Author Anthony Nefouse

The Kaiser Family Foundation (KFF) is an organization that researches a variety of health care topics.

They just released a quiz on health issues with the presidential election standpoint. It’s a brilliant way to test your knowledge of the politicians and their views on health care. With health care being one of the tops of the issue of the presidential election, it might be a good idea to test your knowledge.

https://www.kff.org/quiz/health-issues-and-the-election-quiz/

The democratic candidates are in favor of a more socialized healthcare system if not thoroughly socialized. Having had gone through the Affordable Care Act, it is apparent how healthcare reform can have huge impacts on the current healthcare system.

With candidates supporting a Medicare for all or single-payer system we could see something of this magnitude getting passed into law. Our healthcare system would forever be changed.

A politician that is considering supporting or introducing any health care reform should hear from all impacted parties.

KFF does do an excellent job of creating an online quiz to test the voters’ knowledge of where the candidates stand on health care.

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This is Nefouse & Associate’s sixth open enrollment since the affordable care act has gone into effect. We are one of the last Indiana based agencies to still be active in the individual market. There has been a lot of changes, but one thing has stayed the same, costs continue to rise.

We have just two carriers offering coverage in the individual market, Ambetter & CareSource. Both companies will be offering personal coverage through the marketplace in every Indiana county. Insurance companies are required to file their rates and plan for approval with the Indiana Department of Insurance.

  • CareSource average approved rate increase is 4.90%, with an average premium of $532.95.
  • Ambetter average approved rate increase is 18.9% with an average premium of $567

Each plan design and county will have a different increase and some decrease.

  • CareSource will have a -13.8% decrease and as high as 26.9%.
  • Ambetter will have as low as 5.4% increase and as high as 30.60%.

Plan options are continuing to have a large deductible and out of pockets maxes.

Lowest Costing Plans Deductibles:
CareSource $7,700 deductible.
Ambetter $8,150 deductible.

2020 Health Saving Accounts:

CareSource: $5,300 deductible with 50% co-insurance
Ambetter: $6,750 deductible with 100% coinsurance
The Caresource H.S.A is about costs about 10% below Ambetter.

Network Access:
CareSource: Health Maintenance Organization (HMO)
Ambetter: Exclusive Provider Organization (EPO)

CareSource has increased its participating medical providers in central Indiana.
Ambetter appears to have greater network access with EPO vs. the HMO.
It is essential to research your physicians to see if they are participating in these networks. The networks can change, and physicians may not be accepting new patients.

Drug Formulary:
Both offer similar drug formularies, but cost-sharing does vary from plan. Most tier 3 brand name drugs will apply towards the deductible.

The 2020 Individual open enrollment is through November 1st -December 15th.

Use our Quote Engine to review and enroll in health insurance for 2020: https://www.healthsherpa.com/?_agent_id=tony-nefouse.

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The National Association of Manufacturers (NAM) has launched an association health plan (AHP) that is available in Indiana to start January 1st, 2020. Mercer developed the health plan through UnitedHealthcare.

An association health plan (AHP) is developed specifically for an association and its members. The NAM AHP is operating under the rules where each group/company must go through underwriting to obtain a final rate. This allows for small companies under 50 employees to have an option outside of the Affordable Care Act (ACA) small group market.  

A healthy group could experience a 30% decrease with the AHP vs. the ACA small group plans. The savings come from the underwriting process and how rates are calculated with age bands. The ACA has a restriction on what the scale can be between the youngest and oldest members.

How do I get a proposal on the National Association of Manufacturers (NAM) Association Health Plan here in Indiana?

  • 1st Your company’s nature of business needs to be manufacturing.
  • 2nd You will need an employee census.
  • 3rd Contact Nefouse & Associates, and we can deliver your proposal. 

 Requirements of the AHP

  1. 50% of your full-time employees must elect coverage.
  2. The employer must contribute at least 50% of the employee on premiums.

Do we have to complete applications?

  1. Groups with less than four employees will have to complete applications.
  2. If the group is over 5 employees electing coverage, you do not have to complete applications. UHC is using an underwriting technique to retrieve pharmacy history, which allows them to determine risk.

 The NAM AHP is another group health option for Indiana manufacturing employers with less than 100 employees.  

 

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Short term health insurance has gone through an exciting evolution since the passing of the Affordable Care Act.  Before the ACA going into place, the short term was a health insurance policy that you would use to ensure against major medical claims for a short period.  The most common use was coverage in between jobs.

Affordable Care Act Effect

With the passing of the Affordable Care Act, short term health insurance was becoming a product of the past.  The individual market quickly went to the exchanges, and many people were eligible for premium assistance.   This created very little demand for short term coverage.

By the second year of the ACA, people had real frustrations with the marketplaces, networks, & the skyrocketing premiums. Most people that were not receiving premium assistance started to look for options outside of the health insurance marketplace.

Suddenly, short term health insurance attracted a lot of membership because of costs, PPO network, and what appeared to be low out of pockets. This led to a lot of companies offering short term health insurance.

Short-Term Requirements

To be eligible for a short-term policy, one must go through medical underwriting, and these are where they can get denied for a preexisting condition. The medical underwriting is the reason the insurance coverage is a quarter of the price of ACA policies and why the insurance companies spend less than 50% of the premium collected on actual claims. Low consumer prices and high-profit margins created a short-term market.

In the last few years, there has been a lot of public confusion on short term coverage. This confusion was created by both agent distribution channels and people not willing to read the brochure much less the policy. Typically, the second to last page of the brochure will list most of the exclusions, but there have been additional coverages or situations where there was no coverage. The enrollment process has been a bit suspect where many completed an online enrollment with a couple of questions and a form of payment.

These enrollment procedures and the general public desperate for premium relief led to policyholders having significant issues when it came time to file claims. Post Underwriting became the primary technique of insurance companies to validate a claim. This is when the insurance companies look to deny a claim based on it being preexisting, they would order medical records from the last five to seven years. The medical records would take weeks to be released, which could lead to a disruption in care.

The Future of Short-Term

As we enter 2020, short term coverage has changed from both a coverage standpoint and length of the term. There has also been greater oversight by government bodies like the Indiana Department of Insurance.  The short-term plans must go through an approval process with the state like what permanent insurance plans are required to do.

The new policies have broader coverage and less a gray area exclusions.  In Indiana, you can now purchase a short-term plan that has a term of two years. This is a game-changer.

These policies are no longer just for healthy young people. We are seeing families of five purchase these policies.  The premium saving is enormous for those that do not qualify for premium assistance. A family of five may cost $1,800 a month on the exchange and still have a $6,000 deductible. That upper-middle-class family is spending $21,600 in premium and then potentially another $12,000 in out of the pocket expense. That’s $33K a year in health care! It’s challenging to stay in the middle class with that kind of expense. A short-term policy may cost $600 a month with similar deductibles and out of pockets. The family is taking on additional risk where coverage may be limited or not covered at all, but families have to look at the pros and cons.

The most important is you don’t omit any health conditions on the applications. If the condition is listed and they approve you, there is a much higher chance of getting a denied claim covered.  If you are buying a policy to cover your family, take the time to read the brochure. Purchase the policy from a reputable carrier and broker that is local and cares about their reputation.

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Open enrollment is right around the corner for most people that have health insurance. Most of the employers have a January 1st renewal with the open enrollment period a month prior. The Individual market open enrollment is Nov.1st -December 15th. 

Indiana has become one of the most expensive states for health care; this was revealed by the RAND Corporation study on Hospital Prices in Indiana. From a health insurance standpoint, we have seen the major carriers start to renegotiate their reimbursement prices to all medical providers. This created network disruptions in multiple Insurance carrier networks, and we believe this trend will continue into 2020.

The Affordable Care Act (ACA) small group market will experience a single-digit rate increase. Anthem is increasing 7%, UnitedHealthcare is 9%, and IU Health plan is about 8%. The small group ACA market is now unaffordable for most small employers and employees to carry to dependent coverage.

The level-funded or partially self-funded should stabilize in 2020. In the last couple of years, we have seen many carriers enter the Indiana market. Most of these plans came from smaller companies that did not have a lot of experience in Indiana. They were able to go in, and essential write low-risk groups and small Indiana employers have benefited from the lower rates. Now that these carriers have experience in Indiana, they are not as aggressive, and this has a lot to do with our cost of care.  

With the Introduction on Anthem’s Multiple Employer Welfare Arrangement (MEWA), this adds another option for Indiana small employers that have low risk. Another company called All Savers, which is owned by UnitedHealthcare, offers a small group plan that is also underwritten, which can be very competitive. It’s fair to say that there are multiple options for Indiana small group employers.

The individual market is more of the same under the Affordable Care Act. With just two carriers offering coverage in the Individual market both plans must be purchased through the exchange. CareSource premiums will increase as high as 25% and decrease as low as 15%. Ambetter premiums will have an increase of as high as 28% and a decrease as small at 3.5%. Depending on which county you live in and what plan designs you select will determine what kind of increase you will have for 2020.

One change to the individual market that is worth looking at is the short-term policies. Short term policies have been an option for Hoosiers that needed coverage for a short period, and that was healthy. For 2020, we are now going to have short term health insurance that is has a term of two years. These policies are subject to underwriting, but for Hoosiers that are healthy and not eligible for tax credits on the exchange, this is an option worth looking at.

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Anthem has developed a new Group Health Insurance plan for Indiana small group employers.  This is in direct response to the unintended consequences of the Affordable Care Act (ACA).  

Under the ACA, Indiana small group health insurance rates have doubled, and Anthem has been one of the last large to bring a solution to market. The solution they choose is called a Multiple Employer Welfare Arrangement (MEWA). 

A MEWA allows multiple employers to join for the sole purpose of obtaining health insurance at a more competitive cost. Anthem’s MEWA will offer a Group Health Insurance plan that is self-funded. This allows the plan to operate outside of all the rules and regulations of the ACA. This Chamber care Health Alliance will go back to underwriting for Indiana small group employers. Lower risk groups could see a 40%-50% reduction in health insurance premium vs. the ACA small group market.

MEWA’s are not a new concept and have a lot of history. MEWA’s have been useful tools for companies to reduce their health care costs. They have also gone insolvent due to mismanagement and are prone to adverse risk assessment.

The Indiana Department of Insurance overseas MEWA and has a specific requirement that must be met to prevent insolvency. A board or a trust governs the MEWA itself. Thus, the members of the MEWA are eligible to become board members.

Underwriting is where the ongoing medical history, age, gender, company location, SIC code, and benefit design will determine the rates.  These rating methodologies will deliver significant savings to healthy young groups. The savings could last for years if the Chamber Care keeps a relatively healthy block of business. For a company with less than 50 employees should look at the ChamberCare Health Alliance and Anthem for group health insurance.   

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On 6/24/19, the President of the United States issues an executive order requiring Hospitals and Insurance companies to reveal what they are charging or paying for services.

The idea is to make health care cost transparent, which then would lead to consumerism and then medical providers reducing costs to attract more patients. Primarily pressuring the health care industry to become like any other industry.  “The goal is to create a more competitive marketplace where providers are competing for patients on price and quality.” CMS

The Insurance industry immediately pushed back, stating this action would have unintended consequences by pushing prices higher rather than down.  The insurance industry fears that publicly disclosing proprietary network rates (PPO, EPO, HMO) will only lead to medical providers demanding higher reimbursements based on the highest reimbursement rate.

The Department of Health and Human Services will propose regulations requiring hospitals to disclose what the standard charge for medical procedures in an easy to understand format. 

Both, which includes Insurance companies and medical providers will fight this executive order with all their resources because real price transparency could have huge implications on their business models.

If the public can retrieve what each medical provider charges for a specific procedure, that could lead to that patient going to the lowest costing provider, especially with current deductibles and out of pocket maxes.   Quality care should remain a factor, but a provider charging more for that procedure would have to justify why they are charging more. Maybe they have the best doctor in the state performing that procedure, or they have the newest technology, or it might come down to how the staff treats you before and after the procedure.  Price transparency could lead to lower prices and additional services.  

On the flip side If all the medical providers know what each other are charging, this could lead to higher prices by matching the highest price being charged.  

If the public had access to network discounts that the insurance companies negotiate with the medical provider are, it could have a massive impact on carrier selection.  Large employers with self-funded plans would have a clear picture on which insurance company offers the deepest discounts. A large employer typically will be responsible for the initial claims on each member called stop-loss insurance.   If the employer pays the first $150K in claims on each member and they have a crystal-clear picture that Insurance company X has 10% deeper discount than other carriers that can add up to significant savings.

On the flip side, all the insurance companies could arrive at a similar benchmark on reimbursements and then negotiate additional discounts that could go back to the carrier or client in the form of rebates. Thus, losing transparency

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Congress has bipartisan support on stopping or limiting surprise medical billing if a patient receives care from a non-network provider that provider will “balance bill” the patient which create surprise medical billing. 

Balance billing is happening all over the country, including Indiana.  The patient usually in an emergency receive medical services from a provider that is not participating in their insurance network. A common situation is central Indiana is that the emergency room doctors are not participating in the network, but the facility is.  About 30 days after services have been received, the patient may receive a bill from a medical provider they don’t recognize. Then after some frustrating research, they learn those doctors are not in network and can charge whatever they feel is reasonable.

With Health Maintenance organization (HMO) & Employers provided organization (EPO) we are seeing more and more plan that offers no coverage for out of network claims.   Even PPO’s are starting to have gaps in coverage where the medical provider and the insurance company cannot agree on medical reimbursement rates. 

The stakeholders in this debate are the medical community and health insurance carriers. Each side is point fingers to blame the other.

Solution

The No Surprise Act would set medical rates at 100% of the current median in-network reimbursement rates.  Which would still lead to patients having surprise medical bills but would give a patient a level of protection on what the medical provider could charge. 

If each community starts using an average cost for all medical services, we could see the insurance companies’ proprietary networks become less valuable.  This would have a significant impact on the health insurance industry.  If the medical community is held to a fixed priced for the procedure they perform, this could impact the large medical groups. 

It will be fascinating to see the final bill’s impact on both stakeholders.

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When it comes to health care and group health insurance, Hoosiers have always preferred PPO networks which allow the member to choose which medical provider they want to receive treatment from.  With any group health plan, Indiana employees have demanded that they could choose their medical providers.  This is starting to change because the cost of care in Indiana is one of the highest in the country.

Insurance companies, medical providers and TPA have started to develop their narrow health care networks all so known as skinny networks.   

Medical providers have introduced their own health insurance plans in an attempt to attract employers that want to control costs.  These networks come in the form of Health Maintenance Organization (HMO) and Employer Preferred Organization (EPO).

IU Health Plans has its own hybrid HMO plan that has slowly gained membership. They offer a hybrid HMO that also provide a traditional PPO network.  These options can be competitive but the real cost savings comes from their tier 1 network which is a true HMO.  This HMO can deliver a 25% reduction in the premium vs. a traditional PPO plan.  IU Health plans promote an integrated care experience for members, where are the medical providers are in communication with one another.  The integrated model is supposed to deliver better treatment outcomes and a better overall experience for the patient.

St. Vincent’s recently launched their own health plan called Advantus which utilizes a skinny network of St. Vincent’s and affiliated medical providers.  AdvantUs is offering a self-funded/level funded health plans in the small and mid-size markets. These plans are potentially reduced costs by 10% vs other level funded products.  IF compared to a traditional fully insured PPO plan, the initial saving is more like 30%.

Anthem recently launched their own skinny network called health sync which is an HMO that currently utilizes the Franciscan network.  The product is for both small and large group. There is upfront savings vs. Anthem PPO network along with innovative programs to control future medical costs.

Employer Direct Contracting with the health provider.  Large employers can contract directly with the medical provider, which could exclude the traditional insurance company.  Negotiating directly with the medical provider for an exclusive contract can lead to a significant reduction in the cost of claims.  In some of Indiana’s communities, this approach could reduce medical costs by as much as 50%.

In the past Indiana, employees have been reluctant to accept narrow networks, with the skyrocketing medical cost now being revealed to the general public, employers are starting to entertain these cost controlling techniques.  The younger millennial generation is open to using skinny networks, which may lead to employers implementing these plans.

If you are interested in learning more about these options, contact us.

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There was a study conducted by the Rand Corp that examined payments rates by private health insurers in 25 states and Indiana was one of them.  The purpose of the study was exposing what health care providers charge compared to Medicare.

The study determined the dramatic difference in the cost of health care cost across the country.  This information could show lawmakers the severe challenge they face with regulating healthcare. It is hospitals that are charging the highest rates should have more government and industry attention.

The study proved that Indiana health insurance plans paid on average more than three times what Medicare did.  In Michigan, those medical providers charged closer to 1.5 times Medicare.

Indiana medical providers have been able to charge a great deal more than other states.  This could be a direct result of Hoosiers preferring a PPO network where different states have embraced narrow managed care networks.   Indiana hospitals systems have grown more and more powerful through mergers and acquisitions which may give them more negotiating power to receive higher reimbursement rates.  The medical community lobbying power may also have had something to do with it.

With this RAND study gaining more attention, Indiana businesses are starting to realize how much more we are paying for health care vs. employers in other states.  

What could employers do with this information?

One option would contract directly with medical providers. An employer would contact the hospital group directly and negotiate the reimbursement rates of healthcare for all their members.  This could result in employees using a limited network for care, which Hoosier have notoriously disliked but with this found cost information, Indiana employers may have no choice.

The direct contracting is now available for even small groups though Franciscan, IU or St. Vincent’s.

There is also the option of a group health plan that uses reference-based pricing to reimburse medical expenses. This is where medical costs are paid based off a multiple of the Medicare rate. The medical community in central Indiana has fought this type of reimbursed. Why should they make less than their 3x Medicare rate?

If Indiana medical providers refuse to discount their rates, then maybe a market correction is in order. With the Rand study showing Michigan with one of the lowest medical costs, maybe employers start sending all acute cases to Michigan for treatment.  If the company is self-funded, meaning they are paying the claims up to $500K, and there is member’s that need care that cost’s $400K in Indiana but the same level & quality of care in Michigan cost $200K, that is an easy decision to make.

That employer could charter a private jet for the member and family and still save a significant amount of money.

The Indiana medical community will eventually be held accountable for what they charge by either the government or by a free market.

Kaiser Health News – Market Muscle: Study Uncovers Differences Between Medicare And Private Insurers

Rand Corporation – Prices Paid to Hospitals by Private Health Plans Are High Relative to Medicare and Vary Widely

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