Oh no its snowing!! For the lucky ones not going into work or school today you are likely hunkering down waiting for the 18 inch NY blizzard to pass. Unlike hibernating Bears, Mother Nature does not give you the gift of slowing down your metabolism.
How can snow and wellness go together? How to to prevent cabin fever and weight gain?
1 Water sport in winter. Water guns can be a fun winter activity in the snow as well. Simply mix some kool-aid or food coloring with some water and fill the guns with the liquid dye. Spray the snow with the water guns to create pictures and words. This is a fun project for multiple people, and it will prove that water guns are fun all year round.
2. Work out in front of TV. Just 15 minutes of sit-ups, jumping jacks, push-ups and squats can burn 200 calories.
3. Play video games. No not the sedentary kind you’re thinking. Hit the Wii or X-Box Kinect virtual motion games that get you going such as Dance Revolution, Kinect Sport, Punch Out, andWii Fit Plus.
4. Vitameatavegamin. Lucy Ricardo was onto something, using foods and vitamins play a role in mood.
Boost Vitamin D, the “sunshine vitamin”, with light therapy, 20-30 min of sunshine 3 -5 days a week or daily Vitamin D supplements.
Animal Protein – increasing depression fighting tryptophans found in lean meats such as poultry, eggs and wild seafood.
Selenium – low levels of selenium are also associated with an increased risk of depression. Serve Brazil Nuts at the next Football party.
5. Altruism – Volunteer for Meals for WheelsYes helping others chemically changes neurotransmitters associated with positive feelings, decreasing anxiety and worry, and making people feel stronger and more energetic.
1 cup milk 1 egg, well beaten 3/4 cup sugar 1/4 tsp. salt clean snow Beat egg; add milk, sugar and salt. Mix together well. Add enough snow to make it thick.
Shorter, darker days can cause winter blues but evidentially snow and ice cream bring smiles. Now if I can only get up to doing push-ups to Downtown Abbey.
The Association of American Medical Colleges projects a shortage of 60,000 physicians by 2015 and 90,000 physicians by 2020, roughly a 10-15% shortfall. Although the shortage preceded ObamaCare, the new law will make matters worse. The Physicians Foundation predicts a “silent exodus“ of physicians retiring early or reducing work hours in response to ObamaCare.
Many primary care physicians are overloaded and closing their practices to new patients. If you don’t have a doctor yet, get one before it’s too late.
The Doctor is Not Infograph by Association of American Medical Colleges Kaiser Health
Similarly, if you’re approaching Medicare age (65) and your current doctor will retire in a few years, consider switching to a younger doctor now. Many doctors no longer accept new Medicare patients, and this problem will worsen with anticipated Medicare payment cuts. However, most doctors will continue seeing their current patients even after they turn 65. But if you wait until after age 65 to look for a new doctor, you may have a hard time finding one.
Fiscal Cliff Deal: Doc Cuts Spared. Happy 2013 Fiscal Cliff averted! At least for another year the dreaded 27% Medicare reimbursement have been spared. The so-called “doc fix” would boost the deficit by $31 billion. The President stood firm against any proposed Republican cuts to the Affordable Care Act.
The fear in provider cuts is grounded. According to The Lewin Report Patient Protection and Affordable Care Act (PPACA): Long Term Costs for Governments, Employers, Families and Providers “About half of program costs will be funded with reductions in payments to providers and health plans under the Medicare and Medicaid programs, which the CBO estimates will amount to $498 billion over the ten year period“. The new cost estimate has been updated to $1.4445 trillion from original estimate $938 billion over 10 years.
With millions of new uninsured patients slated to enter the system this would help providers recover reimbursement losses. Additionally, the President was firmly against any Provider cuts in 2013.
The Lewin Report predicts in fact that Provider Reimbursement will recover losses long term and in fact increase gross payments to $129.8 billion under the Act.
“..estimate that utilization of physician services will increase by about $102.7 billion under the Act. This estimate reflects Medicaid the payment levels for the portion of newly insured people covered under that program and commercial payment levels for those who become covered under private insurance. As discussed above, our key assumption is that utilization of services for newly insured people adjusts to the levels reported by insured individuals with similar age, gender, health status and income characteristics. Physicians also will be paid for services formerly provided free to uninsured people resulting in revenues of $8.4 billion. There will be an increase in reimbursement for people who shift from Medicaid to private coverage, and payment rates for Medicare primary care services will be increased for a three year period under the Act. These factors will add 18.7 billion in revenues for physicians.
While there was large Senate consensus 89-8 approval for the American Taxpayer Relief Act the health care debate is far from over. With rising health care costs, combined with the aging of the baby boomers, means the entitlement programs will remain at the heart of the tax-and-spending battles to come.
New Proposed Rules for Wellness ProgramsIn another step forward to ncentivize wellness new proposal can give discounts for managing good health much like good drivers with auto insurance.Newproposed rules issued under Health Care Reform address certain amendments to the nondiscrimination requirements for group health plans offering a wellness program to comply with the federal Health Insurance Portability and Accountability Act(HIPAA).Specifically, the proposed rules would increase the maximum permissible reward under a wellness program that requires an individual to satisfy a standard based on a health factor in order to obtain a reward, from 20% to 30% of the cost of coverage (and to 50% for programs designed to prevent or reduce tobacco use). The rules also include other proposed clarifications regarding the requirements for such wellness programs to avoid prohibited discrimination, including reasonable design and reasonable alternatives that must be offered for individuals to obtain the reward.Other Proposed Rules Released Under Health Care Reform Separately, new proposed rules have been issued for health insurance companies regarding the law’s requirements related to guaranteed availability of coverage and essential health benefits.
Under one set of proposed rules, issuers offering non-grandfathered health insurance coverage in the individual or group market would be required to accept every individual and employer that applies for coverage, with limited exceptions. Issuers in the individual and small group markets would be allowed to vary premiums within limits, only based on age, tobacco use, family size, and geography.
Another set of proposed rules outline issuer standards related to coverage of “essential health benefits.” Essential health benefits are a core set of items and services that must be covered by non-grandfathered plans in the individual and small group markets beginning in 2014.
While its always been known a healthy livingfor employees makes a productive employee. Large businesses have benefited from a healthy work force as they can better afford programs and have a direct rate reduction in rates.
Although employers continue to use cost shifting to control health insurance expenses, many companies are also making wellness programs part of the overall strategy to keep costs down by keeping staff members healthy.“Our entire health care system is organized around treating diseases after they occur, not preventing them before they occur. We need a paradigm shift that places prevention at the center of our health priorities.” – Lynn C. Swann, Chairman, President’s Council on Physical Fitness and Sports
The new proposed rules would apply for plan years beginning on or after January 1, 2014. An overview of the proposed rules is available on Healthcare.gov. Our Summary by Year offers updates on other requirements related to Health Care Reform.
“New Jersey and all other states still await substantial federal guidance on the functioning of all three types of exchanges,” Mr. Christie said in his veto message. “To be sure, the decision of whether to move forward with a state-based exchange can only be fully understood when competitively compared to the overall value of the other options.”
States have until Dec. 14 to decide whether to establish a state-based exchange. They have more time to decide whether to partner with the federal government or let federal bureaucrats design and run the state exchange. Many states with Republican governors have said they would not participate in the process, citing their opposition to the law and its potential costs. This is the current Map of State Exchange Status.
What is an Exchange? One of the centerpieces of the recently passed Patient Protection and Affordable Care Act (PPACA) is the establishment of state based health insurance exchanges by the year 2014.
An “Exchange” is a mechanism for organizing the health insurance marketplace to help consumers and small businesses shop for coverage in a way that permits easy comparison of available plan options based on price, benefits, service and quality. By pooling individuals and small groups together, transaction costs can be reduced and transparency can be increased. Exchanges can create more efficient and competitive markets for individuals and small employers.
States have until Dec. 14 to decide whether to establish a state-based exchange. They have more time to decide whether to partner with the federal government or let federal bureaucrats design and run the state exchange. Many states with Republican governors have said they would not participate in the process, citing their opposition to the law and its potential costs.
Many Republican governors were saying before the Court ruling that the Medicaid expansion was yet another unfunded federal mandate they could not afford. Yes the Supreme Court ruling has given the Republican governors enormous leverage. Republican governors have long argued that state control and flexibility can save lots of Medicaid money. If they put a reasonable plan on the table to expand their Medicaid programs to 133% of poverty–one that saves at least as much as their state match–it could be a win for everyone. The Republican governors get their flexibility and the Obama administration gets their expansion.
Surviving the holidays with one’s waistline, bank account and sanity intact can be challenging for everyone, but the season affords specific pitfalls—and opportunities—for those who are mindful of staying physically and mentally healthy throughout the season and beyond.—try these tips:
1. Protecting Big-Ticket Items:Big-ticket electronics, such as televisions, computers and gaming consoles, are at the top of many holiday wish lists but who can afford to break the bank? How about a Discount Dental PPO/Vision Cardfor less than $10? With eroding benefits you would be amazed how many loved ones need coverage!
2. Never arrive to your social function feeling overly hungry. Avoid skipping meals or snacks to save up your calories- this will encourage over eating. Have a snack ahead of time to take off the edge such as goodness knows snack squares- a four-square serving has 150 calories and is made from slow-roasted whole almonds, fruits, toasted oats and extraordinary deep chocolate. They come in three delicious flavors: Nutty Apple, Very Cranberry and Peachy Cherry.
3. Take care of yourself. Be active and eat well – these help maintain a healthy body. Physical and mental health are closely linked; it’s easier to feel good about life if your body feels good. You don’t have to go to the gym to exercise – gardening, vacuuming, dancing and bushwalking all count. Combine physical activity with a balanced diet to nourish your body and mind and keep you feeling good, inside and out.
4. Deal with stress. Be aware of what triggers your stress and how you react. You may be able to avoid some of the triggers and learn to prepare for or manage others. Stress is a part of life and affects people in different ways. It only becomes a problem when it makes you feel uncomfortable or distressed. A balanced lifestyle can help you manage stress better. If you have trouble winding down, you may find that relaxation breathing, yoga or meditation can help.
5. Incorporate daily, moderate, physical activity. Even doing 2 -15 minute walks each day can make a difference. This is especially easy to do when holiday shopping! If you can’t get to a gym, try wearing a pedometer and increase your steps each day- (10,000 steps/day = 5 miles)
6. Watch the Liquid Calories: A martini contains about 275 calories, and 1 glass of wine has about 130 calories. Also watch out for all of the calories you might consume while you drink. Try substituting with a glass of sparkling water in between alcoholic beverages. Moderation for men is no more than 2 drinks per day and no more than 1 drink per day for women (wine: 5 oz, beer: 12 oz, liquor: 1.5 oz)
7. Plan ahead! It’s no so much of a lack of will power but a lack of preplanning. A great quote related to this is “failure to plan is planning to fail.” Think ahead and set realistic daily goals for yourself. Start thinking about making healthy food choices before you even walk into the party.
8. Portions, Portions, Portions– practice portion control: enjoy your favorite holiday foods but be mindful of your portions. Try eating slower or using smaller plates. Fill up ½ your plate with lower calorie items such as raw veggies or shrimp cocktail.
9. Office Parties, leave the work talk in the office This is a chance to let your hair down, to meet coworkers’ spouses and significant others and children. Make the rounds and mingle with as many different people as you can. And whatever you do, don’t be that guy who brings up work stuff. No matter how fun your light-up Frosty tie is, you will be hated for this. Sales numbers and conference calls and brainstorming sessions can wait. People have lives outside of the office. You should too. Or you should fake it.
10. Rest and refresh. Get plenty of sleep. Go to bed at a regular time each day and practice good habits to get better sleep. Sleep restores both your mind and body. However, feelings of fatigue can still set in if you feel constantly rushed and overwhelmed when you are awake. Allow yourself some unfocussed time each day to refresh; for example, let your mind wander, daydream orsimply watch the clouds go by for a while. It’s OK to add ‘do nothing’ to your to-do list!
Do you have another healthy holiday eating tip we haven’t talked about yet? If so, leave us a comment or a question.
To no one’s surprise the InterfaithHospital in Brooklyn Files for Bankruptcy Protection– Dec3, 2012 NYT . In addition to the $130 Million in debt “…hospital estimates its cash spending will exceed its cash receipts by nearly $2 million, and it will have $7 million in unpaid obligations and $26 million in unpaid receivables, other than professional fees.”
The long time beleaguered hospital has been a stepchild of the State with multiple bail outs in the past decades. “Interfaith officials have said that they need $20 million from the state just to continue operating during the bankruptcy reorganization, and otherwise face the possibility that the hospital will close.” The State promised some financial support last year to accomplish an integrating Wyckoff Hospital, Brooklyn Hospital andInterfaith Hospitalby a Cuomo Pane Administration. Interfaith Hospital, located in Bedford Stuyvesant, took extreme steps to save cash by foregoing malpractice insurance – NYT “Troubled NY Hospital Forgo Coverage for Malpractice”.
Since health care is viewed as a right, the government has been subsidizing and encouraging its growth for decades, helping it to evolve into the juggernaut of 17% of the GNP that it is. Now, as Margaret Thatcher so famously said of all socialist experiments, “they have run out of other peoples’ money”. The law and the courts compel them to give everyone 21st century technology which costs more than many patients make in their whole life ! Now the medical industry is up against the limits of what they can pry out of the taxpayer and the private citizens but they are still compelled to offer insanely expensive health care to everyone. Very bright people try to wiggle around this dynamic but they are finding that they cant. We need to strike at the source, and accept : Health care is not a right, you don’t get it because you exist, you have to buy it. Only by accepting this truth can we begin to save a reasonable health care industry.
Unlike St Vincent’s Hospital Bankruptcy Closurein 2010 was a complete shock to NYC Health Community. For more than 150 years the hospital was a mainstay of Downtown Manhattan. It remains to be seen if this Administration will step in and save Interfaith Hospital again.
Crains Brokers’ Commissions Face Uncertain Future. A quick comment on our quote in Crains “Crains Brokers’ Commissions Face Uncertain Future” today. Insurers are indeed cutting back on services resulting in cost containement measures such as layoffs, outsourcing and significant broker commissions cuts.
A significant negative development is the NYS decision to not allow licensed Agents/Brokers in the Individual Exchange. Many States such as Massachusettes, the inspiration for Health Care Reform, use a Connectorwhich is an Exchange or an independent state agency that helps Massachusetts residents find health insurance coverage and avoid tax penalties. Instead NYS will allow Agents/Brokers to only work in the Commercial Exchange known as SHOP. HealthPass is a good pre-cursor of the SHOP Exchange offering Small Businesses a Defined Contribution Health Planof full options form Health Insurance, Dental, Vision to Term Life Insurance and Disability.
The Individual Exchange will work with an “Assitor” or “Navigator”. In NYS Government and Non-Profit Agencies will comprise the “Navigator” which will only be allowed to operate in the Individual Exchange. By design an income subsidy will only pass through this Individual Exchange an not on the SHOP Exchange. Example: a $50,000 Family Household of 4 can get approximately 80% credited.
The Federal Gov has already spent $2.2 Billion on State Exchanges. And this figures does not include remaining States as there are only 19 States working on an Exchange for 2014. The Exchanges will be built up for 2 years and then must be fully independent by 2016. If 88% of small groups coverage purchased by Brokers acc. to Bostons Wakely Report in research study- Role of Producers and Other Third Party Assisters in New York’s Individual and SHOP Exchanges the distribution infrastructure is already there. Access to care is not the difficulty in finding a plan its the very cost of the plan! Why then does NYS decide to spend on building up new infrastructures? AgentsBrokers can easily outreach and council to uninsured as well. In fact many small businesses such as construction, consulting services and dining have many uninsured that an Agent/Broker already has a relationship with.
Despite all this and the rapid changes in reshaping health care we remain optimistic and look forward to taking on a greater role in health care reform.
With more choice, our groups and their employees will need more direction, allowing brokers to take on more of a consultative role. Healthcare plans are not a simple purchase and one plan doesn’t fit all. By delivering the latest cutting-edge benefits technologies, continued consumer focus approach and leveraging our long time relationships with Benefits/HR/Payroll partners our role will be pivotal in being part of the solution.
Hurricane Sandy Recovery Assistance Resources. Department of Small Business Services (SBS) and the New York City Economic Development Corporation (NYCEDC), is coordinating a set of services to assist small businesses in recovering from Hurricane Sandy.
Below is an outline of available programs & relevant contact information:
For small- to mid-sized businesses that have experienced business interruption
An emergency loan for businesses will be available, patterned after similar programs deployed in past emergencies. Loans will be capped at $10,000. Please click this linkto contact an NYC Business Solutions Account Manager or call 311 and ask for NYC Business Emergency Loan.
Federal Aid Programs for State of New York Disaster Recovery Loans are available up to $2 million for business property losses not fully compensated by insurance, and for small businesses, small agricultural cooperatives and most private, non-profit organizations of all sizes that have suffered disaster-related cash flow problems and need funds for working capital to recover from the disaster. More information can be found at www.DisasterAssistance.gov, or 1-800-621-FEMA (3362). Information from the Federal Small Business Administration on disaster recovery assistance is also available at www.sba.gov.
For mid- to large-sized businesses that need to undertake rebuilding
An emergency sales tax letter from New York City Industrial Development Authority (IDA) will be available allowing businesses to avoid payment of New York City and New York State sales taxes on materials purchased for rebuilding. IDA will also waive all fees and, while following State law, look to streamline its normal procedure. This program is expected to offer economic benefits to reconstruction projects costing $500,000 or more. Please contact Shin Mitsugi at smitsugi@nycedc.com for further information on this program.
For any business that is temporarily displaced from its space
Short-term “swing” office space at Brooklyn Army Terminal available free of charge for the next 30 days. NYCEDC has approximately 40,000 square feet of warehouse space at the Terminal that can be used for this purpose. Please click this link to contact an NYC Business Solutions Account Manager or call 311 and ask for NYC Business Solutions.
For any business in need of other emergency assistance
The SBS Business Outreach Team and Emergency Response Unit’s Large Scale Response Team will be deployed after the storm to help all impacted small businesses. This team is currently on-call for any storm-related business inquiries and is closely coordinating with the NYC Office of Emergency Management. Please click this link to contact an NYC Business Solutions Account Manager or call 311 and ask for NYC Business Solutions.
Federal Aid Programs for Disaster Recovery
Click herefor information from the Federal Small Business Administration on disaster recovery assistance.
State resources
State of New Jersey – The state website has aHurricane Sandy resource centerwith emergency hotlines, updates from the power companies and how you can volunteer.
If you would like to help those hurt by this storm, here are a few ways:
Visit www.redcross.org, call 1-800-RED CROSS (1-800-733-2767), text the word REDCROSS to 90999 to make a $10 donation, or mail a contribution to a local Red Cross chapter or the American Red Cross, P.O. Box 37243, Washington, D.C. 20013. The Red Cross is providing food and shelter to storm victims.
Visit salvationarmyusa.org, text the word STORM to 80888 to make a $10 donation, confirming the donation with the word, “Yes.” The Salvation Army is providing food and shelter to storm victims.
Visit www.redcrossblood.org to find the nearest blood drive site. The Red Cross said more than 360 Red Cross blood drives were canceled due to the storm.
The most effective way to file a claim is to contact your carrier directly. We have compiled a list of our companies and their respective claim department numbers that you can conveniently reference below.
Claim Department Contact Numbers (By Insurance Carrier)
First, and most importantly, we hope that you and your families are safe and sound.
An office status for Health Insurance Carrier post Hurricane Sandy for your information. Millennium medical Solutions Corp is up and running and the offices are open until 2:00 PM today, Friday November 2nd.
Our building has power but we are having on and off phone/internet trouble but some calls are able to come through so you can call if you have any issues.
Carrier Update
• EmblemHealth still closed • Horizon still closed • AmeriHealth still had no power as of yesterday • Oxford Update – see below
A few changes to business as usual in response to the storm:
1. The deadline for payment of October premiums has been extended. We’ve extended the deposit date for payments to November 9th. Customers should make their payments online, however, as we cannot guarantee that our overnight mailing facilities will be open and available to accept mail.
https://www.payerexpress.com/billmail/EBPP/Sites/Oxford/ 2. The deadline for November renewals has been extended from the 1st to the 6th. This includes renewals run through our IDEA portal. As we get any additionalupdates, we will reach out to you.
Anti Mandatory Mail Order Victory. A little noticed NYS Healthcare Law has gone under the radar amidst fast changes in Affordable Care Act tumult. AMMO – Anti-Mandatory Mail Order passed late Dec 2011 effective for groups renewing after Jan 11, 2012. A significant signal by Governor Cuomo to stand up to the billion dollar industry no doubt.
According to trade group Pharmacists United for Truth the PBM (pharmaceutical benefits managemnt) claim that mandatory mail order lowers costs proves otherwisee. Plan sponsors are routinely charged far more than retail price in mandatory mail order plans, and their lack of transparency keeps plan sponsors to detecting the unreasonable prices.
After spending a good part of a day in early March helping a NYS client faced with mandatory mail order I learned of this change. For certain medications the insurer limits retail pharmacy coverage. While the incentivisation of 90 day supply at 2 copays was attractive this has now declined to 2.5 copay. With few exceptions such as specialty pharmaceuticals retail pharmacists are given the same advantages and evening the playing field.
The National Community Pharmacists Association’s blog post below offers a helpful FAQ. Additionally with the steady decline of the local independent pharmacist a quality of personalized care has been eroded. The price paid in patient compliance and safety has received little attention. Independent Pharmacists have been the canary in the mine for fellow small businesses competing with large copra big box chain stores. At least now NYS is finally listening.
Community pharmacists in New York scored a significant win for their patients, communities and pharmacy choice in late 2011 with the enactment of the Anti-Mandatory Mail Order or AMMO with overwhelming, bipartisan backing. What lessons might the campaign in support of the AMMO law hold for community pharmacists across the country?
To find out, NCPA recently asked one of the legislation’s staunchest supporters and advocates to share his observations on the effort to enact the AMMO law. Craig Burridge, M.S., is Executive Director of the Pharmacists Society of the State of New York (PSSNY). Mr. Burridge credits PSSNY members as most instrumental to enacting AMMO over the fierce opposition of mandatory mail order proponents, principally large pharmacy benefit managers (PBMs). He notes people including Ray Macioci, Charles Catalano, Vinny Chiffy and literally hundreds of pharmacy owners helped win a hard fought battle by gathering tens of thousands of signatures on petitions from their patients and coordinating tens of thousands of phone calls, emails and letters.
What follows is a Q&A with Mr. Burridge, in hopes that his advice would benefit patients and independent community pharmacists in other states advocating for patient choice.
NCPA: When it comes to the forced or mandated use of mail order pharmacies, many of the concerns expressed by patients and the community pharmacists who care for them are not new and have, in fact, been voiced for a number of years. What made 2011 different in New York?
Mr. Burridge: In New York, consumers by the tens of thousands signed petitions at their local pharmacy against mandatory mail order. Patients wrote dozens of letters to the editor of many regional newspapers telling about their horror stories with mail order. Finally, pharmacy owners had had enough of losing their patients to self-dealing PBMs. Tens of thousands of phone calls to the Governor’s Office and to Legislators were made by pharmacy owners, their staffs and their patients in support of passage of the no mandatory mail order bill.
NCPA: One obstacle to ensuring patient choice of pharmacy is the myth of mail order savings. This persists in some minds despite what appears to be rampant mail order waste and studies demonstrating how health plan sponsors that incent or require the use of mail order can end up paying more for drugs. Did you encounter such misperceptions and, if so, what did you do to alter or overcome them?
Mr. Burridge: We did in New York. The PBMs came at us with ads stating that costs would go up and that it was a ‘prescription drug tax’ or that it would ‘prohibit mail order.’ We responded with evidence that exposed the ‘spreads’ being used at mail for generics and the fact that the legislation requires participating pharmacies to agree to the same reimbursement and the same co-pays.
NCPA: The health care benefits of a patient’s face-to-face consultation with a community pharmacist and the preference of most patients for going to a local pharmacy are both well-established. But how did you chronicle and reinforce the economic and tax benefits of buying local when it comes to pharmacies?
Mr. Burridge: According to national data (IMS Health) for 2009, the last year we had data before introducing legislation, 22.8 percent of the national drug spend was for mail order prescriptions. Using New York’s percentage of total drug spend (11 percent), we removed hospital expenditures and Medicaid (which had less than one percent mail order) and came up with a mail order drug spend in NY in access of $5.8 billion annually. New York State has no major mail order facilities so this represents thousands of lost pharmacy jobs.
NCPA: Like PSSNY, NCPA continually stresses to its members the importance of grassroots activism, whether it is at the federal or state levels or with local employers and leaders. Did you find that your memberships became more engaged than usual in 2011 and, if so, what did you do to encourage their further involvement?
Mr. Burridge: It helped to have the PBM industry fly in colleagues from around the country and host their own Lobby Day. They told legislators that New York’s pharmacies could survive on acute medications only. This only caused yet another round of thousands of phone calls from our pharmacists, their staffs and patients. Our grass roots turned into a raging grass fire. Livelihoods were at stake and our opponents showed their hand. They wanted ALL maintenance medications going to their wholly-owned out-of-state mail order facilities. Our legislators saw that too.
NCPA: What surprised you the most about your 2011 campaign against mandatory mail order?
Mr. Burridge: I’ve been doing this too long to be surprised. We expected the worst from our opponents and they did not disappoint us.
NCPA: What were some of your opponents’ most challenging arguments and how did you address them?
Mr. Burridge: That depends if you consider outright lies as a challenge. Their ads said that it was a “Prescription Tax” or, when that flopped, they said our bill “would prohibit mail order.” These were easily swept aside and only upset legislators who felt the PBM industry was accusing them of passing a tax on prescription drugs.
NCPA: Do you have any other words of wisdom that you would like to share with concerned patients or your colleagues in community pharmacy?
Mr. Burridge: Choosing one’s pharmacy should be a basic right. If the playing field is level, it only makes sense to buy local. Watch out for PBMs calling all maintenance medications so-called ‘specialty drugs’ as a way of getting around no mandatory mail order laws. We’ll have a lot more to say on that in the near future.
In years past, most health insurance policies had limits or “caps” on the benefits they would pay. These limits were on any health plan participant (individual or family) – either over a lifetime or in a plan year. If someone exceeded that limit, benefits ended. While this rarely occurred, it resulted in major financial troubles for the few people it hit. The new law does not allow lifetime limits on”essential health benefits”. The law also restricts annual limits from now until 2014, when their use will become more limited. However, the law doesn’t prevent a plan from excluding all benefits for a condition.
Lifetime limits Employers must eliminate lifetime limits on essential health benefits.
Effective This applies to all health plans, including grandfathered plans.
Grandfathered plans will lose their grandfathered status if they impose an overall annual or lifetime limit on the dollar value of essential benefits if their plan did not include that limit prior to March 23, 2010. Plans can keep their grandfathered status if they convert lifetime limits into an annual limit at a dollar value that is lower than the lifetime limit on March 23, 2010.
Annual limits Employers must eliminate annual limits by 2014. Until then, plans may place only “restrictive” annual limits on essential health benefits. The limits have been set for plan years that begin:
9/23/2010 to 9/22/2011 – $750,000 annual limit
9/23/2011 to 9/22/2012 – $1.25 million annual limit
9/23/2012 to 12/31/2013 – $2 million annual limit
Annual limits must apply on an individual-by-individual (not family) basis.
Essential Health Benefits defined According to the law, the list of essential health benefits must include:
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
The government has not released the final regulation on essential benefits. Until it does, the government will take into account an employer’s “good faith effort” to comply with reasonable consistent interpretation.
After a six-month delay in the original effective date, group health plans (including grandfathered plans) will soon need to comply with a new requirement under Health Care Reform to provide a summary of benefits and coverage (SBC) so that employees can more easily compare insurance options.
The new SBC notice requirements are effective for plan years and open enrollment periods beginning on or after Sept. 23, 2012. If you need a refresher, the following are some key points for group health plans:
An SBC must be provided to plan enrollees at specific times, such as upon application for coverage and at renewal, as well as upon request.
Insured group health plans can satisfy the requirement if the issuer provides a timely and complete SBC to the participant or beneficiary.
Combining information for different coverage tiers, different cost-sharing selections (such as levels of deductibles and copayments), and different add-ons to major medical coverage (such as FSAs, HRAs, HSAs, or wellness programs) into one SBC is permissible, provided the appearance is understandable.
SBCs may be provided either as a stand-alone document or in combination with other summary materials (for example, an SPD), if the SBC information is intact and prominently displayed at the beginning of the materials and in accordance with the SBC timing requirements.
The SBC must comply with certain appearance and format requirements and must use terminology understandable by the average plan enrollee; an SBC template along with instructions and related materials that may be used to satisfy the notice requirements, is available online.
The U.S. Department of Labor has released three sets of Frequently Asked Questions (FAQs) which address a number of issues relating to the SBC notice requirements. The FAQs also make clear that, during the first year of applicability of the new SBC rules, penalties will not be imposed on plans that are working diligently and in good faith to provide the required content in an appearance that is consistent with the final regulations.
Companies in the Salt Lake City area know productivity is higher and health costs are lower when employees have ways to exercise and reduce stress during the work day, whether it is using a company gym, eating healthier in the cafeteria or taking regular breaks. A study to be published in Population Health Management says “presenteeism,” which means people coming to work with physical or emotional problems, reduces productivity. The Salt Lake Tribune (Utah)
Some of the most popular wellness services offered are providing resources and information at 76 percent, giving onsite seasonal fluvaccinations at 54 percent and hosting health fairs at 42 percent. Other wellness efforts include health and lifestyle coaching at 37 percent, health screening at 39 percent and smoking cessation programs at 34 percent.
Considering that obesity and other chronic health issues continue to impact the well-being of employees and an employer’s bottom line, more respondents on a national level are offering lower health care premiums for getting an annual health risk assessment and not using tobacco according to surveys. The ROI on wellness is starting to pay – wellness plans pay for itself.
For more information, you may review the final rules in their entirety. For MMS Corp previous blogs on wellness, click here. we will keep you posted on future PPACA wellness program opportunities. In the meantime, please visit to view past blogs and Legislative Alerts at https://360peo.com/feed.
The views expressed in this post do not necessarily reflect the official policy, position, or opinions of MMS Corp. This update is provided for informational purposes. Please consult with a licensed accountant or attorney regarding any legal and tax matters discussed herein.
It may come as a surprise that President Barack Obama and GOP vice presidential nominee Paul Ryan are pushing the same target rate for controlling federal spending on Medicare. Each would set it at half a percentage point higher than the growth rate of the economy the gross domestic product after a phase-in period.
With our Bonus Card the Rx discount is FREE and a great way to reinsure after all anyone can save you money by taking away benefits.
What can a Bonus Card card do for you?
Aside from the FREE Pharmacy Discount there added optional benefits. You get all the benefits below in one easy-to-use card for a low family rate of $9.95 or $14.95 per month.
Wouldn’t it be nice to just call a doctor when you need a prescription fast? Skip the office visit and wasted time in that germ-infested waiting room. Now, you can call a doctor 24/7/365 and get a prescription, if needed. Your Bonus Card health discount card gives you VIP access to our Teladoc service with fast treatment (within about 22 minutes, on average) for common ailments, from UTIs to pink eye. It’s like having a best friend who happens to be a doctor. Teladoc is just one of many services, including dental discounts, vision discounts and prescription discounts, all rolled into one easy-to-use health discount card. And, you get all this savings for one low monthly fee. There’s no risk with our 30-day, money back guarantee, so start saving time and money when you need to call a doctor to get a prescription (if needed).
Health Discount Card
Bonus Card is a health discount card that includes the ability to call a doctor 24/7 and get a prescription, if needed. It provides dental discounts at over 92,500 providers, vision discounts at over 12,000 providers and prescription discounts for prescriptions that are expensive or not covered by insurance. All that, rolled into one easy-to-use card! We know you’re busy and sometimes just need a prescription fast. You don’t have time to shop around for health discounts or a health discount card. Bonus Card gives you all these health services plus legal advice, identity theft protection and roadside assistance at one low price. You’ll love the time, money and frustration savings you’ll get with your very own Bonus Card health discount card.
Your 24/7/365 Dr. BFF! It’s like having a best friend who’s a doctor! Did you know up to 70% of medical issues could be solved over the phone? Call a doctor (US-based) & get a prescription written, if needed. No additional cost…no kidding!
Two weeks after I received my discount card, I had a dental emergency. I was able to find a dental provider near our offices. The emergency that I experienced required that I have one tooth capped and another one filled. The discount card saved me $200.00. Wood S. from CA Learn More
With increase in demand and already shortages of Doctors the Obamacare – Affordable Care Act will put significant severe strains on patient access.
According to todays WSJ article – John C. Goodman: Why the Doctor Can’t See You “Here is the problem: The health-care system can’t possibly deliver on the huge increase in demand for primary-care services. The original ObamaCare bill actually had a line item for increased doctor training. But this provision was zeroed out before passage, probably to keep down the cost of health reform. The result will be gridlock.”
The Department of Health and Human Services, estimated the minimum number of primary care physicians to ensure “adequate supply” at 60 to 80 per 100,000 population. By 2020 an estimated 45,000 new PCP would ne needed 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.
The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.
“Take preventive care. ObamaCare says that health insurance must cover the tests and procedures recommended by the U.S. Preventive Services Task Force. What would that involve? In the American Journal of Public Health (2003), scholars at Duke University calculated that arranging for and counseling patients about all those screenings would require 1,773 hours of the average primary-care physician’s time each year, or 7.4 hours per working day.”
In 2014 an expected 30 Million people will be added The expected wait time would increase form 3 weeks to about 2 months. The 2 month estimate is a approximately how long it takes to schedule a check up in Boston which had enacted universal healthcare 5 years ago. Furthermore, the positive measures to encourage preventive care such as healthy screenings and well-care will only add to the gridlock.
“When people cannot find a primary-care physician who will see them in a reasonable length of time, all too often they go to hospital emergency rooms. Yet a 2007 study of California in the Annals of Emergency Medicine showed that up to 20% of the patients who entered an emergency room left without ever seeing a doctor, because they got tired of waiting.” Be prepared for that situation to get worse even with Urgent Care Centers.
“A New York Times survey of dermatologists in 2008 for example, found an extensive two-tiered system. For patients in need of services covered by Medicare, the typical wait to see a doctor was two or three weeks, and the appointments were made by answering machine.However, for Botox and other treatments not covered by Medicare (and for which patients pay the market price out of pocket), appointments to see those same doctors were often available on the same day, and they were made by live receptionists.”
As with any economic model the shorter supply of provider will drive up costs. Aside form provider fees increasing, those who can afford concierge service and pay $2,000-$4,000 may be able to get same day services and easy access but for most Americans with insurance will be waiting longer to see their Doctors. The irony is that people with coverage will have limited access to care.
Bluecard PPO – Outside members home region, the PPO medical plan is known as BlueCard PPO. The BlueCard plan offers a network of quality doctors and hospitals known as the BlueCard Provider Network.
freedom to seek care in-network or out-of-network;
no need to select a primary care physician to coordinate your care;
visit specialists directly — no referrals are required;
no claim forms to submit when using an in-network provider;
no balance bills when using an in-nework provider;
wellness programs, including fitness reimbursement and discounts on alternative health care services, at no additional cost;
enhanced programs to control and manage chronic conditions;
preventive care for children and adults;
enjoy in-network coverage anywhere in the United States when you use providers that participate in the Personal Choice or BlueCard PPO networks;
worldwide coverage and recognition of the Blue Cross® symbol.
How Does it Work?
Blank Suitcase Logo
A blank suitcase logo on a member’s ID card means that the patient has Blue Cross Blue Shield traditional, POS, or HMO benefits delivered through the BlueCard Program.
“PPO in a Suitcase” Logo
You’ll immediately recognize BlueCard PPO members by the special “PPO in a suitcase” logo on their membership card. BlueCard PPO members are Blue Cross and Blue Shield members whose PPO benefits are delivered through the BlueCard Program. It is important to remember that not all PPO members are BlueCard PPO members, only those whose membership cards carry this logo. BlueCard PPO members traveling or living outside of their Blue Plan’s area receive the PPO level of benefits when they obtain services from designated BlueCard PPO providers.
How to Verify Membership and Coverage
Once you’ve identified the alpha prefix, call BlueCard Eligibility to verify the patient’s eligibility and coverage.
1. Have the member’s ID card ready when calling.
2. Dial 1.800.676.BLUE.
Operators are available to assist you weekdays during regular business hours (7am – 10pm EST). They will ask for the alpha prefix shown on the patient’s ID card and will connect you directly to the appropriate membership and coverage unit at the member’s Blue Cross Blue Shield Plan. If you call after hours, you will get a recorded message stating the business hours.
Keep in mind BCBS Plans are located throughout the country and may operate on a different time schedule than Anthem Blue Cross and Blue Shield. It is possible you will be transferred to a voice response system linked to customer enrollment and benefits or you may need to call back at a later time.
International Claims
The claim submission process for international Blue Cross and Blue Shield Plan members is the same as for domestic Blue Cross and Blue Shield Plan members. You should submit the claim directly to Anthem Blue Cross and Blue Shield.
Aetna and Hunterdon HealthCare Partners Forge New Accountable Care Relationship
Hunterdon Healthcare employees and Aetna members in 5 NJ counties will benefit from new ACO committed to higher quality more coordinated care
HARTFORD, Conn.–(BUSINESS WIRE)–Aetna (NYSE: AET) and Hunterdon HealthCare Partners today announced a new accountable care agreement that will improve the quality and cost of patient care, helping members and plan sponsors save money. Hunterdon Healthcare is establishing an Accountable Care Organization (ACO) to deliver a better patient experience, and aims to improve the quality of patient care while reducing the overall cost of care.
“Becoming an ACO not only supports our mission to deliver better access to primary care and specialist physicians, but will allow us to better provide integrated healthcare to improve the health of our community.”
“We are excited to bring our industry-leading technology and care management capabilities together with Hunterdon’s quality-driven team to offer highly coordinated and comprehensive care management to members in New Jersey,” said John Lawrence, president, Aetna New Jersey market. “Beginning this summer, 8,000 Hunterdon Healthcare employees and Aetna members will receive health care in this new patient-focused, accountable care model.”
An ACO is a group of health care providers who coordinate care and are accountable for cost, quality and patient satisfaction for the health care they provide.
“In the past several years, the healthcare industry has changed with the demands of health care reform. The industry trend is shifting from paying for services, regardless of patient outcomes, to paying for care that delivers better value, quality and patient satisfaction. Collaborating with Aetna will help Hunterdon Healthcare deliver better care at a better price. We think patients will see direct benefit from this approach,” explained Robert P. Wise, president and CEO, Hunterdon Healthcare.” Jeffrey Weinstein, executive director for Hunterdon HealthCare Partners added, “Becoming an ACO not only supports our mission to deliver better access to primary care and specialist physicians, but will allow us to better provide integrated healthcare to improve the health of our community.”
About the Hunterdon HealthCare Partners ACO
Under the new ACO agreement, 2,200 members in the Hunterdon Healthcare employee benefits plan, and approximately 5,700 fully insured Aetna members who live in Hunterdon, Mercer, Warren, Morris and Somerset Counties will be served by the ACO. Aetna members served by this new model are ones who primarily received care from Hunterdon Healthcare’s providers in the last 24 months, as well as those who seek care from Hunterdon Healthcare physicians following the start of the agreement.
Hunterdon Medical Center, more than 225 affiliated primary care physicians and specialists, and the affiliated ambulatory surgery, radiology, hospice, and other Hunterdon Healthcare facilities and providers will all be part of the ACO. Working together, and supported by a full suite of Aetna health information technology and care management capabilities, the providers will become part of a coordinated health care network and receive notices of any treatments and medications the patient may be receiving. As a result, the patients will receive an enhanced level of coordinated care in addition to the member benefits of their current Aetna plan.
Aetna and Hunterdon HealthCare Partners are implementing a payment model that will change the way Hunterdon Healthcare is reimbursed for care. Under the ACO agreement, Hunterdon Healthcare will be paid based on achieving certain quality, efficiency and patient satisfaction measures, which are designed to:
improve the patient’s health care experience through greater care coordination and patient engagement;
improve the health of populations; and
reduce the cost of health care by aligning payment with quality, patient outcomes and value.
The measures include, but are not limited to:
the percentage of Aetna members who receive recommended preventive care and screenings, such as increased cancer screenings, flu shots and other vaccinations;
improved management of patients with chronic conditions such as diabetes, heart failure and asthma;
reductions in hospital readmission rates; and
reductions in Emergency Room visits by improving primary care access hours.
Aetna’s Technology Support
To support the full success of the ACO, Aetna will implement the following integrated technologies and capabilities for Hunterdon HealthCare Partners:
health information exchange technology from Medicity, a wholly-owned subsidiary of Aetna, to enable the secure, two-way exchange of health information across a patient’s entire care team, including hospitals, physicians, labs, pharmacies and other ambulatory services;
point-of-care clinical decision support services and the Active CareTeamSM desktop-based workflow tool to track, monitor, coordinate and report on patient health outcomes from ActiveHealth Management a wholly-owned subsidiary of Aetna; and,
reporting tools that will help Hunterdon Healthcare providers evaluate how they are performing against their targeted clinical and financial outcomes.
About Hunterdon HealthCare Partners
Hunterdon HealthCare Partners was created by physicians and the Hunterdon Healthcare System, the parent organization of the Hunterdon Medical Center. The partnership’s goal is to provide the residents of Hunterdon County and the surrounding areas better access to integrated care delivered through their network of primary care and specialist physicians. For more information, contact Jeffrey Weinstein at Weinstein.Jeffrey@hunterdonhealthcare.org.
About Aetna
Aetna is one of the nation’s leading diversified health care benefits companies, serving approximately 36.1 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services and health information technology services. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups and expatriates. For more information, see www.aetna.com.
The Con Ed lockout this Summer couldn’t come at a more heady time. I’m not referring to the obvious temperature swelter but more to the employee health benefits that are at the back bone of virtually every recent Labor dispute. With the Con Ed dispute, Management’s has acquiesced on the health insurance . “Con Ed did accede to “public pressure” on Sunday by reinstating health insurance for the 8,500 members of Local 1-2 of the Utility Workers Union of America, a company spokesman said. The workers have been collecting unemployment benefits for two weeks but had to pay for their own prescription medicine and doctor visits because the company cut off health coverage when the old contract expired, at midnight June 30.”
Interestingly, Unions are major stakeholders in Healthcare as their benefits have been traditionally rich incentives attracting to workers. However, with A.C.A. (Affordable Care Act) otherwise known as Obamacare their health programs are very much in danger of additional taxation or member withdrawal. Unions estimate these provisions will raise the cost of health coverage by an additional $1,000 a year. In fact, a Union members may fare better on the Individual Mandated Exchange with projected individual direct insurance dropping 70% things will open up. A lower/middle income member will likely qualify for an additional discount credit. A more affordable health plan just may be a possibility.
There are other reasons the Individual Health Plan may be better:
Unions as other self insured group must now comply with added benefits for preventive care, maternity care, Age 26 dependent care, pre-existing condition waivers.
No Annual Limits on essential benefits by 2014
No Lifetime Limits
No more mini-med plans – discount health plans are prohibited. The movie John Q , based on a true story, where a father is told his son’s transplant will not be covered based on th elicited mini-med plan covering him up to $20,000. Large companies such as McDonald’s have also sponsored mini meds.
Cadillac Tax – By 2018 a 40% excise tax on health plans that exceed $10,200(single) and $27,500 (family).
The original Cadillac Tax was pushed back by the behest of Unions to 2018 from the original proposed 2014 date. Most Unions with generous health care packages would not be complaint within that time frame.
However, not all is grim for Unions. HHS has issued waivers to 1,625 plans covering 3,914,356 individuals were exempt from these mandates through 2014. According to Heartland “More than half of the approximately four million individuals receiving waivers are union members, including 82.9 percent of those covered in the most recently updated list of waivers.”
With current administration posts coming from Union there wouldn’t be much surprise if these allowances continue. Would it be that bold to predict for Union Members in 2014 will be allowed to use their Individual Exchange income tax credits for their Union benefits packages? Small businesses may not be as lucky.
At 10 AM today the Supreme Court in a 5-4 decision upheld the Patient Protection and Affordable Health Care Act’s individual mandate as constitutional.
Imposition of a tax “leaves an individual with a lawful choice to do or not do a certain act, so long as he is willing to pay a tax levied on that choice,” Roberts says. “The Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.”
According to Footnote 11, which is on page 44 of the slip opinion: Those subject to the individual mandate may lawfully forgo health insurance and pay higher taxes, or buy health insurance and pay lower taxes. The only thing that they may not lawfully do is buy health insurance and not pay the resulting tax.With this decision finalized, New York State (and the rest of the country) can now move forward with implementing the law. We embrace the much-needed clarity and looking forward to working with our clients moving ahead.Millennium Medical Solutions Corp will be planning health care seminars to review the decision and overview to help understand the impact on employers, plan benefits, and providers. We welcome your suggestions on specific topics or questions you want us to focus on. Please join us!
Our office will continue to monitor events and inform our members of any other important news.
The biggest Supreme Court Ruling in a decae is expected this Thursday before the Summer recess. Yet thats when the fun begins.Possible outcomes:
Delay hearing the legal issues associated with case for several years due to the Tax Issue.
Invalidate the Individual Mandate.
Invalidate all or part of the Medicaid Expansion requirements.
Uphold PPACA as is.
Declare the entire Act unconstitutional due to the lack of a Severability Clause if any of the key provisions such as the Individual Mandate overturned.
If individual mandate is repealed but leave other PPACA provisions in place, this outcome could greatly limit the coverage goals underpinning the Affordable Care Act and cause significant problems in the health insurance markets. For example, MIT economist Jonathan Gruber said, “Without a mandate the law is a lot less effective. The market will not collapse, but it will be a ton more expensive and cover many fewer people.”
While States such as NY may follow Massachusetts and set up their own Individual Mandate this becomes challenging with less Federal funding. Funding for the individual market place subsidy with subsidies could collapse. See subsidy calculator here.
Eliminating the mandate would increase premiums and mean that far fewer of the uninsured would be covered. This is known as adverse selection where the sick population would be willing to pay higher premiums and forcing the healthy population to opt out of exchange. States such as NY in fact have seen the Individual Market spiral out of control as they are high risk adverse group in order to supplement the preferred guaranteed non-preexisting condition group marketplace. Furthermore, NYS requires guaranteed issue for pre-existing condition for individual members with prior coverage. If the court invalidates the individual mandate and leave rest of Act in tact it may lead to a death spiral. Popular reforms such as overage 26 dependent coverage and expected pre-existing condition waiver in 2014 would possibly be dismantled.
The decision would punt health-care reform back to Congress, which “isn’t doing anything this year” and thus create major uncertainty going into the November elections. Taxes on pharma and medical devices would remain, while managed-care and hospital companies would suffer big losses. Insurers would be forced to take on sick patients without benefitting from the healthy ones who would have been enrolled under the mandate.
In this scenario, a lot of companies would simply cut their losses and leave the individual insurance market altogether; the law would essentially “run them out of business.
Either way the lack of uncertainty has delayed hospitals and insurers from new hires and taking decisive actions. Same time next week we hope to celebrate July 4th with certainty.
Most are familiar with the AFLAC duck when it comes to supplemental benefits to primary medical plans. Today, primary medical plans are extremely valuable but in many cases the benefits paid cover only a fraction of the true cost of a major illness or injury. For instance, a person who suffers a severe heart attack can expect to experience a lengthy hospital stay, followed by a period of recuperation at home or in an extended care or rehabilitative facility. A primary medical plan will cover a significant portion of the hospital and physician costs, but the insured is likely to be responsible for some expenses. Depending on the terms of the plan, these expenses can be substantial.
Most Popular Benefits
The most in-demand voluntary benefits continue to be those that supplement core medical, life, or disability insurance coverage, according to surveys. These include dental, critical illness, specific illness, hospital supplemental, medical supplemental, disability buy-up, and supplemental life coverage. However, demographic trends are also contributing to growing interest in long-term care and financial planning products.
As more people are faced with their parents’ elder care needs, they begin to appreciate the cost of extended care and anticipate what their needs may be in a few years. And, many mid-career employees face the double crunch of saving for retirement at the same time they are financing college education for their children.
Perhaps reflecting the many demands on the time and money of today’s employees, 28 percent of participants in one survey said they wanted employers to provide a wider array of voluntary benefits. In addition, 30 percent of respondents said they were interested in having employer-provided access to financial planners to assist them in making decisions.
Furthermore, an individual experiencing a health crisis such as a heart attack can expect to be absent from work for some time. A disability plan usually replaces only 60 percent to 70 percent of wages, and not everyone has disability coverage. This disruption to an individual’s income stream, combined with the added medical expenses, can devastate a family’s financial well-being, and can even force tough decisions about treatment options.
The prospect of experiencing a severe health calamity is not as uncommon as one might think. According to a study by the National Heart Lung and Blood Institute, 1.1 million Americans have heart attacks each year. And the American Cancer Society predicts more than 1.4 million new occurrences of cancer annually in the U.S., with men accounting for a slightly higher percentage than women.
Fortunately, insurance products are available that supplement a primary medical plan. Usually available to employees on a voluntary basis and at group rates, these products can fill gaps in traditional health insurance coverage such as the indirect costs of an illness or injury. Surprisingly, the indirect costs can sometimes outweigh the direct cost of medical care.
The following provides an overview of the types and benefits of supplemental medical insurance products. Remember that different carriers may market similar products under various names, and that the specific benefits provided may vary.
Critical illness insurance usually pays a cash benefit upon diagnosis of a life-threatening disease or condition, such as cancer, heart attack, stroke, or the need for an organ transplant. The benefit can be used as the insured — or survivors — see fit. For instance, the benefit may be used to pay for health care from an out-of-network provider under the primary plan; experimental treatment not covered by the primary plan; indirect costs associated with medical treatment, such as transportation, lodging, and child care; as well as lost income.
Some carriers offer disease-specific insurance. The most well known among these products is cancer insurance. Depending on the way the policy works, specific disease insurance may pay a cash benefit upon diagnosis, and/or may provide coverage beyond the primary medical plan for treatments associated with the disease, such as radiation and chemotherapy in the case of cancer insurance. Some cancer insurance carriers provide disease management services through a health care professional with expertise in oncology.
Catastrophe medical insurance provides coverage that kicks in after the primary medical plan has run out. Although many primary medical plans have high lifetime limits, some do not. This is especially true of those purchased with economy of premium in mind. Catastrophe plans carry a high deductible, but typically all medical expenses paid both by the insured and the insured’s primary plan count toward the deductible. In light of the high cost of health care, a low-limit primary plan can be easily exhausted. Consider the medical costs associated with a premature baby or the trauma of a major automobile accident. Catastrophe insurance provides much needed benefits for all of these types of occurrences.
Hospital indemnity insurance supplements the primary medical plan if an illness or injury requires a hospital stay. Depending on the policy terms, benefits may be paid for specified hospital procedures or on a cash per diem basis.
With today’s skyrocketing costs of medical care prompting employers to study how health insurance is offered to employees, voluntary supplemental medical coverage may be an appropriate offering for your workplace. Adding supplemental medical coverage to an umbrella of voluntary benefit offerings can bring value as well as flexibility to your employee benefit package. Remember that coverages vary by carrier, and by state. Speak with your insurance agent to learn which supplemental insurance products provide the coverages that best suit your needs.
For more information on how a work-site supplemental package would help you and your company please contact us at (855)667-4621 info@medicalsolutionscorp.com today.
As reported in NYT last week – New York Hospitals Look to Combine, Forming a Giant “The proposed merger would bring together NYU Langone Medical Center, a highly specialized academic medical center, and Continuum Health Partners, a network of several community-oriented hospitals, including Beth Israel and the two St. Luke’s-Roosevelt campuses.”
Anticipating changes in the way health care is paid for and delivered abound. WIth new Health Care Reform law the traditional fee-for-service model is being sacked in favor of patient care coordination. The consolidations by hospitals are needed in order to deliver the scales build on the ACO model of using independent providers/facilities.
Accountable Care Organization (ACO) – These organizations coordinate patient care and provide the full range of health care services for patients. The health reform law provides incentives for providers who join together to form such organizations and who agree to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to the ACO.
The fee-for-service system has evidentially driven costs by incentivizing volumes of added procedures. The ACO model is built on par excellence hospitals such as Mayo Clinic where there is team of providers are financially incentivized for patient care coordination outcomes and high quality of care. The ACO’s payment would be tied to achieving goals that improve health care and save money. Members of the ACO would divvy up that payment. Today’s payment system, investments in providing better care are doubly penalized. If a hospital hires a nurse to follow up with patients after they are discharged in order to reduce readmissions — for example, to help patients with diabetes improve blood sugar control — it must pay for the nurse, which is typically not reimbursed by insurance companies or Medicare, and it loses revenue by preventing the readmission.
Congress included ACOs in the health care law as a way to rein in Medicare spending. That federal program pays for health care for people 65 and older and the disabled. The federal government estimates ACOs could save the Medicare program up to $940 million over four years. Medicare recently began testing this system with 32 pilot ACOs in 18 states, including one in the New York City area – Bronx Accountable Healthcare Network.
Some have pointed to ACO Model just as a pro-merger supporting argument with the FTC. These significant mergers create market dominance and therefore limit competition and drive up health care dollars. And yet Hospitals operate on thin profit margins and cannot afford to lose market share therein lies is the conundrum.
The NYT article – Waking Up to Major Colonoscopy Bills illustartes what our clients are increasingly running into – increased out of pocket expenses.
“Patients who undergo colonoscopy usually receive anesthesia of some sort in order to “sleep” through the procedure. But as one Long Island couple discovered recently, it can be a very expensive nap. Both husband and wife selected gastroenterologists who participated in their insurance plan to perform their cancer screenings. … And in both cases, the Gastroenterologists were assisted in the procedure by anesthesiologists who were not covered by the couple’s insurance. They billed the couple’s insurance at rates far higher than any plan would reimburse — two to four times as high, experts say.”
Patients can go for Colonoscopies either in an outpatient medical office or in ambulatory hospital setting. Gastrointerologists cannot bill for the anesthesia unless there is an employed licensed Anesthesiologist on staff. The treating Physician cannot be the same person who administer/monitors the sedation. Generally speaking the Anesthesiologist in a hospital settings are separate entities and attempt to bill independently form the hospital charges. Now you can begin to see how patients are getting added billing.
Furthermore, we are seeing increasing out of network charges with Physicians dropping health plans in certain geographic areas as well as insurers shifting more of the costs burden.
The posting Out of Control Out of Network Charges points to examples such as – “a neurosurgeon charged $159,000 for an emergency procedure for which Medicare would have paid only $8,493.” Another example: “ a consumer went to an in-network hospital for gallbladder surgery with a participating surgeon. The consumer was not informed that a non-participating anesthesiologist would be used, and was stuck with a $1,800 bill. Providers are not currently required to disclose before they provide services whether they are in-network.” The average out-of-network radiology bill was 33 times what Medicare pays, officials say.
Our clients get 3 bills with any procedure needing general anesthesia
1) A bill from the hospital
2) A bill from the surgeon
3) A bill from anesthesia
Actually, the physician bill is typically the lowest cost of the bill . On a $5,000 total bill the GI may only get 10%. Sometimes the hospital and anesthesia charges are bundled into a single bill but many times they are not. On most plans patients can negotiate with the hospital depending on pre-authorization the anesthesia bill and resubmit charges. This is probably the most common appeal we perform on behalf of our clients.
Patient on a cost sharing plan with in-network deductibles may fair better with outpatient office colonoscopies. From an insurer costs perspective the charges in an office setting are typically $2,000-$2,500. So why do it in the hospital? The procedure may require general anesthesia and financial incentives. Also, at times the procedure may be a loss to the provider. For example, Pediatricians will not perform Gardasil vaccination because the vaccine costs more than what the pediatrician will get reimbursed to give it.
The vast majority of providers make sure that patients were in-network or arranged pre-payment plan prior to the procedure. As with most non-HMO plans, however, the responsibility rests with patient to make sure everything is pre-authorized and in network is possible.
Oxford /United Healthcare has announced last week their contract termination with the Valhalla teaching hospital, Westchester Medical Center effective May 1, 2012. The NYS “cooling off period” imposes both parties to renegotiate a contract until July 1st. The hospital will be considered in-network until that time.
This marks the second time a large health insurer has terminated their contracts with Westchester medical Center. Empire had terminated their contract on Nov 10, 2010 after a similar dispute and is still not under contract. While contractual posturing is all too common in the health industry with eleventh hour agreements, we are seeing this disturbing trend playing out in other instances now.
We will monitor the situation and keep members posted. Oxford member letters explaing this are going out. Please contact us with any questions.
HSA holders own the assets in the accounts and can build up substantial sums over time. Enrollment in HSA-compatible insurance plans has increased to 10 million earlier this year, from 1 million in March 2005, according to, America’s Health Insurance Plans (AHIP), a trade group.
HSAs were authorized starting in January 2004. Since then, AHIP has conducted a periodic census of health plans participating in the HSA/HDHP market.
The number of people with HSA/HDHP coverage rose to more than 11.4 in January 2011, up from 10.0 million in January 2010, 8.0 million in January 2009, and 6.1 million in January 2008.
30 percent of individuals covered by an HSA plan were in the small group market, 50 percent were in the large-group market, and the remaining 20 percent were in the individual market.
14% of all workers in the private sector that have access to a Health Savings Account acc. to Bureau of Labor Statistics.
States with the highest levels of HSA/HDHP enrollment were California, Ohio, Florida, Texas, Illinois and Minnesota.
HSA Advantages:
Opportunity to build savings – Unused money stays in your account from year to year and earns tax-free interest. The HSA also gives you an investment opportunity.
Tax-free contributions and earnings – You don’t pay taxes on contributions or earnings.
Tax Free Money allowed for non traditional Medical coverage– As per IRS Publication 502, unused moneys can be used for dental,vision, lasik eye surgery, acupuncture, yoga, infertility etc. Popular Examples
Portability – The funds belong to you, so you keep the funds if you change jobs or retire.
Our overall experience with HSAs have been positive when employer funding is at minimum 50% using either the HSA or an HRA (Health Reimbursement Account-employer keeps unspent money). Traditional plans trend of higher copays and new in network deductibles has also led to the popularity of an HSA.
Please contact us for more customized information and how to incorporate this into your employee benefits.
The same analogy would hold true with auto insurance where only the risky drivers would only participate making it impossible to afford coverage. Just imagine buying a health plan on the way to the hospital? Coining this as "ambulance-care" would be more fitting than "ObamaCare".
After 3 days of Health Care Reform Supreme Court Hearings, a central components debated is the constitutionality of forcing an individual to purchase health insurance. Certainly it would be costly if one could just opt out at any time and then come back in you would be left with a high risk pool.
The same analogy would hold true with auto insurance where only the risky drivers would only participate making it impossible to afford coverage. Just imagine buying a health plan on the way to the hospital? Coining this alternative as “ambulance-care” would be more fitting than “ObamaCare”.
Of course there are Individual Mandate penalties. So how does the penalty work?
In 2014, the penalty for being without health insurance is $95 per adult and $47.50 per child (up to $285 for a family) or 1.0% of family income, whichever is greater.
In 2015, the penalty for being without health insurance is $325 per adult and $162.50 per child (up to $975 for a family) or 2.0% of family income, whichever is greater.
In 2016, the penalty for being without health insurance is $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater.
As of now, there are no known method to enforcing the penalty if you don’t buy insurance and you don’t pay the penalty. In fact, the law specifically states that no criminal action or liens can be imposed on you but I am certain that will change. I would also think that if a large numbers of people continue to choose not to enroll and the cost of premiums increase, the chance to revise the low penalties and increased enforcement are inevitable.
In conclusion, the Supreme Court ruling set for June is worth watching but only for legal wonks. With average health insurance single rates costing $600/month wouldnt you pay the penalty and just opt out?
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)/images/NBDrugCard_template1.JPG "Your Free Pharmacy Discount Card")
Doctor Shortages-covered but less access?
