The next Governor of Indianapolis is going to have a huge impact on health insurance in the state.
The first decision the Governor will have to make is on the Essential Benefits. It is the responsibility of each state to form the Essential Benefits. The essential benefits are a set of health care service categories that must be covered by health insurance plan in 2014. The essential benefits will have a huge impact on health insurance premiums. For example, if the state decided one of the essential benefits is that fertility treatment must be covered. This would be a great benefit for Hoosiers that needed that coverage but everyone would pay a higher premium.
The 2nd big decision by the Governor is on establishing a state based exchange. Under the new health care law, a state based exchange can be established for people to buy health insurance policies from. This is a very big decision. The cost of running a state based exchange is anywhere from $66-$88 Million a year. The Department of Insurance has not clarified where this money would come from. If the state chooses not set up a state based exchange then the federal exchange will operate in Indianapolis. The Federal Government has not released a lot of information on how that exchange will operate. It is fair to say the department of insurance will have little control over the federal exchange.
The next Governor of Indianapolis, will make health insurance decisions that will effect every Indianapolis resident.
Under the Health Care Reform there are new preventive care benefits that every Non Grandfathered policy will have to cover. Some of these benefits will be covered at no cost to the insured. It’s very important that you consult your current coverage to determine if these new benefits will be covered. There will be some plan that do not cover these benefits.
Some Indianapolis based insurance companies will not have grandfathered plans. Each health insurance carrier operating locally will determine if they can administer grandfathered and non grandfathered plans. Self Funded plans my also be exempt.
It’s very important to know your current benefits. When seek wellness visits it extremely important to know what is covered and what could end up not covered. Some times our medical providers may not be well versed on coverage changes. Check with your health insurance carrier.
A pregnant woman (Photo credit: Wikipedia)
From Healthcare.gov, the federal government’s site providing basic information on health care reform, including PPACA:
Preventive Services for Adults – Including Senior Citizens
Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
Alcohol Misuse screening and counseling
Aspirin use for men and women of certain ages
Blood Pressure screening for all adults
Cholesterol screening for adults of certain ages or at higher risk
Colorectal Cancer screening for adults over 50
Depression screening for adults
Type 2 Diabetes screening for adults with high blood pressure
Diet counseling for adults at higher risk for chronic disease
HIV screening for all adults at higher risk
Immunization vaccines for adults- -doses, recommended ages, and recommended populations vary:
Hepatitis A
Hepatitis B
Herpes Zoster
Human Papillomavirus
Influenza (Flu Shot)
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Tetanus, Diphtheria, Pertussis
Varicella
Learn more about immunizations and see the latest vaccine schedules.
Obesity screening and counseling for all adults
Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
Tobacco Use screening for all adults and cessation interventions for tobacco users
Syphilis screening for all adults at
Covered Preventive Services for Women, Including Pregnant Women
Note: Services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012. See Affordable Care Act Rules on Expanding Access to Preventive Services for Women.
Anemia screening on a routine basis for pregnant women
Bacteriuria urinary tract or other infection screening for pregnant women
BRCA counseling about genetic testing for women at higher risk
Breast Cancer Mammography screenings every 1 to 2 years for women over 40
Breast Cancer Chemoprevention counseling for women at higher risk
Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
Cervical Cancer screening for sexually active women
Chlamydia Infection screening for younger women and other women at higher risk
Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
Domestic and interpersonal violence screening and counseling for all women*
Folic Acid supplements for women who may become pregnant
Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
Gonorrhea screening for all women at higher risk
Hepatitis B screening for pregnant women at their first prenatal visit
Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*
Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older*l Osteoporosis screening for women over age 60 depending on risk factors
Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
Sexually Transmitted Infections (STI) counseling for sexually active women*
Syphilis screening for all pregnant women or other women at increased risk
Well-woman visits to obtain recommended preventive services for women under 65*
Behavioral assessments for children of all ages
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Blood Pressure screening for children
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Cervical Dysplasia screening for sexually active females
Congenital Hypothyroidism screening for newborns
Depression screening for adolescents
Developmental screening for children under age 3, and surveillance throughout childhood
Dyslipidemia screening for children at higher risk of lipid disorders
Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Fluoride Chemoprevention supplements for children without fluoride in their water source
Gonorrhea preventive medication for the eyes of all newborns
Hearing screening for all newborns
Height, Weight and Body Mass Index measurements for children
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Hematocrit or Hemoglobin screening for children
Hemoglobinopathies or sickle cell screening for newborns
HIV screening for adolescents at higher risk
Immunizationvaccines for children from birth to age 18 -doses, recommended ages, and recommended populations vary:
Diphtheria, Tetanus, Pertussis
Haemophilus influenzae type b
Hepatitis A
Hepatitis B
Human Papillomavirus
Inactivated Poliovirus
Influenza (Flu Shot)
Measles, Mumps, Rubella
Meningococcal
Pneumococcal
Rotavirus
Varicella
Learn more about immunizations and see the latest vaccine schedules.
Iron supplements for children ages 6 to 12 months at risk for anemia
Lead screening for children at risk of exposure
Medical History for all children throughout development
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
Above is a video that address some of the new changes for women’s preventive services covered under the new health care law. In the past there has been coverage for these procedures but it was at a shared cost to the insured. Under PPAC these coverage are now covered at 100% with no cost to the insured as long as they stay in network. For health insurance most providers are participating in the national networks like UHC and Anthem. Finding a network provider to perform these services should not be an problem, but it is always important to ask the attending physician if they are participating in your network. If you are on a health plan that was established prior to 2010 you may want to check to see if these benefit are covered.
Women’s health
The following guidelines for women were effective for plan years beginning on or after Sept. 23, 2010:
Mammography screening (film and digital) for all adult women*
Genetic screening and evaluation for the BRCA breast cancer gene
Cervical cancer screening including Pap smears
Sexually transmitted diseases screening including gonorrhea, Chlamydia, syphilis and HIV
Iron-deficiency anemia, bacteriuria, hepatitis B virus and Rh incompatibility screening in pregnant women
Breast-feeding counseling and promotion
Osteoporosis screening (age 60 and older)*
Counseling women at high risk of breast cancer for chemoprevention
Expanded women’s preventive care services on or after Aug. 1, 2012
New coverage guidelines under the Patient Protection and Affordable Care Act (PPACA) require health plans to cover an expanded list of women’s preventive care services with no cost-share (copayment, coinsurance or deductible) as long as services are received in the health plan’s network. Coverage for the following expanded women’s preventive care services becomes effective the first plan year beginning on or after Aug. 1, 2012:
Anthem just announced that Express scripts and Walgreen’s have reached an agreement. Anthem members can use the Walgreen’s pharmacy as they will be considered a in network provider.
Walgreen’s is a great provider of pharmacy benefit in the area. It is important to remember to check local pharmacies for the most competitive prices on medications. The large pharmacies can sometime have the most expensive prices. If you are on a Health Savings Account it makes sense to be a consumer shopper for RX. Comparing prices of local pharmacies might bring large savings to you.
Healthcare.org has released the medical loss ratio for all health insurance companies operating in Indianapolis. It is interesting to see just how close the carrier are to the 80% or 85% loss ratio. With all of the tools the carriers use to keep cost down it is surprising that the loss ratios are not lower. This is just another indicator how expensive medical care is.
Medical Loss Ratio: Insurers must, in general, spend 80% or 85% of the premium dollars they take in on health care costs and health care improvement activities. If they do not, they must provide refunds to policy owners.
Advantage Health Solutions, Inc.http://www.advantageplan.com
Insurer’s MLR
MLR Standard
Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market:
Not Applicable
Not Applicable
Not Applicable
Small Group Market:
95.8%
80.0%
Not Applicable
Large Group Market:
93.5%
85.0%
Not Applicable
Anthem Ins Companies Inc(Anthem BCBS)http://www.anthem.com
Insurer’s MLR
MLR Standard
Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market:
81.8%
80.0%
Not Applicable
Small Group Market:
79.2%
80.0%
$61.00
Large Group Market:
92.4%
85.0%
Not Applicable
Golden Rule Insurance Companyhttp://www.goldenrule.com/hhs
Insurer’s MLR
MLR Standard
Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market:
76.4%
80.0%
$130.00
Small Group Market:
Not Applicable
Not Applicable
Not Applicable
Large Group Market:
Not Applicable
Not Applicable
Not Applicable
Medical Mutual of Ohio www.medmutual.com
Insurer’s MLR
MLR Standard
Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market:
82.1%
80.0%
Not Applicable
Small Group Market:
81.5%
80.0%
Not Applicable
Large Group Market:
115.5%
85.0%
Not Applicable
Time Insurance Company http://www.assuranthealth.com
Insurer’s MLR
MLR Standard
Average Rebate Per Subscriber (If MLR Standard Not Met)
Individual Market:
77.7%
80.0%
$121.00
Small Group Market:
Not Applicable
Not Applicable
Not Applicable
Large Group Market:
Not Applicable
Not Applicable
Not Applicable
UnitedHealthcare Insurance Company http://www.uhc.com
Insurer’s MLR
MLR Standard
Average Rebate Per Subscriber (If MLR Standard Not Met)
Did you recieve a rebate check from your group health insurance company? This check was sent to you by the health insurance company in accordance with the Patient Protection and Affordable Care Act (PPACA), also referred to as health care reform.
What is this rebate for?
As part of the 2010 Health Care Reform legislation, insurers are required to issue rebates if certain federally mandated criteria are not met. For more information, please refer to the Health and Human Services (HHS) website (http://www.healthcare.gov/law/index.html)
Why was this rebate information sent in more than one mailing?
Some of the regulations and guidance about health care reform was issued later than anticipated. Humana is required by law to send both 1) a check and 2) a government prescribed notification to policyholders who will receive rebates. The fastest and simplest way to comply with this requirement was to send the notification separately from the check.
What is the 85/15 rule?
The 85/15 rule refers the ratio of the amount of premiums that an insurer collects to the amount it spends on claims. Under the PPACA, insurers are obligated to spend a minimum amount of the premium collected on medical claims or towards activities that improve health. In the case of the 85/15 rule, an insurer must spend 85% of the premium collected on medical claims on health improvement activities.
How will we know if we are eligible for a rebate? Does our group have to do anything to
receive our rebate?
Rebate checks are automatically sent to groups and subscribers who are owed rebates.
Rebate checks are starting to be delivered to both group and Individuals. The rebate check is a direct results of the Affordable Car Act.
Medical Loss Ratio Information‐‐The Affordable Care Act requires health insurers in the individual and small group markets to spend at least 80 percent of the premiums they receive on health care services and activities to improve health care quality (in the large group market, this amount is 85 percent). This is referred to as the Medical Loss Ratio (MLR) rule or the 80/20 rule. If a health insurer does not spend at least 80 percent of the premiums it receives on health care services and activities to improve health care quality, the insurer must rebate the difference.
A health insurer’s Medical Loss Ratio is determined separately for individual, small group and large group markets in which the health insurer offers health insurance. No later than August 1, 2012, health insurers must send any rebates due for 2011 and information to employers and individuals regarding any rebates due for 2011.
An accountable care organization (ACO) is a type of payment and delivery reform model that seeks to tie provider reimbursements to quality of care. This health care delivery model is very different from our current fee for service. The ACO is the one aspect of the Patient Protection and Affordable Care Act that could reduce medical cost. There has been mixed reviews from the medical professionalsthat piloted this program. Indianapolis now has 3 ACO medical providers.
Indianapolis University Health ACO, Inc., located in Indianapolis comprised of ACO group practices, networks of individual ACO practices, partnerships between hospitals and ACO professionals and hospitals employing ACO professionals, and a federally qualified health center, with 1,837 physicians. It will serve Medicare beneficiaries in Indianapolis.
Deaconess Care Integration, LLC, located in Evansville is comprised of ACO group practices, networks of individual ACO practices, partnerships between hospitals and ACO professionals and a hospital employing ACO professionals, and a rural health clinic, with 323 physicians. It will serve Medicare beneficiaries in Illinois, Indiana and Kentucky.
Franciscan AHN ACO, LLC, located in Mishawaka is comprised of partnerships between hospitals and ACO professionals, with 245 physicians. It will serve Medicare beneficiaries in the area.
Barack Obama signing the Patient Protection and Affordable Care Act at the White House (Photo credit: Wikipedia)
The Patient Protection and Affordable Care Act, has been upheld by the Supreme Court.
The law will stay intact as it is.
In 2014 we will see the full effect of the law and the true impact on every US Citizen. The Individual and small group health insurance markets will have the big change. Residents will now benefit from the guaranteed issue in the individual market. This means that no one can be declined coverage because of pre existing conditions. Residents will also see the establishment of either a stated based or federal health insurance exchanges. Within these exchanges Indianapolis residents may qualify for federal subsidies. Depending on income, the federal government could a pay a portion of the health insurance premium.
The fear is that we will see health insurance premiums sky rocket. The middle class will be impacted the most especially if they do not qualify for subsidies.
Here at Nefouse & Associates we will continue to find the best options for our clients in both the exchanges and the private market. It will be very interesting to compare both market.
This is a great video explaining the negative consequences of the Health Care Reform law.
The Governor gives an excellent explanation on how negative the impact will be. He also explains our Healthy Indianapolis Plan and how successful it has been. This plan might not qualify under the new federally requirements for health insurance.
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