Webinar: Delay, Deregulate, Derail — Health Care Roiled by Actions of Trump and Congress

Since January, both President Trump and Republican leaders in Congress have talked about a three-step process for repealing and replacing the Patient Protection and Affordable Care Act (ACA). While the first six months of the Trump administration has seen mixed results, its efforts to reign in or hold back regulations, combined with its delay in filling lower-level agency roles, has impacted regulatory review and issuance of new regulations. So, despite Congress’ inability to pass legislation to change parts of the ACA, there is still plenty for providers to be concerned about.

Join Associate Managing Editor Kathryn Beard, JD, on Wednesday, August 2, for this half-hour live webinar covering attempts by the Trump Administration and Congress to delay, deregulate, and derail significant parts of federal health policy. She will discuss the two “repeal and replace” bills, FDARA, and significant executive and regulatory actions taken by the Trump administration which directly impact ACA provisions.

Registration Link:

Preventing and fighting surprise medical billing: steps consumers should take

Thirty-two percent of insured individuals who had problems paying medical bills reported receiving care from an out-of-network provider that their insurance did not cover, while 69 percent of those individuals said they were not aware that the provider was not in their plan’s network when they received the care, according to a Kaiser Family Foundation (KFF) survey published in January 2016. Betsy Imholz, special projects director and a surprise medical bill expert at Consumer Reports, noted in a January 17, 2017, article that “the problem is only growing worse as our healthcare system grows more complex and more insurance companies narrow the network of doctors they contract with or shift to insurance plans that eliminate coverage for out-of-network services.”

What is a surprise medical bill?

A medical bill that an insured individual receives from an out-of-network provider when the individual is unaware that the provider is out-of–network is referred to as a “surprise medical bill.” Out-of-network providers may charge patients whatever they choose and may bill the patient for the amounts that were not paid by the patient’s health plan, referred to as a “balance bill.”

According to a March 2017 KFF report on surprise medical bills, such bills may arise from an emergency when the individual does not have the ability to select providers. Often, emergency room (ER) physicians do not participate in the same health plan networks as the hospitals where they work. In addition, the patient may not have had the ability to choose the hospital or the ambulance provider. In situations when a patient receives planned care, such as a planned surgery from an in-network provider (for example, a hospital or ambulatory surgical center), other providers involved in the surgery may not be in the same network. In many nonemergency situations, the in-network provider rather than the patient arranges for the other providers participating in the procedure or treatment. Such providers may include anesthesiologists, radiologists, pathologists, and surgical assistants.

What consumers can do

Individuals can prevent surprise medical bills by avoiding receiving services from out-of-network providers, when possible, and fight surprise medical bills after receiving them. A Center on Health Insurance Reforms (CHIR) report identified the following steps for patients to take to prevent unexpected charges:

  • Use provider directories and other plan provided information to identify in-network providers;
  • Ask providers if they are in the patient’s health plan network;
  • After receiving a balance bill, the patient should review the plan’s explanation of benefits and notices about consumers rights;
  • Before paying a balance bill, the patient should contact the health plan and the provider to find out if the plan is willing to pay the bill and/or if the provider will accept a lesser amount; and
  • Contact the state insurance department to see if there is a remedy under  state law.

Additional tips for patients were addressed in an April 6, 2017, article in Consumer Reports written by Donna Rosato. In cases of emergency care or if ambulance service is needed, Rosato recommended the individual to ask the first responders or ER doctors to provide documentation confirming that the individual had no choice and transport by ambulance was medically necessary. She noted, however, as a preventive measure, that individuals find out, before needing to go to an ER, which nearby hospitals are in-network and which ER physicians are in-network. Then, in an emergency, if possible, the individual can request to be taken to an in-network ER. In nonemergency situations, such as a planned surgery, Rosato also suggested that individuals obtain a list from the doctor’s billing staff (and hospital) of other providers that may be part of the procedure or treatments such as an anesthesiologist, radiologist, and pathologist. Then contact the insurance plan and ask if the providers identified are in-network. If the providers are out-of-network, the individual should notify the attending physician and request providers who are in-network.

Highlight on Minnesota: Health plans’ red ink worst in a decade

Nonprofit insurers in Minnesota reported an operating loss of $687 million on nearly $25.9 billion in revenue for 2016, according to a trade group for insurers, the Minnesota Council of Health Plans. The financial results were the worst in a decade, with losses in both the state public health insurance programs and the marketplace where individuals purchase coverage for themselves.

Overall, revenue from premiums increased 4 percent over the prior year, while expenses increased 6 percent to $26.6 billion. State public programs accounted for more than half of the overall losses, followed by continued losses in the individual market. According to the report, on average, health insurers paid $763 per second for care. To pay those bills, insurers withdrew nearly $560 million from state-mandated medical reserves. The bulk of the financial losses reported did not result from the employer group and Medicare markets, which remained steady, and where most Minnesotans get health insurance.

In the individual market, Blue Cross and Blue Shield of Minnesota said it lost $142 million for 2016, compared to a $265 million deficit the previous year. The decline mirrored the drop in enrollment, the insurer noted, rather than an improvement in the business. Over the last 10 years, health insurers returned a profit in seven. The numbers reported by the trade group focused solely on revenue and income from the health insurance business, as investment returns made by insurers were not counted in the numbers. Some saw hope in the overall numbers, however, noting that the market was not in a “death spiral,” as some health law critics have argued, because many insurers in 2016 saw slight improvements from the previous year.

AHCA’s Patient and Stability Fund would benefit large states, study finds

Large states and states with fewer insurers offering coverage in the individual and small group markets could receive the most money under the American Health Care Act’s (AHCA) Patient and State Stability Fund, according to a study by Avalere. The AHCA, which consists of two bills that came out of the House Ways and Means and Energy and Commerce Committees, is touted as an effort to repeal and replace the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

Bill

Section 132 of the Ways and Means bill would add title XXII to the Social Security Act to create the Patient and State Stability Fund. The Fund would provide funding for the states and District of Columbia from 2018 through 2026 for eligible states to do any of the following:

  • provide financial assistance to high-risk individuals who do not have employer health insurance to enroll in health insurance coverage in the state’s individual market;
  • provide incentives for entities to enter into agreements with the state to help stabilize health insurance premiums in the health insurance market;
  • reduce the cost for providing coverage in the individual and small group markets;
  • promote participation in the individual and small group markets and increase available insurance options;
  • promote access to preventive services, dental care, and certain services for individuals with mental or substance abuse disorders;
  • provide payments to providers for the provision of health care services as specified by the Administrator; and
  • provide assistance to reduce out-of-pocket costs for individuals enrolled in health insurance coverage in the state.

Funding

The bill would appropriate $100 billion over 10 years to provide allocations to states. According to Avalere, the first 85 percent of the funds would be distributed based on the share of the state’s insurance claims as a percentage of the nation, so states that have more people with insurance and higher medical costs could receive more funding that states lower overall enrollment and spending.

The remaining 15 percent would be distributed to states that have seen an increase in the number of low-income uninsured from 2013 to 2015 or have fewer than three insurers offering coverage in their exchange in 2017.

Distribution among states

According to Avalere, the allocation methodology could result in states like California, Florida, and New York receiving the most money North Carolina, Arizona, Alabama, Oklahoma, and South Carolina could receive disproportionately high amounts of money due to the lack of health insurance participation on their markets in 2017.

The funding levels “vary widely” on a per capita basis compared to the state’s individual market enrollment in 2015, Avalere concluded. They range from $1,830 in the District of Columbia to $220 in Montana.