Obamacare mandate delay costs $12 billion, cuts insurance coverage


WSJ: How to Shop Smart on New Health Exchanges

How to Shop Smart on New Health Exchanges

Tips on Selecting the Right Plan


Millions of Americans will be shopping for their own health insurance for the first time this fall—but they will need to look closely to be sure they get the coverage that best fits their needs.

On Oct. 1, new government-backed online health-insurance marketplaces are supposed to launch in every state, sparked by the federal health law. Around seven million people are projected to buy plans there for 2014, many helped by federal subsidies, and the number is expected to swell to as many as 25 million in later years. Adding to that, some employers are considering new setups where they give workers a set sum of money to select plans in a similar type of exchange created by private companies.

John Nickle

The health law sets many requirements aimed at standardizing plans and making them easier to compare. On the law’s public exchanges, for instance, coverage will be divided into four tiers ranging from the cheapest, "bronze," covering around 60% of health-care expenses on average, through the priciest, "platinum," covering 90%. There will also be limited-coverage "catastrophic" plans for people younger than 30. All plans will be expected to include certain mandated benefits such as maternity care and hospital stays, and they can’t cap annual or lifetime payouts.

Still, despite the rules, plans may vary quite a bit—giving consumers important decisions to make. "Take your time to understand the plan" you’re considering before you buy it, says Carrie McLean, director of customer service at eHealth Inc., parent of eHealthInsurance.com.

For starters, people have to pick an insurer, and in many markets, these could include new players that haven’t sold commercial plans before. The nonprofit National Committee for Quality Assurance offers "report cards" about existing health insurers at ncqa.org.

Importantly, consumers will be able to choose how they will pay out of their pockets for care. The plans will cap the out-of-pocket total for the year at $6,350 for an individual plan and $12,700 for family coverage. But a plan’s charges could come in various forms including deductibles, copayments or a percentage of the cost of certain types of services, a setup known as coinsurance.

"You need to look at it and say, ‘Can I come up with it quickly?’ " since treatments for a serious condition may soon ring up the total out-of-pocket maximum, says Karen Pollitz, a senior fellow at the nonprofit Kaiser Family Foundation. And, she warns, consumers may have to pay out the annual maximum sum twice, if they require care that stretches into more than one plan year.

Another key thing for consumers to examine is what doctors and hospitals are in a plan’s network, says Robert Krughoff, president of Consumers’ Checkbook, a nonprofit that rates health plans and medical providers on quality and cost. Exchange plans are expected to often feature limited choices of health-care providers, and who’s included may vary quite a bit.

To try to figure out if the institutions are the best in the area, consumers can look for quality assessments through resources like the website of the nonprofit Informed Patient Institute, informedpatientinstitute.org; the federal Medicare program’s Hospital Compare at medicare.gov/hospitalcompare; or Mr. Krughoff’s group’s GuideToTopDoctors.org and GuideToHospitals.org.

Some health maintenance organization, or HMO, plans may generally not cover out-of-network services. Plans that are labeled as preferred-provider organizations, or PPOs, may still potentially include large charges for consumers who go to hospitals and doctors outside their networks.

Consumers should also probe whether they could face barriers to accessing certain types of care, experts say. For instance, some plans may require referrals by primary-care providers before a patient sees a specialist, or may have extensive pre-authorization requirements.

Another caution: consumers who require certain prescription drugs should check if their medications are on a plan’s list of covered medicines, and how much they may have to pay to get them, experts say.

Write to Anna Wilde Mathews at anna.mathews

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Press Release: D.C. Agrees to Settle With Chartered Health for $48 Million

DISB header
For Immediate Release
July 24, 2013
Contact: Michael Flagg, (202) 442-7756

D.C. Agrees to Settle With Chartered Health for $48 Million

A Judge and Federal Medicaid Agency Must Still Approve the Deal Before the Medicaid Insurer’s Health-Care Providers Will Begin Seeing Payment

Washington, D.C. (July 24, 2013) – The official overseeing the receivership of D.C. Chartered Health Plan Inc. and the District’s Department of Health Care Finance agreed to settle for $48 million claims that the District under-reimbursed Chartered.

The settlement is subject to approval by the D.C. Superior Court and authorization by the federal Centers for Medicare & Medicaid Services.

Chartered, once the District’s largest Medicaid insurer, had filed claims with the District for more than $60 million, saying the department had under-reimbursed it for providing HIV/AIDS drugs to patients and for other medical and dental care.

The settlement agreement says the parties reached this agreement “in order to avoid the delay, uncertainty, inconvenience and expense of protracted litigation of the claims asserted or that could have been asserted by Chartered….”

The settlement is intended to resolve all Chartered’s claims, including claims it had not yet filed. The District denies all Chartered’s claims. The settlement agreement states that it is “neither an admission of liability nor a concession by the District.”

The settlement agreement provides that the entire $48 million settlement will be used to pay what Chartered owes the medical-care providers who treated its clients.

Chartered estimates it owes hospitals, clinics and doctors more than $50 million for undisputed claims. Chartered intends to set aside funds already in its bank accounts for disputed claims, the largest of which is with MedStar Health, the large regional not-for-profit chain of hospitals and doctors’ offices.

A Superior Court judge supervising the receivership must now determine whether the agreement can be approved. The rehabilitator appointed to oversee the receivership has filed the agreement with the court and soon will file a motion requesting the judge approve it. The next court hearing is scheduled for Aug. 21, but the court may schedule another hearing sooner.

If the judge and the federal Centers for Medicare & Medicaid Services approve the agreement, Chartered could begin paying doctors, clinics and hospitals shortly afterward. The District intends to administer its payments through a grant program; the details will come from the D.C. Department of Health Care Finance.

Chartered was by far the largest of the city’s handful of Medicaid insurers, covering more than 100,000 of the District’s poorest people, before it ran into financial troubles and was taken into receivership.

The receiver sold most of Chartered’s assets to AmeriHealth Group of Companies headquartered in Philadelphia, which operates as AmeriHealth Caritas here, transferring the 100,000 enrollees from Chartered to AmeriHealth with no interruption in their health care.

However, Chartered began to run out of money in April as its contract ended and just before the deal with AmeriHealth closed, and Chartered suspended claim payments to hundreds of doctors, hospitals, clinics and other providers.

The rehabilitator, William P. White, commissioner of the Department of Insurance, Securities and Banking, assumed three major responsibilities when he took over the company in October: Ensuring that Chartered’s vulnerable clients continued to get health care; that Chartered receive fair value for its claims against the District; and that providers be fairly reimbursed.

“We’ve already concluded a complicated sale to AmeriHealth in record time and seamlessly transitioned Chartered’s clients with no interruption of care,” said Commissioner White. “Now this settlement goes a long way toward meeting our second obligation, receiving fair value for Chartered’s claims, and our third, paying the providers what they are owed.”

To view the notice filing, settlement agreement and other related documents, visit disb.dc.gov/chartered.

Living-wage supporters’ latest appeal to Vincent Gray: Save our ‘self-determination’

ObamaCare employer mandate delayed until after 2014 midterms

ObamaCare employer mandate delayed until after 2014 midterms

By Elise Viebeck, Sam Baker and Amie Parnes – 07/02/13 07:15 PM ET

The ObamaCare employer mandate requiring businesses to provide their workers with health insurance will be delayed by a year, the administration said Tuesday in a stunning announcement.

Delaying the requirement until 2015 represents an enormous victory for businesses that had lobbied against the healthcare law.

It also means that one of healthcare reform’s key requirements will be implemented after the 2014 midterm elections, when the Affordable Care Act is expected to be a key issue for vulnerable Democrats.

In a White House blog post, senior adviser Valerie Jarrett wrote that the administration believed they needed to give employers "more time to comply with the new rules."

"This allows employers the time to test the new reporting systems and make any necessary adaptations to their health benefits while staying the course toward making health coverage more affordable and accessible for their workers," Jarrett wrote Tuesday evening.

Jarrett also wrote that the delay would help in "cutting red tape and simplifying the reporting process."

"We have heard the concern that the reporting called for under the law about each worker’s access to and enrollment in health insurance requires new data collection systems and coordination," Jarrett said. "So we plan to re-vamp and simplify the reporting process."

Treasury’s announcement does not affect the individual mandate, which requires most taxpayers to either purchase insurance or pay a penalty, and administration officials said on Tuesday that other aspects of the law wouldn’t be delayed.

The law’s critics quickly framed that as a double standard, accusing the administration of acknowledging the law’s complexity for businesses without offering a similar break to the individual workers who still have to buy insurance. The employer mandate affected businesses with more than 50 workers.

"That the Obama Administration is putting off this job-killing requirement on employers, but not individuals and families, shows how deeply flawed the president’s signature domestic policy achievement is," said Sen. Orrin Hatch (Utah), the ranking Republican on the Senate Finance Committee.

"While a delay of this mandate is welcome news since it shows the challenges the employers are facing complying with it, a delay – conveniently past the 2014 election – only adds to the uncertainty these job creators face because of ObamaCare," Hatch said.

Other Republicans seized on the news, arguing that the delays suggested the law was a "train wreck" and that Democratic candidates in 2014 would have difficulty explaining the delay.

Speaker John Boehner (R-Ohio) and House Majority Leader Eric Cantor (R-Va.) renewed their calls for repealing the law in full.

"This further confirms that even the proponents of ObamaCare know it will hurt jobs, decrease economic growth and make it harder for families to have access to quality and affordable health care," Cantor said in statement.

"Rather than continuing to delay the predictable pain until another election day has passed, we should scrap this entire law and instead implement patient-centered reforms before any more damage is done," he said.

Some Democrats had openly fretted about the law’s implementation.

While GOP leaders were quick to react, hammering the delay as evidence that the law is unworkable, Democratic leaders were quieter Tuesday evening. One exception was Democratic National Committee chairwoman Debbie Wasserman Schultz, who tweeted that the decision shows President Obama is "in it for long haul to fully implement" the healthcare law.

Reta Jo Lewis, ex-State Department official, enters D.C. mayor race

On Exchanges: Uncertainty Not So Much Will They Open — But What They’ll Charge

June 28, 2013 – 5:26 p.m.

On Exchanges: Uncertainty Not So Much Will They Open — But What They’ll Charge

By John Reichard, CQ HealthBeat Editor

Will the health law insurance exchanges open on time in fewer than 100 days? So much drama seems to surround that question that one might think the fate of the entire overhaul rests on the answer.

Republicans on the Hill frequently express doubt that the new marketplaces will be ready on time. Meanwhile, with almost robotic regularity, Obama administration officials say that the grand opening will occur as scheduled on Oct. 1 — often without saying much else.

But given the massive size of the job, snafus and delays here and there are a sure thing.

The much less complex launch of the Medicare prescription drug program in 2006 had glitches too, even though the Bush administration had a couple of years to prepare. Seniors complained about the bewildering variety of plans. In some cases, there were delays in getting poor and sick elderly Americans enrolled in prescription plans that had the medicines they needed.

In the end, the good value seniors got and the protection against illness that came with ready access to pharmaceuticals, made the drug benefit a smashing success.

So glitches associated with the launch of exchanges will likely fade in importance if premiums charged to exchange visitors are affordable and the coverage they get protects them against financial catastrophe.

So far, it looks like rates are going to be a mixed bag next year. Big-population states enthusiastic about implementing the law may wind up being able to offer more attractive premiums. States with smaller populations or that are hostile to the law may see less attractive rates. Why? Because outreach efforts will be weak, insurers won’t expect a big exchange enrollment, and there may be problems in those places with little insurer competition.

Such an uneven experience geographically suggests the current red-state, blue-state divide over the law may never end. But if rates are all over the place and the pocketbook impact of high rates is lessened by widely available premium subsidies, the collapse of the law over the next few years that some Republicans are forecasting is less likely to occur.

Lots of Resources to Make Exchanges Available

There’s been plenty of money flowing from Washington to the 17 states that have decided to open their own marketplaces, and the federal spigot won’t be shut off until 2015.

To date, the Department of Health and Human Services has awarded $3.8 billion in grants to states and the District of Columbia to plan and open exchanges, according to a June 19 Congressional Research Service report.

The health law (PL 111-148, PL 111-152) “provided an indefinite appropriation for HHS grants to states to support the planning and establishment of exchanges,” the report says. “For each fiscal year, the HHS Secretary is to determine the total amount that will be made available to each state for exchange grants.” HHS can award the grants through the end of 2014.

To the extent there are operational problems, that suggests the resources will be there to fix them. What about the 33 states that are depending in whole or in part on a federal exchange to offer health plan choices in their states? Congress isn’t providing added money for outreach for that exchange, but the Obama administration nevertheless has the resources of the federal government, its employees, and their data handling capacities to devote to getting that marketplace going.

HHS officials appear increasingly comfortable with their repeated predictions that the federal exchange will open on time. They have been more forthcoming about exchange details after many months of saying very little. And during the past week HHS officials invited reporters to its headquarters for an extended question-and-answer session on the exchanges and on outreach. And they said they would schedule such meetings regularly in the weeks remaining before the exchanges open. The Government Accountability Office raised doubts about exchanges opening on time in a recent report, but analysts say it’s possible to get the marketplaces started with a less sophisticated computer interface in the early going.

Rate Shock and Rate Joy

If rates for individuals and small businesses in the exchanges were uniformly unaffordable, Democratic support for the health law could begin to crumble threatening its survival. But in recent weeks gleeful supporters of the overhaul have pointed to rates in California and a number of other states as evidence that rate shock at a minimum won’t be the typical marketplace experience (See related story, CQ HealthBeat, May 29, 2013).

A recent study by the consulting firm Avalere Health concluded that premiums in nine states for “silver” plans will be lower than the Congressional Budget Office has predicted.

Princeton University economist Uwe Reinhardt recently said the shopping experience for some consumers will be “rate joy” because of the difficulty some Americans have getting coverage at all and the availability of subsidies to lower premium costs.

An Urban Institute study released Friday by Linda Blumberg and Shanna Rifkin that looked at small business exchanges in six states found that these marketplaces will expand consumer choices, ease administrative burdens involved in signing up for coverage, and increasingly give small business employees a choice of plans, a “rarity” now.

On the other hand, it’s a certainty that rates are going to rise in many instances because of the health law because it will require more comprehensive coverage and because of various fees it assesses on insurers. In Ohio, state officials forecast a rate hike of 88 percent in the individual market. In a U.S. Chamber of Commerce report released earlier this week, Brookings Institution analyst Mark McClellan suggested that small businesses would see rate hikes of up to 30 percent in many instances because of the overhaul.

And even if rates are reasonable, a poor user experience that makes it difficult to compare plans and enroll online could turn many people off initially. And a significant data privacy breach involving personal health and tax data flowing through a federal “data hub” central to the operations of the federal exchange could undermine already shaky public support for the health law.

Results Will Vary by State

According to Joel Ario, an industry consultant who previously led exchange development efforts in the Obama administration, the operational challenges involved in setting up exchanges will prove manageable, while premiums are likely to vary from state to state.

Ario said in an interview that, in general, thanks to “a focus on mission critical elements, and a willingness to jettison things that can be second-year priorities,” the exchanges in general will open on time. “The first iteration on both the state and federal side will not have state-of the-art consumer tools that will make this an Amazon-like experience for people,” he predicted. But “it will keep getting better.”

Ario says that the 17 states planning to open their own exchanges will in most instances succeed. “A couple of them will need assistance from the federal government on the eligibility and enrollment side,” he said.

“You’ve already seen some success stories — California, Oregon — I think you’re going to see some additional success stories, particularly in the larger, more competitive states, including by the way in some federal exchange states. But there will be smaller states, and some of the less cooperative states … that will produce less positive results. So it’s like it usually is about the state marketplace, they vary a lot state by state.”

Attracting the Young Will Be Key

Probably the more pivotal question about the durability of exchanges is not on the operational side but on who they attract. Without young and healthy customers rates will become unaffordable over time. “Pricing matters a lot there,” says Ario. “If the pricing can stay particularly under $200 as it has per month in some of the states on the low end and you add a catastrophic plan that could be even cheaper than that, I think those prices are critical to attracting that group,” he said.

Also important is whether young people take seriously the so-called personal responsibility — mandate — in the law that requires them to get insurance and penalizes them if they don’t. “If we don’t get the sign-up we want, then maybe there should be some additional cost that accrues” for those who wait to sign up as is the case in the Medicare program, Ario said.

The battle over effective strategies for signing up the young is beginning to heat up, with opponents of the law also realizing it will be critical and objecting to tactics eyed by the Obama administration.

HHS is particularly keen on enlisting sports leagues to urge the young to sign up for coverage but Republicans are fighting back. Senate Minority Leader Mitch McConnell, R-Ky., and GOP Whip John Cornyn, R-Texas, sent a letter Friday to the National Football League, the National Basketball Association, Major League Baseball, the National Hockey League, and NASCAR urging them not to cooperate. “It is difficult to understand why an organization like yours would risk damaging its inclusive and apolitical brand by lending its name to promotion,” the letter said.