California Exchange Bills Signed Into Law

The Governor signed both health insurance exchange bills into law yesterday in California.

AB 1602 and SB 900 (companion bills) were signed yesterday, paving the way for the creation of the California Health Insurance Exchange.

I will update as the process moves forward with information on the exchange, how it will work, when it might be operational and so on.

CA Health Bills Up Against Deadline

There are currently four bills in process in Sacramento which need to be passed or rejected by August 31, 2010. If they are not passed or rejected, the bills will die.

The following are the applicable bills:

AB 2578 (D. Jones) - Requires approval from state regulators for increases in health coverage premiums.

SB 1163 (M Leno) - Would require insurers to justify denials of coverage and premium increases.

SB 900 (E. Alquist) and AB 1602 (J. Perez) - Companion bills would establish health insurance exchanges in California to comply with PPACA.

PPACA Update on Existing CA Plan Upgrades

I wanted to add that it may happen that some or all carriers choose to make the PPACA-compliant changes to existing plans on one unified date. Likely this will be the portfolio renewal date.

So, it may be that your existing pre-9/23 healthcare plan gets the upgrade at the renewal of your plan anniversary or on January 1, 2011.

Realistically it makes more sense cost- and logistics-wise for a carrier to make the unified upgrade instead of spacing them out over a period of 12 months.

I will post when I receive clarification from each carrier on how they intend to process the upgrades to existing coverage plans.

9/23/10 What Happens To My California Healthcare Plan?

Have been doing some digging this week on the future of healthcare plan changes for the upcoming 9/23 PPACA compliance requirement. I wanted to outline for everyone in California what the most likely scenario will be for your current and/or future healthcare plan. I expect the process to be generally uniform amongst the carriers.

As I understand it today (this is of course all subject to be changed), plans will be handled as follows for the 9/23 PPACA.

New Subscribers - new subscribers who purchase coverage on or after 9/23 will be purchasing healthcare coverage plans (not yet approved) which comply in full with the PPACA requirements. These plans will be fully compliant right from the start.

Existing Subscribers - existing subscribers, whether on a grandfathered healthcare plan (purchased prior to 3/23/10) or on a non-grandfathered healthcare plan will receive the PPACA compliant changes to their plan at the next renewal anniversary date of their plan. Anyone purchasing a plan between today and 9/22 start date will be considered an "existing subscriber". Example: a person purchased an Anthem Blue Cross SmartSense PPO plan on April 1, 2010. The plan renewal will be April 1, 2011 and at that time the PPACA benefit "enhancements" will be applied to that plan.

Group Subscribers - group health plans purchased after 9/23 will also be PPACA compliant. Plans purchased before 9/23 will be treated the same as existing subscribers on individual plans and benefits will be "enhanced" at the group open enrollment renewal month.

Certain PPACA plan changes will apply to all plans, regardless of grandfathered status. Other PPACA changes will only apply to plans which do not have grandfathered status.

Anthem CA Re-tooling For Obamacare

Effective August 14th, quoting for individual health plans will only be available for start dates of Sept 22 or before. If you request an effective date on or after Sept 23, the system will have a pop up message stating that no plans are available for the requested effective date.

Anthem is currently working on the mandatory changes and rates for plans to be sold Sept 23 and after. Plans sold on or after Sept 23 must meet new guidelines as outlined in the PPACA legislation.

I will post when the new information is available for quoting.

CA Temporary Federal Risk Pool Approved

Yesterday, two legislative bills were passed in Sacramento which will allow for California to run a temporary risk pool using federal funds (under PPACA). The risk pool will provide coverage on a temporary basis until January, 2014.

The two bills, SB 227 (Alquist) and AB 1887 (Beall) will provide both parity for mental health and substance abuse (AB 1887) as well as the temporary risk pool for uninsurable California residents (SB 227). Passage of SB 227 was predicated on prior passage of AB 1887.

California will receive $761,000,000 of federal funds for the risk pool. State sources indicate that the risk pool will not use any California state funds.

Details including qualification requirements, insurance plans (will be PPO style) and rates should be forthcoming from the MRMIB. MRMIP will run the program alongside the state major risk program.

MRMIB Moving Forward on Fed Risk Pool

MRMIB (California's Major Risk Medical Board) is putting together the federal major risk pool program for California. According to the most recent document, MRMIB is targeting PPO model coverage plans allowing for provisions to match the new federal PPACA guideline (no annual or lifetime caps, lower deductibles (under $1500) and so on).

According the the MRMIB, target date for the risk pool to be operating is September, 2010.

According to information provide by Pricewaterhouse Coopers (PwC) to the MRMIB, enrollment in the new risk pool could be approximately 25,000 California residents.

For comparison, MRMIP (California's Major Risk Insurance Plan) enrolls a total enrollment of about 7,100.

The risk pool funding will be a combination of premium from subscribers and federal dollars. No state monies will be used to fund the California federal risk pool.

More information as soon as I get it. Remember, the two primary conditions a person must meet to participate in the federal risk pool are:

1. Uninsured for six months or longer and unable to obtain private, group or public health insurance

2. Must have a health condition determined by the pool as a qualifying condition (these have not been published yet)

Blue Shield CA To Hold Current Rates For July 2010

Blue Shield of California announced today that the company would make no rate or benefit changes to individual & family health plans in California at this time.

Blue Shield's "product cycle" normally allows adjustments of rates and plan benefit changes two times per year, in January and July.

Communication to agents indicates that everything will remain as current in terms of price and benefits until the next product cycle, which will be announced at a later date.

CA SB 890 (Alquist)

There is a current California Senate Bill (SB 890) which I find intriguing.

SB 890 is currently under consideration and, if implemented ahead of full reform, would drastically change the landscape of individual health insurance in California.

Essentially, the bill would require all health insurance companies to offer a "standardized" portfolio of plans which would be limited to 5 PPO plans and 5 HMO plans. Any deviation from these 5 plan designs would be illegal to sell after July 2011. These plan designs generally mirror the design concept of the plans which will be available in the exchanges by 2014.

The plans would be designated as "Gold, Silver, Bronze, Platinum and Catastrophic". They would have a proscribed benefit level and include maternity coverage. By the way, there is another bill out there right now which would require all individual health plans to include maternity benefits again. No more non-maternity plans.

The ten standardized plans (5 PPO 5 HMO) would also function similarly to Medicare Supplements in terms of both standardization and the ability to move from one plan to another. Under SB 890, a subscriber may, at each policy anniversary, move to a plan of equal or lesser coverage on a guaranteed-issue basis. This is very similar to the California "birthday rule" for Medicare Supplement plans.

Another interesting note included in the text of SB 890 is the medical loss ratio information for California's health insurance carriers. Remember, on Jan 1 2011 carriers must comply with the new healthcare reform MLR requirements of 80% for individual and small group and 85% for large group.

You can read the text of SB 890 here

California Moving Forward With Reform

According to a Mercury News article today, the California Legislature is moving forward with several reform bills in the coming weeks.

The legislation, which may include as many as 20 bills, would, amongst other things, create state health insurance exchanges, do away with denials for pre-existing health conditions, extend coverage to children and uncap benefit limits on health plans.

Governor Schwarzenegger has indicated that he wants many reforms in place in California before January, 2011, including health insurance exchanges.

The two most major bills are SB 900 (Alquist) and AB 1602 (Perez). Both bills would create a California insurance exchange which would operate similar to the Massachusetts Connector program.

It appears that California intends to at least try to get systems and programs in place well ahead of the final dates set by federal reform laws.

Current Version of SB 900

Current Version of AB 1602

Health Exchanges and Independent Agents

I am hearing and reading so much lately from the health insurance agent community about the future of agents under healthcare reform. Specifically as relates to the health insurance exchanges set for 2014. A minority believe that independent agents will have a place in the system while a majority, it seems, are suffering from "Chicken Little Syndrome". Truthfully, no one knows yet what place independent health agents will have in the new system. I do have some thoughts.

For those who know me and my business, I write a lot of HIPAA. HIPAA is guaranteed-issue health insurance, available kind of on an exchange (pick from available carriers and plans) and has no underwriting or medical screening component. Somewhat similar to the future exchanges (if you can get information which is generally only available on web sites like mine).

One would think that with the fairly small choice of guaranteed-issue plans (perhaps 25 at most in California) and fairly similar plan designs (HMO are similar and PPO/POS are similiar in deductible and general benefits) that choosing a HIPAA plan would be easy. Honestly, for every 10 people I help enroll under HIPAA, at least 9 of them need help in determining the most appropriate carrier and plan for their needs. And that is a good thing. Getting a coverage plan is important. Getting the best fit for coverage is more important.

There are a variety of factors that come into play during proper case development. Plan design and usage limitations are one area. Plan benefits and any exclusions or limitations is another. Then there is the network of participating providers and the prescription drug formulary to consider. All of these things before we really even look at the price of the plan. These services are easily and readily provided by independent agents who can compare multiple carriers and plans. The other option would be to call each carrier and then try to put it all together yourself. One of the problems with calling a carrier is...they only know their own plan. For example:

Blue Cross of California originated a plan in California called RightPlan PPO. It was the first no deductible non-maternity individuals-only PPO in California. It was subsequently copied by several other carriers and duplicated in their respective plan portfolios. Health Net has SimpleValue PPO (copy) and Blue Shield has ActiveStart PPO (copy).

Under the current market, you could call Anthem Blue Cross about the RightPlan PPO but they are not equipped to compare it against SimpleValue or ActiveStart. Each carrier only knows their own plans. You'd end up having to call three carriers, get whatever information you think is important, put it all together and try to decide which clone plan would work best. Or you could call an independent agent (for free by the way, there is no cost to have an agent) who can run that scenario for you.

Fast forward to the health insurance exchanges. Like HIPAA, the plans will all be similar but, like HIPAA, there will be differences between each insurance company's plans (network, formulary, benefits, tiers of drug coverage and so on).

Let's assume hypothetically that six companies in California offer plans to the exchange. The plans will be denoted as Gold, Silver, Bronze and Platinum. Benefit levels will be determined by mandates in the healthcare reform law. Seems simple enough, right?

Well, what if you take six medications and one of them is not in any drug formulary for the exchange plans? Which plans have tier 3 drug coverage and which don't. Are there restrictions on tier 3 benefits? How do I search their drug formulary? Are my doctors participating with this carrier's Gold plan? How about hospitals? Do the networks differ between Gold, Silver, Bronze and Platinum? Does this plan cover me locally only or can I use it in-network when I travel? Is this an HMO Gold, PPO Gold or POS Gold? What's the difference?

Needless to say, this list could go on forever.

Another factor that I believe may come into play are deviations from basic design. With Medicare Supplement plans, there are some carriers who offer the Medicare mandated benefits but also create enhanced plans with other options above the Medicare minimum standard. Could we see this in the exchange as well? I believe it is very possible. So instead of six carriers offer six Gold plans, you might see something like this:

Carrier A - Gold
Carrier B - Gold, Gold Preferred, Gold Plus, Gold Enhanced
Carrier C - Gold, Gold Preferred
Carrier D - Gold, Gold Select
Carrier E - Gold, Gold Select
Carrier F - Gold, Gold HMO

Gold = Standard Gold design based on reform rules for plan minimum standard
Gold Select = Gold plan benefits with a select network of providers (smaller)
Gold Preferred = Gold plan health benefits plus a long-term care rider
Gold Plus = Gold plan benefits with a dental HMO plan
Gold Enhanced = Gold Plus plan design (with dental) plus additional vision and chiropractic coverage
Gold HMO = HMO plan adhering to Gold plan design rules

Under this scenario, as many as 13 Gold plans could be available (or more, or less) from the six insurance companies. It could get really confusing really quickly. And what if they do the same with Silver and Bronze? Or Platinum?

The bottom line is that a person should not have to match their medical needs to a health plan. All of my case development for HIPAA plans is directed at matching the plan to meet the medical needs, not the other way around. While no plan is always absolutely perfect, good case development should find the one plan that, given overall medical needs, is the "best" fit for each client.

I would think, given these variables, that the role of the independent agent would be extremely important in matching people's medical needs with the appropriate health plan, whether through the exchange or privately outside of the exchange.

Certainly the states, or insurance companies, or federal government could set up "call centers" staffed by non-agents who would be available to review coverage options and answer questions. Would it be less expensive? Probably not. But more to the point, there comes a time in this business when experienced, veteran independent agents really get a feel for the way certain insurance companies operate with regard to networks, formulary and benefits. I have found that EOC (Evidence of Coverage) booklets are often sorely lacking in certain areas when it comes to benefit utilization or the way a claim is "really" processed. Just because something is written in a booklet or spreadsheet or benefit summary does not mean that is exactly how it works, or in all situations.

We learn from experience. I write mostly HIPAA. Claims for HIPAA tend to be much greater and much more varied than underwritten coverage. That is the nature of guaranteed-issue coverage. I have seen situations which absolutely contradict what was written in the benefit summary, spreadsheet or EOC. I have also learned over the years many of the little nuances of the plans and insurance carriers that can be very critical when a prospective client brings their medical needs to me.

I hope that our leadership understands the value that we independent health agents provide.

On a side note:

I was a bit saddened to read an article recently in an industry publication in which President Obama told a health agent who expressed concern about her career that she was "the one who has to tell her clients about the insurance company's rate increase". While that is part of our job, I'd like to think we do a bit more than just pass on rate increase information. I certainly hope this is not how our leadership sees us and perceives our value to our clients.

I don't always have time to tell people about rate increases since the carrier will tell them anyway. I am often quite busy running drug formularies, trying to find which network doctor X is actually in and trying to help my clients get the plan that will best cover their immediate needs like chemotherapy, heart surgery, infusion therapy, transplant surgery or self-injectible life saving medication.

MRMIP Clears Backlog (No Enrollment Waiting Period)

The California MRMIP (Major Risk Medical Insurance Program) has apparently received some additional funding and has cleared the backlog of applications.

As of today (5/19/10) there is no waiting list for MRMIP enrollments.

I am working on obtaining specific information regarding the federal temporary risk pool which is scheduled to open July 1. In the meantime eligible uninsurables may enroll in the MRMIP without an enrollment waiting period.

More MRMIP information here

Large Companies Contemplate Dropping Employee Health Coverage

The Dallas Morning News is reporting that several very large companies "have concluded that they might be financially better off canceling their health care coverage and moving their workers to government-subsidized exchanges that will be available in four years".

At least four companies have investigated to varying degrees the impact of dropping health care coverage and pushing their workers onto the new exchanges, where they will be able to buy their own insurance.

While doing this would subject companies to fines, the size of the fines would be substantially less than the cost of providing health insurance to their workers.

The four companies identified so far are:

*AT&T
*Verizon Communications, Inc.
*Caterpillar, Inc.
*Deere and Co.

If these four are looking at this option, it is a pretty safe bet that other large employers are doing the same.

MRMIP Will Not Be Used For Risk Pool

Today the CA Governor announced that California will not use the MRMIP program as the temporary high risk pool for uninsurable California residents.

Instead, MRMIP will continue to operate alongside the federal risk program to be established by HHS in the next few months.

Stay tuned for more details on the temporary risk pool and how to enroll. Remember, the federal risk pool is a temporary program to 2014 to help cover those who cannot obtain private health insurance and have been without insurance coverage for six months or longer.

MRMIP is a California state risk program for CA residents who are unable to obtain private health insurance. The current waiting list for MRMIP enrollment is 3-4 months from application submission.

Temporary Risk Pool (California)

Just a quick update on one of the provisions of healthcare reform that goes into effect in September--the temporary risk pools for the uninsurable who have 6 months or more uninsured (and are uninsurable).

Each state was given the option to use a federal risk pool (HHS) or, if that state has its own risk pool, to use the state program and receive federal $$ for it ($5 Billion earmarked for these temporary risk pools).

While I assume California will likely us the California MRMIP program for eligible California residents, a decision has still not been made by the MRMIB (Major Risk Medical Insurance Board) in Sacramento.

I called them this week for an update and was told that they are still meeting about it and working through the myriad of implications for using MRMIP.

I will provide updates as they become available and as we get closer to the initial changes under the new Healthcare Reform law.

For more information on California's MRMIP health insurance risk program (and other state programs), visit my CalHealth page.

This Is What Happens When You Don't Read The Bill!

I guess someone forgot to tell the administration and those who voted for health insurance reform to actually read the bill.

The current bill signed into law yesterday does not, in fact, provide guaranteed-issue health insurance coverage from children this year, sort of.

I assume this will be fixed but we will have to wait and see.

Gap in law for children's healthcare protection

Health Insurance Reform Has Passed

In a very close vote, HR 3590 was passed this evening 219-212.

Health Insurance Reform - What To Expect

Happy Sunday to you all. I am watching the House vote and waiting for the final determination on the Health Insurance (Health Care) Reform Bill.

Since I have received many questions concerning changes I thought I'd quickly summarize here what to expect initially if/when this Bill is passed and signed into law today.

During the first year you can expect:

Pre-Existing Conditions - The Bill includes $5 billion in immediate support to provide temporary coverage to uninsured Americans with pre-existing conditions. The money would help until the new health insurance exchanges are created in 2014.

Elimination of Benefit Caps - New policies sold will not have annual caps on benefits nor lifetime caps on benefits.

Children with Pre-Existing Conditions - Children with pre-existing health conditions will not be excluded from purchasing health insurance coverage.

Preventive Care - New insurance policies will be required to offer free preventive care benefits.

Small Business Tax Credit - A tax credit for small businesses up to 50% of premiums to help small businesses purchase health insurance.

Help for Seniors - $250 towards drug coverage in the "donut hole" to help pay for prescription drugs.

Appeals Process - An independent appeals process will be set up for those who feel that they were unfairly denied a claim by their insurance company.

Other changes take place in 2014 and beyond.

Medicare You Can Buy Into Act - Grayson (D-FL)

Congressman Alan Grayson of Florida has authored H.R. 4789. The Bill, titled "Medicare You Can Buy Into Act" or "Public Option Act", would open up Medicare enrollment to US residents of all ages 19 and above. The link below is for this bill, which is only four pages long.

Read The Bill Here