Category: Investigations

“If you get health insurance through your workplace, you’ll probably have a chance this fall to make important decisions about your coverage and costs.
Because many corporate health plans hold their annual open-enrollment periods in October and November, many employees can expect to get a packet of benefits, or instructions for making elections online, as well as updates on changes to their plans required by the Affordable Care Act. Some 55% of Americans have employer-based coverage, according to Mercer, a human-resources consultant.
“From the employee perspective, if there is any year to pay attention to the information, this is the year,” says Brian Marcotte, president and chief executive of the National Business Group on Health, a nonprofit representing large employers.
Starting next year, one change could be an ACA provision requiring some large employers—generally those with 50 or more full-time or equivalent workers—to offer affordable, adequate coverage to employees working more than 30 hours a week.”

“Thursday’s announcement that Pennsylvania will expand its Medicaid program brings the country one state closer to the original expansion outlined under Obamacare. But because of the Supreme Court’s 2012 decision making the expansion a voluntary program, there are still 23 states that haven’t expanded public health insurance to all of their low-income residents.
The expansion in Pennsylvania will add about 500,000 low-income to adults to the Medicaid rolls. According to numbers from the Kaiser Family Foundation, about 281,000 of those people were falling into what’s known as the “coverage gap”— people who don’t qualify for Medicaid but also don’t get subsidies for purchasing insurance on their own, either. About 4.5 million people across the country fall into this coverage gap, according to Kaiser.”

“The Assembly this week approved a bill to limit narrow networks in California’s health plans.
The legislation already passed a Senate vote and is expected to get concurrence today on the Senate floor and move to the governor’s desk for final approval.
SB 964 by Sen. Ed Hernandez (D-West Covina) directs the Department of Managed Health Care to develop standardized methodologies for health insurers to file required annual reports on timeliness compliance, and requires DMHC to review and post findings on those reports. It also eliminates an exemption on Medi-Cal managed care plan audits and requires DMHC to coordinate those plans’ surveys, as well.
“I introduced the bill in response to complaints we’ve heard about inadequate networks in the Medi-Cal program, as well as at Covered California,” Hernandez said. “By increasing oversight and network adequacy enforcement, SB 964 will help consumers select the right plan for themselves and access the care they need.”
Assembly member Rob Bonta (D-Oakland) introduced the measure Tuesday on the Assembly floor, and said the bill came in response to numerous public complaints.
“Since 2012 there have been hundreds of complaints about access and inadequate networks,” Bonta said.”

“The price tag of the Cover Oregon health insurance exchange fiasco continues to grow.
As Clyde Hamstreet, the corporate turnaround expert hired to lead Cover Oregon in April, wraps up his work he leaves behind a stabilized agency – and a hefty bill.
Initially signed to a $100,000 contract, Hamstreet ended up staying longer than expected, with two associates joining him at Cover Oregon after Gov. John Kitzhaber essentially forced out three top officials there in a public display of house-cleaning.
Through July, Hamstreet has billed $598,699 on an amended $750,00 contract. He hasn’t submitted his August invoice. He says the price tag was driven by the exchange’s increasing needs, as his firm stayed longer and did more than initially planned.
“We didn’t do this job to make a lot of money off the state,” he said Thursday. “Our philosophy was to try and help get the boat righted and try to help clean things up and basically help the state. … It turned out to be a bigger engagement than I expected.””

“A lack of transparency in describing and fixing technical problems became an issue in Thursday’s Washington Health Benefit Exchange Board meeting.
Board member Bill Hinkle grew testy at what he said was mutual staff back-patting and excuses for the problems still plaguing thousands of accounts.
“C’mon you guys, let’s quit blowing smoke here,” Hinkle said. “I’m tired of patting people on the back….We’re not doing great yet.”
Board member Teresa Mosqueda pressed staff for numbers of enrollees affected by technical problems.
“We really need to have the data in front of us to manage some of these issues,” she said. “I’m going to ask this question again ­– what is the total number of individuals affected by this, so we have a sense of how well we’re doing?”
The answer appeared to stun some board members: Glitches and technical problems have affected as many as 28,000 people trying to buy health insurance through the Washington Healthplanfinder online marketplace, said associate operations director Brad Finnegan.
In answer to a question, Finnegan conceded that that means one out of every five people has had a problem.”

“When you need emergency care, chances are you aren’t going to pause to figure out whether the nearest hospital is in your health insurer’s network. Nor should you. That’s why the health law prohibits insurers from charging higher copayments or coinsurance for out-of-network emergency care. The law also prohibits plans from requiring pre-approval to visit an emergency department that is out of your provider network. (Plans that are grandfathered under the law don’t have to abide by these provisions.)
That’s all well and good. But there are some potential trouble spots that could leave you on the hook for substantially higher charges than you might expect.
Although the law protects patients from higher out-of-network cost sharing in the emergency room, if they’re admitted to the hospital, patients may owe out-of-network rates for the hospital stay, says Angela Gardner, an associate professor of emergency medicine at the University of Texas Southwestern in Dallas who is the former president of the American College of Emergency Physicians.”

“Insurers can no longer reject customers with expensive medical conditions thanks to the health care overhaul. But consumer advocates warn that companies are still using wiggle room to discourage the sickest — and costliest — patients from enrolling.
Some insurers are excluding well-known cancer centers from the list of providers they cover under a plan; requiring patients to make large, initial payments for HIV medications; or delaying participation in public insurance exchanges created by the overhaul.
Advocates and industry insiders say these practices may dissuade the neediest from signing up and make it likelier that the customers these insurers do serve will be healthier — and less expensive.
“It’s the same insurance companies that are up to the same strategies: Take in as much premium as possible and pay out as little as possible,” said Jerry Flanagan, an attorney with the advocacy group Consumer Watchdog.”

“Bill Jacobs spent four nights in a hospital in Florida battling pneumonia. His kids visited each day, fluffed his pillows, brought his favorite Sudoku puzzles and got regular updates from his nurses and doctors. Imagine their surprise when they found out that their 86-year-old father was never actually admitted; instead, he was treated as an outpatient under what Medicare refers to as “observation status.”
What difference does that make? Actually, more than you might think. If your parents are on Medicare, the difference between being considered an inpatient or an observation patient could be thousands of dollars out of their pocket, if not more.
First, Medicare Part A will cover all hospital services, less the deductible, but only if you’re admitted to the hospital as an inpatient. The one-time deductible covers all hospital services for the first 60 days in the hospital. Doctors’ charges are covered under Medicare Part B. After you meet the deductible for Part B, you’ll then owe 20 percent of the Medicare-approved amount for doctor services, according to the Centers for Medicare and Medicaid Services’ Are You A Hospital Inpatient Or Outpatient?”

“Every day in intensive care units across the country, patients get aggressive, expensive treatment their caregivers know is not going to save their lives or make them better.
California researchers now report this so-called “futile” care has a hidden price: It’s crowding out other patients who could otherwise survive, recover and get back to living their lives.
Their study, in Critical Care Medicine, shows that patients who could benefit from intensive care in UCLA’s teaching hospital are having to wait hours and even days in the emergency room and in nearby community hospitals because ICU beds are occupied by patients receiving futile care. Some patients die waiting.
On one day out of every six, the researchers found, UCLA’s intensive care units contain at least one patient receiving useless care while other patients are unable to get into the ICU.
More than half the time, over a three-month period the researchers examined, the hospital’s intensive care units had a least one patient receiving futile care. The study shows the ripple effects of that futile care within the UCLA hospital and in surrounding hospitals where patients were waiting to be transferred.
“It is unjust when a patient is unable to access intensive care because ICU beds are occupied by patients who cannot benefit,” the authors write.
“The ethic of ‘first come, first served,’” they say, “is not only inefficient and wasteful, but it is contrary to medicine’s responsibility to apply health care resources to best serve society.””

“Cover Oregon will hold a special open enrollment period for 1,400 Oregonians who were incorrectly enrolled into the low-income Oregon Health Plan by the state’s troubled health insurance exchange.
Starting Aug. 31, the people affected will have no coverage through the OHP, the state’s version of Medicaid. However, they will have the option to sign up for coverage from private insurers and to qualify for tax credits through Cover Oregon to bring down premiums.
Meanwhile, Cover Oregon is contacting at least 700 people who should have been enrolled in the Oregon Health Plan, but were incorrectly enrolled in a commercial health plan instead.
If they were receiving tax credits for private plans, those will go away immediately, though they can keep their plan.
Cover Oregon is currently negotiating with the federal government over whether those people will have to refund to the IRS all the tax credits they received incorrectly, said Amy Fauver, Cover Oregon communications director. She said the exchange is optimistic that they won’t.”