Health Insurance and You!

In these tough financial times, it is important that Americans have the ability to discern and identify the types of insurance that bring actual benefit to themselves and their families. On Yahoo Finance yesterday, Investopedia published an article on the “15 Insurance Policies You Don’t Need.” The article offers detailed and practical guidance to saving money, but notice that health insurance is not on the list of policies.

If you have any of these policies, you should analyze whether the likelihood or magnitude of their protection are worth the amounts in insurance premiums that you pay each month. Also, quality health and life insurance policies may make some of the above policies redundant (i.e., there is no need to have both). For example, many mortgage life and accidental-death insurance issues are regularly covered under good term-life insurance policies, and having a good health insurance plan will preclude the need to enroll in a disease insurance policy.

Again, notice that health insurance is not on the list of policies to avoid. This is because health insurance is necessary given today’s medical costs. Without health insurance, a serious injury or disease could lead to hundreds of thousands of dollars in debt. Every year, more than half of all personal bankruptcies in the United States are the result of high medical expenses.

Providing health insurance involves specialized expertise. That’s why it is critical that your health insurance counselor be licensed. To be licensed requires that you study, take an exam, and pass certain background checks in addition to paying a small licensing fee of course. At Getinsured.com, we strive to be the best source of expertise on health insurance. We employ over 80 licensed health insurance counselors and continue to add health insurance plans and counselors every day.

So imagine our disappointment and surprise to hear that two former disgruntled employees complained to the Georgia Department of Insurance, entirely without merit, that our agents are unlicensed. It is the department’s job to investigate such charges and so yesterday we were “visited” by their agents. The false allegation regrettably, disrupted our services yesterday.

We want all our consumers and readers to know that GetInsured.com is cooperating fully to clarify this misunderstanding, producing every document and license number requested. Our mission and that of our agents has been, is and will be the same — to help you find your perfect health insurance plan. We are proud to find new ways to serve the consumer every day — last week, we were the first website nationwide that offers quality ratings from NCQA — a nationally accredited rating agency for plans.

We wish our consumers, readers and partners a great labor day weekend.

Chini

President Obama’s health care reform includes provisions for how insurance companies pay for mental illness conditions. Following the lead of the federal government’s health parity practice, established in 2001, a similar law was passed in 2008 affecting millions more Americans. The Mental Health Parity and Addiction Equity Act of 2008 applies directly to mental illness and all conditions in the category, including substance abuse.

Mental Health Parity and Addiction Equity Act of 2008

The Mental Health Parity and Addiction Equity Act of 2008 is a federal mandate to ensure the same health insurance coverage for treatment of mental health illnesses as medical and surgical conditions. Mental health illness includes psychiatric illnesses, and drug and alcohol disorders. On Jan. 1, 2010, millions of Americans received additional insurance coverage for drug abuse treatment at the same rate as medical treatment.

The Mental Health Parity and Addiction Equity Act of 2008 requires any group health insurance plan, with 50 or more members, to cover substance abuse treatment at the same rate it covers medical treatment. A few key points of the Act are:

• It does not require insurance carriers to cover substance abuse treatment (although just like some auto insurance companies specialize in substandard auto insurance while other companies avoid offering the coverage, there are also health insurance companies that may offer coverage for substance abuse treatment while others elect not to).
• The Act states if a carrier chooses to cover mental illness treatment, it must do so at a rate equal to that of medical treatments. This includes deductibles, copayments, cost sharing, annual or lifetime service limits, annual or lifetime payouts, or any combination of these.
• If plans cover out-of-network medical and surgical benefits they must also cover out-of-network mental health and substance abuse benefits.
• Insurers must disclose criteria used to determine medical necessity of treatment, and why benefits are denied.
• It will not replace existing states’ parity laws, in effect prior to 2008, that offer benefits above and beyond the Mental Health Parity Act.

Before the Mental Health Parity Act went into effect, many insurers:

1. Paid less for psychiatric and drug abuse treatments.


2. Set higher copayments on treatment.


3. Set strict limits on inpatient and outpatient treatment.

Coverage, or lack of, was determined by the insurance carrier, or state law. Differences in parity laws from state to state, without a national minimum standard of coverage, left many in need of drug treatment out in the cold. Those in need of coverage will do well to follow the general guideline of shopping around for coverage and comparing rates and policies from many different insurance providers just the same as shopping for auto insurance quotes or other types of insurance coverage.

Since the law allows insurers the option of offering drug abuse treatment coverage, it has a long way to go in providing coverage to all Americans. But the statistics offer a daunting view of drug use in America:

• Nearly 1/3 of Americans had past drug and alcohol abuse in their immediate families.
• Nearly 1/3 of Americans report 3 or more members of their immediate and extended families had drug and alcohol abuse problems.
• 9% of Americans have a substance abuse problem.
• 90% of substance abusers don’t seek treatment because of lack of insurance coverage.

Why are Private Insurers Reluctant to Cover Drug Treatment Programs?

Cost is one reason why treatments are not covered, or covered at a lower rate than medical treatment. In an environment where health care costs are increasingly scrutinized, coverage is cut, or services withdrawn, to keep costs low. Many who cannot afford to pay for private treatment end up in public treatment programs that are paid for by taxpayers. Poorly managed public programs increase the cost of treatment. For example, Massachusetts taxpayers:

• Pay more than 75% of state substance abuse service costs.
• Bear the increase of costs for treatment at an increase of 6.8% annually while private insurance payments decreased 1.1% between 1991-2001.

Millions of Americans have been touched by drug and alcohol use. Though 1) 77% of Americans agree that treatment of addiction should be a part of health care reform 2) 78% understand drug addiction is a chronic disease 3) 77% believe treatment helps people to live productive lives, there is still a stigma attached to substance abuse. People still carry a subconscious layer of embarrassment, or think drug abuse is a moral failing, preventing consumers from going public and demanding coverage from health insurance carriers.

Substance Abuse Treatment Coverage Post January 2010

Many major national insurance carriers offer coverage for mental illness. To date, studies have shown no increase in insurance costs for substance abuse treatment, and no increase in people seeking treatment. Factors possibly affecting use of the benefit include:

1. Unawareness – many Americans simply may not know.


2. Stigma – the Mental Health Parity Act alone is not enough to make people step out of the shadows of drug abuse.


3. Fear – employees don’t want their employers to find out and risk losing their jobs.

In 2014 the Mental Health Parity Act’s reach will extend to include:

• Small group insurance plans with less than 50 members.
• Plans offered on the individual market.

Advocates of different aspects of health care are cooperatively working to strengthen weak spots in the Act. As health care distribution spreads, and attitudes change, parity of care will be seen as a right, not a privilege. Consumers who want to know if their insurance carrier covers treatment for drug disorders should contact their insurance provider, and request a copy of their treatment criteria.

On May 24, Getinsured was in Sacramento, CA to participate in the California Health Benefit Exchange’s third board of directors meeting. The meeting covered various topics, but most of the discussion was about integrating the state’s eligibility determination processes for its public assistance programs. While far from perfect, the current infrastructure appears to provide a good web and data-sharing framework for California’s Exchange to build on in implementing ACA requirements.

At the meeting, the County Welfare Directors Association (CWDA) and the Managed Risk Medical Insurance Board (MRMIB) presented the two main eligibility and enrollment systems for California’s public health programs. The CWDA provided information about the state’s county-based eligibility determination process, whereas the MRMIB provided information about California’s statewide eligibility determination process. While there is some overlap between the two processes, there also appear to be substantial gaps.

The county-based eligibility method assists Californians in determining their eligibility and enrolling in Medi-Cal (the state’s Medicaid Program), County Medical Services Programs, and other non-healthcare based programs. To enroll, individuals apply according to their county of residence. There are 58 county social service departments in California that are supported by 3 different automated eligibility systems, but all applicants can start the process from a single web portal (www.benefitscal.org). Alternatively, MRMIB discussed a statewide eligibility and enrollment process called the Health E-App (www.healtheapp.net), which has a “Single Point of Entry” process for Medi-Cal, Healthy Families (California’s CHIP initiative) and other public health programs not currently available in the county-based model.

Both eligibility determination processes cannot co-exist under the ACA because they screen for different public programs from different portals. A logical next step is to seamlessly integrate the county-based portal and the Health E-App portal. The ACA requires a one-stop shop for health insurance and individuals should not have to enter their eligibility information twice. Over the next 6 months, such critical decisions are ahead for the California Health Benefit Exchange Board, which also released the following eligibility and enrollment timeline for implementation.

Terri Shaw, project director for Enrollment UX 2014, also briefed the board about their national initiative to help states implement optimal user experience on their Exchanges. She discussed the potential need for Exchanges to accommodate the growing number of tablet users, which are estimated to almost triple in number by 2014 to 71 million users.

The board is still awaiting its 5th member, who will be appointed by the California senate, but their next meeting is scheduled for June 15, 2011. CMS Director Cindy Mann and HHS Director Joel Ario are scheduled to attend, which will provide a unique federal perspective to the Exchange implementation discussions of the state.

Photo by Alexander Boden

Buying health insurance can be a complicated mission. Depending on your age and health status, there may be more or fewer options available to you. This year’s health care reform legislation—the Affordable Care Act—aims to reduce the confusion and streamline the process. However, it does not become fully effective until 2014. Even then, you will still have to play a significant role in shopping around for coverage.

It is essential that your health insurance purchase is not based solely on the monthly premium quote. For one thing, that dollar figure does not include the out-of-pocket costs associated with the coverage. An extremely low premium is often correlated with high co-payments and co-insurance percentages after the deductible is met. Co-payments are fixed amounts that you must pay per service (e.g. $10 per prescription filled or $30 per doctor’s visit), while co-insurance is a percentage based on the fee doctors, specialists, and hospitals charge your insurer. Those amounts can add up fast.

Such plans can be ideal for individuals who almost never get sick. If you are younger and have no pre-existing conditions, an option that limits, for example, the number of primary care physician visits per year may be sufficient. It provides catastrophic medical coverage that those starting their careers on smaller salaries can afford. This is also due to high annual deductibles, which must be paid out-of-pocket before the insurance plan kicks in and starts paying.

The same health insurance plans that work for one group can be disastrous for another. In the previous case, an older person with a pre-existing condition would be out of luck. Financial burdens would befall you if your policy excludes a condition that you either suffer from or are likely to develop in the future. All of these elements should be researched beforehand, including prescription drug coverage; to save money, many insurers will only pay for generics—which lead to major hassles for those on brand-name medications that are either unavailable or less effective in generic form.

Another important aspect of choosing your health insurance plan is comparing the various provider networks. Make sure that there are convenient providers in your area; the plan will be largely useless otherwise. If you have any existing physicians you want to stay with, it is best that they are in-network. That way, it will cost less to visit them. Otherwise, you may have to pay full price for out-of-network health care providers.

All of these concerns can be intimidating for the average person. Still, there are ways to get around this barrier to affordable health insurance. The Associated Press recommends that you use a licensed health insurance broker: their experience and education will prevent them from becoming lost in the confusion of coverage options. Make sure that he or she is licensed in your state of residence.

According to the Associated Press, insurance brokers can be most helpful if you have a pre-existing condition. They know which plans are most likely to underwrite you, and will not waste your time (and money, since some health insurance companies charge nonrefundable application fees) by applying for health plans guaranteed to refuse your particular condition. Instead, they will guide you towards the options that best fit your needs.

Two-thirds of California is experiencing a shortage of doctors, according to the Huffington Post. Almost 30 percent of California’s physicians are above the age of 60, and the problem may well be getting worse. More doctors are close to retirement in California than in any other state in the country.

There is also a cultural component to the issue. Californian Latinos, for example, comprise over 35 percent of the state’s population – but only 5 percent of our physicians. Furthermore, patients and providers often have better exchanges when the patient can relate more readily to the physician. This relation can further increase the quality of primary care.

However, there are a limited few areas in California which meet the US Department of Health and Human Services’ recommendation of 85-100 specialists for every 100,000 people. These include the Greater Bay Area, the Sacramento Area, and Orange County. But even these areas’ futures in terms of primary care physicians are not necessarily secure: by 2014, the LA Times reports, the Los Angeles County may have a serious shortage of doctors across the board – even at the coroner’s department. This severe deficiency of physicians is likely to have an effect on Californians in the foreseeable future despite any progress with the health care overhaul.

Major providers have been promoting more cost-effective health plans with lower premiums that offer customers a more limited array of doctors and hospitals, as reported by the New York Times. These plans are most likely to draw in small businesses, which typically tend to be more cost-conscious, that make insurance available. They tend to have higher deductibles and low premiums. Insurers say that companies that invest in these limited plans may reduce their premiums by as much as 15 percent.

The limited group plan’s network of doctors tends to run smaller than most traditional plans, which would narrow down options and potentially restrict customers for receiving full and proper coverage. At the same time, these plans are the more pragmatic option for cash-strapped businesses. They are also generally convenient for employees who tend to be normally healthy and require little in the form of medical attention.

However, the quality of these limited-but-affordable health care plans has been called into question by the public. While insurers have assured customers that the plans do not sacrifice quality coverage for affordability, it comes down upon the consumers in the end to do the legwork and ensure that they are receiving adequate coverage. These plans may prompt customers to think about buying an individual health plan to retain a wider range of providers

How do you feel about these limited-network group plans?

A recently published government report estimates that 45 million Americans are without dental insurance, a problem which healthcare reform is unlikely to mitigate (Reuters). Following the healthcare reforms passed in March, adults face a fine if they do not buy health insurance beginning in 2014. Notably, the law does not require adults to buy additional types of coverage such as dental care. Dental benefits are something we all need, as recognized by advocates who lobbied for a more significant dental component in the healthcare bill.

The importance of dental care is highlighted by scientific research, which suggests a potentially causal relationship between oral hygiene and cardiovascular health. Although there are certainly a variety of facets that contribute to a healthy heart, Moise Desvarieux, MD, PhD, infectious disease epidemiologist in the Department of Epidemiology at Columbia University’s Mailman school of Public health analyzed bacterial samples associated with periodontal disease from subjects’ oral cavities, and found that patients with one or any combination of these three bacteria also had atherosclerosis. Although this relationship has yet to be fully understood, Desvarieux concedes, “if a causal relationship is found, you’ll already be ahead of the game in regards to your heart health. If there is no relationship, you’ll have a healthy mouth that will benefit your overall well-being.”

The benefits of maintaining good dental hygiene are supported by science and accordingly, finding a plan that offers the best prevention is the key to ensuring your teeth live as long and healthy a life as you do. The good news is, dental plans are generally guaranteed issue; that is to say, everyone qualifies. These plans are relatively inexpensive and start at approximately $30/month to cover your basic needs. An example is this great plan from Humana – Preventive Plus.

A nice article on health care reform and what it means for individuals and families that need to buy health insurance.

It is originally written in the context of the consumers in the state of Texas, but most of the article is applicable anywhere across the country.

To your health,
Chini

Every day, we talk to hundreds of young people who are looking for low cost health insurance solutions..

Lets think about how to achieve this for a second — young adults tend to be healthy, which means they could probably afford plans with higher deductibles (which, in turn, would have lower premiums). At the same time, they would want the basics — a well-ness benefit and also potentially a plan that allows them to see a doctor for a fixed co-pay.

We think there is a smarter way to do this — you can save a lot of $$ by buying a higher deductible plan. At the same time, you could reduce your risk of hospitalization from a skiing or biking accident by supplementing your health insurance with a low cost accident medical insurance plan.

To your health,
Chini