What’s the matter with letting states decide such matters?
Contact your representatives in Congress.
According to Santa Cruz health insurance specialist, Kathleen Brewer de Pozos, more individual subsidized ObamaCare health plans offered by Covered California in Santa Cruz County will be limiting the number of doctors you can choose. The physician networks contracting with each plan may not be finalized until October or November, possibly later. (Blue Shield, for example, did not reach agreement with one of its major providers two years ago until January, two months after the beginning of open enrollment.) Nevertheless, carrier websites continue to offer regularly updated search functions that will assist members in selecting network providers.
Blue Shield will be the only carrier offering a PPO (Preferred Provider Organization) in Santa Cruz County in 2017. PPOs have bigger networks and fewer controls on getting specialty care. PPO plans will also allow members to go out of network, but they will face higher up-front deductibles for those services and be left with paying the difference between what the PPO will pay and what the out-of-network doctor charges.
Anthem and Health Net are offering EPO (Exclusive Provider Organization) plans for 2017. EPOs are more restrictive and may have smaller networks. Members do not need a referral from their primary care doctor to see a specialist. Because they have smaller networks and don’t pay for any non-emergency services outside of the network, EPO premiums are generally lower than those for PPOs.
The Kaiser Foundation Health Plan will offer its HMO (Health Maintenance Organization) plan to Santa Cruz County residents for the first time in 2017. Many local residents have been lobbying for Kaiser to come to the region for over 25 years. Kaiser almost always contracts with its own doctors, The Permanente Medical Group (TPMG).
HMO plans are sometimes called gate keeper plans because members must have a referral from their primary care provider (PCP) in order to consult with a specialist.
Watch for physician network information in October and November. This year (2016) Physician’s Medical Group and certain solo practice doctors contracted with Health Net. Dignity Health (Dominican) contracted with Anthem, Blue Shield, and United Healthcare, as well as some other smaller groups and solo practitioners. The Palo Alto Medical Foundation (PAMF) contracted with Blue Shield.
Provider networks change, so be sure to confirm that your doctor(s) are in-network for the plan you select.
Open enrollment for new members as well as existing plan members begins November 1 and continues through January 31, 2017. For a plan effective date of January 1, 2017, it is essential to complete an application by December 15, 2016. Start early to avoid the rush! The last few days and hours before each monthly deadline typically get a bit crazy and waits for help are long.
For questions or help anywhere in California call Kathy Brewer de Pozos at: 831-713-6438 or email her at: KathyPozos2000@gmail.com
Increasing costs are causing many employers to raise deductible and co-pays on insurance offerings. Take a look at supplemental benefits. Aflac offers hospital and accident policies that pay you directly for all of those costs not covered by your insurance, including deductibles and co-pays.
Smaller employers are often raising deductibles to $1,000 or more. People who don’t qualify for subsidies at Covered California — the Affordable Care Act exchange — can get help from supplemental insurance policies from Aflac. There are group and individual plans with policies for short term disability, dental, life, and cancer.
For more information ask Randy Pozos: Randolfo_Pozos@us.aflac.com. Call or text: 831-588-3423
1. Update your contact information. Covered California, “the Exchange,” will be sending out policy renewal and change information in October. If you have moved or changed other contact information let your agent know before September 30. You can also do it yourself directly online through Covered California. Be sure to let your insurance company know of any changes as well.
2. Renew your Permission to Verify Income. You can’t get a subsidy from Covered California if the State cannot verify your income. Permission has to be renewed periodically. Check with your agent to be sure your permission is up to date or go directly to Covered California and do it yourself.
3. Do you want to keep your doctor? Know your provider options. Different insurance plans contract with different doctors. Plans outside of Covered California may have the same provider networks as those on the Exchange. However, some of the older plans and group plans may have different networks. Be sure to check with your doctor’s office to confirm that they take Covered California insurance plans.
4. Check with your agent about individual plans that are not subsidized as part of Covered California if your subsidy is going to be small or if your income is above the subsidy range. But be careful. Some of the plans outside Covered California can have less expensive premiums up front but be more expensive faster when care is needed than the standard plans on the Exchange.
For questions or help anywhere in California call Kathy Pozos at 831-713-6438 or email KathyPozos2000@gmail.com
On Covered California, look for Kathleen Brewer de Pozos as agent. (The only agent at Covered California with that last name!)
We’ve now entered Renewal season for existing health insurance policies. Open enrollment for people new to Covered CA doesn’t start until November 1, but those with existing policies can make any necessary changes and renew their policies now.
Has anything changed in your life or income? A new member of the family? A child who is no longer a dependent? Have you moved? Did you get a raise? Did your income go down? Did you get a new job or lose a job? If there have been changes we’ll need to open a Change Report and enter the new information into the system that way. If there will be changes for next year, but things haven’t changed for this year, we report that by beginning the renewal process directly.
Once all information has been entered, you can select your policy for next year. Some of the carriers have new types of policies and premiums will be quite different. However, for those who have subsidized policies, the out-of-pocket share does not seem to be going to go up too much. That share is still based primarily on household income.
There is one new carrier in our Central Coast market area, United Healthcare. Many Dignity doctors are on their network provider list. They don’t seem to have a contract with PAMF at this time. Other independent providers are also in their PPO network.
If you want to get a sense of what your premium might be before making any changes, I’ve found the Shop and Compare tool at www.Coveredca.com works with Chrome or Internet Explorer better than with Firefox. I haven’t tried it with Safari.
This year Pozos Insurance Services also offers Aflac supplemental policies that can enhance your protection by providing benefits to fill some of the gaps in traditional health insurance policies. Accident, disability, hospitalization, cancer, dental, and vision supplemental policies are available to groups and individuals. We also offer life insurance.
As always, if you have questions or need help with selecting or managing your policy or Covered California account, or if you’d like to know more about life insurance or Aflac options, please contact us. We’re happy to help you with these important decisions about protection for you and your family.
Blue Shield announced today that the company has reached an agreement on a two year extension of its contract with Sutter Health, including the Palo Alto Medical Foundation (PAMF). This agreement, whose terms are not public, protects both carrier and clients according to Blue Shield.
Sutter Health and the Palo Alto Medical Foundation are major players in the Northern California health care scene. In some counties, including Santa Cruz, Blue Shield will be the only carrier whose network of providers for individual policies includes Sutter and PAMF, in contrast with 2014 in which these providers contracted with both Health Net and Blue Shield. Patients who had already moved from their Health Net policies to Blue Shield effective January 1, 2015 in order to keep their providers were facing the possibility of having to find new doctors anyway. News of the agreement will be welcomed.
The lack of a contract between Blue Shield and Sutter Health/PAMF affected both individual and group members of the plan.
Open Enrollment for individual and family health insurance continues through February 15, 2015. Contact us today for a free consultation and help enrolling in a plan to meet your needs.
Congratulations! You’ve completed the daunting task of researching options for health insurance, finding help to enroll in a plan, confirming which plan will work best for you and/or your family, and completing the application. Once your first premium payment has been made, you move into what may be a brave new world of having and using health insurance. Even if you have always had health insurance, today’s policies differ in important ways from the ones available only two years ago.
Covered California has a new web page specifically for people who have purchased an insurance policy through California’s state exchange/marketplace. I found it instructive, with a video and useful links.
Now it’s time to take advantage of the opportunity to get your preventive care visit and any lab tests or immunizations needed to help keep you healthy. Flu shots are considered to be preventive services, for example. So are vaccinations for illnesses such as whooping cough (pertussis) and shingles. Mammograms, PSA tests, and many other diagnostic exams are also included as preventive care.
If you have questions about whether a service is covered, you can call your health plan directly or speak with your agent. Before you see your doctor, make sure he or she is a contracted provider with your health plan’s network. When your doctor refers you to a specialist, double check that the specialist is also in-network. If the provider is not in the network, it’s possible that your plan will not pay for your care. Insurance plans have “provider finders” on their websites if you need to find a doctor who is in your plan’s network.
In the event you need urgent care rather than emergency care and your doctor’s office is closed, it’s better to go to an urgent care center that is in your network than the hospital emergency room. (Emergency care is for conditions that are life-threatening.) With Bronze and Silver plans, emergency room visits are subject to the deductible. This means that you will have to meet your medical deductible first before the visit will be priced at only the copayment set for your plan. Some of the Enhanced Silver plans have this deductible waived, but regular Silver and Silver 73 plans require payment of the deductible for emergency room visits. Urgent care visits will cost less.
I hope that you will not need any serious medical care in this coming year, but if for some reason you do need care, your purchase of a health insurance policy now has set the stage for a more positive outcome.
To your health!
Costco is offering health insurance to members and the question arises whether the policies offered and the pricing are better than what is available through Covered California or directly from the insurance companies. A bit of research resulted in the following:
Costco is working with a brokerage firm out of Nevada that has agents licensed in California. It offers plans from Blue Shield, Anthem, Health Net, and Assurant Health Plans. The Blue Shield, Anthem, and Health Net plans offer the possibility of subsidy, because they are the ones offered by Covered California, our state Affordable Care Act (ACA) marketplace. Assurant does not offer plans on the marketplace, so no subsidies are available.
The only plans offered are the Bronze, Silver, Gold and Platinum, with many variants of each to match the marketplace and non-marketplace options offered by these carriers. I checked the prices and they are essentially the same. Some are $1-3 per month less expensive. Some are a dollar or two more expensive on the Costco side.
The Minimum Coverage plan is not offered through Costco, at least not for anyone over age 29. It is not subsidized anyway, so clients would be dealing with essentially the same price for coverage as through the other carriers offering policies in this area. Minimum Coverage plans are available to persons over age 29 when the cost of insurance is above 9.5% of their adjusted gross income – a level deemed unaffordable. For 2014, they had to be purchased directly from the carriers, with a copy of the Federal Hardship Exemption application attached to the carrier’s application. The Assurant plans were all more expensive than the plans offered by the other carriers for the same benefits.
Given Costco’s reputation for discounted sales, this is one of the areas where they actually don’t offer any real pricing benefit and the products are identical to those that any licensed insurance agent in California can offer.
Remember, a local agent can provide a level of service that someone from out of state may not offer, if only the knowledge of which medical groups contract with which carriers. There is no additional cost for purchasing a policy through an agent, so don’t hesitate to call and take advantage of our training and experience. We look forward to hearing from you!
According to the U.S. Census Bureau, funding for health insurance in the United States has three major sources. The largest and perhaps least recognized source is employer-sponsored health insurance. According to Census Bureau estimates, in 2012 a majority of Americans (55%) got health insurance as a benefit from their employers. Though generally not seen as a subsidized form of insurance coverage, this insurance is funded using premium dollars that are deductible from the employer’s taxable income. The money paid by the employers for employee health insurance is not counted as taxable income paid to employees. Therefore, both employer and employee benefit from income tax provisions that support including health insurance as an employee benefit. Nevertheless, as a result of the rising cost of health care, a greater share of the out-of-pocket cost of health care has been shifted to employees and benefits have been restricted as employers have faced premium increases out-pacing inflation.
The federal government is the second major source of funding for health care. Federal funded care includes the Veterans Administration, Tri-Care, The Indian Health Service (Department of the Interior), Medicare, and Medicaid. Medicare is funded through a combination of payroll taxes on W-2 income and insurance premiums paid by beneficiaries. Medicaid is funded by a combination of state and federal taxes. The others are all paid from taxes collected and funds appropriated to specific government departments and agencies. An estimated 21.5% of Americans have government funded health care.
The final source of funding for health care is the individual insurance market. Approximately 6.8% of Americans buy their insurance directly from insurance companies. Prices on the individual market are generally higher than group policies because the risk pools are smaller. Additionally, individuals traditionally were charged more for having certain health conditions or based on gender. Insurers were allowed to charge women more for the same policy than men, for example.
An estimated 16.6% are uninsured. Those who are undocumented are not allowed to enroll in insurance policies, but the majority are American citizens by birth. These uninsured citizens include those who have a pre-existing health condition that led to their exclusion from insurance, those who are low income but don’t qualify for Medicaid because they are able-bodied and don’t have children under the age of 18, and those for whom insurance is simply too expensive because of their age, gender, or health condition.
The primary focus of the Affordable Care Act is to help the uninsured and underinsured get affordable coverage. Small business owners and employees will find help getting insurance, as will individuals who must purchase their own insurance. The law requires that all insurers offer 10 Essential Health Benefits in their policies as a way of ensuring that risk pools for higher cost conditions are large enough to make the coverage accessible to all who need it. The Affordable Care Act does not change Medicare benefits except that preventive services are now more affordable and the “donut hole” in the prescription benefits plans is being closed.
Nicole Hopkins’ opinion piece in the November 21, 2013 issue of the Wall Street Journal is headlined, “ObamaCare Forced Mom Into Medicaid“. Ms. Hopkins, a resident of Brooklyn, NY, describes her mother’s situation as a low-income resident of western Washington state and suggests that the opening of Medicaid to low-income adults such as her mother is actually a form of oppression that snuffs out personal dignity and systematizes “learned helplessness”. Granted, her mother is angry that she was not given the option to purchase a policy on the state marketplace, but the assumption that continuing to spend well over 25% of her income on a catastrophic, bare-bones insurance policy is a better use of her limited resources bears a closer look. It may be that in the long run, this change in the way her health care needs are financed will be recognized as one of those proverbial “blessings in disguise” about which we sometimes hear.
Ms. Hopkins’ mother is 52 years old. She is looking for regular work that would provide employer-sponsored health insurance but has been unable to find any. She works as a substitute para-educator in the local school district. Her current income is below the federal poverty line (FPL) — her daughter notes in the article that her mother has long known that she qualified for Medicaid (Washington Apple Health) in Washington state, though as an able-bodied adult without children under the age of 18 she might not actually have been able to get that coverage.
Mother has a long history of supporting herself and her children. She was easily able to purchase health insurance for the entire family from her income when the children were young. Once the children were grown, she tried a career change, becoming a licensed real estate agent. As many other self-employed people discovered during the Great Recession, paying clients proved too few and far between to cover expenses. In 2011 she gave up her license and began looking for other ways to support herself. (No unemployment benefits for the self-employed who don’t get enough clients.) Work as a substitute teacher was available and she took it. She is self-motivated, determined to make her own way in life, not asking for any hand-outs: a woman who lives out the American ideal of the self-sufficient, independent, “fully functioning member of society”.
For the past two years, she has purchased an insurance policy for $269 per month that covers catastrophic health care needs. Such policies typically have high deductibles, offer little access to regular medical care, don’t provide coverage for brand name prescriptions or services such as maternity or newborn care, and before the Affordable Care Act (ACA) could include annual and lifetime limits on claims payments made. For the coming year, the premium for a new policy that will be compliant with the ACA’s requirements will cost $415.20. If we assume Mother’s income is under $957.50 per month (FPL) since she has been income-qualified for help for the past couple of years, the premium she has been paying takes a minimum of 28% of her monthly income. The ACA deems premiums greater than 8-9.5% of monthly income to be unaffordable. The new premium, at over 43% of her income, is out of the question.
Washington is one of the 14 states that have set up their own insurance marketplace. The website is working reasonably well, as is typical of the sites set up by the individual states. Mother was able to create her account, enter her particular information, and find her options for health insurance. The shock came when she discovered that she was eligible for Medicaid and that no other policy outside of Washington Apple Health was open for her to purchase.
She was mortified. In her experience as a middle-class woman, accepting help from the larger community (i.e., federal and state governments) is shameful. The notion of a social safety-net that is available for everyone during times of need is hard to accept, especially when one is first confronted with the reality that he or she is truly experiencing a time of need. Since the belief system under which most Americans live, whether religious or not, is based on the Calvinist notion that our financial success or failure is a reflection of whether we are in good-standing with God or not, being poor is seen as reason for negative judgement from our fellow citizens.These judgements are not necessarily conscious, but having a low income or being “poor” leaves people stigmatized.
Certainly some people are poor because they have made unwise choices in their lives, but others have followed all the rules, done everything “right” and still been unable to move into a comfortable middle-class life. “Falling” into poverty from the middle-class is very hard to swallow.
Ms. Hopkins notes that Mother was always able to provide insurance for herself and her children and blames the ACA for making insurance unaffordable now. This is a common and very understandable reaction. After all, what 52 year old woman needs maternity and newborn coverage? Those with children under 19 may need pediatric dental insurance, but still … And so the ACA’s Essential Health Benefits get blamed for the cost of insurance.
What most people outside of the insurance industry have not seen is the degree to which the price of health care and the price of health insurance have increased over the past 20-30 years at a much faster rate than inflation. Additionally, they don’t see the difference in premium that is based on age of the insured.
When Mother was younger, her insurance was much less expensive in real dollars and as a percent of family income. Additionally real income was higher. (Wages have not kept up with inflation over the years.) Policies all included high cost services such as maternity and newborn coverage. Most had reasonable deductibles and copayments, so families could get care as needed. As the cost of care skyrocketed, policies became more restrictive in terms of benefits in hopes of keeping premiums affordable in both the individual and small group markets.
Most Americans got (and continue to get) their insurance through their employers or the federal government (Medicare, the Veterans Administration, and military benefits). The cost of their insurance has increased, but not as dramatically as that for individuals and small-business owners and employees. The risk pools for the latter are too small to provide the cost savings that can be obtained through larger pools.
In California, where I am licensed, in one region the cost of a minimum coverage policy similar to the catastrophic policy Mother has in Washington, but including all newly required benefits and deductible maximums, varies in price on the marketplace from a low of $194 per month at age 25 to a high of $580 per month at age 64. At age 45 it would cost $279 and by age 55 it jumps to $431. These prices seem similar to what Ms. Hopkins is reporting as the price for a new policy from her mother’s current insurer. Insurers must offer identical policies and identical pricing both on and off the marketplace exchanges, so the policy is likely to be similar to a minimum coverage or perhaps a Bronze policy on the Washington marketplace.
The addition of maternity and newborn coverage is not the primary issue in the increased cost of health insurance. When risk is spread more broadly, it costs less for each person who pays for a part of it. In California, all policies in the state have included such coverage since July 1, 2012 because the cost of not having this coverage in policies had become prohibitive. Women without maternity insurance (over 40% of insured California women who became pregnant) had been covered through Medi-Cal (our Medicaid program). Prices for policies have gone up with the coming of the ACA, but not because they include maternity and newborn care.
The most important thing Ms. Hopkins and her mother can do at this moment is to stop and take a deep breath.
Sometimes great blessings hide in what seem to be awful realities. Mother is not more poor today than she was a week ago. In fact, as of January 1, 2014, she will be $269 per month richer, and she will have a comprehensive medical insurance program with little or no regular out-of-pocket cost. If Mother is unable to bring herself to use her Washington Apple Health coverage, she does not have to do so. But neither will she have to pay for a policy that does not actually protect her.
Will Mother choose to use her new health care options? That is not a question anyone else can answer. She is approaching an age (55-64) at which insurance premiums skyrocket and many Americans have found themselves priced out of the market. At the same time, she has reached the age at which screening tests for deadly diseases begin showing positive results and lives are saved by early interventions. Tests such as mammograms, PAP smears, bone density screening, and colonoscopies are typically ordered for people in their early 50s. These tests are not inexpensive. Prior to the ACA, patients often had to pay for them through their deductibles.
The ACA treats screening exams as preventive care and as such they are not subject to deductibles or copays. Health insurance policies pay for them in full. Medicaid treats them the same way. Mother will not be forced to submit to these exams, but she would be well-advised to get them. They save lives and prevent much suffering for individuals and their families.
What might Mother do with her new-found wealth? If Mother does not have a well-funded retirement portfolio and truly does have enough money to meet her monthly needs, perhaps she and Ms. Hopkins could look at ways to set aside the $269 per month into a savings or retirement plan. Alternatively, if she is not comfortable keeping the money herself, she could donate it to a charity of her choice. However, if she does not have money in a liquid savings account, she should hold on to it and build up her reserves for “rainy days” that might yet come.
When her fortunes turn around and she gets more work, higher paying work, or employer-sponsored health insurance, she can simply report to Washington Apple Health that she no longer needs their health plan. At 138% FPL, she will be able to go to the marketplace and purchase a policy for which she herself pays the premium. Unless her income is greater than 400% of FPL, she will be well advised to accept a bit more help in the form of cost sharing reductions and/or advanced premium tax credits (subsidies). But that’s another issue for another day. Until then, qualifying for Medicaid may turn out to be a huge blessing in disguise.