States Are Cleared to Allow Less-Comprehensive Health Plans

Many families are searching for options in the individual insurance markets. This year we are seeing more non-traditional options added to the mix. This article describes how the US Government may start allowing subsidies on nontraditional plans. The saying “buyer beware” applies in healthcare. If a plan seems very inexpensive or too good to be true, look at the details and ensure there are valid networks and adequate coverage if you have a serious or costly health issue. With deductibles and coinsurance rising so high for most families, small procedures are usually paid out of pocket. So make sure your insurance is there for the large and catastrophic issues to ensure you can afford to get care.

States Are Cleared to Allow Less-Comprehensive Health Plans
Trump administration would let federal subsidies cover plans that don’t meet ACA rules
By WSJ Michelle Hackman

WASHINGTON—States will be allowed to offer less-comprehensive health plans yet still qualify for federal subsidies under a new Trump administration policy that will let them skirt key regulations under the Affordable Care Act.
The change, announced by the Department of Health and Human Services on Monday, marks a fundamental shift in how the federal government enforces the states’ administration of the ACA, accelerating a trend in which red and blue states can craft significantly different health-care policies under the same federal law.
Under the guidelines, the administration will consider state ACA waiver requests that would allow federal subsidies to cover skimpier, less-expensive plans that don’t meet the law’s requirements. Such plans can be cheaper for consumers and might be preferable for younger and healthier Americans, but many health-care analysts say they could end up siphoning healthy customers out of the ACA market, resulting in higher premiums for older people and others with pre-existing medical conditions who need fuller plans.
Seema Verma, who heads the Centers for Medicare and Medicaid Services, which oversees the ACA, described the move as a major step in lowering health-care prices.
“Premiums are still much too high, and choice is still too limited,” she said in a statement. “This is a new day—this is a new approach to empower states to provide relief.”
Democrats said the move contradicted Republicans’ claims that they want to protect people with pre-existing medical conditions from high premiums.
“The American people should look at what Republicans are doing, rather than what they’re saying, when it comes to health care,” said Senate Minority Leader Chuck Schumer (D., N.Y.). “Just weeks before the election, Republicans are once again undermining protections for people with pre-existing conditions and sabotaging our health-care system.”
The Obama administration also allowed states to submit proposals to waive ACA requirements, but with far more limitations.
Obama officials required that under any waivers, individuals still must have health plans that were at least as expansive and affordable as those required by the health law. The current administration will instead require that those plans simply be available, along with the less-regulated options.
Since Republicans in Congress failed last year to repeal the ACA, the Trump administration has steadily pursued policies giving individual states the option of weakening the law’s provisions.
The administration has moved, for example, to permit the sale of short-term health policies and let businesses and some individuals band together in “associations” to obtain plans that don’t comply with the ACA. Congress last year also successfully repealed the ACA’s requirement that individuals purchase health care or pay a penalty. That repeal will take effect in 2019.
“This was the plan from the start,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan health-policy think tank. “If the ACA couldn’t be repealed outright, then the next best thing is to let states do it one by one.”
The latest guidelines respond to requests from conservative-leaning states whose leaders have expressed interest in rolling back ACA rules they say inflate consumers’ health costs, such as a requirement that all insurance plans cover certain benefits.
Iowa and Oklahoma, for example, submitted plans last year that would have erased key ACA regulations. The administration rejected those proposals under the stricter Obama-era guidelines.
The administration in the new guidelines encouraged states to bolster “private” insurance plans, suggesting it might not approve state plans that propose putting federal ACA money toward systems that use more government funding.
Some Democratic-leaning states have signaled an interest in adopting such systems. Gavin Newsom, a Democratic candidate for California governor, has vowed to move toward such an arrangement should he be elected in November.
Separately, the administration will propose a new rule on Tuesday allowing employers to allot their workers money to purchase health plans on the individual market, according to a senior administration official. The Obama administration had prohibited employers from doing so, in part fearing that employers would push only their older and sicker employees onto the individual market, where consumers buy insurance on their own.
Under the new rule, employers wouldn’t be able to choose which workers to offer money rather than an employer-sponsored health plan, limiting the possibility that business owners would take advantage of the new rules to direct only their most expensive workers to the individual market, the official said.
Write to Michelle Hackman at Michelle.Hackman@wsj.com

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Medical Cost Advocate was featured in a documentary by a French journalist

A French journalist from CAPA TV (the equivalent of 60 Minutes in the US) came to our office and interviewed our CEO Derek Fitteron regarding our advocacy services. The interview was also about our client Stella who is featured on the previous blog. Watch how Stella was very stressed over the thousands of dollars in medical bills that she received when her triplets were born prematurely, and how her Advocate helped her in resolving these bills.

To watch it subtitled in English, go to settings➡️subtitles➡️auto translate➡️English.

You will see Stella, Stella’s advocate Maria, and Derek beginning at the 7:20 mark.

 

 

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Why does it cost $32,093 just to give birth in America?

Our company receives many inquiries like this. Stella had approached us last April, emotionally distraught over the thousands of dollars in medical bills she was receiving related to the premature birth of her triplets. One of our expert medical billing advocates was assigned to take her case. She was very happy with the favorable outcome (a reduction in her final balance by an incredible amount), and so were we. Like Stella, we may be able to help you too. 

The US is the most expensive nation in the world in which to have a baby – and it may factor into thousands of bankruptcies each year.

Tue 16 Jan 2018

Jessica Glenza in New York – The Guardian

Stella Apo

Stella Apo Osae-Twum and her husband did everything by the book. They went to a hospital covered by insurance, saw an obstetrician in their plan, but when her three sons – triplets – were born prematurely, bills started rolling in.

The hospital charged her family $877,000 in total.

“When the bills started coming, to be very honest, I was an emotional wreck,” said Apo Osae-Twum. “And this is in the midst of trying to take care of three babies who were premature.”

America is the most expensive nation in the world to give birth. When things go wrong – – from preeclampsia to premature birth – costs can quickly spiral into the hundreds of thousands of dollars. While the data is limited, experts in medical debt say the costs of childbirth factor into thousands of family bankruptcies in America each year.

It’s nearly impossible to put a price tag on giving birth in America, since costs vary dramatically by state and hospital. But one 2013 study by the advocacy group Childbirth Connection found that, on average, hospitals charged $32,093 for an uncomplicated vaginal birth and newborn care, and $51,125 for a standard caesarean section and newborn care. Insurance typically covers a large chunk of those costs, but families are still often on the hook for thousands of dollars.

Another estimate from the International Federation of Health Plans put average charges for vaginal birth in the US at $10,808 in 2015, but that estimate excludes newborn care and other related medical services. That is quintuple the IFHP estimate for another industrialized nation, Spain, where it costs $1,950 to deliver a child, and the cost is covered by the government.

Even the luxurious accommodations provided to the Duchess of Cambridge for the birth of the royal family’s daughter Princess Charlotte – believed to have cost up to $18,000 – were cheaper than many average births in America.

Despite these high costs, the US consistently ranks poorly in health outcomes for mothers and infants. The US rate of infant mortality is 6.1 for every 1,000 live births, higher than Slovakia and Hungary, and nearly three times the rate of Japan and Finland. The US also has the worst rate of maternal mortality in the developed world. That means America is simultaneously the most expensive and one of the riskiest industrialized nations in which to have children.

American families rarely shoulder the full costs of childbirth on their own – but still pay far more than in other industrialized nations. Nearly half of American mothers are covered by Medicaid, a program available to low income households that covers nearly all birth costs. But people with private insurance still regularly pay thousands of dollars in co-pays, deductibles and partially reimbursed services when they give birth. Childbirth Connection put the average out of pocket childbirth costs for mothers with insurance at $3,400 in 2013.

In Apo Osae-Twum’s case, private insurance covered most of the $877,000 bill, but her family was responsible for $51,000.

Apo Osae-Twum was the victim of what is called “surprise billing”. In these cases, patients have no way of knowing whether an ambulance company, emergency room physician, anesthesiologist – or, in her case, a half dozen neonatologists – are members of the patient’s insurance plan.

Even though Apo Osae-Twum went to a hospital covered by her insurance, none of the neonatologists who attended to her sons were “in-network”. Therefore the insurance reimbursed far less of their bills.

There are few studies that estimate the number of families who go bankrupt from this type of unexpected expense. One of the best estimates is now outdated – conducted 10 years ago. But one of the authors of that research, Dr Steffie Woolhandler, estimates as many as 56,000 families each year still go bankrupt from adding a new family member through birth or adoption.

“Why any society should let anyone be bankrupted by medical bills is beyond me, frankly,” said Woolhandler. “It just doesn’t happen in other western democracies.”

Since Woolhandler conducted that research in 2007, 20 million Americans gained health insurance through the Affordable Care Act health reform law, and consumer protections were added for pregnant women. But Republicans and the Trump administration have pledged to repeal these consumer protections.

“People face a double whammy when they’re faced with a medical condition,” said Woolhandler. Bankruptcy is often, “the combined effect of medical bills and the need to take time off work”.

There is no nationwide law that provides paid family leave in the US, meaning most families forego income to have a child.

And although childbirth is one of the most common hospital procedures in the nation, prices are completely opaque. That means Americans don’t know how much a birth will cost in advance.

Dr Renee Hsia, an emergency department physician at the University of California San Francisco and a health policy expert likened the experience to buying a car, but not knowing whether the dealership sells Fords or Lamborghinis. “You don’t know, are you going to have a complication that is a lot more expensive? And is it going to be financially ruinous?”

According to Hsia’s 2013 study, a “California woman could be charged as little as $3,296 or as much as $37,227 for a vaginal delivery, and $8,312 to $70,908 for a caesarean section, depending on which hospital she was admitted to.”

Apo Osae-Twum and her family only found relief after a professional medical billing advocate agreed to take their case. Medical Cost Advocate in New Jersey, where Derek Fitteron is CEO, negotiated with doctors to lower the charges to $1,300.

“This is why people are scared to go to the doctor, why they go bankrupt, and why they forego other things to get care from their kids,” said Hsia. “I find it heartbreaking when patients say… ‘How much does this cost?’

https://www.theguardian.com/us-news/2018/jan/16/why-does-it-cost-32093-just-to-give-birth-in-america?CMP=fb_gu

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Changes to the Affordable Care Act

This week President Trump made the first move to begin the replacement of the Affordable Care Act. By issuing this executive order, this will drive immediate compliance. However, it will touch off reactions from all healthcare stakeholders including patients, providers, insurers, employers and the government. No matter which side of the political aisle you sit on, be prepared. The coming changes to the Affordable Care Act will require cooperation and compromise not seen from Washington in many years. It should be an interesting year for healthcare in 2018.

By John Tozzi and Zachary Tracer, Bloomberg

‎October‎ ‎13‎, ‎2017‎
The Trump administration is cutting tens of millions of dollars from organizations that help Americans enroll in Obamacare health plans, leaving some of the groups scrambling to shrink their operations weeks before enrollment for 2018 coverage opens on Nov. 1.
The organizations, called navigators, say the funding cuts have been arbitrary, opaque and don’t follow the Trump administration’s stated method for calculating the reductions. The groups had been counting on money for the final year of a three-year grant program, and most didn’t learn how deep the cuts would be until after last year’s funding expired on Sept. 1.
When the Trump administration announced in late August that it would make the reductions, it said they would hold inefficient groups accountable and navigators that met prior enrollment goals would maintain funding.
Navigator groups say it hasn’t worked out that way.
Catherine Edwards, the executive director of the Missouri Association of Area Agencies on Aging, said her group helped 3,945 people last year sign up for health insurance, exceeding their goal. Their grant was cut 62 percent, to $349,251, from $919,902.
“This administration has been doing everything it can to make sure the Affordable Care Act fails,” Edwards said. “They’re tying our hands behind our back to make sure this does fail.”
Edwards’ group had to cut enrollment help and advertising, and will field 52 navigators this year, down from 72, leaving some rural parts of the state without any enrollment assisters.
A spokeswoman for the Department of Health and Human Services declined to provide data on navigator groups’ performance or to explain why some organizations that appeared to meet their goals were cut.
Trump’s Dismantling
Navigators focus on enrolling people with complex family or financial situations, and offer in-person assistance to those who have trouble enrolling online because of language barriers or lack of internet access. Some groups serve ethnic enclaves or vulnerable communities unreached by broader marketing campaigns.
The cuts are likely to hit rural areas the hardest, potentially depressing enrollment in parts of the country where insurers have already pulled back.
President Donald Trump, having watched Republicans in Congress fail to repeal the Affordable Care Act, has taken aim at the law using regulations and executive actions. On Thursday, Trump signed an executive order mean to make it easier for people to buy insurance that doesn’t meet the ACA’s standards, potentially drawing healthy people out of the ACA market. Late that evening, the administration said it would stop making subsidy payments to insurers that help lower-income people afford co-pays and other cost-sharing.
“We’re starting that process” of repeal and replace, Trump said at the White House Thursday.
The administration has also slashed advertising for Obamacare signups by 90 percent, and plans to take down the healthcare.gov website for maintenance periods in the middle of the season. Premiums for next year are rising as insurers say they’re uncertain about the law’s future.
A Nationwide Pattern
What happened to Edwards’ group in Missouri has happened around the country.
Covering Wisconsin, the larger of two navigator programs in that state, enrolled 2,287 people in private health plans and another 1,370 people in Medicaid last year, exceeding targets for both, director Donna Friedsam said in an email. Its funding was cut from to $576,197 this year, from $998,960 last year, a 42 percent reduction. As a result, its navigators won’t be in 11 of the 23 counties it served over the last year.
The Ohio Association of Foodbanks, the primary navigator in the state, helped nearly 9,000 Ohioans enroll in private plans and another 35,000 apply for Medicaid since 2013. The group “met, nearly met, or exceeded” goals for four years, said executive director Lisa Hamler-Fugitt. Despite that, funding was cut by 71 percent, to $485,000, from $1.7 million.
The funding cuts seem like sabotage, not accountability, Hamler-Fugitt said. Her group closed its navigator program and let most of its staff go rather than try to sustain it at the lower funding level.
“If we were such poor performers, why were we not notified and corrective action taken? Because we weren’t,” she said.
Smaller and Sicker
Along with the navigator cuts and other regulatory moves, confusion over Obamacare’s fate will likely lead to “a smaller, sicker group of enrollees,” said Sabrina Corlette, a research professor at the Georgetown University Health Policy Institute.
Customers who don’t shop around for coverage could “have huge sticker shock” if they do nothing and are automatically re-enrolled in their current plans, Corlette said.
The navigator grants are funded by a levy on health plans in the insurance marketplaces, which benefit from the marketing and outreach. Trump administration officials didn’t respond to questions about how unspent fees would be used.
Cut at the Last Minute
The Trump administration said in August that it would cut funding to the navigators by 39 percent, down from $62.5 million the last enrollment period. The cuts apply only to states that have health-care markets run by the federal government — 16 operate their own.
They were announced just days before the new grants were supposed to begin. The agency had affirmed grant amounts earlier in the year.
“All indications were everything was going very well,” said Allen Gjersvig, director of navigator and enrollment services at the Arizona Alliance for Community Health Centers. Staff at CMS told the group as late as Aug. 28 that the funding was on track, he said. Days later, the Alliance’s navigator grant was cut from about $1.1 million to $700,000.
His confusion isn’t unique. Of the 48 navigator programs that responded to a survey from the Kaiser Family Foundation, about half said no rationale was provided, and another 40 percent said the explanation was “very or somewhat unclear.”
The Palmetto Project in South Carolina had its navigator grant cut from $1.1 million to $500,000, and will have 30 navigators instead of the 62 it planned on, said Shelli Quenga, the organization’s director of programs. It plans to leave some rural areas without in-person help.
“I think there will be people who choose poorly,” Quenga said. “There will also be people who just give up.”

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Three States Where Obamacare Premiums May Rise More Than 50% in 2018

As of this writing, the Affordable Care Act, also known as Obamacare, still remains the law of the land, despite efforts to repeal and replace it. The uncertainty about where this is headed has created uncertainty in the marketplace and thus rising prices. There are 3 states where Obamacare premiums may rise more than 50% in 2018 including New York, Georgia, and Maryland. The reasons for this premium increase are enumerated in the article below. Is this a sign of things to come in 2018? Medical Cost Advocate can help you navigate our complex health care system and find the insurance plan that best suits your needs.

By Sean Williams, Aug 26, 2017

Despite President Trump having been in office for more than seven months now and Republicans retaining control of both houses of Congress, the Affordable Care Act, which is best known as Obamacare, remains the health law of the land.

The hallmark legislation signed into law by former President Barack Obama in March 2010 has taken care of its primary goal of reducing the uninsured rate. Between late 2013 and mid-2016, we witnessed the aggregate uninsured rate fall from 16% to around 9%, representing an all-time low, according to the Centers for Disease Control and Prevention.

However, Obamacare has also been a relatively unpopular law since its inception. Until recently, when Republicans tried unsuccessfully on numerous occasions to repeal and replace Obamacare, you could easily count on two hands just how many months over the past six-plus years that Obamacare had more “favorable” views than “unfavorable” when it came to Kaiser Family Foundation’s Health Tracking poll. Most Americans never really cared for the individual mandate, which required them to purchase health insurance, and they certainly disliked the Shared Responsibility Payment, which required them to pay a penalty if they didn’t purchase health insurance.

Nevertheless, rate requests have been submitted by insurance companies in nearly every state, and we’re heading into 2018 with the strong likelihood that Obamacare will remain law.

President Trump threatens to go nuclear on Obamacare

Of course, that doesn’t mean President Trump has to like what’s transpired.

The Commander in Chief has suggested that if Congress doesn’t get its act together and repeal Obamacare, he’d consider going nuclear and withholding cost-sharing reductions in order to topple the program. Cost-sharing reductions, or CSRs, are the subsidies paid to lower-income individuals and families making between 100% and 250% of the federal poverty level, and they help cover the costs of heading to the doctor (e.g., copays, deductibles, and coinsurance). More than 7 million people enrolled via Obamacare’s marketplace exchanges qualified for CSRs in 2017. Without CSRs, lower-income folks would have health insurance but would probably be unable to afford the copay and deductible costs of being seen by a doctor.

This all ties back to a 2014 lawsuit filed by the House Republicans against Sylvia Burwell, who at the time was the Secretary of the Department of Health and Human Services (HHS). The GOP argued that only Congress has the right to apportion federal funding, which in this case meant approving funds for CSR payments. Since these subsidies weren’t getting the alleged proper approval, Republicans sued. In May 2016, they won; however, Judge Rosemary Collyer stayed her order, given the likelihood of an appeal from the Obama administration, which did come in. That appeal remains in place today, though Trump has appointed Tom Price as the new HHS secretary. All Donald Trump would have to do is drop the appeal of the case, and Collyer’s order would halt further CSR payments to insurers and low-income individuals and families.

Insurers, not knowing what will happen, have been requesting significant rate hikes to take into account both adverse selection (i.e., getting more sick enrollees than expected) and the possibility that these CSR subsidies could be taken away, in which case members may not be able to pay their medical bills. According to ACASignUps.net, which has aggregated price request data for nearly every state, the average rate hike request if CSRs remain in place is almost 16% in 2018, while premiums could jump by an average of 30% if CSRs are taken away.

Three states with possibly the highest average rate-hike requests

As in years past, we’ve seen a wide variance of rate requests. Alaska, which is known for having the highest monthly premiums, could see premiums drop by an average of 30% to 22% next year, simply depending on whether or not CSRs are kept or taken away. The drop is thanks to a new reinsurance program within the state.

Oklahoma could also see premiums fall by 1.9% in 2018 if CSRs are paid, or rise by an average of 8.7% if they aren’t. While good news on the surface, it’s little consolation considering the 76% that Blue Cross Blue Shield of Oklahoma hiked rates in 2017.

At the other end of the spectrum, three states could be in line to hike premiums by more than 50% if CSRs don’t get paid. Please note the emphasis on that “if,” because it could mean significantly more money flowing out of the pockets of unsubsidized Americans come 2018 if CSRs get taken away.

These states are:

  1. New York: According to published rate requests in early June from the Department of Financial Services, insurers in the Empire State are requesting an average hike of 16.6% if the CSRs remain. This comes on top of the average 18% rate hike they requested last year. However, ACASignUps.net has New York pegged for an average weighted rate hike of up to 50.5% should CSRs be taken away. Last year, regulators only managed to lower New York insurers’ rate-hike request to 16.6% from 18%, so there’s little hope of much solace for New Yorkers on Obamacare in the coming year. Insurers provided little info on what’s driving their double-digit rate-hike requests, but it’s believed to be uncertainty stemming from future CSR payments.
  2. Georgia: The Peach State is another that could be facing some very extreme premium increases should CSRs be taken away by President Trump. The weighted average rate hike for Georgia, inclusive of CSRs, is already a whopping 29.2%. However, if those CSRs aren’t there, Georgians could see premiums spike higher by a weighted average of 52.2%. Feel free to point the finger at Anthem (NYSE: ANTM), the largest in-state Obamacare insurer, whose Blue Cross Blue Shield of Georgia is requesting a rate hike of 40.6% with CSRs continuing to be paid, or 63.6% without them. Anthem is among the biggest beneficiaries of government-sponsored subsidies under Obamacare, and their removal could possibly hurt it more than any other national insurer.
  3. Maryland: Taking the cake with the largest possible average weighted premium increase in 2018 looks to be the Old Line State. Even if CSRs are paid, Maryland’s insurers have requested an average weighted rate hike of 46.1%. However, if CSRs are taken away, this premium increase jumps to a weighted average of 57.1%. Both CareFirst of Maryland and CareFirst Blue Choice requested average rate increases of 58.8% and 50.4%, respectively, with one Cigna plan within the state requesting up to a (I hope you’re sitting down for this) 150.83% increase in 2018 from the previous year. As in numerous states, CSR uncertainty and a need to significantly boost premiums to account for adverse selection are the primary catalysts behind these large rate-hike requests.

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Medical Billing Mistakes to Avoid

We are all busy these days; whether it be the normal requirements of work or trying to get ahead so you can go enjoy that well earned vacation. You are never too busy to take your healthcare billing for granted and just pay. The below article describes three things you can do. Medical Cost Advocate can do all these steps for you and add the rigorous capability of our Healthcare Advocacy Services to manage you billing and insurance ongoing … so you can take that vacation and rest assured your medical bills are being handled by an expert.

3 medical debt mistakes to avoid

Sean Pyles, NerdWallet

Many consumers take their medical bills at face value — and pay the price.

You can limit the hurt by shopping around beforehand, double-checking bills and negotiating your out-of-pocket expenses. Avoid these three mistakes:

  1. Not shopping around

Start by knowing the cost of services. For planned or routine medical expenses, you can ask the billing department to estimate costs. Then shop around if you have a choice of providers.

Resources like New Choice Health and Healthcare Bluebook can show you a price range for services in your area.

  1. Taking your bill at face value

“There’s a large number of people who touch your medical bill when you go to the medical office, from service providers, nurses and office administrators,” says Cheryl Walsh, a medical bill advocate in New York. “Between that, there’s a lot of room for errors for medical bills.”

Medical bills usually have a single total at the bottom. What that doesn’t show are the items, big and small, you’ve been charged for. Request an itemized bill to check for duplications or charges for care you didn’t receive. Compare this with your explanation of benefits to verify your insurer paid what it should.

If you’re overwhelmed, you might need a professional. Medical bill advocates specialize in reducing the amount that people pay. Many give free consultations and charge only if medical bills are reduced, sometimes based on a percentage of savings.

  1. Not negotiating payment options

Negotiating has two parts. First, agree on what you’re going to pay. Then establish how you’ll pay it.

Knowing what others paid can give you leverage, so check the online resources mentioned above. Don’t be afraid to talk to your provider; just prepare by figuring out what you can realistically pay.

“Your job is to say, ‘Look, if you want to be paid, this is what I can afford,’” says Jerry Ashton, co-founder of RIP Medical Debt, a nonprofit that purchases, then forgives, medical debt. “Never make an agreement you know you can’t uphold.”

If you’re facing out-of-pocket costs you can’t handle, you may be able to:

  • Establish a payment plan: Just as prices vary among doctors, so do payment terms. Often, all you have to do is ask to break the cost into manageable chunks.
  • Ask for a financial hardship plan: Some providers offer these to low-income patients. Eligibility varies, and you may have to apply for Medicaid before being eligible.
  • Negotiate: You may be able to settle for less than you owe, especially if your bill is in collections.
  • Consider debt relief: If your debt is more than half your annual income and you see no way to pay it off within five years, you may want to consider bankruptcy.

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A New Plan to Replace the ACA

With the effort to amend/repeal/replace the Affordable Care Act, we are currently one plan down and one to go. The first attempt to enact a new plan failed to come to vote in the House in March. This week a modified plan has surfaced that some are saying may move closer to being approved. In the below Article you will see some of the major provisions we expect to see vetted over the coming days.

 

 Republicans have a new plan to repeal and replace Obamacare

Thursday, 20 Apr 2017 | 10:26 AM ET  by Berkeley Lovelace Jr. – CNBC

Republican lawmakers have a new plan to repeal and replace Obamacare in a bid to bridge the gap between the House Freedom Caucus and moderates, according to a document obtained by CNBC.

A Freedom Caucus source told CNBC the changes to the health bill would secure 25 to 30 “yes” votes from the Freedom Caucus, and the new bill would get “very close” to 216 votes. The source said that 18 to 20 of those “yes” votes would be new.

Here is the document:

MacArthur Amendment to the American Health Care Act – 4/13/17

Insurance Market Provisions

The MacArthur Amendment would:

  • Reinstate Essential Health Benefits as the federal standard
  • Maintain the following provisions of the AHCA:

– Prohibition on denying coverage due to preexisting medical conditions

– Prohibition on discrimination based on gender

– Guaranteed issue of coverage to all applicants

– Guaranteed renewability of coverage

– Coverage of dependents on parents’ plan up to age 26

– Community Rating Rules, except for limited waivers

Limited Waiver Option

The amendment would create an option for states to obtain Limited Waivers from certain federal standards, in the interest of lowering premium costs and expanding the number of insured persons.

States could seek Limited Waivers for:

  • Essential Health Benefits
  • Community rating rules, except for the following categories, which are not waivable:
  • Gender
  • Age (except for reductions of the 5:1 age ratio previously established)
  • Health Status (unless the state has established a high risk pool or is participating in a federal high risk pool)

Limited Waiver Requirements

States must attest that the purpose of their requested waiver is to reduce premium costs, increase the number of persons with healthcare coverage, or advance another benefit to the public interest in the state, including the guarantee of coverage for persons with pre-existing medical conditions. The Secretary shall approve applications within 90 days of determining that an application is complete.

CNBC has reached out to the office of House Speaker Paul Ryan about the document.

Earlier this month, Freedom Caucus chairman Rep. Mark Meadows said the majority of caucus members will support the new bill if changes offered by the White House are included in the legislation, such as coverage waivers related to community rating protections.

In March, House Republicans pulled their first attempt at a repeal and replacement of Obamacare, dubbed the American Health Care Act, due in large part to opposition from both conservative and moderate Republicans.

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The ‘Trump effect’ on your Obamacare coverage

Happy Holidays from Medical Cost Advocate! As we enter a new year and new administration, change is inevitable on many fronts. Understandably people want to know what that means in regards to their healthcare. More specifically they want to know how they will be affected in light of the promised changes to Obamacare. Though we can only speculate at this point, a great overview by healthinsurance.org provides some insights based on what we know so far.

With our newly elected president threatening repeal of Obamacare, should you worry that your health insurance could go up in smoke?

By Louise Norris, healthinsurance.org contributor, November 12, 2016

Donald Trump will be our next president. What exactly does that mean for your health insurance coverage and access to healthcare? It’s a question that has drawn speculation from health policy wonks since the day after Trump’s election – but I’ve also been receiving many of these questions from clients who are curious about whether their coverage will change any time soon.

In truth, nobody can say for sure at this point, since there are still so many moving parts to the law. But we have some educated guesses, based on Trump’s positions and the actions Congress has taken over the last six years with regards to Obamacare.

Here are the best answers we have at the moment for some questions you might have, along with more details about what you can expect in the coming months and years:

Do you still need to buy ACA-compliant coverage?

Q: If Obamacare is going to be repealed, do I need to buy ACA-compliant coverage now?

A: Yes, you still need coverage for 2017, and now’s the time to buy it. On November 9, the day after Trump won the election, 100,000 people enrolled in coverage through HealthCare.gov, according to HHS Secretary Sylvia Burwell. That’s the largest number of sign-ups in a single day since open enrollment began on November 1, so there is considerable momentum in terms of people enrolling in coverage for 2017.

We can assume that Congress will pass legislation to repeal parts of the ACA (more details below), and that Trump will sign it into law. This is likely to happen in 2017. But it’s unlikely that it will have an effective date prior to 2019, as Congress will need time to implement its replacement plan, and the IRS will need time to establish the new tax system that will go along with whatever replaces the ACA (most likely, tax credits to offset the purchase of coverage).

So for 2017, you still need coverage. And subsidies — including premium subsidies and cost-sharing subsidies — are still available. Although they’re likely to be eliminated eventually, at least in their current form, that’s not likely to take effect in 2017. (more…)

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Healthcare Cost and Complexity Continue to Grow – Insurance Consultation and Claims Advocacy are Better Together in This Healthcare Climate

As we enter a new open enrollment period, companies and individuals are reviewing their health care plans. The litany of regulatory and economic changes in our health care system has created a daunting challenge of navigating less choice and availability, along with higher costs. Add to this the uncertain future health care landscape under a new Trump Administration and the complexity multiplies. Healthcare advocacy services are becoming even more necessary to help families manage the ongoing insurance, billing and navigation issues they will inevitably encounter.

Contributed by Derek Fitteron, CEO Medical Cost Advocate

November 1 marked the beginning of the open enrollment period for many individual insurance plans. Open enrollment is the time when individually insured families must enroll in, or make changes to, their health insurance coverage. The individual insurance market has been largely subsumed by the Affordable Care Act (ACA) and the State Exchanges in recent years. This year, choice, availability, features and cost have all deteriorated. Many of the largest insurers are withdrawing from the individual marketplace for economic reasons. The resulting plans have narrower networks, higher deductibles, and fewer features; all for a higher price.

The laws of supply and demand do not apply anymore. Wealthy consumers as well as those requiring subsidies must choose from the same underwhelming plans. Nowhere is this more evident than in New York. Aetna has left the market and Health Republic has become insolvent, leaving only Empire Blue Cross Blue Shield, United Healthcare and three much smaller companies offering plans. Perhaps most startling, none of the available plans are PPO plans that offer out-of-network benefits.

Consumers clearly need help selecting the best plans among available alternatives, but now more than ever they need assistance optimizing their plans going forward.

Consumers who wish to obtain the best care will go out-of-network in increasing numbers and will be largely “self-pay.” They will be on their own to manage filing, billing and administrative complexity. Medical Cost Advocate is recognizing these issues. To provide more value for clients, we have started bundling Insurance Consultation with Comprehensive Bill and Claims Advocacy. The benefits are clear. We can help clients select the best plan available and manage the ongoing issues they will inevitably face. We review bills, resolve problems, file claims, negotiate reductions and provide advice on how to better utilize these plans. For a nominal fee above an Insurance Consultation alone, consumers can obtain the same consultation plus 3 hours per month of billing advocacy over the entire year.

Our clients are looking for solutions to manage complexity in the changing healthcare system. Medical Cost Advocate is an even more advisable solution for those who want to focus on their health, not insurance and billing.

For more information on how Medical Cost Advocate can help your family/company realize value from healthcare, please click here or call us at (201) 891-8989.

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Surprise Hospital Bills – The Debate Continues

The debate continues in New Jersey and New York regarding what to do about out-of-network charges and balance bills when the consumer has no opportunity to choose or shop for care. Several State Legislatures are trying to tackle this problem in order to protect the consumer from large unexpected medical bills. Another related challenge is who should take the financial burden of these bills: the insurance company – by paying out of network bills, or the medical provider – by accepting less payment.

Restarting N.J. hospital billing debate

By Lindy Washburn, The Record

Michael Young, a 24-year-old college student, thought he was going to die a year ago May when he called 911 while visiting his father in Paramus.

It turned out he had appendicitis. The ambulance took him to The Valley Hospital in Ridgewood, where a surgeon performed an emergency appendectomy.

Now Young faces a different kind of crisis: The anesthesiologist that night at The Valley Hospital is suing him for $2,200 — after his insurer paid $726.

Surprise medical bills just keep coming for patients in New Jersey, five months after the Legislature’s effort to fix the problem died. Some come from hospital-based doctors who don’t accept the same insurance plans as the hospital where they work. Others are received by patients with out-of-state or federally regulated coverage who go to out-of-network emergency rooms — New Jersey regulations that require the insurer to protect its members from balance billing in such cases don’t apply to their plans.

Young gets his coverage through a family insurance plan for retired New York City employees; it is outside the jurisdiction of New Jersey regulations.

His anesthesiologist was part of Bergen Anesthesia group, which does not participate in his insurance plan. There were no other choices when the ambulance took him to Valley because it is the sole provider of anesthesia services there.

The insurer — GHI/EmblemHealth — paid about a quarter of the $2,900 he was charged for anesthesiology for lower abdominal surgery under emergency conditions. GHI used its own fee schedule to determine what they considered appropriate; Bergen Anesthesia billed Young for the remainder.

Now Young is stuck with the charges. He has no income of his own.

Other recent examples include:

–At one hospital, the father of a 3-year-old who needed emergency stitches was surprised when the plastic surgeon billed him $2,000, on top of the $3,800 he received from the insurer. When the father took it up with a hospital executive, the executive said his options were limited because the plastic surgeon did not participate in any insurance plans. But he called the surgeon, who agreed to waive the rest of his fee after the child’s father paid $900 — his remaining deductible — toward the balance.

–Another couple chose a Bergen County hospital as their baby’s birthplace because it was in their insurer’s network. They were surprised to learn — when the bills came — that the anesthesiologist, surgeon and neonatologist at the hospital did not participate in their insurance plan. The plan, purchased through the Affordable Care Act on HealthCare.gov, provides no out-of-network coverage.

–In Hudson County, all three hospitals owned by for-profit CarePoint Health no longer participate in the network of the state’s largest insurer, Horizon Blue Cross Blue Shield of New Jersey. Hoboken University Medical Center was the last to opt out, as of Wednesday, when its contract ended. The three, including hospitals in Bayonne and Jersey City, are also out-of-network for Aetna, Cigna, Health Republic of New Jersey, Oscar Health Insurance and UnitedHealthcare. The vast majority of CarePoint’s patients enter through the facilities’ emergency rooms, which enables the hospitals to demand payment from insurers for their charges, among the highest in the nation, while leaving the patient’s obligation the same as it would have been at an in-network facility.

Ward Sanders, president of the state Association of Health Plans, condemned that business model on Thursday, when he renewed his industry’s call for legislative reforms. “New Jersey has become a hotbed for unconscionable out-of-network billing practices,” he said. “Certain facilities and providers … engage in predatory pricing, surprising consumers with unexpected bills, and creating exorbitant costs for consumers, employers and unions.”

“It’s time for the Legislature to step in,” he said.

Now that the logjam over Atlantic City has been broken, lawmakers say they are gearing up to try again on what Democrats and Republicans agree is a pocketbook issue. But recent developments affecting the state’s hospitals may make it more difficult. Legislation that could reduce hospital revenues or diminish their leverage with insurers will be seen as a problem, and lawmakers with hospitals in their districts are likely to hear about it.

Hospitals take a hit

The launch of the Omnia health plan by Horizon Blue Cross Blue Shield of New Jersey alienated half of the state’s 62 hospitals by labeling them as Tier 2, a non-preferred status expected to lead fewer patients to seek care at their facilities, and thus lower revenues. In addition, 30 non-profit hospitals face lawsuits — and the potential loss of their property-tax exemptions — after a precedent-setting state Tax Court decision and Governor Christie’s veto of legislation that would have protected them. And hospitals are fighting additional cuts in state charity care funding this year.

Nevertheless, Sen. Gerald Cardinale, a Demarest Republican and health professional himself — he’s a dentist — has begun circulating his own version of the “Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act” first introduced last year by three Assembly Democrats and the chairman of the Senate Health Committee, Sen. Joseph Vitale, D-Middlesex.

Cardinale’s version is somewhat friendlier to doctors and hospitals, because it would rely on peer review — one panel for doctors and one for hospitals — to settle disputes when insurers and out-of-network providers disagree over how much should be paid for a service. The original version relied on “baseball arbitration” — a choice of one side’s final offer — by outside professional arbitrators.

The Democratic sponsors of the measure that failed last session — Assemblyman Craig Coughlin of Middlesex, and Assemblymen Gary S. Schaer of Passaic and Troy Singleton of Burlington, along with Vitale — have met with interest groups and say they plan to meet again to see what changes might help the bill win passage. And Citizen Action, the consumer advocacy group, plans to call attention to the problem of surprise medical bills at an event in mid-June.

All aim to take the consumer out of the middle of such disputes.

And that’s a goal with which the state hospital association, which did not support the measure last year, can agree. It has suggested changes that would give hospitals a bigger role in preventing staff anesthesiologists and other hospital-based specialists from billing patients beyond their in-network financial obligation after the insurer has paid.

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