I just spent 10 days in Canada and had the opportunity to listen to stories from multiple Canadians about there health care experiences.

I was able to speak to 3 different people about their health conditions and what kind of treatment they received. It was very interesting because as they told me their stories I thought how those conditions would have been treated here in United States.

The first situation was a gentlemen that need a double knee surgery. He needed both knees to be essential rebuilt. He had multiple tears in both knees and really had problems walking. When he would walk down the stairs he had to walk step side ways.  He has been on a waiting list for over 5 years. He lived in Toronto which is a major metropolitan city. I was amazed that it had really been 5 years.  Here in the US he might have waited 5 weeks. Now if was on a private health plan here he might have had to pay his out of pocket max for that surgery. If he was on a subsidized plan like Medicaid he would have paid very little out of pocket.

The next case was a women that suffered from Gall Stones. She had been in extreme pain and unable to eat.  It took the Canadian health care system well over a year to figure out what was wrong with her.  The big problem they had was access to diagnostic imaging to detect the stones.  She started the treatment in a rural hospital that had very little resources. They decided to move her treatment to Toronto. At that point she had no relationship with any of the doctors. She stated to me that in the Canadian system its very important to have your primary car physicianact as a gate keeper to all of your care. Once she lost that gate keeper none of the health care providers really show any case of urgency even though she was losing weight. After 8 months she was finally able to get diagnostic services to detect the stone.  Once the stone was it took about 6 months and 3 outpatient surgeries to remove it. There was problems removing the stones because of a lack of having the correct instruments for the surgery.  On the 3rd procedure they were finally able to remove the stones. It was indicated to the patient that the gall bladder was close to dieing because of a lack of blood.  The patient lost almost 50 lbs and was on her death bed. Her husband though that she had a couple of weeks left had the 3rd surgery not worked.  Here in the US this condition could have been corrected in just a couple of months tops.  There would have been immediate access to diagnostic imagining. With our technology the removal of the gall stone would have had a much higher probability of being success on the 1st surgery.  There is absolutely no reason a person should come close to death because of a gall stone.

The 3rd person had a much different story. She was diagnosed with a very rare kind of cancer. So rare that her life expectancy was months if not treated.  She was treated and the cancer went into remission in just a couple of months. When she told me this I asked how she was able to get such fast treatment. She told me that it was her doctor that saved her. The doctor put her on a list of need treatment immediately.  I did not understand.  I asked if there was a panel of people that make these type of decision and she said no just the treating d0ctor. So in this situation it sound like she a doctor that saved her life. I think had she received treatment here for the condition the treatment level would have been about the same with her sharing a small fraction of the total cost.

 With our current system all three situations would have be treated quickly with less suffering for at least 2 of the 3 cases. The trade off would have been the patients would have had to pays a small portion of the overall treatment.

With the new health care reform pushing Universal Care through an Employer Based plan I fear we are going down the socialized medicine route.  The route is going to ration health care on a very large scale if you are insured through a subsidized health plan.  Will US citizens have to wait 8 months for diagnostic imaging? Will it take 3 out patient surgeries to correct a condition? If your condition is not life threatening will you wait indefinitely?

After 2014 we could see to market of health care in this country. Subsidized plans like welfare and medicaid could have a huge drop off of quality of care and rationing. While the private health insurance market will dictate that you get immediate treatment and the quality of that care is the best.

Only time will tell.

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A new group, the States Alliance for Balanced Insurance Regulation, will represent small and midsize insurance-related businesses in the looming battle over the role of federal regulators. With health care reform we have seen the Office of Consumer Information and Insurance Oversight created by the Federal Goverment and SABIR is being created to in protecting the interests of small and mid-sized businesses within and related to the insurance industry.

David Bass will be the executive director of SABIR, and  former Congressman Barry Goldwater Jr. will be the president.

“SABIR will be fundamentally different from other major insurance associations in that we won’t be inclined to support federal regulation,” Bass says. “We were born of the sentiments and frustration from insurers across the nation. They have always operated under state regulation, and the intrusive federal government threatens not only their way of business but their existence as a whole…. SABIR aims to be the collective organ for the protection and promotion of balanced regulation of insurance.”

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With Sept. 23rd right around the corner health plans are ordered by law to cover certain aspect of reform.

There is real uncertainty in the carrier market. We have already seen an exodus of stand alone children policies being offered. The only carrier offer standalone children’s plan is Anthem. There is a chance that they too could pull out of that market. The problem the carriers are having is as Sept 23rd any child under 19 year age is guaranteed issue which means they can not be declined or pre x for any kind of health coverage.  This could lead to major premium increases if the policies are even available.  The government has agreed to allow the carriers to have an open enrollment period for these type of plans which will help.

The other uncertainty right now is the preventive care coverage that is being mandated under the health care reform. The individual carriers are looking to the government to give clarification on these rules. The problem then occurs is designing a plan that is compliant with health care reform and then getting the new plan design approved with the department of insurance in each state.

With these current issues we could see a black out of indiviudal coverage for new policies.  So on Sept. 23rd you might not be able to get a new individual policy. If you are in the market for a policy you need to act fast because who knows how long it could take before carriers clear up these issues with both the Federal Gov. and local Gov.  On a positive note they could get all this resolved before Sept. 23rd.

Current estimates on possible price increase for individualplans for this aspect of health care reform is anywhere from 4%-8%.  There are no available estimates on the price increases for a stand alone child’s policy.

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Rep. Wally Herger (R-Calif.) filed a discharge petition Tuesday that would get rid of the Democrats’ health care reform and replace it with a Republican alternative.
His push follows Rep. Steve King’s (R-Iowa) petition to simply repeal the reform without replacing it with new legislation. King’s petition currently has 170 supporters, while Herger’s got 28 in its first day.

I think the Repeal process is going to continue. The Republican party realizes the negative impact that the health care reform is going to have.  We are starting to see some estimates of the cost of the health insurance exchange and its very high. The burden to small business that this health care reform is going to have is very high. The cost to the states with the expansion of medicaid is extremely high.  The high probability of small group health carriers dropping out of the market is likely because of the reform. The Medical Loss Ratio impact on all health insurance providers could force carriers to exit certain regions. The medical review panel for Medicare could be seen as the death panel because they will decide what is covered.  The tax penalty for not carrying insurance can be seen as unconstitutional. This is just a few bullet points as you did into the bill from actuarialstandpoint the reform could collapse the entire health care system.

This is why we will contiune to see a push to Repeal this law. We will also see the conservative party go after funding for this law.

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As the health care reform becomes more and more clear we are starting to see the debate to repeal certain aspects. This recent legislation to repeal makes a lot of sense. The entire purpose of the Health Savings Accounts and Flexible Spending Accounts is to make consumers more engaged in their health care spending.  With these plans there is tax free dollars that can be used for the purchases of health care. One of the big issues is over the counter drugs (OTC). From a consumer standpoint if your acid reflux drug can be purchased OTC for $7 for a 90 day supply compared with a brand name drug that is $89 for 30 days supply that is a huge cost savings. If the OTC treats the conditions effectively and your Doctor agree it just makes sense. With the HSA and FSP account you can use pre tax money to buy the OTC drug thus creating consumerism. The new health care law take away the tax incentives of using your money for OTC drugs.

Senator Kay Bailey Hutchison’s (R-TX) recently-introduced Patients’ Freedom to Choose Act, legislation that repeals two provisions included in the Patient Protection and Affordable Care Act.

Under current law, starting in 2011, the PPACA will prohibit individuals from using either their Health Savings Account (HSA) or Flexible Spending Account (FSA) funds to purchase over-the-counter medication unless they have a prescription from their doctor. And, starting in 2013, the PPACA institutes an annual FSA contribution cap of $2,500.

The Patients’ Freedom to Choose Act strikes these arbitrary provisions from the law. Many individuals and employers will benefit from this important legislation. Over 80% of all large employers that offer an FSA to their employees include a limit that is over this $2,500 threshold. According to a report issued by America’s Health Insurance Plan, over ten million Americans are insured with an HSA-compatible plan.

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New Consumer Protections Start This Fall

The new Patients’ Bill of Rights regulations detail a set of protections that apply to health coverage starting on or after September 23, 2010. They are:

No Pre-Existing Condition Exclusions for Children Under Age 19. The new regulations will prohibit insurance plans from denying coverage to children based on pre-existing conditions. This ban includes both benefit limitations (e.g., an insurer or employer health plan refusing to pay for chemotherapy for a child with cancer because the child had the cancer before getting insurance) and outright coverage denials (e.g., when the insurer refuses to offer a policy for the child because of the child’s pre-existing medical condition). These protections will apply to all types of insurance except for individual policies that are “grandfathered,” and will be extended to Americans of all ages starting in 2014.

No Arbitrary Rescissions of Insurance Coverage. Right now, insurance companies are able to retroactively cancel your policy when you become sick, or if you or your employer made an unintentional mistake on your paperwork.

 Under the regulations, insurers and plans will be prohibited from rescinding coverage – for individuals or groups of people – except in cases involving fraud or an intentional misrepresentation of material facts. Insurers and plans seeking to rescind coverage must provide at least 30 days advance notice to give people time to appeal. There are no exceptions to this policy.

 No Lifetime Limits on Coverage. Millions of Americans who suffer from costly medical conditions are in danger of having their health insurance coverage vanish when the costs of their treatment hit lifetime limits. The regulation prohibits the use of lifetime limits in all health plans and insurance policies issued or renewed on or after September 23, 2010.

 Restricted Annual Dollar Limits on Coverage. Annual dollar limits on what an insurance company will pay for health care will phase out over the next three years until 2014, when the Affordable Care Act bans them for most plans. However, employers who demonstrate that current annual limits are necessary to prevent a significant loss of coverage or increase in premiums will be allowed to delay complying with these rules. Limited benefit insurance plans – which are often used by employers to provide benefits to part-time workers — are examples of insurers that might seek this kind of delay. These restricted annual dollar limits apply to all insurance plans except for individual market plans that are grandfathered.

 Protecting Your Choice of Doctors. Being able to choose and keep your doctor is a key principle of the Affordable Care Act. The new rules make clear that health plan members are free to designate any available participating physician as their primary care provider. The rules allow parents to choose any available participating pediatrician to be their children’s primary care provider. These policies apply to all individual market and group health insurance plans except those that are grandfathered.

 Removing Insurance Company Barriers to Emergency Department Services. Some insurers will only pay for health care provided by a limited number or network of providers – including emergency health care. Others require prior approval before receiving emergency care at hospitals outside of their networks. The new rules make emergency services more accessible to consumers and limit the amount of cost-sharing for emergency services received out of network.

 The rules also set requirements on how health plans should reimburse out-of-network providers. This policy applies to all individual market and group health plans except those that are grandfathered.

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Under the Patient Protection and Affordable Care Act, a non-grandfathered group health plan must adopt an improved internal claims and appeal process and follow minimum requirements for external review. On July 23, 2010, interim final regulations were issued implementing these requirements (the Interim Final Rule). The appeals process rules are effective for plan years beginning on or after September 23, 2010. Comments on the Interim Final Rule are being accepted until September 21, 2010.

Key provisions of the Interim Final Rule include information on:

  • How to comply with updated internal claims and appeals processes;
  • Determining whether a state or federal external review process applies for appeals, along with guidance for each process; and
  • Requirements for notices in connection with the appeals process.

This Legislative Brief summarizes the new Interim Final Rule. Please read below for more detailed information. For a copy of the regulations, see


Internal Claims and Appeals Process for Group Health Plans

Health care reform requires group health plans to implement an effective internal claims and appeals process. These plans, as well as health insurance issuers providing their health insurance coverage, must follow the Department of Labor’s claims procedure rules for group health plans.[1]

In addition to the existing DOL claims procedure regulations, group health plans must follow a number of new requirements:

  1. New Definition of “Adverse Benefit Determination.” The definition of the term adverse benefit determination is found in the claims procedure regulations. It includes a denial, reduction, termination of, or failure to pay for (in whole or in part), a benefit under the plan. It includes decisions based on an individual’s eligibility to participate in the plan, a benefit not being a covered benefit, imposition of an exclusion, or a benefit being experimental or not medically necessary. Denials can include both pre- and post-service claims.

The Interim Final Rule adds rescissions of coverage to the definition of the term adverse benefit determination. A rescission is a cancellation or discontinuation of coverage that has a retroactive effect. A cancellation because of a failure to timely pay premiums for coverage is not considered a rescission.

  1. Expedited Notice for Urgent Care Claims. Under the Interim Final Rule, group health plans must notify claimants of a benefit determination involving an urgent care claim more quickly. The new deadline is as soon as possible, taking into account the medical circumstances, but not later than 24 hours after the plan gets the claim. There is an exception to the deadline if the claimant does not provide enough information to the plan. The prior rule required the notice to be given within 72 hours. The change is attributable to faster decision-making capabilities, due to electronic communication.
  2. Full and Fair Review. In addition to complying with the claims procedure regulations’ existing requirements, group health plans must follow additional rules to make sure claimants receive a full and fair review. Specifically, the plan must give the claimant any new evidence related to the claim or new rationale for a decision, free of charge. It must be provided as soon as possible and early enough before the appeal deadline to let the claimant respond.
  3. Avoiding Conflicts of Interest. Group health plans must make sure that all claims and appeals are decided in a way that avoids conflicts of interest. The decision method must be designed to ensure the independence and impartiality of the decision-makers. The decision to hire a person involved in deciding claims or appeals must not be made based on the likelihood that they will support a denial of benefits. For example, a plan cannot provide bonuses based on the number of denials made by a claims adjudicator. Also, a plan cannot hire a medical expert based on his or her reputation for outcomes in contested cases, rather than his or her professional qualifications.
  4. Notice. The Interim Final Rule provides new standards regarding notice to enrollees. Group health plans must provide notices required by the claims procedure regulations in a culturally and linguistically appropriate manner. See the section entitled “Required Notices” below for a discussion of the culturally and linguistically appropriate standards. The notices must also include the following additional content:
  • Information sufficient to identify the claim involved, including the date of service, the health care provider, the claim amount, the diagnosis code and its meaning, and the treatment code and its meaning;
  • The reason for the denial must include the denial code and its meaning, as well as any standard used in denying the claim;
  • A description of available internal appeals and external review processes, including information about how to initiate an appeal; and
  • Contact information for any applicable office of health insurance consumer assistance to assist individuals with the internal claims and appeal and external review processes.
  1. Deemed Exhaustion of Internal Claims and Appeals Processes. If a plan fails to comply with these rules, the claimant will be deemed to have exhausted the plan’s internal claims and appeals process, even if the plan claims that it substantially complied with the requirements. That means that the claimant is free to pursue other remedies, such as external review or a lawsuit.
  2. Continued Coverage Pending Outcome of Internal Appeals. Under the new rules, a plan must continue to provide coverage to the claimant until an internal appeal is resolved. Generally, this means that plans may not reduce or terminate an ongoing course of treatment without advance notice and an opportunity for advance review. Also, anyone in an urgent care situation or receiving an ongoing course of treatment may be allowed to proceed with an expedited external review at the same time as the internal appeal.

External Review Standards

Group health plans must comply with either a state external review process or the federal external review process. The Interim Final Rule provides guidance on which process must be followed.

State Standards for External Review

If a state external review process that applies to and is binding on an insurance issuer includes the consumer protections in the NAIC Uniform Model Act in place on July 23, 2010, then the issuer must comply with that state external review process. In that case, where benefits under a group health plan are provided through health insurance coverage, the issuer must provide the external review process and the group health plan itself is not obligated to do so. Some self-insured group health plans may be subject to the state external review process if they are not subject to ERISA preemption.

Any plan or issuer that is not subject to a state external review process must comply with the federal external review process. A plan or issuer will be subject to the federal process if there is not state external review process or if the state external review process does not meet the minimum requirements of the NAIC Uniform Model Act.

The Department of Health and Human Services will determine whether a state external review process meets the minimum requirements. HHS will also provide a transition period for plan years beginning before July 1, 2011, where existing state external review processes will be treated as meeting the minimum requirements. This transition period will give states the opportunity to review and amend their processes. For plan years beginning on or after July 1, 2011, the federal external review process will apply unless HHS determines that the state process meets the minimum standards.

Federal External Review Process

The health care reform law requires a federal external review process to be established. The Interim Final Rule does not establish that process, but it does describe the standards that will be included. Plans or issuers that are not subject to a state external review process will have to follow the federal process. For an insured group health plan, if either the issuer or the plan complies with the federal process, then the obligation is satisfied for both the plan and the issuer.

The federal external review process will apply to most adverse benefit determinations or final internal adverse benefit determinations, including rescissions. However, it will not apply to denials based on a participant or beneficiary’s ineligibility for the plan.

The standards to be issued for the federal external review process will include procedures for initiating and conducting the review, an expedited external review process for certain claims, additional consumer protections for claims involving experimental or investigational treatment, and additional notices and disclosures to claimants.

Required Notices 

Notices of available internal claims and appeals and external review processes must be provided in a culturally and linguistically appropriate manner. This means providing notices in a non-English language if certain thresholds are met for the number of people who are literate in the same non-English language.

For a group health plan that covers fewer than 100 participants at the beginning of the plan year, the threshold is 25 percent of all plan participants being literate in only the same non-English language. For a plan that covers 100 or more participants, it is the lesser of (a) 500 participants, or (b) 10 percent of all plan participants.

If an applicable threshold is met, the notice must be provided in the non-English language upon request. In addition, the plan or issuer must include a statement in the English version of all notices offering the notice in the non-English language. The statement must be prominently displayed in the non-English language. Once a request has been made by a claimant, all future notices to that claimant must be provided in the non-English language. Also, if the plan or issuer has a customer assistance process that answers questions or gives assistance with filing claims and appeals (such as a telephone hotline), the assistance must be provided in the non-English language.

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Missouri voters on Tuesday overwhelmingly rejected a key provision of health care reform law. About 71 percent of Missouri voters backed a ballot measure, Proposition C, that would prohibit the government from requiring people to have health insurance or from penalizing them for not having it. Missouri is the first state to challenge aspects of the federal law in a referendum.

This is just another clear sign that people are not happy about the health care Law.  Anytime there are 71% of people opposing that is a big number.  The Missouri Hospital Association spent $400,000 trying to warn Missouri residents that Proposition C could raise prices at the hospitals. Even with $400,000 being spent to oppose proposition C it still passed by 71%.  The could start a chain reaction of other states opposing the health care reform by referendum.

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With the Affordable Care Act comes medicare Reforms. Historically, Medicare has often led the entire health care system in the adoption of quality and payment innovation. The reforms that go into place will not only affect Medicare but could change the way the health care system is paid.

Meidcare reform means Reform our health care delivery system, appropriately price services and modernize financing systems, and fight waste, fraud and abuse.

Unnecessary hospital readmissions

The Affordable Care Act creates a “hospital readmissions reduction program,” which will help hospitals smooth transitions for patients and reward hospitals that are successful in reducing avoidable readmissions.

 Hospital acquired conditions

The Affordable Care Act imposes payment penalties on the 25 percent of hospitals whose rates of hospital acquired conditions like bedsores, complications from extended use of catheters, and injuries caused by falls, are the highest.

 Rewarding Better Care

CMS will expand payments for value—in 2013—by rewarding better care for five of the most prevalent conditions. Physician payments will also become more closely linked to value with the launch of a physician value-based payment system and the implementation of a “value-modifier” that rewards physicians who deliver better care.

 Accountable Care Organizations

 The Affordable Care Act promotes team-based health care through Accountable Care Organizations (ACOs) under the Medicare shared savings program

Center for Medicare and Medicaid Innovation

To support the ongoing development of new models of payment and delivery, the Affordable Care Act establishes the Center for Medicare and Medicaid Innovation

 Independent Payment Advisory Board

The Affordable Care Act also establishes the Independent Payment Advisory Board, or IPAB, to monitor the fiscal health of the Medicare program and to recommend payment policy revisions to contain Medicare cost growth.

Improvements to productivity and market basket adjustments in certain provider settings

The Affordable Care Act ensures that Medicare more accurately accounts for productivity when determining provider payments and revises annual payment updates in certain health care settingsTo support the ongoing development of new models of payment and delivery, the Affordable Care Act establishes the Center for Medicare and Medicaid Innovation

Ending Overpayments to Medicare Advantage Plans

A major inefficiency that the Affordable Care Act addresses is overpayments to private insurance plans that serve Medicare beneficiaries, known as Medicare Advantage plans

Modified equipment utilization factor for advanced imaging

Provisions in the Affordable Care Act address widely recognized areas of overutilization, such as advanced imaging services, which not only wastes resources but may also pose a danger to beneficiaries from needless exposure to radiation

Bidding for Durable Medical Equipment 

CMS also continues to implement competitive bidding for durable medical equipment (DME), which the Affordable Care Act accelerated

Targeted and efficient anti-fraud activities

The new law gives CMS the authority to target anti-fraud activities to geographic areas, provider types, or services based on the type or level of risk posed to the program.

 Ensures transparency of ownership and ensures provider compliance with Medicare’s requirements

The Affordable Care Act includes new protections that require all providers to have compliance plans. This will ensure that providers are abreast of Medicare requirements and in compliance with them and can focus their attention on patient-care.

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The new health care reform forces everyone to buy health insurance or pay a tax penalty. This has become a major debate with many who oppose the health care reform. This requirement is the corner stone of the white house health plan.  The argument was that if everyone is on a health plan that will help to offset costs for both the insurer and providers. There is a long legal battle a head but if this aspect was determined to be unconstitutional it would have a huge impact on the over all health care reform.

U.S. District Judge Henry Hudson refused to dismiss the state’s lawsuit, which argued the requirement that its residents have health insurance was unconstitutional.

The Judge who noted that his ruling was an initial step, decided the law was ripe for review. He said the issue the state raised — whether forcing residents to buy something, namely health care, is constitutional — had not been fully tested in court.

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