Health insurance options when you are unemployed

COBRA is pricey, but there are other less expensive options for comprehensive coverage.

By Francesca Lunzer Kritz
January 19, 2009

For people who’ve assumed they’ll take the option of continuing their employer-based health insurance — at their own expense — if they lose their jobs during 2009, it was sobering news. For those who have lost their jobs, it was painfully unsurprising.

In a report released earlier this month, researchers found that the average national cost of that coverage (an option known as COBRA, an acronym for the legislation that created the opportunity) eats up 30% of unemployment benefits for individual coverage and almost 84% for family coverage.

COBRA health coverage is great in theory and lousy in reality,” said Ron Pollack, executive director of health insurance reform advocacy group Families USA, based in Washington, D.C. The group announced the results of its analysis Jan. 9.

COBRA cost’s sticker shock

The report is especially worrisome because even at COBRA’s very high costs, it is “often the only option for people who are looking for comprehensive coverage — particularly if they have any kind of health problem,” says Karen Davenport, director of health policy at the Center for American Progress, a liberal think tank in Washington, D.C.

Companies are permitted to charge, and generally do, the full cost of premiums plus a 2% administrative fee. COBRA must be offered by firms with 20 or more employees as long as they continue to offer health coverage. Generally, it’s offered for 18 months after a job ends, though in some circumstances that can be extended. In many states and in the District of Columbia, health insurance options similar to COBRA must be offered by firms with fewer than 20 employees.

The staggering cost of COBRA can come as a surprise because employers often pay a very large — and frequently unrecognized — share of health insurance premiums.

In 2008, employees paid an average of 16% of premiums for individual coverage and an average of 27% for family coverage, according to the Families USA report. But once the employer drops the cost-sharing, premiums soar. Last year, the full COBRA costs for an individual reached a national average of $4,656 per year, or $388 per month. The full cost for family coverage hit a national average of $12,823, or about $1,069 per month.

In California, individuals receive an average monthly unemployment benefit of $1,322 and pay an average monthly COBRA payment of $380, or almost 29%, of the jobless benefit. Californians with families receive that same $1,322 unemployment benefit, but COBRA premiums for families can rise to $1,079 per month, or 81.6% of the unemployment benefit.

Many individuals and families take their chances and hope they won’t need medical care before regaining employment and, they hope, health insurance benefits kick in again. But that is not an optimal choice, says Families USA’s Pollack. In addition to the potential for devastatingly high medical costs if a health emergency does spring up, going without coverage can affect health insurance coverage later on, particularly for a preexisting medical problem.

We asked Pollack and other health insurance experts to suggest insurance-related steps people should take in the event of unemployment.

* Check whether you can be added to your spouse’s coverage. Even if the benefit year has begun, a plan may allow the addition of family members due to a major event (such as a spouse’s job loss). Being added to a spouse’s plan is likely to be far less expensive than COBRA.

* Act quickly. The option to sign up for COBRA generally lasts only 60 days from the time your employer sends you a notice about it, according to the Department of Labor.

* See if your kids are eligible for health insurance coverage under public health programs such as Medicaid or SCHIP, the state’s children’s health insurance plans. The state program is income-based and charges about $15 per child per month for premiums, says Mabel Ponce-Koch, director of the Health Consumer Alliance in Los Angeles. On Wednesday, the U.S. House of Representatives voted to expand the federal program to millions more children. The legislation is expected to soon be approved by the Senate and then quickly signed into law by the president.

If the kids can be covered under public programs, parents can opt for less expensive one- or two-person coverage under COBRA or an employed spouse’s coverage, if the employer charges a lower premium for two people than for a larger family, says Cheryl Fish-Parcham, deputy director of health policy at Families USA.

Find out if your children qualify for state plans by contacting California’s Healthy Families at www.healthyfamilies.ca.gov or (800) 880-5300. If you’re told your kids don’t qualify, contact the Health Consumer Alliance (healthconsumer.org or [310] 204-4900) to see if the decision can be appealed, and for other healthcare resources.

* Look for options cheaper than COBRA. (You can start at ehealthinsurance.com.) It’s unlikely, but still worth a look. Pollack cautions consumers to look at all the costs involved. A low premium may come with high co-pays and deductibles.

For healthy, young individuals who anticipate few medical costs, the price of a high-deductible plan may be a smart option, says Karyn Schwartz, a senior policy analyst with the Kaiser Commission on Medicaid and the Uninsured in Washington, D.C.

* If you simply cannot afford insurance of any kind, look for healthcare options in your area. Community clinics and health centers offer care on a sliding scale based on income — and may be free, if you can’t afford to pay. Contact the California Primary Care Assn. ([888] 895-0808 or www.cpca.org) for referrals to community centers and clinics.

And the picture could ultimately change. President-elect Barack Obama’s economic recovery program could include ways to help people pay for COBRA as well as expand the number of people eligible for Medicaid.

Source: latimes.com

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Congress, Obama Toil to Help Jobless Get Health Care

Congress, Obama Toil to Help Jobless Get Health Care

By Amy Goldstein
Washington Post Staff Writer
Saturday, January 17, 2009; A03

 

Congress and the incoming Obama administration are contemplating profound shifts in the government’s role in health insurance to try to alleviate a significant ripple effect of the damaged economy: Americans losing health coverage as they lose jobs.

As part of a sprawling $825 billion strategy to heal the economy that House Democrats laid out this week, lawmakers and transition officials envision a two-prong approach to help unemployed people retrieve health benefits. One would reshape a basic entitlement program, allowing states temporarily to sign up jobless residents for Medicaid, with the federal government for the first time paying the entire cost. The other proposal would provide unprecedented federal subsidies to help people afford coverage under COBRA, a law that allows some laid-off workers to buy health benefits that they used to get through their jobs.

The twin ideas, preliminarily estimated to cost $39 billion through the end of next year, would represent sharp departures in two long-standing programs and already are sparking debate along the ideological continuum on Capitol Hill and beyond. In Congress, several key Democratic House members and senators have endorsed the broad contours, while a few Republicans, including Senate Minority Leader Mitch McConnell (R-Ky.) have signaled that they are wary. Debate, however, will not solidify until lawmakers learn more precisely how much the proposals would cost and how many people they might help.

Among outside health policy specialists, conservatives are critical of expanding an entitlement and are predicting that states would have a hard time shutting the spigot of help once the federal money stopped. Liberals are predicting that, even with the large federal investment, coverage could remain unaffordable for too many people.

The ideas’ boldness reflects a precipitous rise in the uninsured. Recent estimates suggest that worsening unemployment, which reached 7.2 percent last month, translates into a loss of health coverage for an additional 2.6 million people. That increase, on top of the estimated 45 million uninsured, is exacerbating a persistent problem in the U.S. health-care system: too many people who lack access to proper care.

Politically, including insurance help for the unemployed in a fast-acting economic stimulus package is part of a strategy by congressional Democrats and President-elect Barack Obama to place attention on health care right away. It is in sync with a decision to pursue immediately an expansion of health insurance for poor and working-class children, long resisted by President Bush, which the House adopted on Wednesday and a Senate panel approved the next day.

Taken together, the insurance for children and laid-off workers signifies an effort by Democrats to create momentum for the more difficult work of broad health reforms that they and the Obama administration plan to undertake soon.

In recent weeks, lawmakers have collaborated with the incoming administration to devise remedies for the jobless uninsured and to decide how much money to allot. A transition aide said: “Obama supports the protection of health insurance through COBRA and Medicaid in a time-limited way.”

House Democrats say publicly that they would like to devote $30 billion over two years to subsidize COBRA and $8.6 billion to expand Medicaid. Privately, legislative sources said those figures are premature, because lawmakers are awaiting budget analyses of how much the proposals would cost — and how many unemployed Americans would be likely to grasp the help.

The Medicaid proposal would give assistance through 2010 and would break with significant features of the program created as part of the Great Society of the 1960s. Medicaid always has been a shared financial responsibility of the U.S. government and the states. But under the proposal, federal money would pay for all benefits and administrative costs for unemployed people who joined. In addition, the expansion would be the largest step ever taken beyond Medicaid’s original purpose of insuring people who are poor or disabled. There is precedent in recent years for opening Medicaid in times of crisis — for some New York residents after 9/11 and for people who fled communities ravaged by Hurricane Katrina — but not on the scale envisioned now.

Specifically, House sources said, the government would give states the option of allowing unemployed people to join Medicaid but would not require states to do so. States could choose whether to include three groups of uninsured residents: people who are receiving or have used up unemployment benefits, no matter how much money they have; unemployed people who qualify for food stamps, which in many states are available to residents somewhat less poor than Medicaid requires; and laid-off people with incomes as much as twice the poverty level who would not otherwise qualify for Medicaid. The last group is aimed, in part, at adults without children who are not allowed into Medicaid in most states.

House leaders said the COBRA proposal would subsidize for one year 65 percent of the price of premiums for private insurance that laid-off workers bought. According to legislative sources, that level of help could ultimately change, depending on feedback from congressional budget analysts.

For the past two decades, COBRA has guaranteed that certain laid-off workers may, if they pay for it, continue the insurance they used to get through work — usually for 18 months. But the government has never helped them afford it, and coverage is expensive. Under COBRA, employers may charge former workers 100 percent of the insurance cost — an average of about $12,000 a year for a family — plus a small surcharge.

Research has shown that a small fraction of people eligible for COBRA buy it. A study released last week by Families USA, a liberal consumer health lobby, said COBRA is “an economic impossibility” for most people, because its typical costs would use up nearly 84 percent of the average unemployment benefits.

Stan Dorn, a health policy researcher at the Urban Institute, predicted that it would still be unaffordable for many if the government offered to pay 65 percent of the price. He has studied the only similar idea in place today, a provision in a 2002 trade bill that offers tax credits worth 65 percent of insurance premiums to a small group of dislocated workers. Just 12 to 15 percent of them have taken the offer, largely because the remaining 35 percent of the premium is still beyond their means. If the COBRA subsidy were for the same amount, Dorn predicted, “there is a very good chance the program will be a major failure.”

However, conservatives worry that the temporary help for people to join Medicaid would be a back door to a permanent expansion of the entitlement. Nina Owcharenko, an analyst at the Heritage Foundation’s Center for Health Policy Studies, predicted that, even if the extra federal money were for two years, states would face pressure to maintain the benefit. Otherwise, she said, “It’s seen as kicking people off the program.” She suggested that the government, instead, offer states help in finding unemployed people private coverage, which might be less generous and less expensive.

One House aide said how much help the government can afford — and how many people might take part — will remain unclear until the budget analyses are finished. In the meantime, he said, “this is far from a perfect solution, but it is going to help some people.”

Source: www.washingtonpost.com

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Why Employer-Based Health Insurance Doesn’t Cut It

By Molly M. Ginty, Women’s eNews
Posted on January 14, 2009, Printed on January 19, 2009
http://www.alternet.org/story/119623/

 

In December, President-elect Barack Obama invited Americans to hold more than 4,000 “health care house parties” and discuss medical reform.

Laura Boylan, a New York City neurologist, hosted one such meeting in the living room of her family’s apartment on Dec. 15.

“The questions they asked us to distribute to attendees didn’t address the single-payer issue, but instead presumed that employer-based and private insurance would continue to take precedence,” says Boylan, a local board member of the Chicago-based Physicians for a National Health Program.

Despite a fierce insurance lobby and an incoming administration pointed in another policy direction, Boylan and her 11 guests — all doctors, nurses or health activists — agreed they were prepared to back legislation to create a single-payer system, in which a publicly financed entity (a “single payer”) reimburses providers for their services instead of having private insurers reimburse for these services, as they do now.

In 2006, California lawmakers approved a single-payer system in their state. Gov. Arnold Schwarzenegger vetoed it, claiming “socialized medicine is not the solution to our health care problems.”

Despite this kind of philosophical aversion to their favored approach, Boylan and her allies note that the single-payer paradigm is succeeding in Canada and Europe and has majority support among physicians and citizens here.

A 2004 Archives of Internal Medicine survey showed 63 percent of doctors believe a single-payer system would provide the best care for the most people. A 2007 CNN poll showed 64 percent of Americans believe “the government should provide a national health insurance program for all Americans even if this would require higher taxes.”

Obama’s Stopgap Pledge

During his campaign, Obama pledged to preserve the employer-based private insurance system and create a stopgap federal program to cover the uninsured.

He is also expected to give serious consideration to a proposal by Senate Finance Committee chair Max Baucus, D-Mont., for mandatory insurance with private companies competing alongside a new Medicare-type program.

For advocates such as Boylan, legislative leadership is coming from Rep. John Conyers Jr., D-Mich., who in 2003 and 2007 introduced the National Health Insurance Act (HR 676) to create a publicly financed single-payer system.

“With 47 million Americans uninsured and 50 million underinsured, it’s past time for change,” Conyers recently told Women’s eNews through a spokesperson.

Supporters of a single-payer system propose two possible funding methods. One would be a 3.3 percent payroll tax and a reversal of President Bush’s tax cuts for the wealthy. Another would be to rely on payroll taxes of 8.17 percent for employers and 3.78 percent for employees. Advocates say that, despite additional taxes, a single-payer system would save citizens money.

Conyers’ bill has been endorsed by only 93 of 535 members of Congress. Fourteen national labor groups and 20 health and civic groups, including the National Organization for Women and the Coalition of Labor Union Women, both in Washington, have lined up behind it. With Obama slated to take office in nine days, Conyers has pledged to hold hearings on his proposal in the House Committee on the Judiciary, which he chairs.

Geri Jenkins, co-president of the Oakland-based California Nurses Association, says the guaranteed health insurance of a single-payer approach is necessary when so many people are losing their jobs. “Unemployment recently surged to 7.2 percent, and for every 1 percent increase in that rate, 1 million more Americans are predicted to lose their health insurance coverage,” Jenkins says.

Industry Opposition

The Washington-based America’s Health Insurance Plans, an insurance trade group, argues a single-payer system could result in lower payments for health care providers and job loss in the health care industry, which employs 12 percent of U.S. workers. Of those 12 million workers, 80 percent are women, reports the National Institute for Occupational Safety and Health.

On Dec. 22, the Washington-based Progressive Democrats of America mobilized thousands to phone their congressional representatives and lobby for Conyers’ bill. A second call-in day is set for Jan. 15.

Single-payer advocates say the current system is not only costly, but in crisis. More than 100,000 Americans die each year of treatable conditions because they are uninsured, underinsured or fall prey to health-care bureaucracy, according to a January 2008 study in the journal Health Affairs. “Such deaths account, on average, for 23 percent of total mortality under age 75 among males and 32 percent among females,” noted the authors, who ranked the United States last among 19 industrialized nations in terms of preventable deaths.

Eighteen percent of women under 65 are uninsured — largely due to financial constraints — and since 2000, the cost of health premiums has increased six times faster than the median income, reports the Kaiser Family Foundation, in Menlo Park, Calif.

Linda Prine, a family physician in New York City, says she’s seen women wait four months for Pap smears, be denied the prescriptions they need and die of treatable diseases because they can’t afford adequate health care.

‘Bureaucracy Threatens Lives’

“The current American health care system is plagued by so much bureaucracy that it’s a threat to patients’ lives,” says Prine. “That’s why I’ve joined the push to urge Obama to replace this system with a single-payer one, which would offer affordable, continuous, universal care.”

Prine says her practice deals with 52 different health care plans. “All have different payment schemes and paperwork. But under a single-paper system, this bureaucracy would be replaced by a streamlined electronic medical records system.”

Instead of a patchwork of private insurance companies that functions as a market-based regulator of costs, covered services and providers, the single-payer system has a public or quasi-public agency pay medical providers. Costs are controlled through bulk purchasing, negotiated fees with suppliers and service providers, and global budgeting, which pays providers from a pooled budget versus a system of itemized, one-by-one claims.

The mixed system of private and public medicine in the United States spends $7,026 per person on health care annually, while countries with single-payer systems spend an average $3,840, reports the Paris-based Organization for Economic Cooperation and Development. A single-payer system would save $350 billion in annual paperwork, enough savings to provide care to all without costing more, reports Physicians for a National Health Program.

“With private insurance, rather than send a patient with chronic alcoholism and liver disease to the detox program where she could get the best care, I have to send her wherever her insurance company dictates she should go, even if it’s not to a qualified specialist,” says Claudia M. Fegan, a physician in Chicago. “In a single-payer system, I could offer her the treatment she really needs.”

Under Medicare, a single-payer system is already in place for U.S. citizens who are over age 65 or who have permanent disabilities. The Medicare program spends 3 percent of its revenue on administrative costs, while private insurers spend 30 percent or 10 times as much, according to the Chicago-based American Medical Association and the New England Journal of Medicine.

“Health insurance costs the average family $8,000 to $10,000 annually, minus co-pays and the cost of drugs,” says Jenkins of the California Nurses Association, referring to households that either receive employer-based benefits or pay for their own insurance. “But single-payer insurance would likely cost them less than this in taxes each year.”

Source: Women’s eNews.

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AG Andrew Cuomo reins in health care giant United on price fixing; systemic overcharging revealed

In a landmark deal with state Attorney General Andrew Cuomo, one of the nation’s largest health insurers agreed Tuesday to spend $50 million to reform its billing practices.

In exchange for avoiding a lengthy and costly court fight, UnitedHealth Group Inc., said it will create a massive database – overseen by an outside nonprofit organization – to determine fair rates for reimbursements.

In addition, Cuomo said he would seek hundreds of millions of dollars in restitution for what he called a decade of “consumer fraud” affecting millions of out-of-network patients.

“It is not an overdramatization to say that it is a matter of life and death,” Cuomo told reporters Tuesday in a packed press conference at St. Vincent’s Hospital in Greenwich Village.

Cuomo outlined how the scheme works:

Ingenix – a UnitedHealth subsidiary and the country’s largest provider of health care billing information – sets “usual and customary” rates for medical procedures that are supposed to reflect market prices.

The problem is, Ingenix determined the rates by asking the insurance companies what to charge. Their estimates for reimbursement generally are much lower than what the patient paid.

“We believe this is a conflict of interest,” Cuomo said. “We have to replace Ingenix with a fair and independent entity.”

Insurers often promise to cover up to 80% of rates for claims from providers outside their network. Cuomo said probers found that insurers using the Ingenix databases underpaid anywhere from 10% to 28% for certain claims in New York.

UnitedHealth Group will post the new estimates on a Web site so patients will know what their procedures will cost.

“We are committed to increasing the amount of useful information available in the health care marketplace so that people can make informed decisions,” said Thomas Strickland, a lawyer for UnitedHealth Group.

Cuomo said he was “optimistic” he could get reimbursements to patients who overpaid with faulty Ingenix estimates within six months. The money would come from companies like UnitedHealth Group, Aetna, Cigna and WellPoint/Empire BlueCross BlueShield.

“We won’t stop until the consumer gets what they paid for,” he vowed.

American Medical Association President Dr. Nancy Nielsen said insurers can drive a wedge between doctors and patients when they underpay medical bills.

“Now the data will be reliable, people will know what they’re getting and it will be clear and transparent,” she said.

Barry Epstein, a lawyer involved in four court cases over the database said the agreement seems to be a “pretty clear admission of invalidity” of the Ingenix system.

“There’s no doubt that it needed replacement,” Epstein said.

Source: www.nydailynews.com

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Obama’s Health-Care Headache

Obama’s Health-Care Headache

By Robert J. Samuelson
Monday, January 12, 2009; A13

 

Barack Obama talked somberly last week about getting the federal budget under control once the present economic crisis has passed. To do that, he’ll have to confront the rapid growth of health spending, which in 2007 was already a quarter of total federal spending of $2.7 trillion. If Obama is serious, he should read a fascinating study from the McKinsey Global Institute, the research arm of the famed consulting company.

American health care has gone haywire. It provides much splendid care but has glaring deficiencies. It is so costly that 15 percent of the population lacks health insurance. Runaway spending is also crowding out other government programs and, through bloated insurance premiums, squeezing workers’ take-home pay. What McKinsey provides is a plausible estimate of the overspending: one-third. In 2006, U.S. health spending totaled $2.1 trillion. Of that, McKinsey figures that $650 billion exceeded the norms of other rich nations.

For the extra money, we receive no indisputably large benefit in national well-being. On some health measures (breast cancer survival rates), we do better than many countries; on some others (life expectancy), we do worse. We are constantly searching for villains to explain this unsatisfactory situation. The McKinsey study debunks some popular candidates.

One is that our mixed private-public insurance system drives up costs through high administrative overhead. Claims forms create a paperwork morass; marketing expenses add to the burden. True, U.S. overhead costs are more than double the level in other countries. But the effect is modest, because all administrative costs (including government programs such as Medicare) account for only 7 percent of total health costs.

The same is true of another common scapegoat: the alleged overuse of emergency room care. In 2006, all emergency room care cost $75 billion, about 3.5 percent of total health spending. That’s too small to explain overall trends.

What really drives health spending, the study finds, is that Americans receive more costly medical services than do other peoples, and they pay more for them. On a population-adjusted basis, the number of CT scans in 2005 was 72 percent higher in the United States than in Germany; U.S. reimbursement rates were four times higher. Knee replacements were 90 percent more frequent than the average in other wealthy countries. In 2005, there were 750,000 knee and hip replacements, up 70 percent in five years, reports the journal Health Affairs.

We have a health-care system that reflects our national values. It’s highly individualistic, entrepreneurial and suspicious of centralized supervision. In practice, Medicare and private insurers impose few effective controls on doctors’ and patients’ choices. That’s the way most Americans want it. Patients understandably desire the most advanced surgeries, diagnostic tests and drugs. Doctors want the freedom to prescribe.

Open-ended insurance reimbursement encourages expensive medicine by making it easier to recover the costs of clinical advances. Economist Amy Finkelstein of MIT has estimated that roughly half the real increase in per capita health spending from 1950 to 1990 reflected the spread of comprehensive health insurance. In 2006, consumers’ out-of-pocket spending represented 13 percent of total health spending, down from about half in 1960. Unfortunately, this semi-automatic system may now frustrate other national goals by displacing other spending and spawning ineffective or unneeded care.

On paper, there are various ways to control health spending: stricter regulation of prices and the availability of care; “market mechanisms” to push consumers toward more efficient or skimpier care. All have foundered, because they cannot be used aggressively. The reason is politics. There is no major constituency for controlling spending. Because most patients don’t pay medical bills directly, they have little interest in using less care or shopping for lower-priced services. Providers (doctors, hospitals, drug companies) have no interest in limiting care. What others call “health costs” are their incomes — wages, salaries, profits.

Unless we rectify this political imbalance, efforts to control health spending may fail. We need mass constituencies that favor cost control. But our consistent policy has been to conceal the burden of health spending by burying it in untaxed corporate fringe benefits or government budgets.

We could change this. We could charge the elderly more for Medicare. We could tax employer-provided health insurance as ordinary income. We could create a dedicated federal tax to cover government health costs — if health spending increased more than revenue, the tax would automatically rise. People would quickly feel the costs of our present system. Of course, that would be unpopular, because it would compel Americans to face a discomforting issue — how important is health care compared with other priorities?

Will Obama be so bold? In the campaign, he proposed more, not less, health spending. It’s easier to embrace the rhetoric of change than change itself.

Source: www.washingtonpost.com

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Joan Aragone column: HICAP helps seniors understand health insurance complexities

By Joan Aragone
San Mateo County Times

Posted: 01/11/2009 04:03:52 PM PST

Updated: 01/11/2009 10:16:14 PM PST

 

 

A Hillsborough woman seeking help for suspected Medicare fraud recently called the San Mateo County office of the Health Insurance Counseling and Advocacy Program, or HICAP, in San Mateo. She was almost in tears.

Hours earlier, she had started her telephone search for information at 1-800-Medicare and found herself in a whirlpool of agency voice mail and frustration.

Finally, somebody in her chain of calls suggested that she call HICAP. She had never heard of the program, but in one conversation she received targeted advice, was directed to gather paperwork and given an appointment with a counselor — at no charge.

Who doesn’t understand the relief she must have felt?

For Medicare beneficiaries of all income levels and their caregivers who are confused about any aspect of health insurance, HICAP is a reliable source of free, personalized counseling and information about all aspects of health care.

The topics covered by agency counselors include long-term care, Medi-Cal (the state’s low-income insurance program) and Medicare (the federal health insurance program for people 65 and older). They also cover regulations, changes in law, co-pays, deductions, drug prices, fraud, differences in policies, fees, how to avoid being scammed, what to do if you are scammed, who to see and what do to. No wonder business is brisk.

It continues to grow. Since the introduction of the convoluted Medicare Part D prescription drug program in 2006, HICAP counselors have spent extra hours each winter advising seniors on ways to maneuver within the world of this complex piece of legislation. (November through December is the only time seniors may change such policies if they choose.)

 

Now, under a new state law, low-income seniors on Medi-Cal will be required in 2009 for the first time to pay their monthly Medicare premium that Medi-Cal had previously paid. Unchanged since last year, the premium for 2009 is $96.40.

This law affects people whose income is less than about $1,600 per month and who have assets of less than $2,000, not including a home.

“Now they are being asked to pay $96.40 per month. That’s a big portion of their income,” said Bob Fucilla, community partnership liaison for Health Plan of San Mateo, which provides health insurance for low-income county residents. The agency has a close partnership with HICAP.

The task of explaining and counseling is done by trained HICAP volunteers, who receive 30 hours of training, plus 20 hours of internship, six hours a day, two days a week for three weeks. At successful completion, they are registered as HICAP counselors with the state of California.

“Counseling for HICAP is a challenging volunteer job,” said Barbara Kammerlohr, program manager since July, who started as a volunteer. “It’s complicated to get into Medicare, but knowing rules and regulations and how to understand them to help other people can be satisfying. When the volunteers get into it, they really want to stay.”

Kammerlohr has replaced longtime program manager Diana Gray, who left in April.

A new training program for volunteer counselors starts Jan. 20, with special focus on Half Moon Bay, East Palo Alto and Daly City.

HICAP places volunteers in their own communities, at senior centers and Social Security offices, with home visits, if necessary.

“People want to stay in their home area for counseling, so HICAP needs volunteers from the community,” said Christina Kahn, community outreach coordinator.

In February, HICAP representatives will explain “Medicare Changes for 2009 and General Enrollment Period Jan. 1 through March 31″ at two meetings. The meetings will take place at 11:45 a.m. Feb. 18 at Fair Oaks Senior Center, 2600 Middlefield Road, Redwood City; and 11 a.m. Feb. 24 at Senior Coastsiders, 535 Kelly Ave., Half Moon Bay.

To volunteer or otherwise contact HICAP in San Mateo County, call 650-627-9350 or 800-434-0222.

HICAP is the name in California for the federally mandated State Health Insurance Assistance Programs, which provide counseling to Medicare beneficiaries and caregivers.

Source: www.insidebayarea.com

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A focused remedy is the best cure for healthcare crisis

A focused remedy is best cure for healthcare crisis

Risa Lavizzo-Mourey and Vernice Davis Anthony

As the Senate considers the nomination of former Sen. Tom Daschle as secretary of health and human services—and as the nation looks forward to health reform—it is important that policymakers focus on what it means to “fix” health care and ask some hard questions about how we deliver medical care.

First off, everyone should agree that we must strive to get every American the health care coverage they need.

Second, we can all agree that getting health care costs under control is both a health and economic imperative. Despite the “good news” this week that health care spending rose 6.1% to $2.2 trillion in 2007, that slowdown from previous years is still substantially higher than general inflation and health care now gobbles up 16.2 % of gross domestic product.

But high costs and the uninsured are only the visible problems with health care. The invisible problem is poor-quality care. Our third area of agreement must go beyond getting people care, to getting them the right care.

Poor quality care and the uninsured are inextricably linked, even though few understand the link. Poor quality care robs the system of precious resources—dollars and services—that could be used to expand access and coverage.

Lawmakers need look no farther than their own back yard to ask questions about the quality and inefficiency problems. Medicare is the largest federal health insurance program, so lawmakers should ask why an elderly person spends about 11 days in the hospital in Bend, Oregon in the last two years of life, compared to 23 in Detroit or nearly 35 in Manhattan. Or why they see doctors about 15 times in Ogden, Utah in the last six months of life compared to 42 in Detroit or 60 in Los Angeles.

They should ask why researchers found that only 57 percent of female patients aged 65–69 in Mississippi got regular mammograms, compared to 70 percent in Michigan or 74 percent in Maine, the top state. Or why in Alaska, only 71 percent of patients with diabetes got important blood tests in 2003–2005, compared to 86 percent in Michigan or 92 percent in Vermont. Or most tragically, why more than 1.6 out of every 1,000 Medicare beneficiaries in Louisiana lost a leg to amputation, compared to 0.9 in Michigan or 0.50 in Utah, a more than three-fold difference from top to bottom?

They should also ask hard questions about why people get care they may not need. Why are antibiotics prescribed inappropriately for children’s ear infections 13 million times a year, when more than 80 percent of infections get better within three days without antibiotics?

Why in a decade did spending for back surgery called lumbar fusion rise 500 percent—from $75 million to $482 million—despite a lack of evidence supporting the effectiveness. And why do some regions of the country use vastly more resources to treat patients with similar illnesses without achieving better outcomes.

They will find what Dartmouth researchers found, that a whopping 30 percent of health care spending—nearly $700 billion a year—pays for services that may not improve people’s health.

That’s money that could be used to cover the uninsured—if we can figure out how.

A good place to start is improving the information we have about the actual performance of doctors and hospitals with wider spread use of reports such as those Medicare has begun to make available on hospitals and a few pioneering community organizations, such as the Greater Detroit Area Health Council (GDAHC), have made available on both hospitals and doctors’ practices in their communities (www.SaveLivesSaveDollars.org). Patients need this information to make informed choices about their own care. Doctors and hospitals need this information to help them improve care. And both consumers and purchasers need information about the value they are getting for their health-care dollars.

A second step is to put serious dollars into quality improvement efforts, building on Medicare pilot programs that spur hospitals and physician group practices to improve care and launch experiments that encourage disparate medical providers to work in teams to coordinate care and deliver it efficiently.

Finally, our payment system must reward providers for giving patients the right care at the right time, the right way.

Now we pay providers for “doing things”: the more treatments and procedures they provide and the more they use expensive technology, the more they get paid. We need to reward, not punish, providers who deliver high-quality, cost-effective care. Moreover, providers should be fairly compensated for preventive care, for time spent coaching patients and for coordinating care for those with chronic conditions.

Many of these concepts are being tested on the ground in living laboratories such as GDAHC’s Save Dollars Save Lives campaign, one of 14 communities working with the Robert Wood Johnson Foundation’s Aligning Forces for Quality program to bring together those who get care, give care and pay for care to improve the quality of care.

As Washington turns it eye to health care reform, by all means let’s start with getting everyone access to care, but everyone should also understand that what happens to them once they get inside the hospital or doctors’ office is just as important as getting them in the door.

Source: www.freep.com

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Ruling removes billing headache from emergency room visits

Patients can’t be billed when their HMOs fail to pay, the California Supreme Court says. Doctors say they’re being squeezed.

By Lisa Girion

January 9, 2009

Winding up in the emergency room is bad enough. But the California Supreme Court ruled Thursday that patients no longer have to worry about getting billed for emergency treatment charges that their HMOs fail to pay.

Health maintenance organizations and patient advocates hailed the decision as an important protection against gouging by hospitals and physicians. But doctors said it would encourage greedy HMOs to underpay them and that that could put emergency rooms in jeopardy.

The decision resolves one part of a contentious debate that has vexed courts, lawmakers and regulators for years. But it leaves open the question of what constitutes reasonable payment for emergency services. Regulations require HMOs to pay hospitals and physicians reasonable fees but do not set out specific amounts.

At issue in the case is a practice known as balance billing, a practice that typically occurs when a patient is treated for an emergency at a hospital that does not have a fee contract with the patient’s HMO.

In such cases, HMOs say, physicians and hospitals often submit inflated charges. But hospitals and physicians say that without minimum fee requirements, HMOs routinely underpay them.

Disputing such underpayments is impractical and costly, physicians say, so they bill patients for the balance, hoping the patients’ complaints will prompt the HMO to pay in full.

Gov. Arnold Schwarzenegger praised the ruling because it “reaffirms that patients should not be put in the middle of billing disputes between providers and health plans.”

Two years ago, Schwarzenegger directed his Department of Managed Health Care to adopt regulations banning balance billing, and last year he vetoed a bill that would have set minimum payments for emergency care.

Chris Ohman, chief executive of the California Assn. of Health Plans, said the ruling would help contain healthcare costs and give consumers “the peace of mind they should have with health insurance.”

“They will no longer face the threat of receiving bills from emergency room doctors who want more than the fair payment a health plan is willing to cover,” he said.

Physicians said they were disappointed by the decision and bristled at the notion that they would overcharge. They said the loss of patient billing removed what little leverage they had with big HMOs to get fair payment.

“I understand taking the patient out of the middle, but you can’t just give a blank check to the HMOs at the expense of doctors,” said Dev A. GhanaDev, president of the California Medical Assn. and a trauma surgeon at Arrowhead Regional Medical Center in Colton.

“Me, the little trauma surgeon, going up against Blue Cross of California is like David against Goliath — no chance,” he said.

The case considered by the Supreme Court stemmed from a dispute between emergency physicians and the Prospect Medical Group, a Southern California physician organization that operates like an HMO. It centered on emergency care rendered to its patients at Saint John’s Health Center in Santa Monica and Northridge Hospital Medical Center.

In August, after failing to negotiate a compromise between physicians and HMOs, the Department of Managed Health Care issued regulations banning balance billing.

Since then, some HMOs and large HMO-like physician groups have declined to renew or have canceled contracts with emergency room physicians in apparent attempts to avoid paying negotiated rates, said Andy Selesnick, a lawyer for the emergency room physicians in the case. “Everybody wants 24-hour service, but nobody wants to get a bill,” he said.

Many doctors say they fear that any loss in income resulting from the ruling could further strain already strapped hospital emergency rooms and discourage specialists from taking emergency cases.

“This is really bad for emergency medicine,” said Dr. Ramon Johnson, an Orange County emergency room physician. “This is going to shift a lot of money to HMOs and away from people who actually provide the care.”

Representatives of the Prospect group did not return calls.

DMHC Director Cindy Ehnes praised the ruling and sought to allay physicians’ concerns. “We won’t retreat from efforts to make sure that doctors are paid fairly,” she said.

Much work is ahead for the DMHC and the Department of Insurance, which also supervises health insurance, said Bryan Liang, executive director of the Institute of Health Law Studies at the California Western School of Law in San Diego.

“The court really avoided the big issue — what is ‘reasonable and fair’ payment” for doctors and hospitals, he said. The DMHC and Department of Insurance “will have to weigh in on this, and how the amounts will be determined.”

The ruling could affect a battle between Kaiser Permanente and Prime Healthcare over bills the hospital chain sent to thousands of Kaiser members for emergency care. Kaiser said it was pleased by the decision.

“The decision provides much needed protection for California patients, taking them out of the middle of billing disputes between providers and health plans,” said Benjamin Chu, president of Kaiser’s Southern California region. A representative of Prime Healthcare could not be reached for comment.

Source: www.latimes.com

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Unemployed squeezed on health insurance

By KEVIN FREKING – Jan 9, 2009

WASHINGTON (AP) — Newly unemployed Americans will have to spend about 30 percent of their jobless benefits on average to pay for health insurance through their former employer, according to a new report.

And if they want coverage for their families, the report by Families USA says it will take more than 80 percent of their unemployment check.

Unemployment hit a 16-year high last month as another 524,000 jobs were cut. For all of 2008, government says the economy lost a net total of 2.6 million jobs.

When workers lose their jobs, they are usually eligible to maintain their health insurance coverage through their old employer if they pay the premiums, plus a 2 percent administrative fee. The benefit is referred to as COBRA insurance, because of the law that established it.

As part of his economic stimulus package, President-elect Barack Obama is proposing to spend about $80 billion dollars to extend unemployment benefits and to subsidize health care for people who have lost their jobs.

Families USA, a liberal advocacy group says it’s report comparing average COBRA costs and unemployment benefits shows the need for the subsidy proposed by Obama.

At present, paying for COBRA borders on unrealistic for most people who lose their jobs. The cost cuts too deeply into their government-paid jobless benefits.

“This very important right is not meaningful in reality,” said Ron Pollack, the group’s executive director.

Continuing health coverage through former employers is particularly difficult for families. Indeed, in nine states, the average premium for family coverage equals or exceeds their unemployment benefits, the Families USA report said. Those states are Alabama, Alaska, Arizona, Delaware, Florida, Louisiana, Mississippi, South Carolina and West Virginia.

COBRA coverage is more affordable for individuals, but in six states, jobless workers would have to spend more than 40 percent of their unemployment insurance on COBRA premiums for individual coverage. Those states are Alabama, Alaska, Arizona, Louisiana, Mississippi and West Virginia.

Source: associatedpress.com

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Health Insurance If You Lose Your Job

CBS) When people lose their jobs, they also lose their health insurance. Finding alternative insurance can be intimidating, and expensive. But in this column, Early Show financial adviser Ray Martin goes through some of the available options.

For starters, he says, do NOT go without insurance, assuming it’s going to be prohibitively expensive. The No. 1 reason individuals file for bankruptcy is medical bills that can’t be paid thanks to a lack of insurance. But, he stresses, you do have some choices.

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According to recent statistics, about 46 million Americans are going without health insurance coverage. With the souring economy and rising unemployment, the number of folks losing job-related health insurance benefits is set to rise significantly. And with more folks looking for jobs, finding a job will take longer, which means more displaced workers can go without health insurance for longer periods of time.

Unfortunately, there is no universal health insurance plan for folks who need temporary health insurance coverage due to loss of coverage when they are between jobs or no longer qualify as a dependent under a spouses or parents plan. However, many insurance companies are developing more individual and “gap” plans in an effort to make some options more affordable to individuals, due to a growing market demand. Sorting through the available options and finding affordable short-term health insurance can be challenging, but it’s not impossible.

Here’s what to look for:

COBRA Continuation of Coverage

Under a Federal law called COBRA (Consolidated Omnibus Budget Reconciliation Act), displaced workers are provided the right to continue coverage under their employers’ group plans after they change or lose jobs. Continuation of coverage can also apply to children who no longer qualify as covered dependents because they are no longer full-time students. This option is available to employees of companies with group health plans that cover 20 or more workers. Some employers with other health plans (such as self-insured plans) may not be required to provide COBRA continuation coverage. The cost of health coverage under COBRA for displaced workers is usually more expensive than health coverage for active employees, since, usually, the employer pays a part of the premium for active employees, while displaced workers are required to pay the entire premium themselves. Since it is the full cost for the coverage, it can be expensive: On average, the monthly premium for an individual policy in 2008 was $392, and for a family plan, about $1,056 a month, according to a recent Kaiser/HRET survey. But typically, that is still less expensive than individual health coverage with the same features and benefits.

Coverage under COBRA can be continued for up to 18 months, and up to 36 months when loss of coverage is due to divorce, disability, etc. When electing COBRA coverage, you must be sure to do so within 60 days of your “qualifying event” (such as loss of your job, divorce, etc.); after that time, the insurance company can decline your eligibility. Once you select COBRA, your coverage is effective with no gaps, so your eligible medical claims during that period of time should all be covered. Because this is the same coverage that the worker had before losing his or her job, the same benefits and features are available, and there are typically no restrictions for preexisting conditions. You can also discontinue participating at any time after permanent coverage is found.

But continuation of health insurance under COBRA is not always available for workers of companies that go out of business: When a company shuts its doors and also terminates its health insurance plan, usually there is no COBRA coverage available. If, however, there is another plan offered by the company, you may be covered under that plan.

Short-Term Medical Insurance

Short-term medical insurance can provide coverage for a limited period of time, and may be a good solution for those between jobs or waiting for other health insurance to start. This form of coverage is offered by a select group of insurance companies and features coverage from one-to-12 months. This can be a good option for those between jobs, when COBRA is not available and you do not have significant pre-existing conditions. For example, the Celtic Insurance Company offers a short-term medical plan for a 45 year-old male that can cost as little as $74 a month. Of course, the cost of this coverage will depend on your age, other health related factors, and the deductible you select (some products feature a selection of deductibles from $250 to $2,500). After the deductible is paid, covered individuals typically pay 20 percent of covered expenses up to an out-of-pocket limit, and then all covered expenses are covered 100 percent up to $2 million. Another provider that offers short-term medical insurance is Golden Rule (a UnitedHealthOne Company). Also, check out www.ehealthcobra.com, a Web site developed by eHealthInsurance that offers quotes and side-by-side comparisons of several short-term and high-deductible medical plans for individuals and families.

Catastrophic Health Insurance

As the name implies, these policies are primarily designed to cover major emergency medical expenses. The cost is relatively low, because insured people must first satisfy a high deductible, ranging from $500 up to $15,000, depending on the plan purchased. These policies are not intended to pay for routine doctor office visits or trips to the emergency room for the flu, nor for preventative care, maternity care or mental health care. However, most catastrophic plans cover hospital stays, X-rays, and surgical expenses. Think of this as affordable medical coverage for the worst that can happen, which primarily provides coverage so your other assets do not get wiped out from the high cost of a true medical emergency. Folks who get this coverage will need to be prepared to pay a deductible if they incur a serious illness or accident. If you have a pre-existing condition such as heart disease, cancer or diabetes, you are generally not eligible for this type of coverage. There are several Web sites that will compare catastrophic plans in your area and provide quotes for you, including gohealthinsurance.com and medhealthinsurance.com.

Association Coverage

Many trade, professional or other associations offer health insurance to their members. If you belong to any groups or associations, call their membership services to find out if they offer this coverage. There can occasionally be a small, additional administrative fee such as two percent of the annual premium that the Association may charge you, but this is still a good way to obtain a group rate for coverage.

Non-Group Coverage

Many health insurance companies offer individual health insurance coverage. This can be very expensive and may not available in your state. Often, application requirements will apply, and preexisting conditions will be excluded from covered health and medical conditions. Some states mandate a “high-risk pool” that guarantees by law that they accept those who apply, under certain conditions. Check with your state’s insurance department for more information.

Local Clinics

Some uninsured adults turn to local clinics for low-cost or free medical care for things such as routine visits or check-ups. But this is not a viable alternative for a major illness or accident, as hospitalization is not provided. If you decide to forgo health insurance, it does not mean that you can’t still seek care from your family physician or local doctors; you will just need to pay as you go. And don’t be afraid to negotiate those fees. This is a much more affordable way to seek care then going to an emergency room, where the cost can be more than 10 times higher.

Medicaid

This is a joint federal-state health insurance program for individuals who meet near poverty-level income and asset qualifications. States usually provide Medicaid for individuals who receive federally-funded cash assistance payments, such as SSI. The set poverty-levels can vary by state so, for more information about Medicaid, contact your state’s Medicaid agency, social service or welfare office.

Source: www.cbsnews.com

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