2017 Renewal of Individual and Family Medical Plans

Insurance companies are mailing renewal information for individual and family policies, both benefit and premium changes. Some of the benefit changes are positive, some are not but most of these changes are dictated by The Affordable Care Act (ACA) commonly referred to as Obamacare. In most cases the premium increases are very substantial. I do not have complete rates for all the insurance companies as of yet.

Changes for 2017 cannot be made until November 1st for an effective date of January 1, 2017.

The individual health insurance market is shrinking. I will be setting phone appointments to begin on November to review plans. I strongly encourage that you to contact me. If you want to set a phone appointment with me, please respond to this e mail now and I will send you dates and times as options beginning in November.

Before your phone appointment, I will need to know the exact spelling of the names of doctors you want to continue to see, including their zip code. I will also need the exact spelling of any medications you need and the dosage.

If you believe you may be eligible for a subsidy through Covered California, I need to know your Estimated Modified Adjusted Gross Income for 2017. If you do not report a 2017 amount, I cannot complete a Covered California application as it will not be accepted into their system. I would encourage you to have a discussion with your tax professional. I need this information at the time of a phone appointment.

Some Grandfathered plans will be discontinued in 2017, we need to discuss replacement of those plans.

Anthem Blue Cross Individual and Family Plan 2017 Renewal

Anthem Blue Cross is mailing your renewal information, both benefit and premium changes. Some of the benefit changes are positive, some are not but most of these changes are dictated by The Affordable Care Act (ACA) commonly referred to as Obamacare. In most cases the premium increases are very substantial. I do not have complete rates for all the insurance companies as of yet but I am told the rate increases will be much the same.

Here is what needs to be done:

Changes for 2017 cannot be made until November 1st for an effective date of January 1, 2017. You have to wait until November 1st.

The individual health insurance market is shrinking. I will be setting phone appointments to begin on November 1st to review your plan. I strongly encourage you to contact me. If you want to set a  phone appointment with me, please respond to this e mail and I will send you several dates and times as options.

Before your phone appointment, I will need to know the exact spelling of the names of doctors you want to continue to see, including their zip code. I will also need the exact spelling of any medications you need and the dosage.

If you believe you may be eligible for a subsidy through Covered California, I need to know your Estimated Modified Adjusted Gross Income for 2017. The 2016 guide is attached for reference. The 2017 figures should be very close. If you do not report a 2017amount, I cannot complete a Covered California application as it will not be accepted into their system. I would encourage you to have a discussion with your tax professional. I need this information at the time of a phone appointment.

Grandfathered plans probably will not receive a benefit change or a rate increase. If your plan is grandfathered, feel free to set an appointment with me.

If you have questions, please send an e mail.

2017 Individual and Family Medical Plans Require a Primary Care Physician

Beginning January 1, 2017 all individual and family health plans in California will require that members select a Primary Care Physician (PCP) or have one recommended by their health plan.

The terminology used in this case is confusing. A PCP has historically been a physician who is associated with an HMO which limits your choice. This is not the case in this instance.

You must choose a general physician who is in the network of your insurance company. If you do not choose a physician the insurance company will assign one to you. I know that at least one company will review your claims history in order to assign a physician that you have seen in the past.



The thought behind this is that if one is attached to a name of a physician, it is less likely that one will go to Urgent Care or the Emergency Room. An office visit or a phone call supposedly will lower health care spending.

In Summary, choose a physician or have one chosen for you.

2017 Open Enrollment for Covered California Individual and Family Plans

Although no official date has been sent as of yet, this is what is expected from Covered California:

You will receive information from Covered California asking you to update information that will include but not limited to:


change in modified adjusted gross income- this requires a discussion with your tax professional

change of address

change in marital status

change in the number of dependents in your house hold

please respond to all Covered California requests

Changes might require a new application.

If there are no changes and your income listed on your Covered California application will remain the same for 2017, your policy will passively renew unless you decide to make a change, for example, enroll with a different insurance company.


This year there will be premium increases, changes in benefits which are influenced by Affordable Care Act rules and changes that have been made as a result of insurance company decisions.

Keep in mind that your 2016 subsidy has been based on the Modified Adjusted Gross Income that was listed on your Covered California application. Covered California will issue you an IRS form 1095 A to be filed with your 2016 tax return which will then be reconciled with your income. You may receive a tax credit or debit depending on your actual income.

Covered California has not determined when Open Enrollment will begin. In all likelihood it will be November 1st. As soon as I know the exact date I will send you an e mail. I will be setting up phone appointments to begin during Open Enrollment. If you would like to review your policy please let me know.

Remember, your 2016 subsidy is related to your 2016 Modified Adjusted Gross Income. Covered California will send you a 1095 A IRS form to be filed with your taxes. Your subsidy will be adjusted with your taxes depending on whether your income is more or less than what was reported on the enrollment application with Covered California.

Rate Increases for 2017 Medical Insurance Plans

There will be a significant rate increase for 2017 plans. The reasons given are the end of funding that was available in the first three years to offset rates, the rise in specialty medication and claims from those who enroll during Special Enrollment Periods.

In regard to the specialty medication, sometimes pharmaceutical companies are raising prices of medications when the need for a medication increases. Newer specialty medications can approach $100,000 per course of treatment and/or per year.

Below is the press release from Covered California on July 19, 2016

SACRAMENTO, Calif. — Covered California unveiled its rates for 2017 on Tuesday and announced that some health insurance plans will be expanding into new areas throughout the state to compete for consumers in California.

The statewide weighted average change will be 13.2 percent, up from approximately four percent in each of the last two years. However, most consumers will see a much smaller increase — or pay less next year — if they switch to another plan.

“Shopping is going to be more important this year than ever before,” Covered California Executive Director Peter V. Lee said. “Almost 80 percent of our consumers will either be able to pay less than they are paying now, or see their rates go up by no more than 5 percent, if they shop and buy the lowest-cost plan at their same benefit level. That’s the power of shopping.”

Lee said the opportunities to shop and save show that California has succeeded in building a competitive marketplace for health insurance, with rate increases that are still below trends in the individual market before the Affordable Care Act was passed.

“This is a new era of health care, where the consumer is in the driver’s seat with the power to look easily for a better deal, and where subsidies help absorb the impact of rate changes,” Lee said. “These options did not exist before the Affordable Care Act.”

Some consumers who choose to keep their plan will see a significant increase in their premium for 2017, while others will see a more modest increase, depending on where they live and what insurance plan they have. Consumers will begin receiving notices in October, when they will have an opportunity to review their new rates and change plans for their 2017 health coverage.

For many of those insured, the bulk of the premium increase will be absorbed by the subsidy paid by the government to help enrollees buy health insurance. Approximately 90 percent of Covered California enrollees get help to pay for their premiums. The average subsidy covers roughly 77 percent of the consumer’s monthly premium, and while premiums will rise, the subsidies will rise as well.

“Even though the average rate increase is larger this year than the last two years, the three-year average increase is 7 percent — substantially better than rate trends before the Affordable Care Act was enacted,” Lee said.

Lee said the average rate increase reflects the cost of medical care for consumers, not excessive profit.

“Under the new rules of the Affordable Care Act, insurers face strict limits on the amount of profit they can make selling health insurance,” Lee said. “So, while all plans are experiencing different cost pressures, we can be confident their rate increases are directly linked to health care costs, not administration or profit, which averaged 1.5 percent across our contracted plans.”

For consumers who get a tax credit to lower their costs — which is about 90 percent of those who sign up through Covered California — the amount they pay is impacted not only by the premium choice, but by changes in their tax credit. While the average rate increase is higher than past years, Covered California’s risk mix — the ratio of consumers who are healthy vs. sick — remains one of the best in the nation according to the Centers for Medicare and Medicaid Services (https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/index.html).

Other reasons for rate increases include:
A one-year adjustment due to the end of a funding mechanism in the Affordable Care Act known as reinsurance, which was designed to moderate rate increases during the first three years when exchanges were being established. The American Academy of Actuaries estimates this will add between 4 percent and 7 percent to premiums for 2017.
Special enrollment by some consumers who may be enrolling in health insurance only after they become sick or need care, which seems to have had a significant impact on rates for two insurance plans.
The rising cost of health care, especially specialty drugs.
Pent-up demand for health care now being accessed by those who were locked out of the health care system before the Affordable Care Act was enacted.
Lee said Covered California is working to address some of these issues on multiple fronts. The exchange is aggressively marketing to attract healthy consumers year-round, and it is working to ensure special enrollment is available only to those who meet qualifying circumstances. It is also sampling the special enrollment population to better understand how to make any further improvements needed.

“We work hard to build a robust exchange that drives competition by attracting as many consumers as possible,” Lee said. “Now, consistent with the vision of the Affordable Care Act, we will redouble our efforts to make sure our consumers and potential consumers understand the importance of signing up during open enrollment and remaining covered throughout the year.”

Lee said Covered California’s 11 health insurers are competing across the state for its 1.4 million members.

“The sheer number of enrollees and their overall health means consumers in the individual market are benefiting from competition,” Lee said.

Below is the complete list of the companies selected for the 2017 exchange:
Anthem Blue Cross of California
Blue Shield of California
Chinese Community Health Plan
Health Net
Kaiser Permanente
L.A. Care Health Plan
Molina Healthcare
Oscar Health Plan of California
Sharp Health Plan
Valley Health Plan
Western Health Advantage
Rate details by pricing regions can be found in “Covered California’s Health Insurance Companies and Plan Rates for 2017,” posted online at:http://coveredca.com/news/pdfs/CoveredCA-2017-rate-booklet.pdf

The preliminary rates are subject to a 60-day public comment period and regulatory review by the California Department of Managed Health Care. In addition, the California Department of Insurance will review Health Net’s EPO.

Some insurance carriers will be increasing their coverage areas in 2017:
Oscar will be entering the market in San Francisco, Santa Clara and San Mateo counties.
Molina will expand into Orange County.
Kaiser will be available in Santa Cruz County.
With the expansion of its current carriers, almost all consumers (92.6 percent) will be able to choose from three or more carriers, and all will have at least two to select from.

In addition, more than 93 percent of hospitals in California will be available through at least one Covered California health insurance company in 2017, and 74 percent will be available in three or more plans.

Covered California also is improving its patient-centered benefit designs by increasing a consumer’s access to care by reducing the number of services that are subject to a consumer’s deductible.

Starting in 2017, consumers in Silver 70 plans will save as much as $55 on an urgent care visit and $10 on a primary care visit. In addition, consumers in Silver, Gold and Platinum plans will pay a flat copay for emergency room visits without having to satisfy a deductible, which could save them thousands of dollars.

These improvements build on features already in place that ensure most outpatient services in Silver, Gold and Platinum plans are not subject to a deductible, including primary care visits, specialist visits, lab tests, X-rays and imaging. In addition, some Enhanced Silver plans have little or no deductible and very low copays, such as $3 for an office visit. Even consumers in Covered California’s most affordable Bronze plans are allowed to see their doctor or a specialist three times before the visits are subject to the deductible.

In addition, the contract with health insurers for 2017 ensures consumers select or are provisionally assigned a primary care physician within 60 days of effectuation so they have an established source of care.

“Health care reform isn’t just about making insurance affordable, it’s about doing things to make it easier for consumers to get the right care at the right time,” Lee said.

In May, the Centers for Disease Control and Prevention announced that California’s uninsured rate had fallen to 8.1 percent at the end of 2015, down from 17 percent at the end of 2013, right before the Affordable Care Act began offering coverage.

“We can all be very proud of the extraordinary gains we have made in reducing California’s uninsured rate to a historic low,” Lee said.

About Covered California
Covered California is the state’s marketplace for the federal Patient Protection and Affordable Care Act. Covered California, in partnership with the California Department of Health Care Services, helps individuals determine whether they are eligible for premium assistance that is available on a sliding-scale basis to reduce insurance costs or whether they are eligible for low-cost or no-cost Medi-Cal. Consumers can then compare health insurance plans and choose the plan that works best for their health needs and budget. Small businesses can purchase competitively priced health insurance plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits.

Covered California is an independent part of the state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the Governor and the Legislature. For more information about Covered California, please visit www.CoveredCA.com.

This article is from the Los Angeles Times date July 20, 2016

California Obamacare rates to jump

Premiums are set to go up an average of 13.2% next year. Rising medical costs are one reason, officials say.


Premiums for Californians’ Obamacare health coverage will rise an average of 13.2% next year — more than three times the increase of the last two years and a jump that is bound to stir debate in an election year.

The big increases come after two years in which California officials had boasted that the program helped insure hundreds of thousands people in the state while keeping costs moderately in check.

Premiums in the insurance program called Covered California rose just 4% in 2016 after rising 4.2% in 2015 — the first year that exchange officials negotiated with insurers. The program insures 1.4 million Californians.

On Tuesday, officials blamed next year’s premium hikes in the program on rising costs of medical care, including expensive specialty drugs and the end of a mechanism that held down rates for the first three years of Obamacare.

Two of the state’s biggest insurers — Blue Shield of California and Anthem Inc. — asked for the biggest hikes. Blue Shield’s premiums will jump an average of more than 19%, according to officials, and Anthem’s rates will rise more than 16%.

For consumers, the effect will depend on whether they get taxpayer-supported subsidies for their premiums and whether they are willing to switch to less-expensive plans that may come with higher co-pays and deductibles. Changing plans could also mean a new network of physicians, which could be disruptive to care for those with chronic conditions.

The rates vary significantly by region and insurer. Los Angeles and the rest of southwest Los Angeles County will see an average increase of almost 14%.

Blue Shield’s preferred provider organization rate in Los Angeles, chosen by 21% of those using the exchange, is increasing by an average of 19.5%. For a 40-year-old single person making $17,820 to $23,760, choosing a silver level plan, the monthly rate currently is $122, while the government pays Blue Shield $196. Next year that same person would pay $170, while the government would chip in $211 a month.

“We’re paying more for less,” said Jamie Court, president of Consumer Watchdog in Santa Monica. “Insurers are limiting access to doctors and hospitals while also demanding a higher price.”

Horacio Chavez, 34, of Boyle Heights said he made less than $25,000 last year as an education coordinator at a youth center. He currently pays a $100 premium for a Covered California plan that he uses for an annual checkup and a safety net in case of emergencies.

“I do want healthcare — I want the peace of mind that if anything happens to me that there’s some kind of coverage,” Chavez said. But “a 13% hike … that’s going to affect people.”

He said he’s already barely making ends meet trying to pay his rent, student loans from the University of Chicago, car payments and his health insurance premium.

“I’m already living check to check,” Chavez said.

Covered California officials defended the system Tuesday, saying that the competition among insurers offering coverage on the exchange was working to keep rates lower than they otherwise would be.

“California has a very competitive marketplace,” said Peter Lee, executive director of Covered California.

Obamacare has significantly reduced the number of uninsured Californians. Since the state’s health insurance exchange began offering coverage in 2014, the share of Californians without health insurance has fallen from 17% at the end of 2013 to 8.1% at the end of last year, according to officials.

Rates are expected to jump in other states too, although complete details won’t be available until later this year.

An analysis of 14 metro areas that have already announced their 2017 premiums found an average jump of 11%. The changes ranged from a decrease of 14% in Providence, R.I., to an increase of 26% in Portland, Ore., according to the analysis by the nonpartisan Kaiser Family Foundation.

The federal healthcare-  .gov   exchange provides insurance under the Affordable Care Act in 38 states. California and a few other states operate their own exchanges.

Around the country, several insurers, including giant UnitedHealth, have stopped selling health plans on the exchanges, and a number of new nonprofit health insurance co-ops have gone out of business.

Those decisions have fueled charges from the law’s critics that Obamacare isn’t working.

Former Secretary of State Hillary Clinton, the presumptive Democratic presidential nominee, is pushing a number of specific steps to ease price pressure on consumers, including allowing Americans ages 55 to 64 to buy into Medicare.

Republican presidential nominee Donald Trump has argued the health law should be repealed.

The health law’s next enrollment period begins a week before election day.

The state and federal health insurance exchanges provide coverage to about 12 million people nationally, representing just a fraction of the nation’s total insurance market. The vast majority of Americans — more than 250 million people — are in health plans purchased through an employer or provided by a government plan such as Medicare or Medicaid.

But the exchanges are a pillar of the Affordable Care Act’s program for guaranteeing Americans’ insurance coverage. And monthly premiums have become a closely watched barometer of how the law is performing.

Covered California’s Lee told the House Ways and Means Committee on July 12 that 2017 would be “a transitional year” for Obamacare, with rates seeing “significant adjustments” across the nation.

He said one reason for the increase was the end of a program designed to keep rates down during the insurance exchange’s first three years. The program had assessed a fee on all health insurers and then redistributed those funds among carriers whose members had the highest medical expenses, Lee said.

Lee added that some insurers had also not charged enough in the first two years because they didn’t have full data on the medical costs or health status of those signing up. Now they’re adjusting to account for those higher costs.

Mia Campitelli, a Blue Shield spokeswoman, said Tuesday that the insurer’s average 19.9% premium increase was “driven by our members using more healthcare services than we expected,” as well as the phaseout of the federal mechanism that had kept rates down in the law’s early years.

Anthem spokesman Darrel Ng said: “Factors such as increased use of medical services and added costs of drugs and medical therapies put upward pressure on rates and underscore the additional work that needs to be done to moderate the growth in healthcare costs.”

The financial pain for most Californians getting insurance through the exchange will be muted because 90% get taxpayer assistance to cover the premiums.

Americans making less than four times the federal poverty level — about $47,000 for a single adult or $97,000 for a family of four — qualify for the assistance.

Nonetheless, Americans who make too much to qualify for subsidies are likely to feel the brunt of the higher premiums. That will probably increase pressure on the new president — Democrat or Republican — to review the exchanges in 2017 for ways to make health plans more affordable.

A year ago, Lee wrote an op-ed in The Times saying that Covered California’s power in negotiating with insurers was allowing Obamacare to work in the state.

“We now have the full picture in California, where we are proving that health insurance exchanges can keep prices in check,” he wrote.

Though the Affordable Care Act has improved care for millions of Americans — for example, insurance companies can no longer set lifetime limits on care or exclude anyone because of a preexisting condition — the 6-year-old law contains few controls on overall costs.

Spending on the country’s medical system averages more than $10,000 for every American, according to statistics released by the Obama administration this month, far higher than any other nation. melody.petersen

@ latimes.com   noam.levey@latimes.com   Times staff writer Soumya Karlamangla contributed to this report.


“CALIFORNIA has a very competitive marketplace,” said Peter Lee, executive director of Covered California. Above, Lee discusses the program last year.

Regulator OKs healthcare deal

Below is an article from the Associated Press which appears in the Business Briefing Section of the Los Angeles Times dated June 21, 2016.  It discusses the acquisition of Humana by Aetna.

I believe that this limits consumer choice and will be harmful in the long run.


A California regulator is approving Aetna Inc.’s proposed acquisition of rival health insurer Humana Inc.

Shelley Rouillard, director of the California Department of Managed Health Care, announced her decision Monday.

As a condition of the approval, Aetna agreed to limit premium increases in the small group market and to allow greater state oversight of its rates. The company will also have to keep certain decision-making functions in California and must invest in various health initiatives.

The proposed $35-billion cash-and-stock deal would make Hartford, Conn.-based Aetna a sizable player in the rapidly growing Medicare Advantage business, which offers privately run versions of the federally funded healthcare program for the elderly and some people with disabilities.

The merger still requires approval by the U.S. Department of Justice.

Aetna shares rose $1.24, or 1%, to close at $122.34 on Monday. Shares of Louisville, Ky.-based Humana climbed $2.75, or 1.5%, to $189.90.

Blue Shield Will Cancel All Grandfathered Plans On January 1, 2017

Your Blue Shield of California Grandfathered Individual and Family Medical Insurance Plan will no longer be available after December 31, 2016. You will be automatically enrolled in what Blue Shield considers to be an Affordable Care Act (aka Obamacare) plan that is similar to your current plan.

Starting January 1, 2017 you will qualify for a Special Enrollment Period which will allow you to switch to another company with an effective date of no later than March 1, 2017. Using the Special Enrollment Period may not necessarily be in your best interest, for example, if you use part of a Blue Shield deductible between January 1, 2017 and March 1, 2017, this amount may not carry over to another company. A similar situation may exist with the Maximum Out of Pocket limit.

We should discuss your plan change within Blue Shield or to another company during Open Enrollment which begins on November 1, 2016 for an effective date of January 1, 2017. I will be sending an e mail in the middle of October to set up phone appointments to discuss all your options.

Blue Shield will be notifying you beginning this month.



Kaiser Medical School to be in Pasadena

Kaiser’s medical school will add focus to more practical areas of medical care.

here is an article from the Los Angeles Times date, March 11, 2016
Site is near freeways, public transportation, affordable housing, medical provider says.
Kaiser Permanente is moving forward with its ambitious plan to open a medical school that’s more in tune with new technologies and local communities.
The Oakland-based healthcare provider said Thursday its institution will be located in Pasadena. And it talked about how it will try to attract a more diverse student body.
Kaiser said it chose central Pasadena because the site is close to major freeways, public transportation options and affordable housing. Kaiser is also well-established in the surrounding area, with 14 hospitals in Southern California and medical office complexes in Pasadena and Glendale. The school will also be within several miles of facilities where students will be trained.
“We have major medical facilities and resources in that particular marketplace, so we feel really great about the extension of Kaiser Permanente beyond the four walls of that medical school,” said Kaiser Chairman and Chief Executive Bernard Tyson.
Pasadena’s diverse community was another driving factor, as Tyson said it was “essential” to the model of medical education Kaiser wants to establish. Kaiser officials have said it wants to recruit more minority students and teach doctors how to care for an increasingly diverse patient population.
There are no set plans yet for recruitment, but Kaiser is considering offering scholarships or tuition forgiveness to students who can help them “reach the communities that we wish to reach,” said Dr. Edward Ellison, executive medical director of the Southern California Permanente Medical Group.
“When you look at what’s happening in the country today, healthcare has never gone through as much change as it has today,” he said. “We believe that the way in which we deliver care has a lot of applicability for solving challenges of the future.”
Kaiser first announced plans in December to open a medical school.
The campus size in Pasadena, as well as the tuition, has yet to be determined.
The school will be built on land that Kaiser already owns. The property, located at 94 S. Los Robles Ave., currently houses an unoccupied building, which will be torn down and replaced with a larger building, Kaiser spokesman Marc Brown said. A Kaiser office building and the Kaiser Permanente Department of Research and Evaluation are on the same lot and will remain there, he said.
That part of Pasadena is already being revitalized, said Mayor Terry Tornek. A new residential building and hotel are set for construction nearby and other parts of the city are also seeing new developments.
“It’s a big deal,” he said of the medical school. “You bring in these students, you bring in their instructors, you bring in their support staff…. It has a multiplier effect.”
Kevin Trieu, owner of Beany’s Cafe, located a block away from the Kaiser school site, said he thought the institution could increase the foot traffic around his restaurant.
“Any time you get more people within walking distance to us, then that’s going to generate business for us, especially since we don’t have our own parking lot,” he said. “The fact they’re so close, I think it’s going to be wonderful.”
Groundbreaking for Kaiser’s medical school is planned for next year, and the first class of about 40 to 50 students is expected in 2019. In time, Tyson said he hoped the class size would increase to 200 to 300.
He said the plan for the medical school was an evolution of what Kaiser was already doing. The organization has more than 600 physicians in residency programs at its facilities and thousands of others do some training at Kaiser.
Kaiser has said that its approach to medical education will differ from that of many established medical schools. The curriculum and teaching methods will more closely align to the company’s commitment to quickly adopting new technology and adhering to the latest medical evidence in patient care. Kaiser has been a leader nationally at adopting electronic medical records and offering doctor visits online.
It also plans to integrate hands-on learning early on so that “what you’re learning, you’re going to immediately apply,” Ellison said.
For example, Kaiser plans to train students as emergency medical technicians when they arrive at the school to give them a practical grounding in healthcare. Students will also go into the community, visiting patients’ homes and learning how to better implement health behavioral changes, Ellison said.
“Not all innovation is about shiny new technology,” he said.
Analysts have said that a medical school teaching Kaiser’s method of healthcare might not appeal to all students. Critics have also worried that a Kaiser medical school would focus on cutting costs that could negatively affect patient care, since some patients have said Kaiser’s system limited their care.
Kaiser operates 38 hospitals nationwide, owns hundreds of clinics and has almost 18,000 salaried doctors at its affiliated medical groups. Nearly 80% of its 10.2 million members are in California, though the healthcare provider operates in eight states and the District of Columbia.
With the location settled, Ellison said Kaiser is now working to create a curriculum, forming a search committee for the school’s first dean and going through the accreditation process. samantha.masunaga
@ latimes.com
Twitter: @smasunaga

Eliminating Confusing Health Plans

It has been my experience as an insurance broker that some insurance companies have far too many plan designs which are very confusing for the consumer. Hopefully changes will be adopted to make the process of choosing a plan more consumer friendly.
Below is a partial excerpt from Covered California’s Daily News, dated March 9, 2016 which discusses the issue.
New Analysis Urges Shift to Patient-Centered Benefit Designs to Cut Costs and Help Consumers Get Care
Posted: 09 Mar 2016 02:52 PM PST
Lessons Learned in California Can Help Avert a Collision Between Conflicting Reform Initiatives

SACRAMENTO, Calif. — A new analysis urges state-based marketplaces, the employer-sponsored insurance market and health insurance plans to take action and move toward plan benefit designs that put consumers first, and remove existing barriers to getting needed health care.
In an article written in the New England Journal of Medicine by Dr. Elliott Fisher, Director of The Dartmouth Institute for Health Policy and Clinical Practice, and Covered California Executive Director Peter V. Lee, both stress the importance of patient-centered benefit designs to reach the next level of health care reform.

“Health plans, states and employers should take to heart the lesson that offering a lot of different designs does not serve consumers well,” Fisher said. “Too many health plans, in exchanges and the employer sector, offer confusing benefit designs with out-of-pocket costs that prevent people from seeing their doctor.”

Lee said Covered California has a model that has worked for its consumers since the agency opened its doors in 2014.

“Covered California has led the way in the fight for consumers by shaping benefit designs that help consumers make apples-to-apples comparisons and to get the health care they need,” Lee said. “A good patient-centered benefit design is critical to making sure consumers get the right care at the right time.”

Fisher and Lee noted that the current health care system seeks to improve care and cut costs through provider-focused and consumer-focused reform initiatives that directly conflict with one another.
For example, provider-focused initiatives encourage physicians, hospitals and other providers to coordinate and improve care to lower costs. However, the consumer-focused approach discourages people from seeing their provider because of increased cost-sharing.

Studies show the proportion of Americans with employer-sponsored coverage involving deductibles of more than $1,000 has increased from 10 percent to 46 percent since 2006, with many plans requiring people to fully meet their deductible before receiving any coverage for primary care. A 2015 National Bureau of Economic Research study showed the adoption of a high-deductible health plan in a relatively high-income population led to a 10 percent reduction in the use of preventative services and an 18 percent drop in physician visits, with the greatest reductions occurring in the sickest patients.

“We want consumers to be able to see their doctor when necessary, so their health care needs can be met in the most effective and efficient way possible,” Fisher said.

The authors cite California’s approach as an example of how it might be possible to avoid this collision between provider- and consumer-focused efforts. Covered California, the state’s insurance exchange, requires plans to adopt patient-centered benefit designs that allow consumers at every metal tier (cost-sharing split between insurer and enrollee) to visit their primary care physician without the cost being subject to a deductible. “When a consumer is able to get the right care at the right time, it cuts down health care costs for everyone,” Lee said.

The Centers for Medicare and Medicaid Services recently announced it would allow health insurance companies to offer patient-centered benefit designs on the federal exchange.
“This is a good step for consumers,” Lee said. “However, more needs to be done if we are going to reach the next level in health care reform.”

The article, “Toward Lower Costs and Better Care – Averting a Collision between Consumer- and Provider-Focused Reforms,” is available atwww.nejm.org/doi/full/10.1056/NEJMp1514921.

About The Dartmouth Institute
Since 1988, The Dartmouth Institute for Health Policy and Clinical Practice has been working to find solutions to some of the most challenging problems in health care delivery. Our goal is to help create an affordable, high-performing health system for everyone.

About Covered California
Covered California is the state’s marketplace for the federal Patient Protection and Affordable Care Act. Covered California, in partnership with the California Department of Health Care Services, was charged with creating a new health insurance marketplace in which individuals and small businesses can get access to affordable health insurance plans. Covered California helps individuals determine whether they are eligible for premium assistance that is available on a sliding-scale basis to reduce insurance costs or whether they are eligible for low-cost or no-cost Medi-Cal. Consumers can then compare health insurance plans and choose the plan that works best for their health needs and budget. Small businesses can purchase competitively priced health insurance plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits.

Covered California is an independent part of the state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the governor and the Legislature.


Will a drop in C-Sections decrease insurance rates?

I have personally know someone whose C-Section was performed for the convenience of the doctor.

Below is an article from the Los Angeles Times dated March 8, 2016.

Low-risk surgeries in state hospitals fell from 27.3% in 2013 to 26.1% in 2014 amid pressure to cut costs.
At hospitals across California, administrators are pushing doctors to perform fewer caesarean deliveries, hiring birth coaches and asking pregnant women to stay in labor longer.
For years, medical experts have said that C-sections were being done too often, yet the rates kept climbing.
In 2014, however, delivery hospitals in California reduced the number of C-sections performed by more than 1,000 compared with 2013, according to a Times analysis of new data.
What’s changed recently, some experts say, is the nature of the healthcare system, which focuses increasingly on eliminating unnecessary expenses.
In the era of the Affordable Care Act and its emphasis on low-cost medical care, C-sections — which cost more than vaginal deliveries — have become a sticking point for hospitals and a target for the people paying the bills.
Childbirth is the most common reason for hospitalization in the U.S., said Katy Kozhimannil, a health policy professor at the University of Minnesota, so when insurers and self-insured employers “look at where their costs are going, you start to see caesarean delivery rises to the top.”
Hospitals not only face direct pressure from insurers to curb C-sections, but they’re also concerned that a high rate could affect business. As more data on medical facilities is available to patients, hospitals don’t want to fall to the bottom of the pack and lose patients who see higher C-section rates as unfavorable.
Dr. Allyson Brooks, an obstetrician and chief quality officer at Hoag Memorial Hospital Presbyterian in Newport Beach, remembers that a few years ago the hospital was under fire from its insurer because of a higher-than-average C-section rate.
In California, maternal care plus a vaginal delivery cost commercial insurers $15,259 on average, while maternal care plus a C-section cost $21,307, according to a report commissioned by the Center for Healthcare Quality and Payment Reform, a nonpartisan research center.
Over the last two decades, many U.S. doctors began opting for C-sections in part out of convenience, because the procedure is often much quicker than waiting for a woman to deliver vaginally, experts say.
Some patients chose to have C-sections — a trend made famous by celebrities in the 2000s and labeled “too posh to push.”
Though generally safe, C-sections are still invasive surgeries, with a longer recovery time than vaginal deliveries.
And once a woman has one C-section, she has a 90% chance of delivering her next babies by C-section.
The World Health Organization says the ideal C-section rate is around 15%, but in the U.S. it reached 32.9% in 2009.
The rates were influenced by factors such as the culture of a hospital and type of community it serves. Three years ago, Brooks recalled seeing posts on social media by Orange County residents such as, “If you want to have a vaginal delivery go to a different hospital, if you want to have a C-section go to Hoag.”
Brooks said that though most obstetricians agree C-section rates are too high, it can be difficult to get them to consider doing fewer.
They worry that trying to bring down rates will harm women. C-sections can be necessary if the umbilical cord is dangerously tied around a baby’s neck or a woman’s uterus is at risk of rupturing.
So she began calculating a low-risk, or NTSV, C-section rate for her hospital. It includes only women considered the least likely to need C-sections — first-time mothers, having a single baby around their due date, and carrying a baby positioned head down.
The U.S. surgeon general has called for reducing the low-risk C-section rate to 23.9% by 2020.
Hoag began requiring that doctors show clear medical reasons to induce labor in women, and also started calculating and sharing each doctor’s low-risk C-section rate.
At Hoag, the low-risk C-section rate dropped from 31% in 2013 to 26% in 2014, one of the biggest declines in the state.
And it wasn’t just Hoag. From 2013 to 2014, the rate of C-sections among low-risk moms in California dropped from 27.3% to 26.1%, a reduction of 1,219 procedures statewide, according to data released last month by the California Hospital Assessment and Reporting Task Force and analyzed by The Times.
The analysis also found that the percentage of California’s 244 delivery hospitals that met the surgeon general’s goal jumped from 32% to 42% between the two years.
Hoag negotiated with its insurer to be paid an equal rate for C-sections and vaginal deliveries so it wouldn’t lose money when rates dropped.
But other hospitals that have reduced their C-sections rates have faced financial consequences.
The six Providence Health & Services hospitals in Southern California took a revenue hit from doing fewer C-sections, said Regional Chief Medical Officer Michael Bernstein. They also spent money to hire obstetricians to staff the labor and delivery wards in shifts, so doctors wouldn’t feel rushed and opt for C-sections because they’re quicker procedures.
Bernstein said he thinks the change is better for patients and could be good for the hospital group in the long run.
Increasingly, under changes set into place by the Affordable Care Act, hospitals aren’t paid per treatment, but based on the quality of the care. Hospital leaders say C-section rates could become one of the metrics used in such calculations.
But Dr. Aaron Caughey, chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University School of Medicine, said there’s no single low-risk C-section rate that all hospitals should aim for, and that rates will vary from hospital to hospital because of differences in the patient population.
“I would hate it if Medicaid said, ‘Every hospital whose rate is above the median, we’re not going to pay you a chunk of money.’ That is a bad approach because then people squeeze it down without attention to what’s best for patients,” Caughey said.
Even if hospitals aren’t being officially penalized for high C-section rates, administrators are worried about the financial effect of losing patients who want a vaginal birth.
Deliveries aren’t big moneymakers for hospitals, but once a hospital treats a mother, it’s likely to care for the rest of her family in the years to come.
Some mothers say that they felt as if their physicians rushed into C-sections, and they don’t want to repeat the experience.
When Anastasia Stone, 32, was pregnant with her first child, her doctor told her she needed to be medically induced to begin labor, which resulted in a C-section. “I was a typical first-time mom,” she said.
Stone, who lived in Santa Cruz at the time, said she later came to believe she could’ve had a vaginal delivery instead of a C-section if her physician had waited.
When she was pregnant with her second child, Stone went looking for a doctor who would try for a vaginal birth.
Dr. William Gilbert, regional medical director for women’s services at Sutter Health in the Sacramento region, said Sutter Davis Hospital has drawn such women from around the area because it had the lowest C-section rate in the state in 2014 — 12%.
The hospital uses nurse midwives, who deliver most of the babies, and reserves obstetricians for backup. Birth is treated as a natural process instead of a “health condition” that always requires medical intervention, said Carolyn Campos, nursing manager of the hospital’s birthing center.
Gilbert thinks that as more data on specific rates of procedures or treatments is available, patients will increasingly turn to that information when choosing where to seek care.
In 2014, low-risk C-section rates ranged from 12% to 70% at California hospitals.
Six years ago at Sutter Medical Center, Sacramento, Gilbert began encouraging physicians to allow longer labor in women, and began posting each physician’s low-risk C-section rate in the doctors’ lounge.
From 2010 to 2014, the hospital’s low-risk C-section rate dropped from 31% to 27%.
Gilbert thinks that most of the success came from publishing the doctor’s rates internally.
“Doctors don’t want to be the highest rate,” he said. soumya.karlamangla
@skarlamangla ryan.menezes

MARK BOSTER Los Angeles Times
LOW-RISK C-section rates at Hoag Memorial Hospital Presbyterian, where Dr. Allyson Brooks is chief quality officer, fell from 31% in 213 to 26% in 2014.


Get every new post on this blog delivered to your Inbox.

Join other followers:

The Dennis L. David Insurance Agency | Long Term Care Insurance, Los Angeles Medical Insurance, Anthem Blue Cross Healthcare Insurance, Whole & Term Life Insurance Policies, Cigna, Disability Insurance, Blue Shield of CA, Group Health Plans, Aetna, Group Medical Insurance, Skilled Nursing Insurance, Medicare Supplement Insurance, Medicare Part D Prescription Drug Plans, In-Home Care, Disabled Work Insurance, Disability Benefits, Culver City Health & Life Insurance, Family & Individual Health Insurance, Health Care Reform & Affordable Care Act Assistance, Obamacare, Covered CA Health Insurance, Health Plans, Kaiser Insurance, Genworth Life, John Hancock Life, Culver City Long Term Care & Disability, Employee Benefits, Beverly Hills, Hollywood, West Hollywood, Santa Monica, Pacific Palisades, Marina Del Rey, West Los Angeles, Los Angeles, El Segundo, Sherman Oaks, Encino, Los Angeles, Manhattan Beach, Los Angeles County CA, California

CA Insurance License Number:  0668857

TX Insurance License Number:  1774174