   I can’t imagine what this would have looked like in a managed care situation.  (My friends) were stunned at the level of care I received as well as the immediacy in this crazy pandemic.

So thank you Bob. You know your Medicare and I’m here in good health because you do !!

Her story continues . . .

(Before enrolling in Medicare) I never had an IV. I never had an operation . Not taking any drug 

So truly I had every reason to get managed care (no premium Medicare Advantage plan). Things change quickly. 

Did I mention from urgent care to surgery was 3 weeks with one of the top doctors in Atlanta. 

Yeah it’s been a whirlwind but great. 

Feel free to use my story for your use. 

People need to take heed and listen to you !!  

Forever grateful 

Her email made my day, and my year.

You can find me on YouTube.

P&C Files Bleg: COVID vs Football

 I'd be very interested if one of our readers has the inside scoop:

If you know a casualty actuary, pass this along. I’d love to hear their thoughts on this perspective. https://t.co/qTUg0KjGQ3

— Greg Fann (@greg_fann) August 12, 2020

Thanks!

Tell us again about "Affordability"

 So this pops up:

ACA Affordability Threshold for 2021 Announced https://t.co/UEO6O9t0EM

— Healthcare Reform (@Health_Reforms) August 11, 2020

The article to which that refers explains:

"In order to avoid triggering a penalty ... an applicable large employer must offer full-time employees health plan coverage that provides minimum value and is affordable."

Of course, the gummint's definition of "large employer" is somewhat .... perplexing:

"... if you employ more than 49 people, you've either got to offer (and help pay for) a group plan or pay a penalty tax."

In this case, the income test - "affordable" - for next year is just shy of 10% of one's income. And keep in mind, that's just counting the premiums, not the thousands (or, commonly, tens of thousands of dollars in potential out-of-pocket costs).

Pretty bizarre definition of "affordable," no?

Monday Linkage

■ First up, interesting product news from Anthem:

"Beginning January 1, 2021, for new and renewing business, your clients will receive affordable access to groundbreaking gene replacement therapies through our new benefit protection program, Anthem Gene Therapy Solutions."

That's the good news. The catch?

"The program will be embedded in Large Group administrative services only (ASO) plans with 51 or more eligible employees (CA & CO 101+) ... New York is excluded from this program
offering."

So if you're a small group anywhere in the US, or any group in New York, no soup for you.

■ Next, another in our seemingly endless series of Business Interruption vs The 'Rona" posts:

"Legal experts Glenn Jacobsen and Mark Binsky examined the Houston Rockets lawsuit and expressed doubt that the suit would be viable or eventually prevail at trial ."

The issue is that the team's games were suspended by the NBA, and thee was no actual physical damage that would net a successful claim.

■ And last (but most assuredly not least), this:

U.S. residents under age 45 spent July shopping for life insurance as if it were a hot new phone, or hand sanitizer. Consumers in that age group filed close to 20% more life applications last month than they did in July 2019, according to MIB Group.https://t.co/zFVFypqgij

— ThinkAdv Life/Health (@TA_LifeHealth) August 10, 2020

Not-So-Intransigent Providers: An Update

The other day we posted about what appeared to be a rather unfortunate problem for one of my clients:

"Dr. [redacted - for now] is in our system under 2 separate Tax ID’s. Only one is actually in our network, and the location the patient's supposed to go to isn't."

So, I reached out to co-blogger (and certified medical office manager) Kelley B, who reached out to the doc's practice manager, who shed a great deal of light on the matter:

"We reached out to the patient to explain that [the doctor] is not in network through our practice.

There was a renal physician who passed away suddenly earlier this year in a different practice. [Our doctor] is also a nephrologist and offered to help them a little while they got their staffing situated.

[Our doctor] is in-network through them for this plan as a nephrologist not an endocrinologist."

Ah-hah!

At about the same time, I got an email from the practice's Accounts Manager, who added that they had long ago decided - as have *many* providers - to forego contracting with ACA-plan networks, and aren't presently interested in reconsidering that decision. And of course she (and the aforementioned practice manager) stressed that since my client would be out-of-network she was on her own (which we already knew).

She also mentioned something that my client and I had discussed: that she'll want to be careful about any lab work that might be ordered, in case that becomes a network issue, too.

One bright spot: the plan is HSA-compliant, and she has socked away a few shekels into it, so she can use some of those to pay for the visit (and, if necessary, lab work). Oh, and I suggested that she ask the practice if there's a discount for paying cash (never hurts to ask).

So, mystery solved, just not a very satisfying answer.

By the way, there are some great comments on that original post, worth going back and reading.

[Special Thanks to co-blogger Kelley B, as well as the folks from the doc's practice]

From the P&C Files: D&O insurance heads' up

It's been a while since we've blogged on Directors and Officers (D&O) liability coverage, and both of those times had to do with churches. But D&O coverage is for pretty much any business or charitable enterprise with boards of directors (or elders, or council members, etc), among others. And just what is this type of policy?

Well:

"Think of D&O insurance as coverage for management decisions ... Who makes the decisions? That’s who needs protection."

That's from a recent post over at the Cincinnati Insurance Company's blog, and it's really quite interesting. As the author notes, many organizations, and especially small businesses, hear the term and automatically (and erroneously!) presume it refers exclusively to organizations with a  "Board of Directors," which, if you're a sole prop or very small business, you don't have. But turns out that that kind of thinking can get a small business in a heap o'trouble:

"Anyone who believes they have been harmed by the actions of a company can take legal action against the company and its decision makers."

And who might comprise this list of possible litigators?

That would be folks as diverse as vendors and suppliers, customers, even competitors (and the list goes on).

Absent this coverage, a small business owner (or owners) could be left with some pretty big expenses, even if they prevail at trial.

How's that?

Well, attorney's aren't free, and they aren't cheap (well, you do get what you pay for, one supposes). And those legal costs are going to be out-of-pocket without proper coverage in place, including D&O.

So if you're a small business owner, make sure you discuss this with your agent. It could save you a major headache (and wallet drain) down the road.

[Hat Tip: FoIB Deb C]

Intransigent Providers

So I have a client that has some health issues, and who has an ACA plan (not mentioning the carrier because they're not necessarily in the wrong here). My client, we'll call her Sally, has a specific, chronic health condition that requires the care of an endocrinologist. Unfortunately, there haven't been any in-network endo doc's nearby, and because it's an ACA plan, out-of-network means out-of-luck.

Fortunately, one such doc has recently been added to the network, and Sally quickly made an appointment to go see her. The rub is that she apparently has two offices (or not, depending on whom you ask - more on this in a moment), and only one is in-network. The problem is that she doesn't actually have an office at Location #2, and apparently never has. But according to the carrier:

"Dr. [redacted - for now] is in our system under 2 separate Tax ID’s. Only one is actually in our network, and the location the patient's supposed to go to isn't. We've reached out to the provider to confirm."

Rock and a hard place, indeed, since she doesn't seem to actually practice at Location #1.

So with Sally's blessing, I reached out to the billing folks at the doc's office. I told them that, although I'm happy to pay conduit, my word holds no sway, but that a letter from the doc confirming Location #1 and denying Location #2 would go a long way. The billing lady didn't seem too keen on that, explaining that she saw her job as keeping this kind of thing out of the doctor's way. I thought that this was an odd way of putting the patient's interest first, but she did agree to discuss the issue with her supervisor.

Oh goody.

She then questioned whether this was even a worthwhile exercise, since it was unlikely that the matter could be resolved in time for Sally's upcoming appointment. I pointed out that the longer they put off helping her the more likely such an outcome became.

She appeared unmoved.

So as it stands, the doc may or may not have an office at two locations, and may or may not actually practice at either one, and may or may not really care about her patient's well-being (both physical and financial).

Nice gig.

In any case, I'll keep this on the top of the pile. and hope for the best.

Travel Medical: A Perspective

Recently, a colleague referred one of his clients to me (a very wonderful compliment) for help with a travel medical plan for a visiting guest. He introduced the two of us via email, and the client called me shortly thereafter.

Turns out, this wasn't just any guest, but his son and granddaughter coming in from Europe for a two month stay in our lovely Buckeye State. He was concerned that there would be insurance in place if either were to become ill or injured. No problem, pretty standard, although currently kind of out of the ordinary. I was just glad to see that international travel wasn't completely dead.

In any case, the gentleman had been doing a lot of online research for this kind of plan and, in frustration, called his agent for hep, and thus the referral to me.

I do a fair amount of this kind of thing, so I was pretty familiar with what he needed. I answered his questions, and then got the information I needed to obtain a quote. For these kinds of plans, I pretty much exclusively use our friends at Global Underwriters, primarily because they know what they're doing and, as important, I have a long history with them so that I know I can count on them if any glitches develop. I'm sure that other vendors are also reliable, but I know that the GU folks are.

I also know that their plans and rates are competitive, and there won't be any surprises.

Okay Henry, we get it: you know and trust them, why are you beating this horse?

Well, the client also asked me about my relationship with his agent, and I explained that the gentleman and I are colleagues and that he has referred these types of cases to me in the past. He then said "well, [agent] always gives me several quotes, will you also be doing this?"

I immediately replied no, for the reasons stated above. He seemed satisfied with this, and I agreed to send him a quote ASAP. Which I did, but did not realize that I had forgotten to attach a summary of benefits, and he asked me for that. Of course I obliged.

I had now spent a total of almost an hour on the phone, obtaining and sending the quote, and sending the Summary of Benefits. All in a day's work, and happy to do so.

Now, my commission on this plan will be in the neighborhood of $35, not bad for an hour or so's work. And of course, I'm happy to assist a colleague. But would I be upset if the client ultimately chose to DIY? No, not really: disappointed, sure, but not upset. After all, it's his choice, no?

Oh what a tangled web

Our friend Jeff M sent along this (poorly written) article about the sometimes duplicitous world of reinsurance:

"A businessman and political donor ... has been sued by Universal Life Insurance Company (ULICO) over a personal guaranty Lindberg made to back PB Life and Annuity Company."

It appears that the companies had come together to form a reinsurance agreement (this is essentially a contract that helps minimize risks that carriers take on, more here). and it seems that one of the parties has been ... negligent ... in holding up his end:

"ULICO alleged that PB Life was not in compliance with the reinsurance agreement because 65% of the investments of the trust fund were in loan obligations to affiliates of PB Life which exceeded the threshold of 10% established by the insurance code."

As FoIB (and extremely knowledgeable carrier rep) Brian D explains:

"This guy doesn’t stand a chance.  PB Life is out of compliance.  The worst part of this (agreed it’s a poorly written) story is what Lindberg’s connection is to PB Life and why he would ever personally guarantee a loan of that size.  Seems ridiculous.  But as a reinsurance entity, you cannot have 65% of your assets in loan obligations.  Not in this economy.  That is insane."

Oh, I think we can tell right away why Mr Lindberg agreed to underwrite this out of pocket.

Will be interesting to see how this plays out.

Stay tuned....

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?