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.

YOU DO NOT EVER NEED TO SEE THE PHYSICIAN CHOSEN

YOU CAN CHANGE THE PHYSICIAN AT ANY TIME

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.

Medicare for More

The following article from the Atlantic states that lowering of the Medicare age from 65 to a younger age might infuse needed money into the Medicare system. Additionally, rates for those who are younger and not Medicare eligible might benefit if older sicker people enroll in Medicare. All will depend on the healthcare needs of those who are shifted around.

Hillary Clinton’s new proposal to expand coverage for middle-aged adults provides a glimpse at how she would make Obamacare her own.

VANN R. NEWKIRK II

MAY 23, 2016

What’s the next step for Obamacare? Much of the 2016 presidential race functions as a referendum on just what to do with the the six-year-old Affordable Care Act. Despite some mixed returns on costs and the stability of insurance markets, the health-reform law has brought the uninsured rate to its lowest point in American history. Reflecting that mixed legacy, most Americans now favor modifications to the ACA over continuing to implement it as it is or repealing it.

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That puts most Americans on the opposite side of whatever Donald Trump’s health care plan might be. But both Hillary Clinton and Bernie Sanders have plans to modify and expand Obamacare. Sanders’s plan of “Medicare for All,” a radical overhaul of the current system based on a single-payer system, has received most of the attention. Clinton’s more modest proposals to expand tax credits and allow undocumented immigrants access to health-insurance marketplaces have garnered less press. But recently, Clinton has made waves with a new idea to allow people over 50 or 55—the specifics have not yet been announced—to purchase Medicare plans.  At present, only those over 65 and a select few of their dependents are eligible for Medicare. This “Medicare for More” concept is a significant addition to the Clinton health plan, but what does it mean for the future of Obamacare?

A new report from Avalere extrapolates what it might mean for the future of 50-somethings. There are about 13 million people between the ages of 50 and 65 who are either uninsured or have purchased private insurance on the Obamacare marketplaces. This population represents most people in the age range without affordable employer- or group-insurance coverage and who don’t qualify for Medicaid. Assuming that this is the population that would be eligible for Clinton’s Medicare for More, Avalere reports that it is “unclear” if Medicare would automatically be a good deal for them.

With no knowledge of premiums or subsidies yet, a Medicare buy-in might just be too costly for those uninsured adults above 50 who have low incomes but are ineligible for Medicaid because of state rules. For those in private plans, Medicare has a distinct number of cost disadvantages, including a 20 percent cost-sharing requirement, no lifetime cap on out-of-pocket expenditures, and drug benefits that are generally less generous. Also, it is unclear if people under 65 could qualify for the Medicare Advantage plans that help fill in gaps in coverage. Sicker elderly adults regularly run up against the limits of Medicare, and it is hard to envision cases in which Medicare would make more financial sense for near-elderly adults with serious chronic illnesses than medium-cost marketplace plans.

Medicare for More is a step away from Clinton’s position as a defender of President Obama’s legacy and towards her central policy identity as an architect of American health policy.

But Medicare has always been a good deal for those who don’t use many health-care services, and it might beat out low-cost marketplace plans for healthy adults between 50 and 65 with few health problems. Medicare provides access to one of the broadest networks of physicians, providers, and benefits possible, and consumers value continuity. A buy-in at 50 could allow people to remain on the same insurance coverage with the same providers for the rest of their lives. Also, while Medicare has not been shown to have a serious effect on health trajectories for uninsured adults who become enrollees at age 65, at age 50 it might provide services early enough to change outcomes. Medicare also provides protection against medical debts, and if premiums could be made affordable to uninsured adults over 50, it could have serious value as health issues mount with age.

Medicare for More might have more value to the Medicare program than to any individual beneficiary. People between 50 and 65 are healthier than those over 65, and many of the costs that penalize high utilization can be seen as offsets for having to cover the most expensive population in the country. Even for Medicare, which has broad power to affect prices and policy, covering services, visits, drugs, surgery, and hospital stays costs money, and as patients near costly end-of-life holding patterns, the cost curve skyrockets. Adding healthier, younger people to the risk pool might bring down the per-person costs of the program. If the subsidies are equivalent to marketplace subsidies, premiums and savings from the over-50 crowd could actually cut back net costs for the Medicare albatross. Removing more middle-aged adults from marketplace risk pools might actually make insurance cheaper for young adults as well.

The results of a Medicare buy-in for potential beneficiaries and the program will likely depend on specifics as detailed by the Clinton campaign, but its rhetorical value is much more readily assessed. Allowing private purchase of one of America’s two big public-insurance programs is an addition to Obamacare’s willingness to blur the lines between public and private insurance, risk, and public-health responsibility. The proposal gives Clinton ammunition both against Sanders in the primary and, should she win, Trump in the general.

But above all, Medicare for More is a step away from Clinton’s position as a defender of President Obama’s legacy and towards her central policy identity as an architect of American health policy. Obamacare could very well be a platform for Clinton to achieve some of the goals that remain unfulfilled from the 1993 health plan that she spearheaded. Combined with some recent support from Clinton for the idea of a public option, a Medicare buy-in can be seen as a very Clinton-esque way of using the market to provide universal care. The free market solution to coverage, along with the major expansion of Medicare as a coverage pathway for non-elderly adults, is reminiscent of the ‘93 plan, and the population that it impacts is massive. Medicare for More would also cement Obamacare as the foundational law of all of American health policy, and establish a regime of incrementalism not unlike the coverage shifts seen in the decades between Medicare and Obamacare. The proposal might open the door for other shifts, such as allowing even younger people or government employees Medicare buy-ins.

For those further to Clinton’s left, however, Medicare for More might close the door for hopes of more radical overhauls while the figurative iron is still hot and while the ACA is still a hotly debated law. Sanders’s plan rests on frustrations about the compromising nature of the Affordable Care Act, which whittled down some of the more ambitious coverage plans in favor of  a market-based solution that still leaves millions uninsured. The current Obama-Clinton doctrine of health-care views zero uninsurance as a lofty and likely unreachable goal more than a first-order cause. Much of Sanders’s momentum with Medicare for All comes from the fact that the liberal benchmark––a universal public option supported by high, progressive taxes––has still not been reached. Clinton’s incrementalism would in all likelihood reset the clock on that dream.

Medicare for More isn’t Sanders’s Medicare for All, and it certainly isn’t what many Sanders supporters are looking for, but it is a step for Clinton and would be a significant addition to the massive impact of Obamacare. If Clinton does wind up in the White House, it could be the beginning of a piecemeal process to bring the ACA closer and closer to its originally intended ideal of universal coverage, as Obamacare is a perfect platform for incremental increases in coverage. Now, it is another sign that the work of providing coverage and making the health care system more affordable and better is not yet done.

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.

Health Law Insurance Plans to be Rated by Network Size

Below is an article from the New York Times date March 6, 2016 which also discusses the increase in out of pocket costs for 2017.

WASHINGTON — The Obama administration, responding to consumer complaints, says it will begin rating health insurance plans based on how many doctors and hospitals they include in their network.

At the same time, the maximum out-of-pocket costs for consumers under the Affordable Care Act will increase next year to $7,150 for an individual and $14,300 for a family, the administration said. Consumer advocates said those costs could be a significant burden for middle-income people who need a substantial amount of care.
Under new rules to be published Tuesday in the Federal Register, insurers will still be allowed to sell health plans with narrow networks of providers. But consumers will know in advance what they are getting because the government will attach a label indicating the breadth of the network for each plan sold on HealthCare.gov.
About 12.7 million people signed up or had their coverage automatically renewed in the third annual open enrollment season, which ended on Jan. 31.

Many health plans offered in the public marketplaces provide a limited choice of doctors and hospitals, and some insurers narrowed their networks this year by excluding some doctors and dropping popular teaching hospitals.
Consumers have grumbled about the changes, and some say they have had difficulty finding medical specialists. But cost-conscious consumers have gravitated to these plans because they tend to offer lower premiums than health plans providing a greater choice of doctors and hospitals.
Consumers can already find out which health plans include a specific doctor. But until now they had no reliable way to determine if a health plan had a large or small network of providers. The new ratings will indicate how the breadth of a health plan’s network compares with that of other plans in the same geographic area.
“This could be really helpful for a lot of consumers,” said Sabrina Corlette, a consumer advocate and professor at the Health Policy Institute of Georgetown University.
Consumers have also complained about the out-of-pocket costs for many health plans under the Affordable Care Act.
“For many people, $7,000 of costs can be a huge impediment to actually receiving care,” especially if patients incur those costs in a month or two at the start of a year, said Marc M. Boutin, the chief executive of the National Health Council, a coalition of advocacy groups for people with chronic diseases.
Out-of-pocket costs, as defined by the government, include deductibles and co-payments, but not the premiums that people pay for insurance. Each insurer sets limits on out-of-pocket costs for its health plans, and the limit cannot be higher than the maximum specified by the government. The maximum for an individual will exceed $7,000 next year for the first time. It will go up by $300 in 2017, after an increase of $250 this year.
Consumer groups say this rate of increase is unsustainable. Moreover, they say, high out-of-pocket costs have deterred some people with insurance from using expensive prescription drugs.
Ben Wakana, a spokesman for the Department of Health and Human Services, said that in setting the new ceiling on out-of-pocket costs, the administration had used a formula laid out in the Affordable Care Act. Before the law was adopted, he said, people with cancer or other serious illnesses could be bankrupted by hundreds of thousands of dollars in medical bills, and the law provides new protections.
People with low incomes can obtain discounts that reduce their deductibles and other out-of-pocket costs if they choose midlevel silver plans. Slightly more than half of the people with marketplace coverage received such “cost-sharing reductions” last year.
Ms. Corlette, the Georgetown University professor, said that in writing the new rules, “the administration was walking a very delicate line, pushing forward with consumer protections while trying to keep insurers onboard and participating in the marketplaces.”
In some markets, consumers can choose from dozens of health plans. In a move intended to simplify the shopping experience, the Obama administration has devised six model health plans that it describes as standardized options. Federal officials specify the amount of deductibles, co-payments and other charges for doctors’ services, hospital care, X-rays, laboratory tests and prescription drugs.
The standard features will make it easier for consumers to compare plans, officials said, and the government will highlight these plans in some way on HealthCare.gov. But the government is not requiring insurers to offer the standardized options or limiting their ability to offer other plans in 2017.
Another new requirement is meant to guarantee “continuity of care” for certain patients. If a health plan drops a doctor from its network without cause, the insurer must allow patients in “an active course of treatment” to continue seeing the doctor for up to 90 days. This protection would apply, for example, to patients receiving chemotherapy or radiation therapy for cancer and to women in the second or third trimester of pregnancy.
Under the new rules, consumers using the federal marketplace will be able to get help year-round from insurance counselors financed by the government. The counselors, known as navigators, help people sign up in the annual open enrollment period. The administration is expanding their duties to include teaching people how to use insurance, appeal denials of coverage and obtain exemptions.

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