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Around the PIA Western Alliance States

Posted By Administration, Tuesday, September 25, 2018

California — Fair Claims Settlement: From the California Department of Insurance: After a decade of legal wrangling over the regulations that implement the Unfair Insurance Practices Act (UIPA), a three-justice panel of the California Court of Appeal, 4th Appellate District, upheld the Insurance Commissioner's Fair Claims Settlement Practices Regulations, which prescribe how insurance companies must process insurance claims and are the foundation in determining the number of violations committed when assessing fines against insurers that have committed unfair claims practices.

Department of Insurance examinations of PacifiCare's claims-handling uncovered evidence of numerous unfair claims practices-which included wrongful denials for life-saving treatment for people battling serious illness and claim payment denials for providers and hospitals-all because the insurer was focused on maximizing profits through what it called "efficiencies" measures after the 2015 botched $7 billion acquisition of PacifiCare by UnitedHealthcare. The Department examinations also uncovered evidence the company was well aware of the egregious issues.

Under the Insurance Code, these unfair acts or practices include misrepresenting what medications or treatments an insurance policy covers, failing to promptly pay claims where liability is reasonably clear, and forcing claimants to file lawsuits to get full payment, and other acts. The Insurance Code allows the commissioner to impose fines of up to $5,000 each time an insurer commits an unfair act or practice on a consumer, or up to $10,000 each time if the insurer did so willfully.

"UnitedHealthcare purchased PacifiCare and imposed cost-cutting measures that destroyed PacifiCare's claims-handling processes and its arguments in litigation that insurance companies should be allowed to willfully harm consumers as long as they don't do it too often, reflect a gross disregard of the lives and well-being of the consumers who paid for the promise of coverage," Commissioner Jones said. "Customers have no choice but to rely on the integrity of their health insurance companies. PacifiCare breached that trust. By any measure, 908,000 violations reflect a general business practice of violating consumer protection laws. I am delighted the court of appeal has affirmed the authority of the insurance commissioner to punish insurance companies for knowingly harming even one consumer." 

Based on departmental examination results and following an administrative hearing that took three years, Insurance Commissioner Dave Jones found PacifiCare committed 908,547 separate violations of the UIPA, and he imposed fines aggregating $173,603,750 in penalties. On behalf of PacifiCare, UnitedHealthcare sued the commissioner, arguing that none of its harmful conduct violated the Insurance Code.

PacifiCare argued that insurers are immune from fines for committing these unfair acts, even if the insurer did so intentionally, unless the commissioner is also able to show that the insurer knew it had committed the acts frequently enough to constitute a "general business practice." The court of appeal rejected the argument, stating: "PacifiCare's interpretation of section 790.03(h) is not only internally problematic, it stands in contrast to virtually every other statute the Legislature has enacted in connection with (1) enforcement of the Insurance Code against insurers generally; (2) enforcement of the UIPA in particular; and (3) the imposition of administrative penalties against insurers in other contexts."

The court also rejected PacifiCare's argument that the commissioner must prove an insurer had "actual knowledge" of its illegal conduct and held that it was within the commissioner's authority to hold the insurer responsible if its agents or employees were aware of facts that would cause a reasonable person to know of the violations. The court also found the commissioner's reasoning was sensible in that restricting the definition of "knowingly" to one particular individual's actual knowledge would fail to take into account that many people handle a claim, and an unfair practice can be committed by cumulative acts, not simply the intentional act of one person."

Further, the court of appeal also upheld the commissioner's interpretation that an insurer's "willful" violation of the act may be established by showing a purpose or willingness to commit the act and agreed that penalties for willful violations do not need to require a showing that the insurer intended to violate the law or injure someone. The court held, "As the Commissioner points out, he engaged in an extensive, formal rulemaking process in the course of promulgating these regulations. That careful consideration, combined with the Commissioner's expertise in the area, weighs in favor of according significant deference to the Commissioner's interpretation of the terms, and we do so."

Jones sues biopharma giant AbbVie

Insurance Commissioner Dave Jones filed an insurance-fraud complaint in Alameda County Superior Court on behalf of the State of California against AbbVie Inc. alleging AbbVie gave illegal kickbacks to health care providers to prescribe HUMIRA-an expensive and dangerous drug with potentially deadly side effects. The case, which is filed on behalf of the State under the Insurance Frauds Prevention Act, alleges that private insurers have paid out $1.2 billion in HUMIRA-related pharmacy claims, making this the largest health insurance fraud case in department history.

According to the complaint, AbbVie engaged in a far-reaching scheme including both classic kickbacks-cash, meals, drinks, gifts, trips, and patient referrals-and more sophisticated ones-free and valuable professional goods and services to physicians to induce and reward HUMIRA prescriptions. These professional goods and services included free insurance processing and prior authorizations, gifts of medical practice management hardware and software, and even marketing assistance, all of which save physicians valuable staff time and resources.

"AbbVie spent millions convincing patients and health care professionals that AbbVie Ambassadors were patient advocates-in fact, the Ambassadors were HUMIRA advocates hired to do one thing, keep patients on a dangerous drug at any cost," said Insurance Commissioner Dave Jones. "Pharmaceutical companies know financial inducements are illegal, and patients depend on their health care professionals for straightforward honest information about their care and medication risks. In this case, patient care was traded for $1.2 billion in ill-gotten gains."

The key to AbbVie's success in pulling off its scheme, and among the most troubling aspects of it, is the fact that AbbVie inserts its own personnel directly into the homes of patients. When doctors prescribe HUMIRA, AbbVie sends its registered nurses-which AbbVie calls "Ambassadors"-into patients' homes, representing them to be an extension of the doctor's office.

The system AbbVie established takes advantage of the Ambassadors' nursing background and direct access to patients to serve the biopharma giant's financial interest in getting patients to take HUMIRA by downplaying its risks. Ambassadors are trained to send patient complaints directly to AbbVie and not the patients' treating physicians. Ambassadors also provide unbalanced information, as they are trained to tout the drug while at the same time also instructed on methods to avoid directly answering patient questions about risks of the medication, including those pertaining to HUMIRA's serious and important side effects.

At no cost and considerable gain to the physician's office, AbbVie nurses provide pharmacy and insurance authorization assistance, open enrollment resources, paperwork help, advice on insurance products, and other services, all of which provide a substantial value and save physicians' time, money, and resources. The catch is AbbVie only provides the Ambassadors as long as the physicians continue to prescribe AbbVie's drug instead of selecting another course of treatment.

The allegations of AbbVie's misconduct were brought to the attention of the department by a whistleblower. The whistleblower, referred to legally as a relator, is a registered nurse and was employed as an AbbVie Nurse Ambassador in Florida. The relator continues to be a party to this action and is represented by Rachel Geman, Robert Nelson, and Jason Lichtman of the law firm of Lieff Cabraser Heimann & Bernstein, LLP.

Idaho — Fatal Crash: Illya Tsar is the truck driver who is said to have caused a crash that killed three airmen from Idaho and himself. He had over 20 driving violations in scattered around several states.

Tsar was a contract driver for Krujex Freight Transport Corp. That company’s rate of out-of-service traffic violations is three-times the national average. An out-of-service violation is where a driver is ordered off the road for a number of reasons.

Most of his violations were in Oregon and Idaho though there is evidence of tickets in other states. One of Tsar’s charges was driving without a license. He picked up that ticket in Boise. He failed to show up in court on that charge.

When a warrant was issued for his arrest, he turned himself in but was released in an hour. A month later he appears to have caused the fatal crash.

Source link: Claims Journal

Washington — Work Comp Reduction: A 5% drop is being proposed for workers’ compensation rates for Washington State’s employers. The pure premium rate reduction for 2019 is due to lower on-the-job injuries and programs that have improved the rate of recovery for injured workers.

This is the second straight year for a reduction and is the largest since 2007.

Source link: Seattle Times

Washington — From the Office of the Insurance Commissioner: Health plan coverage of reproductive healthcare and contraception access rule stakeholder draft released

We released a stakeholder draft for the reproductive healthcare and contraceptive access rule R 2018-10. The purpose of this rulemaking is to update applicable WACs and add new sections to align with SSB 6219, now, codified in RCW 48.43.072 and RCW 48.43.073, which discusses requirements for coverage of reproductive health care and contraception.

Comments on the stakeholder draft are due October 12, 2018; please send them to rulescoordinator@oic.wa.gov.

For more info: https://www.insurance.wa.gov/health-plan-coverage-reproductive-healthcare-and-contraception-r-2018-10?utm_content=&utm_medium=email&utm_name=&utm_source=govdelivery&utm_term=

Health plan special enrollment rule withdrawn

We have withdrawn the notice to start rulemaking (CR-101) on the health plan special enrollment rule (R 2015-16). We withdrew the proposed rule because as we progressed through the process, clarifications were made to the federal regulations and guidance that sufficiently addressed our concerns regarding potential confusion.

For more information, including the withdrawal letter, please visit the rule's webpage: https://www.insurance.wa.gov/health-plan-special-enrollment-rules-r2015-16-formerly-2015-10?utm_content=&utm_medium=email&utm_name=&utm_source=govdelivery&utm_term=

Office of the Insurance Commissioner Issuer disclosures, notices and processes to protect privacy of health care information rule withdrawn

We have withdrawn the notice to start rulemaking (CR-101) on the issuer disclosures, notices and processes to protect privacy of health care information rule (R 2013-11). We withdrew the proposed rule because we are considering other options to ensure the full protection of confidential health information.

For more information, including the withdrawal letter, please visit the rule's webpage: https://www.insurance.wa.gov/issuer-disclosures-notices-and-processes-protect-privacy-health-care-information-r-2013-11?utm_content=&utm_medium=email&utm_name=&utm_source=govdelivery&utm_term=

Adjusted licensing special education stakeholder draft posted

We released a stakeholder draft for the adjuster licensing special education rule R 2018-14. The proposed rule would likely create new and amend some existing sections of WAC 284-17-123 to clarify the special education condition found in RCW 48.17.380(3)(d) for an adjuster license candidate.

Comments on the stakeholder draft are due October 2, 2018; please send them to rulescoordinator@oic.wa.gov.

For more information, including the text of the stakeholder draft, please visit the rule's webpage: https://www.insurance.wa.gov/adjuster-licensing-special-education-criteria-r-2018-14?utm_content=&utm_medium=email&utm_name=&utm_source=govdelivery&utm_term=

Tags:  Around the PIA Western Alliance States  Healthcare  Insurance Content  Insurance News  Weekly Industry News 

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The Senate Goes to Work on ObamaCare

Posted By Administration, Monday, June 12, 2017

The U.S. Senate is now going to work on the repeal and replacement — maybe — of the Affordable Care Act. The House’s American Health Care Act (AHCA) is pretty much dead on arrival. While some parts of the House plan will survive, a lot of it will have to change.

Republicans also must find a way around a potential — but very likely — filibuster.

And while both political parties pose and posture, insurance commissioners in state after state are doing all they can to keep the few insurers participating in the ObamaCare exchanges in the game. To do it they are offering new — and never heard of before — incentives to stick with it for another year.

Insurers meanwhile continue to look to Washington and at Congress and the Trump administration for some sign of what they should do. They’re not sure if the Trump administration is going to continue to subsidize the out-of-pocket costs for lower-income households.

That’s a deal-breaker for most.

On the table is $7 billion that will help keep insurers participating. The president has said yes to the money but has made no move in that direction. That has insurance commissioners extending rating filing deadlines and giving other concessions that would not be the normal order of business.

John Franchini is the insurance commissioner of the PIA Western Alliance state of New Mexico. He said, “As a regulator, instead of being rigid on timelines, the type of pricing I’m going to want, I’m being more open about this. I’m trying to be more flexible to give them confidence that if things change, we as regulators will be flexible with them.”

In California — also a PIA Western Alliance state — commissioner Dave Jones has let insurers submit two different sets of rate requests. One is if ObamaCare continues and the other if it goes away. “Based on what we were hearing from insurers, we anticipated Trump rates would be double-digit increases over the past year. I wanted to give insurers the opportunity to file rates based on Trump,” Jones said.

In the PIA Western Alliance state of Washington Insurance Commissioner Mike Kreidler said he’s thinking of following Alaska’s lead and developing a reinsurance program that is a mix of state and federal money to help subsidize insurers. However, Kreidler said, “I don’t have any leverage to tell a health insurer they have to stay in the market. The GOP is scaring the bejesus out of them, and I’m trying to calm things down and work it out.”

House Ways and Means Chairman and Texas Republican Rep. Kevin Brady said the administration needs to make those payments to keep insurers involved. “We should act within our constitutional authority now to temporarily and legally fund Cost Sharing Reduction payments as we move away from ObamaCare and toward a patient-centered system that truly works for the American people,” Brady said.

Republicans — upon the election of Donald Trump — said they’d immediately repeal and replace ObamaCare. The self-imposed deadline at that time passed about two months ago. In other words, it’s kind of a mess.

Senate Majority Leader Mitch McConnell has vowed to take a vote on something by the end of July before the annual August recess but what that something will look like is anybody’s guess. And McConnell and others in Republican leadership admit that it is going to be hard to get enough votes to pass reforms.

A sort of a plan was put forth last week and it is already raising hackles on hardcore conservative Republicans and on the more moderate of the party. The issues range from preexisting conditions to essential health benefits and a plan to let states dump them to allowing states to repeal all ObamaCare regulations.

And then there’s Medicaid and what to do with it.

Part of the problem is there are four groups vying for control. A task force of 13 men started the process but criticism that no women are involved led the group to open its planning to any senators wanting to come.

Then there’s the group led by Louisiana Republican Sen. Bill Cassidy and Maine Republican Sen. Susan Collins. They have blasted the House’s American Health Care Act and crafted a plan of their own called the Patient Freedom Act.

 

A conservative group led by Ohio Republican Sen. Rob Portman is completely focused on Medicaid expansion.

The last group is made up of ultra-conservatives led by Texas Republican Sen. Ted Cruz and Utah Republican Sen. Mike Lee. They want whatever the Senate does to be as close as possible to the House bill.

In what may be bad news for employers, some Republicans want to tax employer-sponsored health insurance plans to help support and stabilize the public health insurance market. As it stands today, those plans aren’t taxed but the tax-favored status of employer-sponsored insurance cost the federal government $250 million in 2016.

Taxing that insurance could affect 177 million employees around the country.

Joel Wood does government affairs for the Council of Insurance Agents & Brokers (CIAB). His group is totally opposed to the idea. “I’m not saying we feel naked, but we feel vulnerable. All we are trying to do is keep that drumbeat going on whatever Congress decides to do to resolve issues associated with exchanges, high risk pools, Medicaid. [We want to ensure that Congress does not] solve those problems at the expense of the employer-provided system,” he said.

Nevada is a PIA Western Alliance state. Sen. Dead Heller is that state’s Republican in the Senate and he thinks in the end the Senate will move more in the direction of preserving much of what is good about ObamaCare.

Dan Holler of the group Heritage Action for America said that kind of talk is going to make it difficult for the party’s very conservative Senators to vote in favor. “There has to be a give and take, and right now it seems like conservatives are being told just to take it all and not get anything,” he said.

And while the Republicans in the Senate can’t quite figure out what they want to do, President Trump took to criticizing Democrats. “We're having no help; it's only obstruction from the Democrats. The Democrats are destroying health care in this country. If we gave you the greatest health plan in the world we would get no votes. The Democrats are really in our way,” the president said.


Source links: The Hill — link 1, link 2, link 3, link 4, The Washington Post, Employee Benefit Advisor

Tags:  Healthcare  HealthCare.gov  Insurance Content  Insurance Industry  Insurance news  ObamaCare  The Affordable Care Act  The Senate Goes to Work on ObamaCare  Weekly Industry News 

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UnitedHealth Group May be in Trouble with Feds

Posted By Administration, Tuesday, June 6, 2017

The Department of Justice has filed charges against UnitedHealth Group for overcharging the federal government more than $1 billion through its Medicare Advantage packages.

The suit — filed in a Los Angeles court — said UnitedHealth made patients appear to be much more infirm than they actually were so they could collect higher Medicare payments.

A report from Salon.com said the federal government’s conservative estimate is that UnitedHealth “knowingly and improperly avoided repaying Medicare” for the more than $1 billion in overcharges during the decade ending in 2016.

U.S Attorney Sandra Brown said, “To ensure that the program remains viable for all beneficiaries, the Justice Department remains tireless in its pursuit of Medicare fraud perpetrated by healthcare providers and insurers. The primary goal of publicly funded health care programs like Medicare is to provide high quality services to those in need — not to line the pockets of participants willing to abuse the system,” she said.

This is the second time UnitedHealth has been under Justice Department scrutiny under the False Claims Act. In 2011 a similar complaint was filed by the firm’s former finance director.

UnitedHealth is the nation’s biggest Medicare Advantage participant and in 2016 it covered 3.6 million policyholders. The price tag for that insurance was $56 billion.

The company denies any wrongdoing and spokesman Matt Burns said it will go to battle over the accusations. “We are confident our company and our employees complied with the government’s Medicare Advantage program rules, and we have been transparent with (Centers for Medicare and Medicaid Services) about our approach under its unclear policies.”

CMS declined to comment.

 

Source link: Insurance Business America

Tags:  Healthcare  HealthCare.gov  Insurance Content  Insurance Industry  Insurance News  ObamaCare  The Affordable Care Act  UnitedHealth Group May be in Trouble with Feds  Weekly Industry News 

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ObamaCare Repeal & Replace: The Usual Confusion

Posted By Administration, Tuesday, June 6, 2017

The Senate is back in session. They’ll go to work on the repeal and replacement of the Affordable Care Act. Or we should say, Republicans will go to work. Democrats will sit on the sidelines and complain.

Most Republican leaders are skeptical that anything can get done before the July 4th break or even before August’s month-long recess. The Trump administration — and in particular Vice President Mike Pence — wants it done and done quickly. Several things will make that difficult starting with the enormous unpopularity of the bill Republicans in the House sent over a few weeks ago.

The unpopularity is with many moderate Republicans in the Senate and with many consumers. A tracking poll released by the Kaiser Family Foundation’s Kaiser Health says 55% of Americans have a negative view of the House bill. And equal number want the Senate to dump it or make major changes. Just 8% of those polled want the House version passed.

Breaking it down by political party:

  66% of Republicans want the Senate to pass the House bill

  78% of Democrats view the Affordable Care Act positively

  48% of Independents like the ACA

  30% of Independents like the House bill

Kaiser also looked at the popularity numbers for ObamaCare and found 49% view it positively compared to just 42% with a negative view. Spokesman Drew Altman said, “There is nothing in this poll, that if you were in the Senate, would cause you to rush out and pass the House bill.”

One of the biggest problems facing Republicans in the Senate is the whether to keep the House’s $664 billion in tax cuts that are repealed in the House bill. They stretch from the Cadillac tax to investment income.

Senate Finance Committee Chairman Orrin Hatch of Utah laughed at the reluctance of some of his Republican colleagues. He says those taxes all must go and they have to go soon or the party will be very embarrassed. Why? The party has spent a better part of the last seven years trying to get it repealed.

“We should not be treating the Obamacare taxes as a smorgasbord, picking and choosing which ones to keep and which to discard. I don’t think there is a single tax increase in Obamacare that has enjoyed support on this Republican side,” Hatch said.

Republican Sen. Bill Cassidy of Louisiana — who along with Maine Republican Sen. Susan Collins — has authored the Patient Freedom Act. It’s an alternative that’s more or less in the middle between the Draconian House bill and ObamaCare. He and Collins think President Trump’s pledge to give the American people a healthcare plan to be proud of ought to be honored. 

President Trump’s contract with the voter, when he was running, was that he would continue coverage caring for pre-existing conditions, eliminating mandates but also lowering premiums. If we think that Trump’s contract with the voters is important to us, then the fiscally conservative thing to do is to pay for it,” Cassidy said in a statement.

To keep Collins in the fold and to placate Alaska Republican Sen. Lisa Murkowski, Sen. Mitch McConnell and the other very conservative Republicans are going to have to keep some of those taxes to pay for a better repeal and replacement plan. 

As for the president? These days it’s hard to figure out where Trump stands on the issue.

Stan Collender is the executive vice president Qorvis MSL Group. He is also a former congressional budget aide. He said, “This is undoubtedly one of the things that has to be driving Mitch McConnell crazy. It’s the key difference between the House and Senate Republicans. Tea Party members of the House want to cut taxes all the time, any way they can on any legislation. The Senate is willing to be more moderate and almost has to be, given its constituency.”

As to what direction all this will go? We’ll keep you posted.

 

Source links: The Washington Post, Insurance Business America

Tags:  Healthcare  HealthCare.gov  Insurance Content  Insurance Industry  Insurance news  ObamaCare  ObamaCare Repeal & Replace: The Usual Confusion  The Affordable Care Act  Weekly Industry News 

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Huge: California’s Single Payer System Price Tag

Posted By Administration, Tuesday, May 30, 2017

Democratic California Sen. Ricardo Lara — Bell Gardens — wants California to do away with health insurance companies and put together a government-run health care system. He proposed it a few weeks ago and it is being pushed by the California Nurses Association.

Late last week the price tag became clear. It’s $400 billion a year.

Lara says the plan is to have much of that cost to be offset by state, federal and private spending but the rest will have to come via significant tax increases. And then there’s the prediction of annual health care costs jumping by $50 billion to $100 billion a year. These figures are massive and the task daunting when you consider the yearly California state budget for the entire general fund is $125 billion.

Here’s how Lara’s plan works. Health coverage with absolutely no out-of-pocket costs will be provided to all living in California and that’s including those here illegally. The state then contracts with doctors, hospitals and other health care providers for prices and then pays all the bills.

This is much how the federal government does Medicare.

All public money spent on healthcare — from Medicare, Medicaid and other federal public health funds and ObamaCare subsidy dollars will go into the pot to pay the bills.

The current estimate is that’s about half of what is needed to support Lara’s single payer system. The rest will have to come from higher taxes on business and a 15% payroll tax.

Tax increases? No problem Lara said. He, the California Nurses Association and other liberal supporters are totally energized by the idea and a tax plan to pay for the system is currently on the drawing board. The good news — they say — is we’ll be doing away with insurance company profits and the administrative costs of insurers. That will mean more money can be spent on the care of patients.

Republicans like Sen. Jim Nielsen of Gerber and business groups and health insurers aren’t too keen on the idea. “The impact on employers I think is going to be absolutely astounding. How can you possibly say this is going to be fiscally prudent for the state of California, not a burden for the state?” Nielsen said.

Businesses say — if this passes and is enacted — it will be much harder to expand their workforce.

For the tax increases to be implemented, two-thirds of the Assembly and two-thirds of the Senate must approve. That’s a daunting task. Even if it does pass, it must pass muster with Governor Jerry Brown. He’s a Democrat but has expressed skepticism at the logistics of the plan and the high cost.

Then if by some miracle the Legislature gets the two-thirds vote and Brown signs it into law, California will need to convince the Trump administration to waive the rules about how Medicaid and Medicare dollars are spent in California.

By the way, if you’re curious, Lara’s bill is SB562.

 

Source link: Insurance Journal

Tags:  Healthcare  HealthCare.gov  Huge: California’s Single Payer System Price Tag  Insurance Content  Insurance Industry  Insurance News  ObamaCare  The Affordable Care Act  Weekly Industry News 

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Keeping Up with ObamaCare Repeal & Replace

Posted By Administration, Tuesday, May 30, 2017

It used to be we tried to keep up with the Joneses. These days it’s trying to keep up with the latest developments in the Republican attempt to repeal the Affordable Care Act and replace it with something “better” is a much harder task.

Senate Majority Leader Mitch McConnell said he’s being pressured by Department of Health and Human Services Secretary Tom Price and leaders in the House to get something done by the end of summer. They at least want something to consider by the end of July when Congress goes on its annual August recess.

Apparently both fail to remember how slow the U.S. Senate moves. All McConnell would say is the Senate is “all about healthcare these days ... which we will move forward sometime in the near future.”

Others in Senate leadership think they’ll have something by then.

Meanwhile, while most of us took the Memorial Day weekend off, Senate staff began — says Sen. Ron Johnson of Wisconsin — drafting a bill.

 

Source links: The Hill — link 1, link 2

Tags:  Healthcare  HealthCare.gov  Insurance Content  Insurance Industry  Insurance News  Keeping Up with ObamaCare Repeal & Replace  ObamaCare  The Affordable Care Act  Weekly Industry News 

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ObamaCare Passed the House: Now What?

Posted By Administration, Tuesday, May 9, 2017

 

The repeal and the replacement of the Affordable Care Act has been chaotic. It finally passed the House last week and is now in the Senate. It’s anybody’s guess what will happen now. Will the Senate use the House bill as a framework or will it get tossed completely and something new put it its place?

No one knows. All we can report on now is what we know.

Everyone from politicians to the people have opinions and interpretations of exactly what the Republicans are doing or want to do. On Sunday now former President Obama took a shot at Republicans. While receiving a Profile in Courage Award in Boston, Obama said his work covered 20 million Americans.

And on the topic of courage, Obama said he hoped some in Congress — regardless of party — will have the courage to step up and do the right thing.

“I hope that current members of Congress recognize that it takes little courage to aid those who are already powerful, already comfortable, already influential. But it takes great courage to champion the vulnerable, the sick and the infirm and those with no access to the corridors of power,” he said.

Maine Republican Sen. Susan Collins (R-Maine) said Republicans in the House ought not be gloating. She said the Senate is awaiting a Congressional Budget Office (CBO) score and will then likely “starting from scratch.”

None of that worries House Speaker Paul Ryan who told ABC on Sunday, “The Senate is going to complete the job of saying just how much more money. This is one stage in a multistage legislative process.” You know how this works. They pass a bill through the House. Then they pass a bill through the Senate and then you go to conference and iron out the differences.”

In the meantime, rhetoric is flying from both parties and both sides of the political aisle. Democrats say the House bill is dead on arrival and Republicans — as Collins noted — are likely to start over.

Pundits say there are five things that will no doubt change:

  Tax credits — more tax credits will be added to help low-income people afford health insurance.

  Medicaid — That coverage ends in 2020 and some Republicans want this to be pushed out to a much later date.

  Coverage — Citing that President Trump promised to make sure everyone is covered and has excellent health insurance; some Republicans will push to make sure that happens.

  Pre-existing conditions — Letting states opt out of covering those with pre-existing conditions isn’t sitting well with many in the Senate.

  Essential health benefits — ObamaCare insists that insurers cover a long list of services and some in the Senate want to make sure this stays.

This is one of the things most Republicans like about the repeal of ObamaCare. It’s the repeal of what the party considers onerous taxes:

  It abolishes the Obamacare Individual Mandate Tax which hits 8 million Americans each year.

  It abolishes the Obamacare Employer Mandate Tax. Together with repeal of the Individual Mandate Tax repeal this is a $270 billion tax cut.

  It Abolishes Obamacare’s Medicine Cabinet Tax which hits 20 million Americans with Health Savings Accounts and 30 million Americans with Flexible Spending Accounts. This is a $6 billion tax cut.

  It abolishes Obamacare’s Flexible Spending Account tax on 30 million Americans. This is a $20 billion tax cut.

  It abolishes Obamacare’s Chronic Care Tax on 10 million Americans with high out of pocket medical expenses. This is a $126 billion tax cut.

  It abolishes Obamacare’s HSA withdrawal tax. This is a $100 million tax cut.

  It abolishes Obamacare’s 10% excise tax on small businesses with indoor tanning services. This is a $600 million tax cut.

  It abolishes the Obamacare health insurance tax. This is a $145 billion tax cut.

  It abolishes the Obamacare 3.8% surtax on investment income. This is a $172 billion tax cut.

  It abolishes the Obamacare medical device tax. This is a $20 billion tax cut.

  It abolishes the Obamacare tax on prescription medicine. This is a $28 billion tax cut.

  It abolishes the Obamacare tax on retiree prescription drug coverage. This is a $2 billion tax cut.

The biggest concern from the public has been the pre-existing conditions part of the Republican bill. Rumors are flying as are reports on what’s going to happen that contradicts other, similar reports.

Here’s what we know:

  The American Health Care Act (AHCA) does keep protections for pre-existing conditions. Insurance companies cannot deny or limit coverage.

  All that has changed is allowing the companies on the individual market to charge higher rates for pre-existing conditions but ONLY if the person involved does not maintain continuous coverage.

  Even then the insurance company can only charge higher rates for that condition for a year.

  The bill provides $138 billion for states wanting to opt out to set up pools for high risk people and help them afford insurance.

  Another $8 billion was added to help reduce premiums and out-of-pocket costs.

And at that point a definition of pre-existing conditions is in order. This is how most states define them:

  Alzheimers or dementia

  Alcohol or drug abuse

  Arthritis, fibromyalgia, or other inflammatory joint disease

  Cancer within a period of time (the example cited by KFF is 10 years, "often other than basal skin cancer")

  Cerebral Palsy

  Congestive heart failure

  Diabetes mellitus

  Emphysema

  Epilepsy

  Heart disease

  Hepatitis

  Kidney disease

  Mental disorders - bipolar, or eating disorders, e.g.

  Multiple

  Sclerosis

  Muscular dystrophy

  Obesity (severe)

  Organ transplant

  Paraplegia

  Paralysis

  Parkinson's disease

  Pending surgery or hospitalization

  Pneumocystis pneumonia

  Pregnancy or expectant parent

  Sleep apnea

  Stroke

  Transsexualism

California Insurance Commissioner Dave Jones best sums up Democrat opposition to the Republican plan. “The latest amendments to the already fatally flawed bill would permit the sale of insurance policies that do not cover many essential health benefits, rendering the coverage nearly useless when illness strikes. This bill also weakens existing prohibitions against annual and lifetime limits, which protect Americans from catastrophic medical costs. This bill would permit charging sick people prohibitively high premiums, depriving people of the ability to buy coverage. High-risk pools have failed patients in the past and this bill does not provide sufficient funding to make them work,” Jones said.

Some doctor, hospital and health insurance groups aren’t happy either.

Marilny Tavenner of America’s Health Insurance Plans (AHIP) said, “The American Health Care Act needs important improvements to better protect low- and moderate-income families who rely on Medicaid or buy their own coverage.”

Blue Shield of California CEO Paul Markovich said, “It raises the specter that the sickest and neediest among us will be disproportionately hit in losing access.”

Source links: The Washington Post — link 1, link 2, The Hill — link 1, link 2, MSN — link 1, link 2, Americans for Tax Reform

Tags:  Healthcare  HealthCare.gov  Insurance Content  Insurance News  ObamaCare  politics 

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The ObamaCare Saga Continues

Posted By Administration, Wednesday, May 3, 2017

At the time this is written things are in motion. Even if the Republicans pass something before this is published, once you get past the part of getting a vote, the story is still relevant and will give you perspective on what is happening with the bill.

Republicans are short of the votes to pass the repeal and replacement of the Affordable Care Act but they’re pushing to correct that says New York Congressman Peter King. He thinks it needs to be passed and then given to the Senate to correct.

“I would hope it gets changed over there,” he said.

Republican Sen. Roy Blunt of Missouri agrees. “If you’re in the House, what you should be thinking now is that if it doesn’t survive, it all comes back to you. I think what they should be focused on is getting the process moving and, frankly, passing the obligation over to the Senate.”

But Republicans are still battling those who promised to repeal ObamaCare and won’t stop until it’s done. And then there’s those like Missouri Rep. Billy Young who hates an amendment wanted by the Freedom Caucus.

“I have always stated that one of the few good things about Obamacare is that people with preexisting conditions would be covered. The MacArthur amendment strips away any guarantee that preexisting conditions would be covered and affordable,” Long said

The House Freedom Caucus said they like that revised version of the Republican plan and the one that deals with preexisting conditions. It will allow states to ask for the ability to opt out of that part of the plan if they establish a high-risk pool for people with preexisting conditions.

This is the part of the Affordable Care Act that opponents say drives up premiums. States — under this plan — could set up high risk pools for insurance. Those pools could charge more for insurance than those not in the high-risk categories.

Other than pressure to just pass something, none of this is going to move moderates in the party to support the plan and get the 216 votes needed to move it to the Senate.

In a statement the Freedom Caucus Members Rep. Tom MacArthur of New Jersey and Rep. Mark Meadows of North Carolina said, “While the revised version still does not fully repeal Obamacare, we are prepared to support it to keep our promise to the American people to lower healthcare costs. We look forward to working with our Senate colleagues to improve the bill. Our work will continue until we fully repeal Obamacare.”

Meanwhile, the president continues to say whatever is passed will offer protections to those with preexisting conditions and calls the bill “beautiful” but hasn’t said exactly what “beautiful” looks like.

Nothing done these days — it seems — is done without controversy. In the acceptance of the bill and the amendments that won over the Freedom Caucus is a stipulation that exempts members of Congress and their staffs from the possibility of changes in preexisting conditions.

Immediately Democrats jumped on that one. Leslie Dach of the Protect Our Care Campaign said, “The best evidence yet that the new GOP repeal plan is a disaster for people’s health care is that the GOP exempted members of Congress from living under it.”

No. No. No. That’s not what this means says MacArthur’s aide Camille Gallow. “Congressman MacArthur does not believe Members of Congress or their staff should receive special treatment and is working with House Leadership to make absolutely clear that Members of Congress and staff are subject to the same rules, provisions, and protections as all other Americans,” she said.

Republicans keep trying to find a way to please the majority of the party’s conservatives and Democrats are opposing anything that has to do with repeal. It’s politics. And politics is fine but there are 10 patient advocacy groups that are screaming at the two parties and saying their political games are impacting REAL people.

The group includes the American Cancer Society Cancer Action Network, the American Heart Association and several others and all of them have pegged the American Health Care Act and the new modifications on preexisting conditions and the ObamaCare provision that mandates what insurers must cover as “inadequate” and “unaffordable.”

The group issued a statement saying, “As introduced, the bill would profoundly reduce coverage for millions of Americans — including many low-income and disabled individuals who rely on Medicaid — and increase out-of-pocket costs for the sickest and oldest among us. We are alarmed by recent harmful changes to the AHCA, including provisions that will weaken key consumer protections.”

The groups say these high-risk pools are just not a viable option. “Previous state high risk pools resulted in higher premiums, long waiting lists and inadequate coverage,” the groups said.

The problem is the high-risk pools let insurers charge people that are sicker more money for insurance. Some of them cannot afford those prices and what it does is return health care back to what it was before ObamaCare.

“As Congress considers this legislation, we challenge lawmakers to remember their commitment to their constituents and the American people to protect lifesaving health care for millions of Americans, including those who struggle every day with chronic and other major health conditions,” the groups added.

In another odd twist, Democrats reached across the aisle and made a proposal to Republicans and said they’d agree to $15 billion in additional military spending in exchange for the funding of healthcare subsidies. These are $10 billion cost-sharing dollars that help the poor afford to purchase health insurance on the ObamaCare exchanges.

The Trump administration has since said it will continue to provide those funds. No word if this is part of the deal.

Meanwhile pressure continues on Republicans in the House who have promised for seven years to repeal and replace ObamaCare and who have over 40 times passed bills to do just that. And now they can’t pass anything.

Putting that in perspective is Louisiana Sen. Bill Cassidy who told CNN the House bill is a work in progress and some of what it eventually passes will be dumped when negotiations with the Senate starts.

His vision is a bill — and he’s written one — that looks a lot like the Affordable Care Act.

“The House has to pass a bill. It’ll go to conference committee. I’m sure the administration will be involved. There will be two other times when what the White House is advocating can be addressed,” he said.

Cassidy — though — like many others is not happy with the House Freedom Caucus preexisting condition compromise. “I suspect the advocates for the bill will say that’s their guarantee. I will insist that the president’s pledges be met. And the president pledged that he would take care of people with preexisting conditions,” Cassidy added.

Senate Texas Sen. Ted Cruz also gave perspective to what that body will have to do if the House ever passes a bill. “Legislating takes time. It’s worth remembering it took Obama 14 months to pass Obamacare. The House repeal bill was on the floor for 14 days. That’s not nearly long enough to draft legislation as consequential as this.”

That’s politics. That’s Washington. But what do the people think? An ABC/Washington Post poll conducted a couple of weeks ago suggests Congress and the president might want to consider fixing and not replacing ObamaCare.

  79% think President Trump should make ObamaCare work instead of letting it fail

  Overall 61% want it fixed not replaced

  88% of Democrats want it fixed

  21% of Republicans want it fixed

 

But whatever they do, large percentages in both parties want pre-existing conditions covered. Period. That depends on the poll but it runs around 70%.

Another poll by NBC News and The Wall Street Journal said 50% have no confidence the Republicans will put forth anything that will make health care better for the masses. That’s up 16% from a similar poll in February when just 34% said they had no confidence.

No one is sure what ought to be done though 47% think ObamaCare does need a major overhaul but doing away with it is a split along party lines:

  75% of Republicans say repeal and replace

  Just 13% of Democrats feel that way

 

Source links: The Hill — link 1, link 2, link 3, link 4, link 5, link 6, link 7, The Washington Post — link 1, link 2

Tags:  Healthcare  HealthCare.gov  Insurance Content  Insurance Industry  Insurance News  ObamaCare  The Affordable Care Act  The ObamaCare Saga Continues  Weekly Industry News 

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Republicans Plunge Ahead & Trump Pressures Insurance & Democrats

Posted By Administration, Tuesday, April 18, 2017

Rep. Greg Walden

Oregon Congressman Greg Walden is the chairman of the House Energy and Commerce Committee. It crafted most of the ObamaCare replacement plan — the American Health Care Act — that died an ignominious death a few weeks ago and didn’t even get a full House vote.

Efforts to get it passed — or even considered — before the current congressional recess also stalled and then died. Since it won’t likely get a vote, Walden said reforms may have to be attached to a future budget measure. “You could make an argument that says, ‘Okay, we couldn’t get it done now.’ We’ve had people tell us: ‘Why take this on first? You should have done infrastructure, you should have done tax reform. It may be where we end up,” he said in a recent interview.

Just after the failure to pass, President Trump said he’s moving on to other things and will let the Affordable Care Act implode. However, last week the president told Fox Business that ObamaCare has to happen first before he can do the rest of his agenda — an agenda that includes infrastructure repair to the tune of $1 trillion and tax reform.

“Health care is going to happen at some point. Now, if it doesn’t happen fast enough, I’ll start the taxes. But the tax reform and the tax cuts are better if I can do health care first,” Trump said.

And to up the ante to get Democrats to negotiate, Trump told The Wall Street Journal he might withhold the ObamaCare payments to insurers which hurts those getting cost-sharing insurance subsidies.

Democrats responded immediately via Senate Minority Leader Sen. Chuck Schumer.

“President Trump is threatening to hold hostage health care for millions of Americans, many of whom voted for him, to achieve a political goal of repeal that would take health care away from millions more. This cynical strategy will fail,” Schumer said.

Insurers and major medical groups aren’t that happy with the threat either. From the insurance perspective, this move could wreak havoc on the individual insurance markets.

The subsidies amount to about $7 billion a year and are paid directly to insurers who — along with major medical groups — dashed off a letter to the president urging him to not make that move.

Trump’s “maybe” decision also muddies up an already muddy situation. Republicans in the House sued President Obama over the payments and wanted them denied.

The president said he doesn’t want to deny those payments but indicated he feels forced to do something. “I don’t want people to get hurt. What I think should happen — and will happen — is the Democrats will start calling me and negotiating,” he told the WSJ.

As for Sen. Schumer and House Minority Leader Nancy Pelosi, Trump said, “Schumer should be calling me up and begging me to help him save Obamacare. He should be calling me and begging me to help him save Obamacare, along with Nancy Pelosi.”

A Pelosi aide pooh-poohed the president’s comments and said it “will increase costs, is a threat to the good health of the American people and a threat to keeping government open.”

Oregon Sen. Ron Wyden agreed. He’s the top Democrat on the Senate Finance Committee and said the Democrats will not negotiate with a hostage taker.

“There is no outcome in which the administration sabotaging insurance markets persuades Democrats to pass Trumpcare, a disastrous proposal which would only make our health care system worse. When the president drops his threats on Americans’ health care — including the latest threat to withhold insurance payments, which he clearly understands puts people’s care in danger — Democrats will be prepared to work on bipartisan improvements to the Affordable Care Act,” Wyden said.

California Insurance Commissioner Dave Jones almost instantly responded to Trump’s statement. He said, “The cost-sharing subsidies, an important part of the Affordable Care Act, lower deductibles and other out-of-pocket costs to make healthcare more affordable. President Trump's threats to withhold the cost-sharing assistance create fear among consumers and instability in the health insurance market. President Trump's stated intention to hold hostage for political gain the healthcare of millions of Americans who rely on cost-sharing assistance is outrageous. We can expect rates to increase and insurers to leave the market because of President Trump's actions undermining the Affordable Care Act.”

Meanwhile, Democrats say they’ll try to secure those payments as part of the negotiations for a new spending bill. It’s the same bill Oregon’s Rep. Walden says the Republicans are going to try to put their plan into.

Stay tuned. This will continue to stay interesting.

 

Source links: The Washington Post — link 1, link 2, link 3, Insurance Business America, Insurance Journal, MSN

Tags:  Healthcare  HealthCare.gov  Insurance Content  Insurance Industry  Insurance News  ObamaCare  Republicans Plunge Ahead & Trump Pressures Insuran  The Affordable Care Act  Weekly Industry News 

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Update: California Single Payer & ObamaCare Repeal & Replace Still Stalled

Posted By Administration, Tuesday, April 11, 2017
Sen. Ricardo Lara

California Democrat Sen. Ricardo Lara thinks Congress and the Trump administration have failed the people. His solution is a single payer health care system for the Golden State. Lara introduced a bill to set one up.

Under his proposal, the state will negotiate with providers, carriers, medical suppliers, and pharmaceuticals on prices for policyholders.

Lara’s office told The Sacramento Bee that all California residents will be required to sign up. Insurers will not be allowed to offer coverage that is outside of what the state authorizes.

“With Republicans’ failure to repeal the Affordable Care Act, Californians really get what is at stake with their healthcare. We have the chance to make universal healthcare a reality now. It’s time to talk about how we get to healthcare for all that covers more and costs less,” Lara told the newspaper.

He’s named Senate Bill 562 The Healthy California Act and its comprehensive covering:

  All medical care — inpatient, outpatient

  Emergency care

  Dental

  Vision

  Mental health

  Nursing home care

In addition, the bill does away with co-pays and insurance deductibles. It allows members — which in this case is all Californians — to choose their doctor or doctors.

Governor Jerry Brown — when he heard about the bill — did some head scratching. “This is called ‘the unknown by means of the more unknown.’ In other words, you take a problem, and say “I am going to solve it by something that’s…a bigger problem,’ which makes no sense,” Brown said.

What Lara didn’t say is how he’d pay for it.

As for the rest of us. Congress is in recess and will be for another week. It adjourned without being able to take any action on the repeal and replacement of the Affordable Care Act. And it wasn’t as if no one tried. The effort to come up with an agreement was Herculean.

The recess doesn’t mean a deal can’t be done before the return of Congress. House Majority Leader — and California Republican — Kevin McCarthy said if a deal gets done members will be expected to return.

“Should we be prepared to advance our bill through the House in the coming two weeks, we will advise Members immediately and give you sufficient time to return to Washington,” McCarthy wrote in a memo to House members just before the adjournment.

Most think that’s wishful thinking. Leaders of the repeal and replace movement from Vice President Mike Pence and House Speaker Paul Ryan on down failed last week in negotiations. Divisions within the Republican Party and with the president are so deep that no deal is going to be forthcoming anytime soon.

Pence offered to do away with three huge ObamaCare regulations:

  The requirement to cover people with pre-existing conditions

  The requirement that makes it illegal for insurers to charge sick people more for coverage

  The mandates that say what insurers must cover

In the House, the Rules Committee considered finding ways to subsidize those with high health care costs. It would give $15 billion over nine years to help insurers afford to pay the costs of sick patients with high expenses.

Meanwhile, as talks continue insurers have about six-weeks to decide what to do for 2018. Rate concerns or whether to leave the exchanges altogether are on the mind of executives. The ticking insurer clock isn’t helped much when President Trump says, “I’ve been saying for the last year and a half that the best thing we could do, politically speaking, is let ObamaCare explode. It’s exploding right now.”

Cynthia Cox of the Kaiser Family Foundation says that’s not what insurers or even the majority of the people want to hear. “It’s not sending them the message that the Trump administration is going to try to stabilize the market. ObamaCare or the marketplaces are not going to explode on their own. To hear the Trump administration say it’s going to explode may suggest they’re going to take some action to weaken the market,” she said.

 

Source links: Insurance Business America, The Washington Post, The Hill — link 1, link 2

Tags:  Healthcare  HealthCare.gov  Insurance Content  Insurance Industry  Insurance News  ObamaCare  The Affordable Care Act  Update: California Single Payer & ObamaCare Repeal  Weekly Industry News 

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