Posts Tagged ‘health care reform’

Breaking News: Individuals May Opt-Out of Insurance Program in Health Care Reform

August 24, 2012 1 comment

Breaking News regarding health care reform.

Individuals are not  required to participate in health insurance programs under health care reform. Section 1555 of P.L. 111-148 (Patient Protection and Affordable Care Act) allows for individuals not to be required to participate in any health insurance program. They will not be penalized if they do not participate. Language from the provision is listed below and can also be read HERE


Section 1555 – Freedom Not To Participate in Health Insurance Programs
No individual, company, business, nonprofit entity, or health insurance issuer offering group or individual health insurance coverage shall be required to participate in any Federal health insurance program created under this Act (or any amendments made by this Act), or in any Federal health insurance program expanded by this Act (or any such amendments), and there shall be no penalty or fine imposed upon any such issuer for choosing not to participate in such programs.

Stay tuned for more on this Breaking News story regarding health care reform. For more information on health care reform, please click  HERE


The Truth About Ron Wyden’s Medicare Plan

August 21, 2012 1 comment

What You Should Know About Ron Wyden‘s Medicare Plan

On August 11th, GOP Presidential Candidate Governor Mitt Romney introduced Representative Paul Ryan as his choice for Vice President. Once this was announced, media outlets “freaked out” over the Medicare plan Senator Ron Wyden (D-OR) wrote with Representative Paul Ryan (R-WI, Chairman of U.S. House Budget Committee). The plan is a bipartisan plan officially called “The Guaranteed Choices to Strengthen Medicare and Health Security for All: Bipartisan Options for the Future” and it is a roadmap for how to strengthen and fix or failing Medicare system. Senator Wyden and Representative Paul focus their plan on choice, affordability, and protecting seniors. You can read more about the plan by clicking HERE


Starting in 2022, a new Medicare program will begin offering seniors a choice among private plans and the traditional Medicare plan – much like plans Members of Congress have. Any senior at or above age 55 today will see no changes in their Medicare. (Page 2)


Coverage will be guaranteed through a new “premium support” system that encourages plans to provide high-quality care more efficiently. Private plans will compete directly with traditional Medicare based on their ability to provide quality coverage at an affordable lower cost. Low-income seniors shopping for coverage would be offered the same range of high-quality options offered to all other seniors. They would be guaranteed the ability to choose a traditional fee-for- service Medicare plan, or they could choose a private plan on the Medicare Exchange with a fully- funded account from which to pay premiums, co-pays and other out-of-pocket costs. (Page 2,9)

Protecting Seniors
To ensure ample protection from scam-artists and bad actors, the program will not only require insurance coverage protections such as guaranteed issue and risk adjustment, but it will also require the Centers for Medicare and Medicaid Services (CMS) to actively review marketing practices and benefit adequacy. Plans that fail to comply with established standards of participation would have their contracts terminated. Building upon Medicare’s current marketing rules, all plans would also be required to have their marketing materials approved annually by CMS. (Page 2, 10)

Above are the facts of Senator Ron Wyden’s Medicare Plan. Keep in mind that is only a proposal and it can not become reality without passing Congress first. You can read more about the plan by clicking HERE

Health Insurance Companies Profits Drop 147% Due to Health Care Reform

August 6, 2012 2 comments

Health insurance company profit falls 147% due to health care reform.

Insurance company profits are falling despite the fact that enrollment is skyrocketing. Falling profits are specifically due to insurance companies violating Health and Human Services’ ingenious medical loss ratio rule which requires companies to pay premiums on actual medical care (not profits) or be forced to pay rebates back to their customers. Insurance companies are on pace to pay out $1.3 billion this year alone on rebates. The fact that insurance company profits is falling is a clear sign that health care reform is working!
Aetna  – Profit drops 15% (Source 5)
Cigna –  Profit drops 44%  (Source 1, 2, 4)
Humana – Profit drops 80% (Source 3, 5)
WellPoint (aka BCBS) – Profits drops 8% (Source 6)
Health insurance company profits continue to fall due to the implementation of health care reform. Executives and  shareholders will continue to lose profits as long as they continue to violate Health and Human Services’ ingenious medical loss ratio.


What Every Medical Practice Manager Should Know About Health Care Reform

August 6, 2012 Leave a comment

Below is what every Medical Practice Manager should know about health care reform.

The provisions listed below will have a direct impact on medical practice management and practice managers need to take the time to familiarize themselves with the new regulations.

Section 1001 Subsection 2712- Prohibition on Recissions
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved.

Section 1001 Subsection 2713 – Coverage of Preventive Health Care  

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for-evidence-based items or services that have in effect a rating of `A’ or `B’ in the current recommendations of the United States Preventive Services Task Force; immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

Section 1001 Subsection 2714 – Extension of Dependent Coverage
A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age.

Section 1201 Subsection 2704 – Prohibition of Preexisting Conditions
A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage.

Section 1421 – Tax Credit for Employee Health Insurance Expenses of Small Businesses
An eligible small employer, the small employer health insurance credit amount is 50 percent (35 percent in the case of a tax-exempt eligible small business).

Section. 3111 – Payment for Bone Density Tests
For dual-energy x-ray absorptiometry services (identified in 2006 by HCPCS codes 76075 and 76077 (and any succeeding codes)) furnished during 2010 and 2011, instead of the payment amount that would otherwise be determined under this section for such years, the payment amount shall be equal to 70 percent of the product.

Section 3134 – Misvalued Codes Under Physician Fee Schedule

For purposes of identifying potentially misvalued services pursuant to clause (i)(I), the Secretary shall examine (as the Secretary determines to be appropriate) codes (and families of codes as appropriate) for which there has been the fastest growth; codes (and families of codes as appropriate) that have experienced substantial changes in practice expenses; codes for new technologies or services within an appropriate period (such as 3 years) after the relative values are initially established for such codes; multiple codes that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple times for a single treatment; codes which have not been subject to review since the implementation of the RBRVS (the so-called `Harvard-valued codes’); and such other codes determined to be appropriate by the Secretary.

Section  4104 – Elimination of Co-Pay

Elimination of coinsurance (co-pay) on preventive services (ie. physical exams). Elimination of coinsurance (co-pays) in outpatient hospital settings.

Section  4108 – Incentives for Prevention of Chronic Diseases

Incentives for prevention of chronic diseases. A program described in this paragraph is a comprehensive, evidence-based, widely available, and easily accessible program, proposed by the State and approved by the Secretary, that is designed and uniquely suited to address the needs of Medicaid beneficiaries and has demonstrated success in helping individuals achieve one or more of the following: ceasing use of tobacco products, controlling or reducing their weight, lowering their cholesterol, lowering their blood pressure, avoiding the onset of diabetes or, in the case of a diabetic, improving the management of that condition.

Section 4204 – Immunizations
Funds received under a grant under this subsection shall be used to implement interventions that are recommended by the Task Force on Community Preventive Services (as established by the Secretary, acting through the Director of the Centers for Disease Control and Prevention) or other evidence-based interventions, including–providing immunization reminders or recalls for target populations of clients, patients, and consumers;educating targeted populations and health care providers concerning immunizations in combination with one or more other interventions; reducing out-of-pocket costs for families for vaccines and their administration; carrying out immunization-promoting strategies for participants or clients of public programs, including assessments of immunization status, referrals to health care providers, education, provision of on-site immunizations, or incentives for immunization; providing for home visits that promote immunization through education, assessments of need, referrals, provision of immunizations, or other services; providing reminders or recalls for immunization providers;conducting assessments of, and providing feedback to, immunization providers; any combination of one or more interventions described in this paragraph; or immunization information systems to allow all States to have electronic databases for immunization records.
Section 5202 –  Nursing Student Loan Repayment

The Secretary shall establish and carry out a pediatric specialty loan repayment program under which the eligible individual agrees to be employed full-time for a specified period (which shall not be less than 2 years) in providing pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care, including substance abuse prevention and treatment services.

Section 5301 – Financial Assistance for Students Going Into Primary Care
To provide need-based financial assistance in the form of traineeships and fellowships to medical students, interns, residents, practicing physicians, or other medical personnel, who are participants in any such program, and who plan to specialize or work in the practice of the fields of family medicine, general internal medicine, or general pediatrics training programs.

Section 5501 – Incentive Payments for Primary Care Physicians
Incentive payments for primary care physicians. In the case of primary care services furnished on or after January 1, 2011, and before January 1, 2016, by a primary care practitioner, in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent of the payment amount for the service under this part.

Every Medical Practice Manager must take time to read and understand the above regulations. For more information, click HERE

U.S. House Votes to Repeal Healthcare Reform 244-185

July 11, 2012 1 comment

The U.S. House today voted to repeal the Affordable Care Act 244-185.  Five Democrats voted FOR repeal and they are:
Dan Boren (D-OK 02), Larry Kissell (D-NC 08), Jim Matheson (D-UT 02), Mike McIntyre (D-NC 07), Mike Ross (D-AR 04). You can see how each member of the House voted by going here: The bill the House approved (H.R. 6079) can be read here:

Keywords:  health care insurance, health care, health plan, health policy, U.S. Congress, health care reform

Health Insurance Companies Raise Premiums by 181.4% Since Health Care Reform Passage

July 5, 2012 Leave a comment
We are barely 7 months into 2012 and already health insurers are dramatically hiking premium rates. Specifically, they are raising premiums in order to get as much profit as possible. The insurers themselves refuse to justify their rate hikes publicly because they claim they would be giving away “trade secrets” (Source 1).  As you will see in the data below, the country’s largest  insurers have raised premiums by 181.4% (16.5% average) since health care reform officially passed in 2010. Approximately 787,000 policy holders were effected. The insurers were fined a whopping total of $116,750,000 as a result of their deed. The Affordable Care Act (ACA) is supposed to curb this unethical act but the consumer will not see significant relief from this until 2014.                                                            R74BG8W84C8B
Rate Hikes By Insurer
8% increase   – April 2012 (Source 3)
Blue Cross Blue Shield
20% Increase  – July 2012
7% increase   –  May 2012 (Source 2)
9.35%  increase  – January 2012 (Source 5)
12.9% increase   – September 2011 (Source 6)
22% increase     – May 2011 (Source 8)
59% increase     – January 2011 (Source 9)
12.4% increase small group  – May 2010 (Source 10)
13.4% increase large group – May 2010 (Source 10)
Kaiser Permamente
10% increase – June 2011 (Source 7)
United Healthcare
11.8% increase on businesses of fewer than 50 employees  – May 2010 (Source 10)
15.5% increase on business of greater than 50 employees  – May 2010 (Source 10)

Members Effected by Rate Increase
73,000 members   – April 2012  (Source 3)

Blue Cross Blue Shield
90,000  – July 2012
31,000   – April 2012     (Source 2)
86,000    – January 2012 (Source 5)
45,000   –  September 2011 (Source 6)
59,000   – May 2011  (Source 8)
193,000  – January 2011 (Source 9)
300,000   – June 2011  (Source 7)
Impact on Profit
Profit UP 27.7% due to 8% premium increase  (Source 4)
Fines for Rate Increases
Assurant fined $2,750,000 for unapproved rate increase  – May 2012 (Source 11)
11 insurers (United Healthcare, Aetna, Blue Cross Blue Shield) fined $114,000,000  -January 2012 (Source 12)

Keywords: health care insurance, insurance premium, blue cross blue shield, health insurance company, united healthcare, health care reform

Health Insurance Companies to Pay $1.3 Billion in Rebates for Violating Medical Loss Ratio Rule

July 5, 2012 Leave a comment

There is finally some good news coming out of the ACA in regards to the fact that the Medical Loss Ratio is in full effect. Under this rule, large plan insurers (Humana, United, BCBS, etc) must PAY 85% of premiums towards providing actual medical care(not profits). In addition, small plans must PAY 80% of premiums towards providing actual medical care as well. These money-loving insurers should thank God that this rule was not in place back in 2010 because if it had been, they would have had to cough up $2,000,000,000 for violating the rule (Source 1). According to a report done by the Commonwealth Fund, Individual market insurance companies in Texas and Florida would have had to pay rebates back to consumers totaling $281,000,000. Large group Insurers in Maryland and Florida would have had to pay $40,000,000 in rebates back to consumers (Source 1).

Insurers are already off to a brilliant start this year at violating the MLR. The National Journal reports that Insurers could cough up $1,300,000,000 in rebates by the end of the year. This will account for $426,000,000 in rebates to the individual plan market and $541,000,000 to the large group plan market (Source 2).  An estimated 4,900,000 in the individual market  will be getting rebates this year totaling $377,000,000. Alaska, Alabama, Oregon, Louisiana, and Massachusetts are expected to receive an average of $256.50 per enrollee. An estimated 7,500,000 in the large group market will be getting rebates this year totaling $541,000,000. Vermont, Nebraska, Minnesota, New York, and North Carolina are expected to receive an average of $208.60 per enrollee (Source 3). If the MLR had been in effect in 2010, the total amount in rebates that could have been paid out by the end of this year could have totaled $3,300,000,000.
The following insurers (so far) have had to pay out rebates back to consumers for violating the MLR rule.
$11,495,614     – November 2011 (Source 6)
Blue Cross Blue Shield
$82,507,470       – November 2011       (Source 6)
$283,000,000  – October 2011            (Source 5)
$167,000,000  – September 2011        (Source 4)
$487,768    – November 2011 (Source 6)
$15,462      – November 2011 (Source 6)
Group Health
$4,168,935   – November 2011  (Source 6)
Health Net
$5,052,467    – November 2011 (Source 6)
Health Now
$4,492,327   – November 2011 (Source 6)
HIP Health Plan
$182,194    – November 2011  (Source 6)
$5,144,676  – November 2011
United Healthcare
$4,838,675  – November 2011 (Source 6)
Keywords: health care, affordable health insurance, medical loss ratio, insurance rebate, blue cross blue shield, united healthcare, health care reform