Health Insurance

FactCheck, one of my "go-to"websites for checking on political myths and misleading information, recently published an article about deceptive political ads from a Karl Rove-connected group that attacks Democratic Senate candidates with faulty claims about the new health care law.

Crossroads GPS, a group with ties to Karl Rove sends viewers astray in a $2 million ad campaign attacking Democratic Senate candidates in Pennsylvania, California and Kentucky. The ads make badly misleading claims about the health care legislation that those Democrats supported.

Pennsylvania
An ad attacking Rep. Joe Sestak in Pennsylvania claims that "hard-hit families"will see $2,100 premium hikes. But that's not true for the large majority, who are likely to see somewhat lower premiums, according to the very source the ad cites. Any families that do see such large premium increases are likely to also get federal subsidies to help pay them, resulting in lower cost to most of them as well.

The ad also claims that "Sestak voted to gut Medicare."That's a wild exaggeration. It's true that the law calls for restraining the future growth of Medicare spending by about $555 billion -- about a 7 percent reduction spread over the next 10 years. And millions who now have private Medicare Advantageplans are likely to see their extra benefits reduced. But that hardly amounts to eviscerating the program.

California
An ad attacking California's Sen. Barbara Boxer claims that she voted to "cut spending on Medicare benefits"by $500 billion. But Boxer didn't vote for cuts in benefits. Rather, as we note above, the law puts restraints on the growth of future spending, mostly payments to hospitals and other providers. And that won't necessarily lead to cuts in benefits, except for Medicare Advantage plans.

Kentucky
A third ad, attacking Jack Conway in Kentucky, also makes misleading references to higher taxes, Medicare cuts and higher premiums.

FactCheck.org, a project of the Annenberg Public Policy Center of the University of Pennsylvania, is a nonpartisan, nonprofit "consumer advocate"for voters that aims to reduce the level of deception and confusion in U.S. politics.

Although expensive, COBRAcontinues to be an important safeguard for some people who lose their jobs. If your former employer has 20 or more employees, the company is required by a 1986 federal law to offer you the option to pay for an extension of your health insurance coverage for at least 18 months. This law is known as COBRA, which stands for Consolidated Omnibus Budget Reconciliation Act.

COBRA and the Affordable Care Act
The Affordable Care Actsigned into law in March 2010 addresses access to health insurance coverage and assures that all Americans who need coverage will be able to get health insurance. The legislation does not make any changes in COBRA. However, starting in 2014, you will be able to purchase insurance in health insurance exchangesin your state or region.

COBRA rules can be complicated, especially when applied to family members. I recently received the following question from one of my readers:

The Question
Several weeks ago, I was fired due to elimination of my regional sales management position. During this time, I was married but going through a divorce, which became final one week after I was laid off. I would like to know if my husband is still entitled to COBRA benefits since we were still married the day I was fired.

My Answer
I'm sorry to hear about your job elimination. Take a look at the following article from the U.S. Department of Labor:

In an editorial in the Boston Herald published online today, the newspaper's staff said, "The notion that if you like your health plan you can keep it under Obamacare has already been proven a lie. Just ask the 200,000 Massachusetts residents enrolled in Medicare Advantage who will be forced to switch, with the elimination of that popular program."

This statement is not correct - Medicare Advantage plans are not being eliminated!

Changes to Medicare Advantage
According to the U.S. Department of Health and Human Services:

From a Massachusetts Resident
I am a resident of Massachusetts and I am currently enrolled in a Medicare Advantage plan offered by Harvard Pilgrim, a not-for-profit health plan. This plan continues to offer me my guaranteed Medicare benefits as well as convenience and some additional benefits. It also is less costly than regular Medicare + a Part D plan + a Medicare supplemental plan. In fact, my wife goes on Medicare on October 1 and has also joined the same Advantage plan.

I would suggest that the Boston Herald editor make sure that his staff reads and understand the law!

I recently highlighted some articles I wrote about denial of health insurance claims based on medical necessity. Most health plans will not pay for healthcare services that they deem to be not medically necessary.

Medical necessityrefers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.

The Question
I recently went to the hospital with severe headaches and was diagnosed with a brain aneurysm. The doctor ordered two MRIs- one without contrast and one with contrast - to see if the aneurysm was bleeding. My health plan denied the claim because they said that it was not medically necessary and that the doctors at the hospital were practicing medicine by trial and error. What can I do?

My Answer
You have the right to appeal your health plan's decision. Check your benefits book, which should outline the process. Also, in most states, if you are not satisfied with the outcome of the appeal process, you can have an independent review and decision. It is important that your doctor help you with this situation by providing documentation of why the tests were ordered and why the doctor thinks they were medically necessary.

The Kaiser Family Foundation provides an outline of the external review processfor each state.

Don't Take No for an Answer!
If you feel that you are not being treated fairly or you disagree with your health plan's coverage decisions, don't be shy about appealing. You also have the right to complain to your state's health insurance department. Many states have an online complaint process or a toll-free complaint phone number.

State Healthcare Quality Snapshots - Where You Live Can Make a Difference!

The State Snapshotsprovide state-specific healthcare quality information. You can learn about your state's strengths, weaknesses, and opportunities for improving the health of state residents.

National Healthcare Quality Report
Information about your state is based on data collected by the U.S. Agency for Healthcare Research and Quality for the National Healthcare Quality Report. The report tracks the health care system in each state through quality measures, such as the percentage of people suffering a heart attack who received recommended care when they reached the hospital or the percentage of children who received recommended vaccinations.

Quality Measures
Your state's healthcare quality snapshot includes:

Overall healthcare quality
Types of care, including prevention services, and the care you receive for an acute or chronic health condition
Settings of care, the quality of care you receive in a hospital, ambulatory care facility (such as a clinic or doctor's office), nursing home, or from a home health agency
Five health conditions, including cancer, diabetes, heart disease, maternal and child health, and respiratory diseases

State Selection Map
Take a look to see how your state performs. The State Selection Mapallows you to choose your state to explore the quality of your state's health care against national rates or best performing States.

What do you think? Please leave a comment below or in the Health Insurance Forum.

To stay up to date on health insurance issues get Dr. Mike's Health Insurance Newsletter.

Last month I met with Kathleen Sebelius, Secretary of the Department of Health and Human Services. She is responsible for the implementation of many of the provisions of the Affordable Care Act. Because of time constraints the Secretary was not able to answer more than a few of the questions submitted by About.com readers. As a follow-up, the Secretary and her staff sent in replies to written questions. I will share a question and her answer on a weekly basis.

Question
I currently have a 3k dollar deductible - 6k for family. Along with a pay cut, this is forcing me to ration health care for my family. I had better coverage for less money 5-10 years ago. I could pay my $30 co-pay and never have to worry about bills. How would you respond?

Answer
The Affordable Care Act will help to shift power back to consumers, through new consumer protections, and new rules and resources to help prevent insurers from making unreasonable premium increases. Millions of dollars in grants will be made available this year to states to help create a health insurance consumer assistance office where consumers can learn how to enroll in a plan or file a complaint. There is also a new website, HealthCare.govthat helps consumers identify and compare health coverage options. Information is presented in a standardized, easy-to-understand format to ensure that individuals and families understand their options and purchase the right coverage for their needs.

The Administration is also encouraging states to monitor and review premium rate increases and insurance companies will be forced to publicly justify any unreasonable increases. Additionally, new standards for the amount an insurance company must pay out in benefits as opposed to profits and administrative expenses will go into effect in 2011. Insurance companies will be required to give money back to consumers if they do not meet those standards.

Beginning in 2014, American families will have more opportunities to purchase quality, affordable coverage through the new health insurance Exchanges. Plans sold in the Exchanges will have limits on out-of-pocket costs, and plans will need to cover recommended preventive services without any cost-sharing. In addition, many families will receive premium and cost-sharing tax credits to help cover the cost of insurance.

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Photo © Cristine Balderas/iStockphoto.com

Health care costs continue to grow along with the nation's waistline. According to the Centers for Disease Control and Prevention (CDC), approximately 72.5 million U.S. adults are obese - almost 27 percent of the adult population.

Although the number of people with obesity continues to rise all over the country, individual states vary significantly in the percentage of obese adults. In 2009, at least 30% of adults were obese in nine states - Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and West Virginia - compared with no states in 2000. At 34.4%, Mississippi had the highest obesity rate in the U.S. and Colorado at 18.6% had the lowest obesity rate.

According to the CDC study, State-Specific Obesity Prevalence Among Adults - United States, 2009, made public last week,no state met the Healthy People 2010 goal of a 15% obesity rate, suggesting that past and current efforts and investment of resources to address the problem have not been sufficient.

Obesity Is Common, Serious, and Costly
Obesity is a major risk factor that contributes to several leading causes of death, including heart disease, stroke, diabetes, and some types of cancer. Also, if you are obese you are more likely to die prematurely!

The CDC report also includes a medical cost analysis of the impact of obesity. According to the CDC, "Recent estimates of the annual medical costs of obesity are as high as $147 billion. On average, persons who are obese have medical costs that are $1,429 more than persons of normal weight."

Federal Government Initiatives
The federal government is intensifying efforts to address the problem through new initiatives such as:

Hopefully, these initiatives will have an impact on the obesity problem by mobilizing public and private resources and partnerships, providing guidance and funding to states and communities to change state and local policies related to diet and physical activity, and helping reduce financial barriers to screening (such as restricting out-of-pocket expenses for prevention services).

Question
I live in Texas and currently am in a very expensive state high-risk insurance pool because of a preexisting condition. I understand that our governor, Rick Perry, refuses to run the program for Texas residents. At one time I read that people will need to be uninsured for six months to be eligible. If that is so, can I cancel my current state high risk policy, remain uninsured for six months and then at that time buy into the federally administered program?

I, of course, do not want to be uninsured for six months, but the Texas high risk pool insurance is becoming increasingly unaffordable. What should I do?

Answer
Many Americans, especially Americans with pre-existing conditions, fall through the cracks in the current broken insurance market. Beginning this fall, all employer-based plans and new plans in the individual market will be prohibited from denying coverage to children with pre-existing conditions. Starting in 2014, insurers will be banned from discriminating against adults based on pre-existing conditions, and Americans will be able to shop for quality, affordable coverage through the new health insurance exchanges.

In order to provide immediate help for Americans who are uninsured and have a pre-existing condition, the new law creates the Pre-existing Condition Insurance Plan, a transitional program aimed at providing immediate help to Americans who are uninsured and have a pre-existing condition, while building a bridge to the larger reforms and exchanges in 2014.

As of July 1, on-line applications will be available in many states, including Texas, where the U.S. Department of Health and Human Services is running the Pre-Existing Condition Insurance Plan. Beginning on July 1, Americans who are uninsured and have a pre-existing condition are encouraged to log onto www.healthcare.gov to learn about the Pre-Existing Conditions Plan. For consumers in states where HHS is running the plan, you will be linked directly to our application page.

Applicants in most States should keep copies of denial letters from private insurance companies to prove that they tried to obtain insurance. Those applicants who don't have a denial letter should apply for insurance so that they can get one.

The U.S. Department of Health and Human Services (HHS) recently announced a major step in the process of partnering with states to begin creating health insurance Exchanges. HHS will provide up to $1 million in grants per state to help states begin work to create Exchanges.

Additionally, HHS is asking for public input as the government develops standards and regulations for the Exchanges.

Health Exchanges Scheduled for 2014
In a July 29 press release, HHS stated that, "Starting in 2014, health insurance Exchanges - new, competitive, consumer-centered health insurance marketplaces - will put greater control and greater choice in the hands of individuals and small businesses. The Exchanges will make purchasing health insurance easier by providing eligible consumers and businesses with "one-stop-shopping"where they can compare and purchase health insurance coverage."

"With most states struggling to keep their budgets in balance, these grants will give them the resources to conduct the research and planning needed to build the health insurance marketplace of the future,"said HHS Secretary Kathleen Sebelius. "We are working hand-in-hand with states as we carefully implement the Exchanges to make sure they best meet people's health insurance needs."

Each state has the option to establish and operate its own Exchange or partner with another state or states to operate a regional Exchange. If a state decides not to create an Exchange for its residents, HHS will help establish one on their behalf.

"Over the next decade, the Affordable Care Actis likely to stabilize and reverse the growing exposure to health care costs that women have experienced over the last decade, ensuring that women and their families can get the health care they need without the risk of incurring catastrophic medical bills."This statement concludes a report from the Commonwealth Fund - Realizing Health Reform's Potential: Women and the Affordable Care Act of 2010- published in July.

The report details the problems women have obtaining affordable health coverage and the lack of coverage for pregnancy-related costs in many policies. According to the report, "Women's higher health care costs mean that they are more likely than men to experience problems paying medical bills - their own and those of family members. And women, both insured and uninsured, are more likely than men to delay health care to avoid the associated costs."

The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.