Category Archives: Healthcare

Volkswagen: The Union, the Worker and Intimidation

For the next three days, workers at the Volkswagen (VW) Plant in Tennessee will decide whether they want to organize as a Union. Volkswagen is a German company at which every plant across the world, except Chattanooga, TN and China, which manufacture these vehicles is unionized.  However, conservative law makers in Tennessee, as well as other vocal conservatives across the United States are outraged about the possibility that this plant may unionize.

The Volkswagen Corporation has taken a neutral stand in this issue for the Tennessee plant, but that has not stopped lawmakers from what appears to be both intimidation of the actual workers as well as the Company.  For example, “I’ve had conversations today and based on those am assured that should the workers vote against the UAW, Volkswagen will announce in the coming weeks that it will manufacture its new mid-size SUV here in Chattanooga”, said (Sen. Bob) Corker, without saying with whom he had the conversations. (http://www.dailykos.com/story/2014/02/13/1277294/-Corker-threatens-jobs-if-Volkswagen-workers-unionize?detail=facebook)  The article also points out however that VW is neutral when it comes to the unionization of the plant. Sen. Corker suggesting that there is a direct link between the workers voting down unionization in order to be named as the place chosen to build VW SUV’s seems disingenuous at best.

Senator Corker is not the only one making statements which appear to intimidate the election taking place at the plant.  Tennessee State Senator, Bo Watson said that if the workers choose to unionize they “would jeopardize any future financial incentives the state might offer Volkswagen.” (http://www.latimes.com/opinion/opinion-la/la-ol-vw-unions-uaw-republicans-crony-capitalism-20140212,0,7108450.story#axzz2tEu4mAyr)  This comment is more of a threat than it first appears to look.  Volkswagen has indicated they will be looking to expand to build an SUV in the United States as well.  Currently, VW has narrowed down the choices to expanding the plant in Chattanooga or building a plant in New Mexico.  Withholding financial incentives could possibly impact the decision of Volkswagen and seems like an outright threat.

Grover Norquist, a leading Conservative well known for his hard hitting and bullying political tactics, has purchased billboards all over Chattanooga encouraging people to vote down the bid for unionization at the plant.  The billboards have a very simple message “United Auto Workers” but the word United is crossed out and in its place is the word “Obama.”  (http://www.newsmax.com/US/grover-norquist-union-volkswaqen-tennessee/2014/02/07/id/551465)

He also makes the statement that in the past 30 years almost every job lost in a manufacturing plant has been at a unionized plant.  Why are these conservatives so concerned about the possible unionization of one plant in Chattanooga TN?  The simple answer is politics.  Historically, Unions have financially backed Democratic candidates.  In general, Republicans view Unions as a threat to their political power.

Radio and television ads abound about the “terrible” unions.  It is important to remember a few facts about unions and how they made significant and lasting changes to the American workforce which are now being threatened by Conservatives across the United States.  Changes that can be both directly and indirectly attributed to Unions include:

  • 40 hour work weeks
  • Overtime pay
  • Child Labor laws
  • Workers being paid a living wage vs. a minimum wage or less
  • Workers get employer paid benefits such as vacation pay, sick leave, and even health care insurance

There is a reason there are unions in America.  It wasn’t an impulsive decision or created as a means to steal from employers.  Unions were created because workers were being taken advantage of in companies all across the nation.  Workers were poorly paid and lived in tenements.  Children often started work as young as 8.  If someone missed work due to illness or an emergency, someone else was hired to take their place.  There was no such thing as maternity leave.  Jobs were not protected.

We have Unions because most employers didn’t treat employees in a humane manner.  Now, we have Conservatives saying that Unions are the cause of the very things they worked so hard to protect.  Do you really believe that employers would simply do “the right thing” if we did not have Unions and/or the laws in place to protect workers?

Remember the Conservatives, who say employers will treat employees “better” without unions and minimum wage laws, also believe that the group of people in America called “servers” which is made up of waitresses, waiters etc. are paid approximately at $2.13 an hour because they make so much more in tips.   Perhaps that is true in metropolitan areas or up-scale eating establishments, but what about the folks who work at diners or in more rural areas.  Ryan’s is a restaurant that offers a buffet and also pays their servers this wage.  Customers dish up their own meals, carry them to the tables, and get their own condiments.  Servers ask customers what they want to drink and refill their glasses as needed.  Do you think that customer’s tip these people the same as they do in an establishment where the customer orders the food and the server does the rest?

Reviewing the history of unions and the changes they have brought as well as understanding the perceived impact they may have on political races results in an understanding of why Conservatives fight so hard to try “union busting”.  In addition, German plants that are unionized have an additional benefit of participation in “works committees.”   These committees are made up of both workers and management at plants.  These committees review things such as production, safety, and technical issues and how to improve the plant.  They give worker’s a voice and a stake in the actual product. How many employees who have worked for companies have not at one time or another thought of ways that would improve the product or the working environment in their company?  Volkswagen has created a process where these thoughts and opinions are valued and considered.

As we look to what is happening in Chattanooga it is important to remember the adage “if we don’t learn from history we are doomed to repeat it.”  Unions have an important place in American history and played and continue to play an important role in the lives of working people.  Intimidation of workers is against the law when voting on unionizing.  It is my opinion that some of the tactics being used by Conservatives, including but not limited to, suggesting that the plant will not receive any incentives from the state or federal government if they vote to unionize crosses the line into bullying and intimidation.  As workers, each of us owes a debt of gratitude for our working conditions to Unions.  We must never allow anyone to intimidate workers in the work place.

Is It A Junk Plan?

Every day the authors of this blog are bombarded with questions about what makes a junk policy?  We have seen these plans and know based on previous experience that a “junk policy” can have a catastrophic impact not only on the person’s physical health, because many conditions are simply are not covered, but also on a person’s financial health.  Please refer to part one of the “junk policy” blog published earlier.

Junk policies do not cover a large variety of services or diagnoses and if they do the reimbursement is extremely limited.  For example, most do not include drug and alcohol treatment, mental health treatment, maternity care, and/or ambulance services just to name a few.  Even so many people are reluctant to change policies.  Who can blame them, there has been so much fear mongering about the state and federal health exchanges and change is hard, even if the outcome is positive. The Affordable Care Act (ACA) guaranteed that people could keep their policy, even if it was a “junk policy,” as long as the plan was in place prior to the ACA being enacted in March/2010, but due to the abundance of cancellations by the insurance companies, ANY plan can be “grandfathered” if the INSURANCE COMPANY so desires.  It is important to remember that the mass of health plans cancelled just prior to a person’s ability to sign up for the ACA was due to the choice of Insurance Companies.  However,  just because you can keep the policy, doesn’t mean you should.

Don’t just assume the plan you have is a “good plan” or refuse to consider all your options because you heard negative things about the state and federal health exchanges on FOX News, from a Republican, a member of the Tea Party or someone who “dislikes” government.  Do what is best for you or you could end up like Caleb Howell, who Erick Erickson, North Carolina conservative  describes as his right hand man at RedState, a very conservative blog.  Mr. Howell is apparently the lead blogger on RedState.  He was recently diagnosed with cancer, which is causing his liver to fail  and Mr. Erickson blogged about the need to raise money for Mr. Howell who is a father of two young girls.  Why?  He has NO insurance .(http://www.gofundme.com/3rrv74) (http://www.dailykos.com/story/2013/07/31/1228070/-RedState-s-Chief-Blogger-in-Critical-Condition-in-NC-No-Insurance#)  You owe it to yourself and your family to get health insurance because, as the story of Caleb Howell shows,  none of us know what tomorrow holds.  It is hard enough to fight an unexpected illness or accident without having to worry about how the medical bills will get paid or if you can get the required treatment for your self or a loved one due to no insurance or sub-par insurance.

Some people, mostly conservative Republicans and members of the Tea Party indicate they will not sign up for the ACA even if the multiple myths, misrepresentations and flat-out lies are not true.  The list of myths about the ACA is long and seems to change daily, but they are myths.  Consider this statement made by Rand Paul in a speech to the University of Louisville medical students about an upcoming exam:

That appears to be exactly the path chosen by Republicans and Tea Party associates with the ACA. There have been upwards of 20 rumors and actual lies told to the public as a means of undermining the ACA.  The fact that a member of Congress would suggest giving out misinformation or trying to trick other people as an acceptable tactic to winning makes everything he says less credible and less ethical.  It’s not only Mr. Paul who is spreading “misinformation”, including not limited to other Congressmen, Strategists and FOX News. With every statement they make you have to ask yourself if it is misinformation, trickery, or truth? What is the difference between misinformation and lying? I used to think misinformation was not intentional, however, as defined by Senator Paul, there is no difference.  Unfortunately, it appears there is a lot of trickery and misinformation passed out by Conservatives, Republicans, and the Tea Party designed to make people afraid of the Affordable Care Act. It is simply mind-boggling that people in leadership positions would do something like this to the people they are supposed to serve.  Is possible political gain really worth putting the medical needs and financial stability of constituents at risk?  The Conservatives, Republicans, and members of the Tea Party in Congress seem to think it is.

There were serious issues with the federal health exchange immediately upon roll-out. While frustrating, much of this was primarily due to the overwhelming number of people trying to access the site. In general, the federal exchange website is improving each day.  The health exchanges represent capitalism in motion.  There is little difference between shopping on the exchange and choosing between plans than finding the best possible price on televisions, groceries, or any other product.  Once you understand how to access the information for each plan, you can compare prices on the health exchange with quotes from private insurers or private health exchanges.  You want to insure you get the best coverage at an affordable price.  Here is what you should look for on both the plan you have now, any plan your current insurance company offers you, and the plans offered by the health care exchange:

  • Does the plan offer the ten essential benefits determined to be minimum levels of care as indicated by the ACA.  These 10 benefits include:

    • Ambulatory patient services

    • Emergency services

    • Hospitalization

    • Maternity and newborn care

    • Mental health and substance use disorder services, including behavioral health treatment

    • Prescription drugs

    • Rehabilitative and habilitative services and devices

    • Laboratory services

    • Preventive and wellness services and chronic disease management

    • Pediatric services, including oral and vision care

(https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/)

Be sure and check with the company, if you choose a plan that is not on the federal or state exchanges.  There are still some companies trying to see plans that do not include these services.  While you think you may not need them in the future, it isn’t a good risk to take and could end up being very costly.

  • What is the monthly premium for the plan?  Remember it is important to complete the WHOLE enrollment process on the health exchange to see what your premiums will be.  You do not have to pay for the plan, but you must get to the point just before paying so that you can see any and all tax incentives or subsidies you may qualify for.  Think of it as finding the “final” discounted price on websites, where they require you to give your email address and some demographic information to get “the lowest possible price.”

  • What is your deductible?  When reviewing the plans on the health exchange remember to complete the WHOLE application enrollment process.  Also, when you look at the plans, don’t just assume that the gold plan or bronze plan is best for you or that they will have the lowest deductibles and co-pays.  Review the silver plan, because based on your income you may also qualify for an added subsidy that will impact your deductible, co-pays, and out of pocket maximums.  This  added  subsidy is available ONLY on the silver plan and will not show up until you have verified your identity, citizenship, and income, so be sure to complete the whole process.

  • What is your co-pay for doctor’s visits?  This will vary from plan to plan.  It can be impacted by a subsidy depending on your income, but only if you enroll in  the silver plan.  I have seen enrollees end up with co-pays as low as $10 on the silver plan, due to this subsidy.

  • Check out the deductible for the plan.  Always be sure to check the silver policy, because a subsidy, if you qualify financially can significantly decrease the amount of your deductible.  I have seen people have their deductibles cut down to $100.00.

  • What is your maximum out of pocket maximum for the year?  It is important to remember there are no more life time or yearly caps on insurance company payments.  Although this probably sounds like a broken record, be sure to compare every plan for this and especially the silver plan offered through the health exchange because I have helped people apply for a plan on the health exchange who end up with as low as  a $100.00 maximum out of pocket expenses per year on this plan.

  • Check out the approved provider list.  Is the doctor or facility you currently use on the list?  Is the hospital you prefer to use on the list? Most plans on the exchanges list the website of the plan you are considering.  You may have to go to the plan’s website and check the provider list to insure your doctor’s are on the plan.  Do the same for your preferred specialists and hospitals.

  • Check out the list of prescription drugs that are on the company’s formulary?  Are the drugs you are prescribed regularly on the plan?  Do you have to use a mail-order pharmacy or do you prefer to use a pharmacy near you?  Sometimes there is a significant difference in price between the two, so you need to choose what your highest priority is: buying at a local pharmacy or having your medications delivered automatically.  There should be a link on the plan website to determine if the medications  you take are on the formulary.  If you can’t locate a list, call the health plan and ask.  You are your own best advocate.

Not all plans are the same. Regardless of what individual insurance companies call their plans, the only plans you can depend on to offer the same benefits as the bronze, silver, gold, or platinum plans are those on the federal or state health exchange.  In helping people research and determine the plan best for them we have run into companies who are using the same names as the health exchanges but do not offer the same benefits even though this is clearly against the law. We have also run into people who say their brokers have indicated they must disclose any pre-existing illness in order to qualify.  The ACA does away with the use of health issues having anything to do with pre-existing conditions and you should not be asked about this. Again however, I talk to people each day where they are still be told they will have a waiting period for “pre-existing” illnesses.  Look carefully at your options, consider using a tablet to write down each plan so when you have looked at each one you will be able to compare them fairly easily.  Make your own table or drop a note to the authors and we will send you a table to complete. Just fill out the contact form below and request your table/spreadsheet.

While clearly President Obama has stated that everyone will have the opportunity to keep their current plan, if the insurance company agrees to offer it, it is important for people to shop around.  Determine which of the benefits above are a part of your current plan as well as the importance of having that coverage. Remember you will be taking responsibility for whatever plan you choose.  If you choose to keep your “junk plan” you are taking a risk and betting that you won’t have a serious illness or an unexpected accident.  Medical bills can add up very quickly, so make sure you are protected.

Follow the link below to a Google spreadsheet which will help you easily compare Plans. Just substitute your own information in the Plan columns of the Matrix worksheet (see the tabs at the bottom of the spreadsheet) to compare up to 5 plans side by side. Please also read the information in the Read Me tab before you start.

https://docs.google.com/spreadsheet/ccc?key=0At1ZO71uykGwdC1HMG5MRWFYbnZWYXRyMUFEaDViR1E&usp=sharing

Note: The material at the link is copyrighted, but can be shared with attribution. Please read and adhere to the Copyright notice at the end of the Blog.

ByBarbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J Wills, Accountant and Business Software Support Consultant.

About the Authors:

Barbara is an independent consultant in healthcare providing consulting for physicians.  She is an industrial engineer from RPI with an MBA from NYU. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services.

Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. She is currently a recipient of the Pre-Existing Condition Insurance Plan, which she was able to purchase following the ACA being enacted.

Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.

Peter is an Accountant and Business Software Support Consultant. Prior to moving to America to marry he was an Accountant in public practice in Australia for most of his working life. For the last three years before moving here he worked as a Business Software Support Consultant for a business software developer in the housing, mining and engineering field. Peter is using his computer and business talents to assist Barbara and Lynne.

Please direct your questions and/or inquiries to askcobuzzi@gmail.com

Copyright:

© 2013 Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J. Wills. All Rights Reserved. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J. Wills,  and The Place for Facts: Not Rhetoric with appropriate and specific direction to the original content. Permission for more comprehensive use may be obtained by contacting the authors at askcobuzzi@gmail.com

The Insurances Companies have Created Two Classes of Insureds

I received an interesting email from one of my physicians in Manhattan NY.  I am copying and pasting it here.  I am making some modifications to protect the innocent.

I would like to first make a few comments before pasting the email.  It appears from this letter as well as an article that I read in the Washington Post a few weeks ago, the unwillingness of the insurance companies to learn how to work in a more competitive market, to become more efficient, more innovative because they have to be more price competitive is creating two classes of insureds.

The only way that insurance companies know how to deal with reduced premiums is to reduce what they pay to the facilities and providers of healthcare.  They don’t understand that another option is to find ways to reduce their costs of operations as others have been doing for the past 15 years as the insurance companies have continued to put downward pressure on the fees paid to doctors and the only cost doctors have had is to find ways to operate more efficiently and make less money.  They had no one to pass their reduced fees on to.

But insurance companies operate differently.  If their premiums are reduced, this time because of the increased competition that the Exchanges create for them, they in turn pass those reductions on to the facilities and the providers of healthcare.  But the reductions get too low at some point when the facilities and providers will finally say, no more, we refuse to accept your fee schedules.

And that has happened, as the Washington Post article has indicated, there are hospitals that are not included in exchange policies and now, I am finding out there are doctors groups selecting to not accept the reduced fee schedules being pushed on them by the insurance companies due to the Exchange competition forcing premium reductions.  These physician groups have said no and will not participate with these insurance plans because the fees offered by these insurance plans are too low.

So, the physicians and the hospitals participate with an insurance if it is not an exchange policy, but they do not participate with their exchange policies.  As a result, we have two classes of insured patients.  Those who have been lucky to have had insurance all along, usually through large employers, have the better class of insurance which more of the hospitals and doctors participate because the fee schedules, although not great, are more palatable.  Those who only have the choice to purchase their insurance via the Exchanges have a lower class of insurance and the same insurance companies are not considered participating plans with many of the same doctors and hospitals.  And these doctors and hospitals are the best and the brightest available to the population.  So, those purchasing in the exchanges are relegated to the second tier of hospitals and physicians, those who don’t have a choice but to accept the unacceptable low fees that these Exchange offer because they fear that they will not have enough patients to fill their schedules.

Here is the email I received from my specialist in Manhattan, part of the NYU Physician Group Independent Physician Association (Contracting arm for the physicians associated for the physicians):

Dear Patient

If you will be signing up for insurance through the New York State Health Insurance Exchange, there are some things you need to know.  I am currently in network with BCBS, Aetna, Cigna, United and Oxford.  For anyone with insurance that is a standard insurance plan, either obtained through your employer OR through the standard insurance market there will be NO CHANGE.  I WILL REMAIN IN NETWORK FOR THESE PLANS.  

BUT, if you purchase insurance through the NYS Exchange, the plans offered will be using a different network of providers.  That is, BCBS, Aetna, Cigna, and other insurers will have plans available but NYU Physicians have chosen to not accept to contract with those networks.  

On the other hand, I will be in network for Oxford and United insurances that are purchased on the NYS Exchange. 

If you will be insured under the NYS Exchange I will not be in network for any plans other than United/Oxford.

I will continue to accept commercial insurances as I have been and will remain in network for commercial non NYS Exchange plans in Oxford, United, Cigna, Aetna and BCBS.

Please feel free to contact me or my practice manager (Mary Jones, MaryJones@gmail.com) if you have any questions.

I think that we are going to still see things shaking out in the insurance company / provider of services relationships over the next year of so.  Part of the Affordable Care Act Law includes that the insurance companies have to sufficient quality care for the insureds.  If the remaining hospitals and physicians after fee schedule negotiations result in insufficient to support the number of patients needing care, there should be a basis for complaints to be filed against the insurance companies.  However, no one is sure what the process is for enforcing this provision at this time.

Insurance companies have had excessive operational waste because they have had no incentive to become efficient given the way their industry has worked.  All costs have been able to be passed on to their customers in the form of increased premiums (dollar inflow) as well as in reductions in fees to the providers of healthcare services (dollars outflow).

According to an article in the National Journal: (http://www.nationaljournal.com/healthcare/health-premiums-up-50-percent-from-2003-to-2010-report-20111117 )

Health insurance premiums rose by an average of 50 percent nationwide from 2003 to 2010, the Commonwealth Fund found in a report  (http://www.commonwealthfund.org/Publications/Issue-Briefs/2011/Nov/State-Trends-in-Premiums.aspx)  released on November 17, 2011. And costs went up even more for people covered at work—employee contributions to annual premiums increased by 63 percent, the report found.

The average family health insurance plan cost an average of $13,871 a year in 2010, the report found. Annual premiums rose in every state over the seven years from 33 percent in Idaho to 70 percent in Mississippi.

Even though Insurance Companies do not show large profit margins on their income statements, they still pay their executives large salaries and give excessive bonuses.  This is accepted modus opererandi in the industry. One of the reasons the profit margins are reported at only 3-5% is that insurance companies use transfer pricing, moving services and assets between divisions to hide profit, reducing the bottom line. (http://www.iedc-consulting.com/profit-margin-for-health-insurance-companies/ ) This is for two reasons.  They do not want to appear to be the wicked insurance company, taking advantage of the customer, so low profit margins support the image they want to portray.  The second reason is the best reason.  Lower profits lower income tax liabilities.

One of the reasons that insurance companies do not want to add to their efficiency is because of the income they get from float, being able to hold onto premium dollars while not paying it out for services provided.  According to Uwe E. Reinhardt, an economics professor at Princeton: (http://economix.blogs.nytimes.com/2009/09/25/how-much-money-do-insurance-companies-make-a-primer/ )

About 1 percent of WellPoint’s total revenue came from a category simply called “other revenue.” For the most part this probably comes from interest earned on the “float.” An insurer’s “float” is the money temporarily on hand when premium payments come in earlier than the outlays for insurance claims covered by these premiums.

In times when interest rates are high, an insurer’s float can be a major source of revenue, which is why sometimes health insurers stand accused of deliberately dragging out claims processing, strictly to increase the size of the float at any point in time.

WellPoint Inc. was formed from the merger of two companies that were once known as Blue Cross and Blue Shield of Indiana (Now Anthem BCBS) and Blue Cross of California, both originally not-for-profit plans. It is now one of the nation’s largest commercial health insurers.

Those of us who have policies from the Exchanges can no longer just call a healthcare provider (physician, imaging facility, hospital, lab, etc) and ask if they participate with our insurance company.  We need to qualify our question and ask if they participate with our insurance company with plans that come from the ACA Exchanges.  We need to check this out before making an appointment to make sure that we are going to a provider that participates with our Exchange plan.

Our Exchange plan should also provide us with a director of providers, probably via an internet website.  So, if you are having problems finding a participating provider, check with your plan and find out where they have a list of participating providers. They may even have a help line to assist you in finding a participating provider.  Use the resources made available to you by your insurance company.

If your insurance company does not provide a sufficient breadth of options available to you in a reasonable geographical radius of quality providers, you should complain to the insurance company.  If they do not assist you in getting more providers available, ask for permission to see an out of network provider who will be paid their full fees.  If this is agreed to, because of a lack of available providers in the specialty you require in your geographical area, make sure you get this agreement in writing from your insurance company.  NEVER TRUST ANYTHING TOLD TO YOU OVER THE PHONE BY YOUR INSURER UNLESS YOU GET IT IN WRITING. 

If your insurer refuses to make any accommodations for you, contact HHS with a written complaint, outlining your requirements, needs, and what the offerings are from your insurance company and explain why those offerings are inadequate.  Explain in the letter to HHS that you requested accommodations to see an out of network physician and that the insurance refused your request.  Explain you understood that ACA requires that insurance companies are required to provide sufficient quality providers for participants in the ACA Exchanges and your insurer is not providing sufficient quality providers for the following reasons…1), 2), 3), etc.

Do not anticipate that this will deny you access to providers.  There should be providers who participate and accept the fee schedules and contract terms of the Exchange plans.  Just understand that the insurance companies have created a two tiered system for insured in the short term because they are not quite sure how to deal the stresses of the increased price competition in the Exchanges.

About the Authors: By: Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW. Barbara is an industrial engineer with an MBA. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services. Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.  Please direct your questions and/or inquiries to askcobuzzi@gmail.com.

Copyright:

© Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW, 2013. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO and Lynne Smith, MSSW,  and The Place for Facts: Not Rhetoric with appropriate and specific direction to the original content. Permission for more comprehensive use may be obtained by contacting the authors at askcobuzzi@gmail.com

Project Gratitude…Americans Get Insured!

Thanksgiving is quickly approaching.  It is the one time of the year, when most people take time to inventory those things for which they are most grateful and identify their hopes and dreams for the coming year. The lists are varied and often include family, friends, good health and a good job just to name a few.  This year we hope you will take the time to participate in Project Gratitude.  Project Gratitude encourages people who are looking forward to the New Year with an especially thankful heart, because they will be on the receiving end of Affordable Health Care, to share their stories around the Thanksgiving table.

My guess is you or someone you know has faced a difficult time due to a medical issue.  You may even know someone, or perhaps you have been pushed to the financial brink due to gigantic medical bills.  If someone you love or care about is faced with a catastrophic illness or accident you know you can’t put a price on life.  It is our hope that the many and varied people throughout the United States whose hope has been renewed due to the ability to purchase affordable health care insurance will take a moment and share their story  and encourage others to check out the health care exchange and protect their families from the difficulties that come from having no insurance, a junk plan, or needs that outweigh their ability to pay.

Since the roll-out of the federal health exchange, the focus seems to have been on “all” the problems with getting coverage. Misinformation and mistruths have been spread by pundits and the media for the sole purpose of having ACA/Obamacare fail for political purposes.  Any way you look at it, it is sad.  By keeping people worried, afraid and suspicious of ACA/Obamacare it appears that many have missed the benefits it has provided to many others, many of whom who could not get insurance because it was too expensive or because they had a pre-existing illness.

It is common knowledge that the recession had a serious impact on many, many families throughout the United States.  People lost their jobs, their homes and in many cases their health insurance.  While some of these people may have qualified for unemployment, following a job loss, anyone who has ever tried to get a COBRA policy in between jobs, knows they are often very expensive.  The loss of a job, the inability to quickly find another job and the high cost of COBRA plans has resulted in numerous individuals and families going without health insurance.

It seems that in the last 30 years employees and/or individuals and families have had to pay a larger share of the cost of their health insurance.  Due to financial pressures, many people have come to view health insurance as a luxury instead of a necessity.  More and more people have dropped their insurance plans due to cost, as they feel they are unable to pay the increasing premiums and deductibles.  The following table compares the cost of health insurance premiums over the past ten years in comparison to worker’s wages.  Wages have increased less than 20% compared to health insurance premiums which have risen over 80%.  No wonder people believe health insurance has become just too expensive.  (http://t0.gstatic.com/images?q=tbn:ANd9GcSQrvziv3UOxK84MsCr5MRJC57xOonqWzUhJ3Fg2o2hFwEYA46u)

Since the ACA rolled out in early October thousands of people have applied for and obtained health insurance beginning in January 2014.  Consider the case of David Heitler-Klevens. He and his family were paying a $625 premium for health care per month and had a family deductible of $6,000 per year. They were able to cut their costs for health insurance considerably by shopping on the health care exchange.  Beginning in 2014, they will pay a premium of $67 per month and have a $1,000 deductible. Who wouldn’t be excited and thankful about that?

Not every person who accesses the exchange is eligible for tax incentives or subsidies.  That doesn’t mean they don’t benefit from being able to shop on the exchange.  Judy Tomlinson Hampson did not qualify for tax incentives or subsidies.  However, she was able to purchase a plan with about the same premium, but her deductible and co-pays will be half of what she had been paying.  In addition, all her doctors, clinics and hospitals  are on the  provider list so she will simply continue her care.

There is also an additional group of people who are thankful for Obamacare/ACA this year. Someone in their family has been diagnosed with a pre-existing condition and has been unable to buy affordable health insurance or has a plan in which the premiums and deductibles are so high that, while covered, it isn’t very helpful.  Sometimes families have had to make a choice to insure some members of their family and not others.

Cheryll Athorp from Alaska was unable to obtain affordable health insurance due to a pre-existing illness.  She is self-employed, but was diagnosed with breast cancer in 2003.  While she successfully completed treatment, she  only option prior to the federal exchange opening was to buy insurance that was sub-par due to a pre-existing condition. During 2013 this plan would have cost $1,700 a month in premiums and had a $20,000 deductible.  She accessed the federal health exchange and purchased a silver plan for a premium of $134 per month.  That means her savings are more than $1,500.00 per month on premiums alone.

Then there is Terri Mitchell from Iowa.  She needs to have surgery on her eyes but was worried about the financial strain it would place on her. She shopped on the health care exchange and found an affordable plan.  She is looking forward to having her surgery and is thrilled she will be able to maintain her eyesight.  Her two sons, ages 24 and 26, hadn’t had insurance since they were 18.  From January 1, 2014 they will have health insurance that they were able to purchase for the first time since becoming adults.

The final group of people who are purchasing health insurance plans on the state and federal exchanges are people with pre-existing conditions who in the past two years were able to purchase insurance through ACA.  Most people believe that ACA will be effective January, 2014.  While this is true, for the vast majority of people,  when the law was enacted it directed the federal government to set up a Pre-existing Condition Insurance Plan.  In many ways it was the “first” roll-out of ACA.  Premium prices were determined based on age only.

This insurance plan saved my life.  Three years ago I was in the hospital, swollen from Lymphedema, experiencing considerable difficulty breathing, malnourished, unable to walk and under insured.  After admission, late that night, the staff put in a call to my son, telling him he should probably come to the hospital because they weren’t sure I would make it through the night.  That hospitalization and subsequent Nursing Home stay almost drove me into bankruptcy and that didn’t even include all the help I needed that I just didn’t get because it was so unaffordable.

I live today because, due to ACA, I have received the medical care I needed.  While I will never walk again, my quality of life has vastly improved and I have hope that I will live many more years. If I had had good insurance, would I have been able to walk again?  Probably, I don’t know, but I am simply grateful for the opportunity to watch my son grow up and be around for many years to come.

Spike Dolomite Ward of California has a story similar to mine.  She too benefited from the PCIP program.  She was diagnosed with late stage breast cancer during a period she was uninsured.  She was able to purchase Affordable Health Insurance through the PCIP program.  She credits PCIP with saving her life as it allowed her to get the treatment she needed.  Like me, she has also become an advocate of ACA, telling her story in an attempt to pay it forward.  You can learn more about her on her website http://www.spikespeaks.net.

This year when you gather around the Thanksgiving table with friends, family, or acquaintances, consider the stories you read here or one of the hundreds you will find at https://www.facebook.com/acasignupsuccessstories.  For every story here, there are thousands of other people who share a common hope and gratitude for Affordable Health Insurance.  Our stories may be different, our needs varied, but each of us represents one of the reasons health care reform is needed. We  hope you will join us and institute Project Gratitude at your Thanksgiving table this year. Tell your story about how your life will change due to affordable health insurance.  After Thanksgiving, take a few minutes drop by our Facebook page and share your experiences.  We look forward to hearing from you and wish you and your family a wonderful Thanksgiving.

By Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J Wills, Accountant and Business Software Support Consultant.

Barbara is an independent consultant in healthcare providing consulting for physicians.  She is an industrial engineer from RPI with an MBA from NYU. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services.

Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. She is currently a recipient of the Pre-Existing Condition Insurance Plan, which she was able to purchase following ACA being enacted.

Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.

Peter is an Accountant and Business Software Support Consultant. Prior to moving to America to marry he was an Accountant in public practice in Australia for most of his working life. For the last three years before moving here he worked as a Business Software Support Consultant for a business software developer in the housing, mining and engineering field. Peter is using his computer and business talents to assist Barbara and Lynne.

Please direct your questions and/or inquiries to askcobuzzi@gmail.com

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Summary: Cancellation of Health Insurance Policies – Undeniable Lies and Deliberate Misinformation Revealed and Obama Vindicated.

So many people, including news organizations, political groups and in fact anyone with a vested interest in maintaining the status quo as it existed before the ACA, have been blaming President Obama for “lying” about being able to keep their insurance plans , especially since the rash of cancellation letters forthcoming from the insurance companies. Well, guess what? We have evidence that completely proves Obama’s statements about being able to keep your health insurance if you wanted to were true!

The evidence comes directly from the ACA Law and the Federal Register, indisputable and irrefutable evidence that President Obama told the truth about the law. Under the provisions of the ACA people could keep any insurance policy in effect when the law was signed on March 23, 2010, including their “Junk” healthcare policies, by virtue of the “grandfathering in” provisions contained in the ACA. But the insurance companies decided on their own to bypass this option, cancel existing policies and try to sell more expensive plans instead, plans that would not provide subsidies and cost shares.

Read more and link to the proof directly from the ACA Law and the Government’s implementation. This fully sourced Blog will show you that no one had all the facts straight, no one! Continue reading in the “Let’s Talk Facts not Rhetoric” Blog at www.bit.ly/1b24GJH

Note: The material at the link is copyrighted, but can be shared with attribution. Please read and adhere to the Copyright notice at the end of the Blog.

ByBarbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J Wills, Accountant and Business Software Support Consultant.

About the Authors:

Barbara is an independent consultant in healthcare providing consulting for physicians.  She is an industrial engineer from RPI with an MBA from NYU. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services.

Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. She is currently a recipient of the Pre-Existing Condition Insurance Plan, which she was able to purchase following ACA being enacted.

Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.

Peter is an Accountant and Business Software Support Consultant. Prior to moving to America to marry he was an Accountant in public practice in Australia for most of his working life. For the last three years before moving here he worked as a Business Software Support Consultant for a business software developer in the housing, mining and engineering field. Peter is using his computer and business talents to assist Barbara and Lynne.

Please direct your questions and/or inquiries to askcobuzzi@gmail.com

Copyright:

© Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J. Wills, 2013. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J. Wills,  and The Place for Facts: Not Rhetoric with appropriate and specific direction to the original content. Permission for more comprehensive use may be obtained by contacting the authors at askcobuzzi@gmail.com

Cancellation of Health Insurance Policies – Undeniable Lies and Deliberate Misinformation Revealed and Obama Vindicated.

Implementation of the Affordable Care Act (ACA) has not been without its bumps in the road. Every day there appears to be a new crisis or a new aspect exposed that suggests the Affordable Care Act was not ready for implementation. Initially, these concerns seemed to center around problems and glitches associated with the roll-out of the online healthcare.gov website. Recently however, opponents, including various news organizations, politicians, and pundits expanded their drumbeat of attacks on the ACA, claiming that President Obama knowingly lied to the American people about being able to keep their current health insurance plan, “grandfathering them in,” rather than being forced against their “will” to choose a different plan, even if their plan does not meet the minimum standards of coverage required by the ACA law.

Sound bite after sound bite has been played with President Obama telling Americans they will not have to change their plans unless they choose to do so, resulting in the added benefit of being able to continue to see the same doctor (http://www.youtube.com/watch?v=wfl55GgHr5E.)  However, these statements have now been called into question.  Conservatives, as well as many media organizations, have jumped on the “bash President Obama and the Affordable Care Act” bandwagon expressing their outrage at the President’s alleged audacity at intentionally misleading or lying to the American public about protections afforded consumers through the ACA as it related to keeping their current health care plan.  Leading Republicans and Conservatives want the law scrapped or at the very least demand  implementation of the Affordable Care Act be delayed.   Recently, even some Democrats have expressed “their concern” about the promises President Obama made and indicate they are willing to consider extending the implementation of the ACA to ensure the problems are resolved.   Did President Obama consistently and continually lie to the American people?  Did he know that, in fact, the promises he made about people being able to keep their insurance plans, even if they were “crappy policies” or “junk policies” as the media has coined them, were allegedly false or at the very least, misleading? The evidence provided in this article will prove, beyond a shadow of a doubt, that President Obama spoke the absolute truth when he made those statements.

The Obama Administration and the authors of the Affordable Care Act recognized that people in general have a hard time with change, even if the result of the change will be positive for them (http://www4.uwm.edu/cuts/bench/change.htm). Even though health care reform will ultimately have positive consequences, a small percentage of the American people, encouraged by Conservative politicians and pundits appear to have resisted health care reform.  Resistance, in general, is often based on one or more of the following factors, including but not limited to when:

  • People do not fully understand why the change is needed.   Many Americans believe that we have the best health care in the world.  This statement is not necessarily supported by the facts.  Studies suggest that the United States is now ranked 37th in the World, according to the World Health Organization (http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/).
  • People feel as if they had no participation in making the change.  In other words, people don’t like being told what to do just because someone said to do it.  If an action is required that is preceded by “must, have to, or need to”, a person is less likely to complete the action than if they decide they “want” to change.  This has proven to be true in the roll-out of the ACA state and federal health care exchanges.  There are people who have been unable or unwilling to purchase adequate health insurance due to pre-existing conditions, financially out of reach premiums, lack of a belief that healthcare is a necessity, and/or lack of health insurance as an employee benefit.  So much disagreement about aspects of the law have played out in the media, around kitchen tables and in the midst of social gatherings as well as political functions that nothing has been done to “fix” or resolve problem areas since the law was enacted in March, 2010.  When a new law is enacted it is not unusual to have to resolve “glitches” or make process adjustments, as was the case when the Medicare Part D law took effect during the Bush Administration. It took both parties working together for the good of the American public to resolve the glitches and make other adjustments (http://crooksandliars.com/jon-perr/how-democrats-saved-bushs-medicare-drug-program).
  • Jobs, power, or financial pay-outs may be in jeopardy. Stake holders may attempt to undermine the change, or in this case health care reform, as appears to have been the case with healthcare insurance executives and/or stockholders, whose salaries and financial bonuses may be reduced due to ACA rules directing that on a schedule outlined by the federal government, at least 80% of premiums collected from enrollees, must be collectively used to provide healthcare services to the enrollees by 2014.  Prior to passage of the ACA, researchers determined that in many cases less than 60% of premiums were used on healthcare services for enrollees, with the rest being used for administrative costs, including but not limited to, what appears to have been excessive salaries and bonuses for upper management. (http://www.cms.gov/CCIIO/Resources/Files/Downloads/mlr-report-02-15-2013.pdf)

Based on the research associated with resistance to change, the authors of the ACA stated the following, in regard to the goal of the ACA:  “The Affordable Care Act balances the objective of preserving the ability of individuals to maintain their existing coverage with the goals of ensuring access to affordable essential coverage and improving the quality of coverage.”  (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34542)  “Section 1251 of the Affordable Care Act provides that “nothing in the ACA requires an individual to terminate the coverage in which the individual was enrolled on March 23, 2010.”  This contradicts the information provided to enrollees by letter from various insurance companies stating that due to the ACA, policies that did not offer the mandated services must be cancelled effective December 31, 2013.

This clearly proves that President Obama told the American people the truth, that the ACA gave people currently enrolled in a particular plan on or before March 23, 2010 the choice to change plans or continue with the same pre-ACA plan and, if it was grandfathered, then there would be no penalties imposed if a person kept their old plan.    The law also provides that, “with respect to group health plans or health insurance coverage in which an individual was enrolled on March 23, 2010, various requirements of the Act shall not apply to such plan or coverage, regardless of whether the individual renews such coverage after March 23, 2010.”  (Source:  Overview of the Regulations: Section 1251 of the Affordable Care Act, Preservation of Right To Maintain Existing Coverage (26 CFR 54.9815– 1251T, 29 CFR 2590.715–1251, and 45 CFR 147.140)  The Affordable Care Act specifically outlined how health care plans that were in effect prior to the ACA being signed into law on March 23, 2010 could be “grandfathered” and people who purchased these plans through their employment, as a part of the group or as an individual could choose to continue to be covered under their plan EVEN IF IT DID NOT MEET CERTAIN STANDARDS REGARDING ESSENTIAL BENEFITS SET FORTH BY THE ACA.

“Grandfathered” plans are defined by Bernadette Fernandez in the CRS Report R41166 as “those individual and group plans that an individual or family was enrolled in on the date of enactment (March 23, 2010).”  A “grandfathered” plan may “provide for the enrolling of new employees (and their families) in such plan after March 23, 2010 as long as the plan did not cease, and someone, although not necessarily the same person was continually enrolled in the plan.”  (CRS Report R41166, Grandfathered Health Plans under the Patient Protection and Affordable Care Act (ACA), Bernadette Fernandez)  Simply put a person that continues with a “grandfathered” policy, from before March 23, 2010, is not subject to fines and penalties even if they do not purchase a new conforming ACA health insurance policy as long as they remain enrolled in the “grandfathered” plan.  This points out again that President Obama told the American people the truth, that the ACA gave people currently enrolled in a particular plan on or before March 23, 2010 the choice to change plans or continue with the same pre-ACA plan and, if it was “grandfathered,”  then there would be no penalties imposed. 

The responsibility for gaining approval for a plan to be “grandfathered”  lies strictly with the health insurance company that sold the plan. The authors of the law, as well as proponents of the law just could not have conceived that insurance companies might intentionally cease providing these policies as a means to attempt to bypass the exchanges, dramatically increasing premiums while trying to sell different plans to their customers at a much higher rate.  In fact, insurance companies were given specific guidelines dictating what the insurance company had to tell consumers about the implementation of the ACA.

  • If a health insurance plan was “grandfathered”, was not “grandfathered” or ceased to be “grandfathered” at some point, the insurance company was to inform the enrollee of the status of the plan, whether it met minimum ACA guidelines, offer them a choice to continue on the plan or choose to shop for a plan through the appropriate federal or state health care exchange.
  • Insurance companies were also required to inform the consumer they might qualify for pre-tax incentives and/or cost-sharing subsidies if they purchase a plan through the exchange.
  • Finally, enrollees had to be told that if they chose to buy a plan outside of the exchanges they would not be eligible for incentives or cost-sharing subsidies.

In the three months after the ACA was signed into law, as is typical when a new law is enacted, rules and guidelines were developed, implemented and publicized through the Federal Register that outlined what health insurance plans were eligible to be “grandfathered”, even though they did not meet the 10 new essential benefits.  It also outlined what could cause a plan to cease being a grandfathered plan.  “Grandfathered”  plans according to “Section 1251 of the Affordable Care Act, as modified by section 10103 of the Affordable Care Act and section 2301 of the Reconciliation Act, specifies that certain plans or coverage existing as of the date of enactment (that is, grandfathered health plans) are only subject to certain provisions” of the ACA. (https://webapps.dol.gov/federalregister/PdfDisplay.aspx?DocId=23967, Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34539)  The language, although somewhat confusing, clearly outlines what health care plans are eligible to be “grandfathered” based on the law as well as the conditions that insurance plans must adhere to, in order for the plan to continue to be a “grandfathered” plan including but not limited to:

  • The policy had to be in force before the Affordable Care Act became law on 3/23/2010 (For the record these rules were posted June 17, 2010 so it should have been something insurance companies informed enrollees of soon after that date.) In part two of this investigative blog, which will be available by November 6, 2013 we will explore this very issue.  Why weren’t enrollees informed of the status of their plan more than 30 to 60 days before the state and federal health exchanges were opened?
  • No substantial financial change to the “grandfathered” plan can take place after the enactment of the ACA on 3/23/2010.
    • Financial substantial change is defined as “no significant increase in a percentage cost-sharing requirement such as co-insurance”.  The rules also outlined the definition of significant increase as “the maximum percentage increase is medical inflation (from March 23, 2010) plus 15 percentage points”.  Medical inflation is defined in these interim  final regulations “by reference to the overall medical care component of the Consumer Price Index for All Urban Consumers, unadjusted (CPI), published by the Department of Labor”. (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations  34543)\
    • “The employer contribution cannot decrease by five percent or more” in order to still be considered a “grandfathered” plan. (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34543)
    • Employers and/or insurance companies cannot significantly change the dollar value of all benefits”.  This could include co-insurance, deductibles, and maximum out of pocket yearly or lifetime maximums.  (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34543)
  • Substantial change to coverage cannot be made after the enactment of the ACA on 3/23/2010 including but not limited to what services, illnesses, or treatments are covered by the plan dated on or before March 2010.”  (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34543)
    • If the enrollee’s plan covered a certain condition such as asthma prior to March 23, 2010 when the ACA was enacted and the plan was “grandfathered”, changes that deleted asthma from coverage would result in a substantial change and the plan would cease to be a “grandfathered” plan.
    • Substantial change could reflect an addition of a covered condition or service as well as a deletion of a covered condition or service.

The Federal Register also outlined the conditions that would result in a previously “grandfathered” plan losing its designation as a “grandfathered” plan resulting in enrollees having to purchase a different health insurance plan that would meet the guidelines of the ACA. Some of the things which could result in a health insurance plan losing this designation includes but is not limited to:

  • “An increase in a percentage cost-sharing requirement” (such as coinsurance) causes a plan or health insurance coverage to cease to be a “grandfathered” health plan. (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34543)
  • “With respect to fixed- amount cost-sharing requirements other than copayments, a plan or health insurance coverage ceases to be a “grandfathered” health plan if there is an increase, since March 23, 2010, in a fixed-amount cost-sharing requirement that is greater than the maximum percentage increase. The maximum percentage increase is defined as medical inflation (from March 23, 2010) plus 15 percentage points. Medical inflation is defined in these interim final regulations by reference to the overall medical care component of the Consumer Price Index for All Urban Consumers, unadjusted (CPI), published by the Department of Labor.” (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34543)
  • If a company tries to decrease its employer contribution to the plan its eligibility to be “grandfathered” stops.  Specifically, the rules state that the employer contribution cannot decrease by five percent or more in order to still be considered a “grandfathered” plan. (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34543)
  • Insurance companies can’t change what services, illnesses, or treatments offered on a plan dated on or before March 23, 2010 or it is no longer a “grandfathered” policy. (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations).  For example, if the plan had a stated life time out of pocket maximum, employers and/or insurance companies can’t change the dollar value of all benefits or it ceases to be a “grandfathered” health plan.  (Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations)

As you are probably aware, some politicians, pundits and business owners have indicated they have “had to” cut back on the hours employees work due to the expense of the ACA and/or had to offer a much more expensive health care insurance plan to enrollees based on changes made to the law by the ACA.  This is simply not true. In fact, what the rules and regulations specifically state in the Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34545, is that companies CAN continue to offer a plan that existed prior to March 23, 2010 and let employees choose between what some members of the media and some politicians refer to as a “junk plan” or “plan I have always had” even if it doesn’t meet ACA guidelines.  This rule clearly proves that many pundits, politicians and insurance companies are flat out lying or at the very least are flat out uninformed about the ACA when calling President Obama a liar.

This evidence points out again that President Obama told the American people the truth, that the ACA gave people currently enrolled in a particular plan on or before March 23, 2010 the choice to change plans or continue with the same pre-ACA plan.  Perhaps these Conservative politicians and pundits, who have been so quick to call President Obama dishonest should have spent their time actually READING and STUDYING the law, as well as the guidelines and rules published in the Federal Register, before labeling President Obama as a liar.

While many people call healthcare reform “Obamacare” and/or ACA (Affordable Care Act) it is important to remember neither of these two are the correct name of the law.  It is actually the Patient Protection and Affordable Care Act or PPACA. (http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf)  The law was enacted to PROTECT the health care plan consumer/enrollee as well as ensure that every American has the opportunity to obtain adequate, affordable health care insurance.  Why was this necessary?  Over the past several decades it appears that the percentage of the US budget being used to provide health care has sharply increased. (http://www.usgovernmentspending.com/past_spending) Premiums have risen dramatically in the past decade.  The trend over the past several decades has seen employers asking employees to bear a bigger share of the health care provided. (http://www.ahrq.gov/legacy/research/empspria/empspria.htm)  Due to the high cost of health insurance, many people have begun to view it as a luxury, as opposed to a necessity.  PPACA/ACA establishes regulations to reign in the Health Insurance Providers from consistent and continual efforts to undermine current plans, stop the reduction of employer responsibilities in providing this benefit, and ensure the benefits provided are adequate and affordable to meet the needs of the average American worker.

It seems abundantly clear that each of the three factors described above which impact the average person’s reaction to change, along with the consistent and continual negative barrage by Conservative politicians and pundits appear to have impacted the American people’s embrace of the healthcare reform as well their understanding of the provisions and the consumer protections it offers.   The ACA was intentionally structured to provide many choices for the consumers of healthcare insurance.  As a result, Americans were assured they could continue with their current plan via the “grandfathered” rules, purchase a plan through the appropriate state or federal health care exchange that meets the standards outlined by the ACA, or purchase a plan by a private insurer that does not offer the potential for pre-tax subsidies and/or cost sharing.  This points out again that President Obama told the American people the truth, that the ACA gave people currently enrolled in a particular plan on or before March 23, 2010 the choice to change plans or continue with the same pre-ACA plan.

People are more tolerant of change when they are given opportunities to make their own choices about a new concept.  The authors of the PPACA law, anticipating some people’s reluctance to change health insurance plans even if it would provide them better care at a lower cost, made the decision to allow insurance companies and employers the opportunity to “grandfather” plans in place prior to the ACA being enacted on March 23, 2010. Unfortunately, it appears that intentionally or unintentionally HEALTH INSURANCE COMPANIES, negated this choice for many Americans by canceling plans that could have met the guidelines for “grandfathered” plans. Consumers across the United States indicate they have received letters, from their insurance company, indicating their health insurance plans have been cancelled effective December 31, 2013.    The letters from the insurance companies seem to have some common elements:

  • The enrollee is notified their plan is being cancelled effective December 31, 2013.
  • The reason the plan is being cancelled is that it does not meet the requirements of the ACA.
  • Enrollees are offered the opportunity to purchase a new plan, typically for a significantly higher premium which is identified and compared with their previous rate.
  • Enrollees are encouraged to purchase the new plan and “lock-in” the rates before they increase again.
  • Enrollees are NOT informed that they can choose to shop in the state or federal health care exchange for a plan which may include tax incentives and/or cost-sharing subsidies that may significantly decrease the cost of a health insurance plan, as well as copayments and deductibles via cost sharing.

People who have received the letters or heard about the letters appear outraged, shocked, and worried about how this will affect them. Was their worst nightmare coming true, as Republicans foreshadowed, that health insurance plan rates were going to sky-rocket and make health insurance even more unaffordable to a greater percentage of the population?  While it seems to be the consensus of most people who are very familiar with the canceled plans, that these plans could be labeled as “junk plans,” canceling  these health plans was entirely the decision of the insurance company since they had the option to continue offering them via the “grandfather” option under the ACA law. The insurance companies, not the requirements of the ACA law, decided that it was more profitable or less trouble to discontinue offering these policies and try to sell other, higher priced policies. The letters sent by insurance companies to enrollees informing them their plan was being cancelled, do not appear to meet these guidelines in most cases.

In fact, two insurance companies in Kentucky were investigated and fined for sending misleading instructions regarding the ACA and/or misinforming consumers about their ability to shop in the state exchange. (http://www.insurancejournal.com/topics/kentucky-humana-obamacare-letters/)(http://talkingpointsmemo.com/dc/insurance-companies-misleading-letters-obamacare)  In another case in California, a Stage 4 Cancer Survivor expresses her fear, concern and abject disappointment at the negative impact the Affordable Care Act will supposedly have on her quality of care.  She had been covered by a United Health Care (UHC) plan, but recently received a letter from them indicating her plan would no longer be available effective December 31, 2013.(http://thinkprogress.org/health/2013/11/04/2881581/wall-street-journal-horror-story-cancer-patient-losing-doctors-wrong/)  UHC went on to explain they were pulling out of the individual health care market and she would have to find a plan through the state exchange.  The exchange offered her one of two plans, but neither one allowed her keep the same provider’s she has used for her Cancer treatment. She stated, “Stanford has kept me alive—but UCSD has provided emergency and local treatment support during wretched periods of this disease, and it is where my primary-care doctors are.” (http://thinkprogress.org/health/2013/11/04/2881581/wall-street-journal-horror-story-cancer-patient-losing-doctors-wrong/)  Having to choose between the doctor who saved her life and directed her treatment and the facility where she received her care seems like a cruel choice at the very least. Igor Volsky, in his article published on the website Think Progress concludes the following about UHC. “The company packed its bags and dumped its beneficiaries because it wants its competitors to swallow the first wave of sicker enrollees only to re-enter the market later and profit from the healthy people who still haven’t signed up for coverage.” He supports his premise based on a statement made by UHC Chief Executive Officer Stephen Helmsley who according to Volsky, told investors last October. “UnitedHealth will watch and see how the exchanges evolve and expects the first enrollees will have ‘a pent-up appetite’ for medical care. The company’s plans reflect its concern that the first wave of newly insured customers under the law may be the costliest.” This is just a few of the horror stories told by people who thought they would be able to retain the insurance they have had for years, but instead in ALL the cases reviewed by the authors, regardless of whether they are described here, involved the health insurance company cancelling the plan as opposed to any dishonesty by President Obama and/or members of his Administration. This points out again that President Obama told the American people the truth, that the ACA gave people currently enrolled in a particular plan on or before March 23, 2010 the choice to change plans or continue with the same pre-ACA plan.

Some of the letters, sent by health insurance companies to enrollees in various health care plans, contained misleading or false information about the proposed cost of plans through the federal and/or state health care exchanges prior to any announcement of what the actual cost of the plans would ultimately be. (http://talkingpointsmemo.com/dc/insurance-companies-misleading-letters-obamacare ) One pointed example in Kentucky involved enrollees in a plan offered by a large health insurance company sent letters to their enrollees telling them their plan had been cancelled due to the ACA and that they would need to purchase another plan. In addition, many health insurance companies did not adequately notify an enrollee that if they chose to purchase another plan directly from the insurance company as opposed to through the federal or state health care exchange, that tax incentives and/or cost-sharing subsidies would not be available. Finally, it does not appear that enrollees were offered the opportunity by health insurance companies or their employers to remain covered under a plan that was initially purchased prior to March 23, 2010 as afforded by the law.   This points out again that President Obama told the American people the truth, that the ACA gave people currently enrolled in a particular plan on or before March 23, 2010 the choice to change plans or continue with the same pre-ACA plan.  What President Obama or his Administration could not control was whether the insurance company chose to offer the same plan.  It appears, based on preliminary evidence, that in most cases insurance companies did not choose to “grandfather” plans.

Certainly, Health Insurance Companies would not intentionally mislead the American people or would they? While it would be a terrible thing to do, it is a question that should be asked and investigated.  The American people are facing a different situation now, than what has occurred in the history of the United States previously when a bill was signed into law, like the Affordable Care Act was on March 23, 2010.  Examples abound throughout our history of strenuous, loud, and almost violent debates on proposed laws.  But, once the bill is voted on and becomes law, our nation’s history shows that people from both political parties have come together and abided by the law, worked together to enact the law and correct problems or confusion associated with the law and did not undermine the law when it goes into effect.

For example, although there were was great push back from the public with President George W. Bush’s Medicare Part D Prescription Drug Plan along with a difficult system roll out, the Democrats worked with the Republicans in educating their constituents, answering any questions holding town meetings and supporting the law once it had passed and was implemented. (http://crooksandliars.com/jon-perr/how-democrats-saved-bushs-medicare-drug-program)

Unfortunately, this has simply not been the case with the Affordable Care Act.  Even though the law was debated, changed, amended, and debated again and again prior to its passage, some members of Congress were determined, by their own admission, to do whatever it took to make this law fail, even after the law was enacted.  https://progressiveandproud.wordpress.com/2013/10/05/another-acaobamacare-myth-no-negotiation-between-democrats-and-republicans-on-acaobamacare/ )  Everyday, Conservative politicians and pundits seem to take to the airwaves and gleefully tell about supposedly “new” crises about aspects of the ACA.  Their refrain is the same each day, “We told you this was a bad idea.”  “We told you the law was not ready to be put in force”.  It reminds us of small children who when having a temper tantrum repeat over and over “told you so.”  However, based on the evidence presented here it is clear that President Obama told the American people the truth, that the ACA gave people currently enrolled in a particular plan on or before March 23, 2010 the choice to change plans or continue with the same pre-ACA plan. 

Clearly, the record shows that Conservatives have been somewhat successful in the pursuit of blaming President Obama for the problems with the roll-out of the ACA and up until today in calling him a liar about whether or not people could keep their same insurance plan, if they chose, even though it did not meet the minimum standards established by the law.  History will show, we think, that the determination of Conservatives such as Mitch McConnell, Rand Paul, Paul Ryan, John Boehner, Eric Cantor, Mike Lee and Ted Cruz just to name a few, to attempt to MAKE the Affordable Care Act fail was due almost entirely to the overwhelming desire on the part of these Conservatives to keep President Obama from having any legislative success or fulfilling any of the goals he set for his Administration.  This apparent rabid desire by Conservatives in opposing the Affordable Care Act is not good for the American people who will have paid an incredible price for this misplaced and misguided tenacity of opposition to the ACA.  They seem willing to let the American people go untreated, even die, and when receiving treatment, potentially go bankrupt all for the ability to be able to say that the current President did not succeed. They brought our country to the brink of financial disaster in an effort to try and stop the law from being enacted.  They appeared unconcerned about the $24 billion wasted in shutting down the government.  It does not seem that the American people are foremost in their minds, when the American people should be the only thing in their minds. They work for the American people.

President Obama has achieved what no other President before him was able to do even though many have tried, both Republicans and Democrats.  He led the pursuit for healthcare reform so that everyone in the United States would have the opportunity to have health insurance when and if needed. He stood in the gap for people like one of the authors of this blog, who developed an illness, and was unable to purchase adequate health insurance due to the presence of  pre-existing illness clauses which successfully precluded people from obtaining quality health insurance.  In 2011, based on the passage of the ACA, people like this author, were able to purchase affordable health insurance, prior to full implementation of the PPACA in 2014.  The author credits the ACA with saving her life.  Today, we, the authors, stand in the gap for President Obama, just as he did for one of the authors and many others, to report we have proven, beyond a shadow of a doubt, that President Obama told the American people the truth, that the ACA gave people currently enrolled in a particular plan on or before March 23, 2010 the choice to change plans or continue with the same pre-ACA plan. The choice WAS provided by the ACA, but the insurance companies decided that people should not have that choice. That is the bottom line.

Please Note:  This blog is based on the Federal Register that is issued regularly by the Federal Government and is used in the rule making process for every aspect of the government.  Preliminary, interim and final rules are published in the Federal Rules.  Since the Government provides stake holders the opportunity to provide comments during the rule making process, the comments are published as well along with rationales why those comments effected changes in the rules or did not.  The conclusions in this blog were solely based on information coming from the PPACA law and the implementation via the Federal Government rule making found in the Federal Register.  The interim rules that are applicable to the grandfathering of policies in effect prior to the signing for the PPACA can be found in the following Federal Register.  We relied on this Federal Register which defines the rules followed by the Federal Government for this content:

Federal Register section 1251 of the ACA (Source:  Overview of the Regulations: Section 1251 of the Affordable Care Act, Preservation of Right To Maintain Existing Coverage [26 CFR 54.9815– 1251T, 29 CFR 2590.715–1251, and 45 CFR 147.140] https://webapps.dol.gov/federalregister/PdfDisplay.aspx?DocId=23967 , Federal Register/ Vol. 75, No. 116 / Thursday, June 17, 2010 / Rules and Regulations 34539)

ByBarbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J Wills, Accountant and Business Software Support Consultant.

About the Authors:

Barbara is an independent consultant in healthcare providing consulting for physicians.  She is an industrial engineer from RPI with an MBA from NYU. She worked in the pharmaceutical industry for many years before moving into the healthcare industry where she had a company where she provided top quality coding, compliance and revenue cycle management services for physicians. She has since moved into full time consulting for physicians. Barbara is a nationally known expert known for her education, consulting and expert witness services.

Lynne has dedicated her career to helping others. She has experience as a social worker in a rural county, an administrator in a large hospital network and as a College Professor. She uses the skills she developed over the years as an advocate in a variety of areas including her most recent venture serving as a Healthcare Advocate. She is currently a recipient of the Pre-Existing Condition Insurance Plan, which she was able to purchase following ACA being enacted.

Together, Lynne and Barbara own the ACA Healthcare Advocates consulting firm and are available to individuals, families and businesses to help them meet the requirements of the Affordable Care Act in order to meet the specific needs of the client while optimizing the fiscal considerations.

Peter is an Accountant and Business Software Support Consultant. Prior to moving to America to marry he was an Accountant in public practice in Australia for most of his working life. For the last three years before moving here he worked as a Business Software Support Consultant for a business software developer in the housing, mining and engineering field. Peter is using his computer and business talents to assist Barbara and Lynne.

Please direct your questions and/or inquiries to askcobuzzi@gmail.com

Copyright:

© Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J. Wills, 2013. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CPCO, Lynne Smith, MSSW and Peter J. Wills,  and The Place for Facts: Not Rhetoric with appropriate and specific direction to the original content. Permission for more comprehensive use may be obtained by contacting the authors at askcobuzzi@gmail.com