Fighting for Coverage

https://www.managedhealthcareexecutive.com/news/fighting-coverage?rememberme=1&elq_mid=12155&elq_cid=876742&GUID=A13E56ED-9529-4BD1-98E9-318F5373C18F

Fighting for Coverage | Managed Healthcare Executive

One of the main goals of the ACA, sometimes referred to as Obamacare, was to provide affordable health insurance to every American.

The law’s passage in 2010 made it possible for nearly 54 million Americans—previously denied coverage due to pre-existing medical conditions—to purchase coverage, as well as landmark provisions to protect those who developed an expensive medical condition while insured from being unexpectedly dropped by their health plan.

By all accounts, such provisions helped a record number of Americans procure medical insurance coverage—and, by extension, reduce healthcare costs and avoid medical bankruptcies.

Yet, with the elimination of the individual mandate penalty in 2017, and other policy changes that have forced up the cost of premiums, many Americans are looking for options off the healthcare exchange.

One such option is the short-term limited duration insurance (STLDI) plan, loosely defined as bare bones medical coverage that can last up to 12 months with the potential for renewal. Managed Healthcare Executive® Editorial Advisor Margaret Murray, chief executive officer of the Association for Community Affiliated Plans (ACAP), said such plans “are not really insurance,”—and refers to them as “junk insurance.” With a new 2018 HHS rule that dramatically expands access to this type of coverage, she worries that their availability will hurt consumers.

“Insurance brokers may offer these plans to consumers and those consumers may not realize that they largely reverse ACA protections regarding pre-existing conditions and coverage limits,” she says. “These plans don’t cover what you think they will cover, the insurance companies can cancel your policy at any time, and they can deny your access to maternity care and certain drugs. It’s not really major medical insurance and it’s not always easy for your average consumer to see that.”

Changing regulations

The Trump Administration contends, with rising insurance premiums, that such short-term plans make health insurance more affordable for the average American.

Cathryn Donaldson, a spokesperson for America’s Health Insurance Plans, a health insurance trade association, says such plans “can provide a temporary bridge for those who are going through a life transition or gap in coverage such as having a baby or changing jobs.”

Yet, Karen Pollitz, a senior fellow at the Kaiser Family Foundation, says STLDI plans embody the old adage about getting what you pay for. STLDI are not required to comply with many of the ACA’s most important protections, which means insurance companies can exclude coverage for pre-existing conditions, charge higher premiums based on health status, impose annual and/or lifetime caps, and opt out of coverage for things like maternity care or mental health treatment. They can also revoke coverage at will.

“Under the ACA, it used to be that short term and minimum essential coverage [MEC] policies had to have a prominent warning printed on the front place that said, if you buy this, you are not getting full coverage and may even owe a tax penalty,” she explains. “Those warnings are no longer there and that’s of concern.”

Furthermore, late last year, HHS put forth a final rule extending the duration of STLDI from a mere three months up to 364 days. In addition, insurers can offer renewals and extensions for up to three years. What is even more concerning, Murray says, is the current Administration is now actively promoting the use of private web broker sites to market STLDI. This can make it more difficult for consumers to understand which plans offer comprehensive medical coverage and which are the riskier STLDI plans.

“The current administration says such plans offer consumers more affordable options—and more choice,” Murray explains. “But the marketing for these plans is really disingenuous. It’s not just that they are just short-term. They don’t cover what people think they will cover. They are very profitable for insurance companies. But they can be very costly for consumers, who likely won’t realize they don’t have comprehensive coverage until they are sick or injured.”

The fall-out

Over the past few months, several high-profile publications like Consumer Reports and the Washington Post have printed stories about the dangers, and unexpected costs, of STLDI for consumers.

“It’s like you are in the market for a car and someone offers you a really affordable roller-skate,” says Pollitz. “But a roller-skate is not the same thing as a car. It’s not going to get you as far if you really need to travel. And it’s going to cost you more in the long run.”

Murray also cautions more widespread adoption of such plans can affect the entire insurance market, siphoning cost-conscious consumers from risk pools and driving up premium costs for everyone.

“There are always some young invincibles, who think they won’t get sick—and there are some invincibles, too—and they will be attracted by the lower premiums,” she says. “But in doing so, that will leave people who are sicker to pay higher rates by moving people out of the ACA marketplace.”

That’s one reason why ACAP, as well as six other health organizations, filed a lawsuit in the U.S. District Court for the District of Columbia on September 14, 2018 in order to roll back the new STLDI rule and stop the expansion of such plans. Murray said the HHS rule violates the ACA, “undercutting plans that comply” with the still active legislation. They argue the Trump Administration is using these new rules to try to overturn the ACA—which they have not yet been able to successfully repeal in Congress.

“We thought this was important enough that it was worth suing the federal government in order to try and stop it,” she says. “We had hoped to get a summary judgment last year because we wanted to stop the spread of STLDI plans for the 2020 open enrollment. Unfortunately, we didn’t get that. The judge ruled against us. But we are appealing it—and the hope is that we will have a decision to stop these things being sold in 2021.

The take-home message

Donaldson says it is vital the healthcare community educate consumers about the risks of STLDI plans and make sure they are better aware of what sort of comprehensive plans are available on the Healthcare.gov marketplace.

“While alternative plans such as association health plans and STLDI may present more affordable premiums, they are not a replacement for comprehensive coverage and may not cover the treatments or prescriptions an individual may need throughout the year,” she says.

Pollitz agrees.

“We understand that life happens and there may be all manner of reasons why you are separated from coverage,” she says. “But it is becoming harder and harder to distinguish these plans from real coverage especially now that they are now being aggressively marketed to people all over the country. And it’s vital that people understand that 90% of consumers will play less than the listed price on Healthcare.gov marketplace because they qualify for subsidies. It really does pay to take the time to look before you sign up for one of these short-term plans.”

 

 

 

 

California accuses healthcare sharing ministry of misleading consumers

https://www.healthcaredive.com/news/california-accuses-healthcare-sharing-ministry-of-misleading-consumers/573900/

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Dive Brief:

  • The California Department of Insurance issued a cease and desist order to a major Christian group Wednesday for misleading consumers about their health insurance plans and acting as a payer without proper certification, joining a handful of other states scrutinizing the limited coverage.
  • Deceptive marketing by Aliera Healthcare, which sells health ministry plans, and Trinity, which runs them, led to roughly 11,000 Californians belonging to the unapproved “lookalike” plans that don’t cover pre-existing conditions and other required benefits, with no guarantees their claims will be paid, the state’s insurance regulator said.
  • Healthcare sharing ministries (HCSMs) are organizations where members share a common set of religious or ethical beliefs and agree to share the medical expenses of other members. They’re increasingly controversial, as policy experts worry the low-cost insurance attracts healthier individuals from the broader insurance market, creating smaller and sicker risk pools in plans compliant with the Affordable Care Act.

Dive Insight:

Aliera, founded in 2011 and based in Georgia, and Trinity allegedly trained sales agents to promote misleading advertisements to consumers, peddling products that don’t cover pre-existing conditions, abortion, or contraception. The shoddy coverage also doesn’t comply with the federal Mental Health Parity and Addiction Equity Act and the ACA.

The deceptive advertising could have pressured some Californians to buy a health sharing ministry plan because they believed they missed the deadline for buying coverage through Covered California, the state’s official insurance marketplace.

“Consumers should know they may be able to get comprehensive coverage through Covered California that will protect their health care rights,” California Insurance Commissioner Ricardo Lara said in a statement.

HCSMs, which began cropping up more than two decades ago as a low-cost alternative approach to managing growing medical costs, operate either by matching members with those who need help paying medical bills or sharing costs on a voluntary basis. They’re often cheaper than traditional insurance, but they don’t guarantee payment of claims, rarely have provider networks, provide limited benefits and usually cap payments, which can saddle beneficiaries with unexpected bills.

About 1 million Americans have joined the groups, according to the Alliance of Health Care Sharing Ministries.

At least 30 states have exempted HCSMs from state regulation, according to the Commonwealth Fund, meaning the ministries don’t have to comply with health insurance requirements. California does not exempt the religious-based groups from the state insurance code.

In January, Aliera and its subsidiaries, which includes Trinity, were banned from marketing HCSMs in Colorado after being accused of acting as an unlicensed insurer. One month later, Maryland issued a revocation order against Aliera for trying to sell an unauthorized plan in the state. Earlier this month, Connecticut issued a cease and desist order for conducting an insurance business illegally.

Aliera argues states are limiting the choices available to consumers, telling Healthcare Dive it was “deeply disappointing to see state regulators working to deny residents access to more affordable programs.”

“We will utilize all available opportunities to address the false claims being made about the support and management services we provide to Trinity HealthShare and other health care ministries we represent,” Aliera said.

However, Aliera and Trinity don’t meet the Internal Revenue Code’s definition of a health sharing ministry, according to California’s cease and desist, meaning their beneficiaries don’t meet California’s state individual insurance mandate.

The state can impose a fine of up to $5,000 a day for each day the two continue to do business, along with other financial penalties.

 

 

 

 

SUPREME COURT TAKES UP $12B DISPUTE OVER ACA RISK CORRIDOR PAYMENTS

https://www.healthleadersmedia.com/finance/supreme-court-takes-12b-dispute-over-aca-risk-corridor-payments

U.S. Supreme Court

The justices agreed to hear arguments over whether Congress can pass riders that withhold funds in contravention of the relevant law’s intent without actually repealing the relevant law.


KEY TAKEAWAYS

The health plans argue the ACA’s mandate to issue risk corridor payments could not be repealed through an appropriations rider.

The approximately $12 billion in payments at issue in this dispute are for three benefit years: 2014-2016.

The U.S. Supreme Court agreed Monday to take up three consolidated cases from health plans challenging Congress’ refusal to authorize $12 billion in risk-mitigation payments under the Affordable Care Act.

The cases—which were brought by Maine Community Health Options, Moda Health Plan Inc., and Land of Lincoln Mutual Health Insurance Co.—argue that the ACA’s risk corridor program obligated Health and Human Services to make payments that the law intended “to induce insurer participation in the health insurance exchanges by mitigating some of the uncertainty associated with insuring formerly uninsured customers.”

Following the 2014 midterm election, lawmakers on Capitol Hill enacted an appropriations law for fiscal year 2015 that “would potentially allot money to HHS to cover” any such payments for the 2014 benefit year, but the law included a rider that required HHS to maintain the budget neutrality of the risk corridor program, the health plans said in their petition.

Because the amounts collected under the risk corridor program for 2014 “came nowhere close to what the government owed to insurers,” the government paid out only 12.6% of the total owed for the year, prorating the funds it owed to each insurer, the health plans wrote.

Similar riders were included in appropriations bills for fiscal years 2016 and 2017. But HHS used the funds it collected from benefit years 2015 and 2016 to further pay what it owed from the 2014 benefit year, making no payments for the 2015 and 2016 benefit years, the health plans wrote. (The program ended after three years.)

The health plans proposed two questions in the petition for a writ of certiorari for the justices to consider, but the justices agreed to hear argument only on the first: “Given the ‘cardinal rule’ disfavoring implied repeals—which applies with ‘especial force’ to appropriations acts and requires that repeal not be found unless the later enactment is ‘irreconcilable’ with the former—can an appropriations rider whose text bars the agency’s use of certain funds to pay a statutory obligation, but does not repeal or amend the statutory obligation, and is thus not inconsistent with it, nonetheless be held to impliedly repeal the obligation by elevating the perceived ‘intent’ of the rider (drawn from unilluminating legislative history) above its text, and the text of the underlying statute?”

In its response to the health plans’ petition, the U.S. government argued that a Government Accountability Office report identified only two possible sources of funding for the risk corridor payments: (1) the funds collected by HHS under the program itself, and (2) any lump-sum appropriation to manage certain Centers for Medicare & Medicaid Services programs. By enacting the appropriations laws as it did, Congress said that only the first funding source would be allowed, the response states.

America’s Health Insurance Plans (AHIP) President and CEO Matt Eyles said in a statement that insurers need stability from the government.

“Millions of Americans rely on the individual and small group markets for their coverage and care. Health insurance providers are committed to serving these patients and consumers, working with the federal government to deliver affordable coverage and access to quality care,” Eyles said. “The Supreme Court’s decision to hear this case recognizes how important it is for American businesses, including health insurance providers, to be able to rely on the federal government as a fair and reliable partner. Strong, stable and predictable partnerships between the private and the public sector are an essential part of our nation’s economy, and our industry looks forward to having this matter heard before the Court.”

The justices allotted one hour for oral argument on the dispute.