Colorado Health Insurance Insider - Latest Comments

Re: Connect for Health Colorado Enrollment Update And Upcoming Deadlines

belinda — Tue, 01 Apr 2014 21:48:11 -0000

File for Colorado Health insurance on-time to avoid the rush.

Re: Connect for Health Colorado Exceeding Enrollment Targets

Charles Gaba — Mon, 10 Mar 2014 12:22:48 -0000

No problem. Some states had their targets changed pretty radically, others stayed about the same like yours.

Re: Connect for Health Colorado Exceeding Enrollment Targets

Louise — Mon, 10 Mar 2014 12:19:09 -0000

Thanks for taking the time to stop by here and provide more clarification - I really appreciate it! I've added an edit to the post, letting people know that there's more info in the comments.

Re: Connect for Health Colorado Exceeding Enrollment Targets

Charles Gaba — Sun, 09 Mar 2014 09:49:56 -0000

Hi, saw your link to my site (thanks!) and just wanted to let you know that I've actually issued a revised version of my "% of 7 million" / "% of 6 million" projection formula.

When I first devised the "14%" method, I forgot about 3 important factors. First, I forgot to remove undocumented immigrants, who aren't eligible for either Medicaid *or* the ACA exchanges. Second, I forgot to *separate* those who qualify for Medicaid from those who qualify for private QHPs; it's not a pick-your-poison situation...if you qualify for one, you don't qualify for the other. Third, I forgot to remove the poor folks stuck in the "Medicaid Gap" in non-expansion states.

Finally, it seems that Kaiser has revised their total uninsured estimates since the original study; I've corrected for that as well. Details here:

http://acasignups.net/14/03...

For Colorado, the end result of these modifications is actually not all that different--a slight reduction in the target numbers to 102,000 (7M) or 87,000 (6M).

http://acasignups.net/poten...

Re: Understanding Drug Formularies On New Individual Health Insurance Plans In Colorado

Louise — Sun, 02 Mar 2014 17:51:47 -0000

Absolutely. It's also important to note that every category/class of drug has at least one covered medication on every formulary. If someone is taking a drug that isn't covered, there's a good chance that her doctor can switch her to a formulary drug that will work just as well. And if not, there's a solid appeals process in place. That said, if given a choice between two plans, one of which covers the drugs a person is taking, and the other of which requires them to switch to different medications, most people seem to prefer the plan that covers their existing prescriptions. So knowing how to compare formularies is valuable for consumers with on-going prescription needs.

Re: Understanding Drug Formularies On New Individual Health Insurance Plans In Colorado

Maggie Mahar — Sun, 02 Mar 2014 17:37:55 -0000

Thanks Louise. Most people want to be sure that the drugs they currently take will be covered by their plan. I do. But if a drug isn't covered, it's worth asking why. Try Goggling the name of the drug:
are their questions about its safety and risks?

Ask your pharmacist; he/she can be a valuable resource.

Re: Understanding Drug Formularies On New Individual Health Insurance Plans In Colorado

Louise — Sun, 02 Mar 2014 16:22:06 -0000

Good points Maggie! I've updated the article to refer readers to your comment. My purpose in writing this was to provide a resource for our clients who are wondering whether the medications they're currently taking will be covered by a new plan. We want to make sure they're aware of the formularies and how to compare the various options based on drug coverage, if that's an issue for them. But you make a great point about the fact that narrow formularies - just like narrow networks - can be found on excellent plans.

Re: Understanding Drug Formularies On New Individual Health Insurance Plans In Colorado

Maggie Mahar — Sun, 02 Mar 2014 15:18:09 -0000

Louise--

Very helpful information. Just one comment--the fact that Kaiser covers a smaller percentage of all drugs doesn't tell us whether its formulary is better or worse.

Kaiser P. uses its own extensive electronic records to figure out which drugs are safe and effective for patients who fit a particular medical profile. In order words, when setting up a formulary it is practicing evidence-based medicine. (Many insures make the decision primarily by looking at price and what is popular. They don't want to lose market share if they don't include popular drugs.)

Kaiser, on the other hand, worries about safety. In the past,Kaiser, the Mayo Clinic and the VA all took a very popular drug out of their formularies because there was concern that it was killing people. Turns out it was. A year or two later the drugmaker was forced to take it off the market. (Sorry I can't remember the name of the drug--maybe you do?)

Meanwhile, both Medicare and large-for-profit insurers continued to cover the medication until it was withdrawn.

There are too many drugs out there that hurt some or even most patients.
Good insurers narrow their formularies--just as they narrow their networks--in an effort to provide safe effective care. Btw, Kaiser docs can prescribe drugs not in the formulary for patients who, for some reason, cannot take the preferred drug.
They just need to ask another doctor to sign off.

Re: Future Healthcare Expenses Will Not Necessarily Mirror Past Expenses

Louise — Mon, 17 Feb 2014 14:20:02 -0000

It's true that health insurance policies have drug formularies that do not include all FDA approved medications. But that has always been the case. And in the past, policies could be sold that didn't cover prescriptions at all, or that covered only generics or low-cost brand name drugs, leaving higher-cost drugs as a non-covered expense. Those policies are no longer for sale.

Just as you have a chance to switch to a new Medicare D plan each year during open enrollment (a very good idea if a drug you're taking is no longer covered by your plan), people who enroll in new individual plans - either through the exchange or off-exchange - also have a chance to switch to a new plan each year during open enrollment.

Connect for Health Colorado (the state-run exchange) has links to each plan's formulary, so applicants can browse the drug lists to find the plan that works best for them.

All policies must cover at least one drug in each class, so in many cases a doctor will be able to substitute a formulary drug for a non-formulary one. If there is no medically-acceptable substitute, the doctor and patient can petition the carrier to try to get the medication covered and/or added to the formulary. And of course, the patient can also switch to a new plan during open enrollment or if life events trigger a special open enrollment.

Re: Future Healthcare Expenses Will Not Necessarily Mirror Past Expenses

TexasOlTimer — Mon, 17 Feb 2014 07:41:09 -0000

While Obamacare requires that pre-existing conditions be covered, one should ask what is involved in covering that pre-existing condition - or any condition for that matter.

Obamacare has a "closed drug formulary." This is similar to what we've seen in our insurance policies but we've been allowed to pick and choose the appropriate policy that will cover what we need. Medicare also has the same type of formulary. Medications that were covered last year under Medicare may not be covered this year (as two of mine are not). These will be out of pocket and will not count toward any deductible.

If a needed drug that must be taken daily for the rest of one's life isn't covered, is the pre-existing condition actually covered?

Re: Do Not Assume Your Provider Network Will Be The Same As It Was Last Year

Maggie Mahar — Thu, 16 Jan 2014 12:53:06 -0000

Louise --A great post!

Thanks much for pointing out that Cedars Sinai in L.A. isn't providing great value for the prices it charges. As you say, "bling" doesn't improve hospital care, though it can add to the perception that the hospital is better. (In fact, we have no evidence that higher prices correlate with higher quality.)

Also when consumer reports looks at insurers (using NCQA quality measures) it finds that HMOs (that have narrower networks) get high ratings for preventive care, making sure that patients chronic diseases are managed, and patient satisfaction than PPOs.http://www.healthbeatblog.com/2011...

Non-profits also rank "head and shoulders" above for-profit insurers. This is something people might keep in mind when picking a plan.

Finally "integrated health plans" (that both provide health care and insure you) such at Group Health in Wisconsin, or Kaiser in Colorado anywhere are, by definition narrow networks and get very high ratings. http://www.healthbeatblog.c...

Re: Getting Past The Health Insurance Plan Cancellation Hysteria

Margie — Sun, 17 Nov 2013 16:48:53 -0000

I think you've hit the nail on the head, with the importance of medical history questions not being on the application. As to reputable carriers though, I've heard of or experienced problems with "reputable" carriers, so I'm not sure that "reputable" means much. We had a "reputable" carrier that continued to just say claims were "pending" while we continued to get bills from doctors that were getting more and more past due. We finally had to get help from our state's insurance department (we had a good insurance commissioner at the time), and I had to spend hours putting together a five-page explanation and documentation of everything that had gone on. It was a good thing that I keep very good records, including records of conversations with the insurance company, or there's no way I could have gotten the problem resolved. And sometimes a carrier that might be fine as long as you have a group policy with a large corporation, becomes a problem when you get into the individual market. In other words, when they've got an incentive to behave, because they don't want to lose the business of a large corporation, they are more likely to behave. But when they're dealing with an individual, the situation changes.

Re: Getting Past The Health Insurance Plan Cancellation Hysteria

Louise — Sun, 17 Nov 2013 14:27:13 -0000

Yes, policy rescission was definitely a potential problem. Although it wasn't as common as you might think, especially if applicants were using a reputable carrier and a broker who explained the importance of not being fraudulent in the health history section of the application, no matter how trivial the issue might have seemed (out of all the clients we've assisted with applications in nearly 12 years, we've never had a policy rescinded). Rescission was a scary possibility, and it's true that some carriers (especially the ones that were shady in other respect too) did go back through applications after the fact, looking for medical history info that an applicant omitted. Now that medical history questions are no longer being asked, this is no where near as much of an issue as it used to be (the ACA still permits rescission in cases of fraud or misrepresentation, but there's not as much possibility of this without medical history questions on the application).

Re: Getting Past The Health Insurance Plan Cancellation Hysteria

Margie — Sun, 17 Nov 2013 13:52:15 -0000

At yet it seemed to happen to plenty of people. Or people got their insurance cancelled. Part of it might be dramatic increases in the entire group because of age or because some people in the group got sick as time went on. That's the danger of small pools or pools based on age. But I think there were also games based on pre-existing conditions, like combing through someone's health records when they got sick and saying, "Here's something you didn't tell us about," when it was something so minor, you didn't think to tell them about it.

Re: Getting Past The Health Insurance Plan Cancellation Hysteria

Louise — Sun, 17 Nov 2013 12:13:36 -0000

Lots of good points Margie. The ACA does a good job of spreading the risk across a larger pool. Younger people will pay more than they used to in the past, but they will benefit directly from the law as they get older and/or develop health conditions.

It's a common misperception that pre-ACA health insurance could raise your rates simply because you got sick. This was not the case. People could not be singled out for rate increases based on their own health status, even prior to the ACA. Their initial rates when they applied for a policy were based on their health history - that's what medical underwriting was all about. But once you had coverage, rate increases had to be applied uniformly across the group of insureds you were in (usually age-banded groups and geographic locations).

Re: Getting Past The Health Insurance Plan Cancellation Hysteria

Margie — Sun, 17 Nov 2013 01:51:46 -0000

And that guaranteed issue is what makes insurance actually insurance. People talking about "the young and healthy" seem to think being young is a permanent state of being. Up until the ACA, once people became sick or older, their premiums often shot way up to the point they were unaffordable, or their policies were cancelled altogether. That might be another reason why the insurance companies raised rates. The pool of people the policy covered passed a certain age, so the insurance company might have to actually pay out on the policy. With the ACA, there's a limit to how much higher the premium can be due to age, and your premium doesn't go up because you get sick. In addition, for many people, there are the subsidies which bring costs down. The way insurance has been until the ACA, you could pay for it and pay for it when you were younger and then find its not there for you when you're older and really need it.

Re: Getting Past The Health Insurance Plan Cancellation Hysteria

Louise — Sun, 17 Nov 2013 01:35:07 -0000

Margie, even if the coverage isn't dramatically different, the primary difference is that the new plans are guaranteed issue, while the old plans were medically underwritten. This makes a huge difference in premiums. If you compare existing individual plans with small group plans, you'll find that the individual plans are usually about half the price of the group plans, even for comparable coverage. That's primarily because group plans are guaranteed issue. The new ACA-compliant plans are much more like group plans in that regard. Although the existing individual plans were much less expensive than group coverage, they were only available to people in relatively good health. People with pre-existing conditions either paid more for their coverage or were declined. With the new plans, that's no longer the case.

The ACA brought in medical loss ratios (which have already been in use since 2011), limiting total admin expenses - including profits - in the individual market to no more than 20% of premiums collected. So premiums cannot be raised just to raise profits.

Re: Getting Past The Health Insurance Plan Cancellation Hysteria

Margie — Sun, 17 Nov 2013 01:03:51 -0000

I've got to wonder about those plans that are being cancelled because of some minor thing that makes it non-ACA compliant. In some cases, insurance companies are telling people that they can switch to a different plan that is ACA compliant, but the cost for the new plan is far higher than the cost for the old plan. It seems to me that if the changes are minor, the cost of the new plan doesn't need to be all that much higher than the cost for the old plan. This sounds like just a case of insurance companies trying to push people into buying a much more expensive plan, for the sake of padding their own profits.

Re: Capping Profits And Admin Costs Across The Healthcare Industry

JayInColorado — Sun, 10 Nov 2013 11:53:38 -0000

Monica, read the article and re-think your math. It's a percentage of healthcare costs. If the insurance company just arbitrarily doubles premiums without healthcare costs increasing, their profits would exceed 20% and they would have to pay it all back.

Pretend you sell lemonade. It costs you $8 to sell $10 worth of lemonade. You made 20%. If you just double the price of your lemonade without your costs actually increasing, it costs you the same $8 to sell $20 worth of lemonade. You now have a 60% profit. If there were MLR rules about your lemonade profits, you would have to pay back that extra "premium" you just charged without justification.

Premiums are simply a function of healthcare costs. Period.

Re: Capping Profits And Admin Costs Across The Healthcare Industry

Monica McLaughlin — Sun, 10 Nov 2013 03:12:07 -0000

When the rates go up the insurance company keeps 20%. 20% of $1000 is twice as much as as 20% of $500. All the insurance companies have to do to increase profits is to raise the cost of premiums.

Re: Getting Past The Health Insurance Plan Cancellation Hysteria

Sick of the Nonsense — Sat, 02 Nov 2013 11:27:01 -0000

Best analysis I've read on the ACA. Thank you.

People keeping asking if the President lied about keeping your existing health plan. Based on the 2010 ACA grandfathering, the President appeared to be (reasonably) accurate when making this statement in 2009.

Why didn't he "pivot" to a more complicated post-2010 statement? Something to the effect that the quality early ACA plans were part of the path to fair insurance that includes a larger risk pool.

I'm one of those that's enjoyed two years of free yearly checkups, a free colonoscopy, relatively low premiums with a hard OOP max, etc. I don't like being mislead, but I get that politics has become like the famous Jack NIcholson line in "A few good men" -- "You can't handle the truth!"

Re: Risky Business

Matthew Jayden — Tue, 29 Oct 2013 04:20:18 -0000

I, too, agree with David. Rather than 'empowering the patients' to 'take charge,' this simply seems like a way for health professionals to find somebody else to blame, in case the doctor didn't wash his/her hand. Like David says, " Hire someone else to do the job." No need to drag the patient into this.

Re: Early Renewal Does Not Mean You’re Taking Advantage of a Loophole

Matthew Jayden — Tue, 29 Oct 2013 04:15:34 -0000

I think a lot of people find themselves in the same situation as you. They like their current policy, and need a lot of time to weigh their option before making a decision. Good luck with your decision! Hope whatever you choose works out well for you!

Re: Government Shutdown: Is The Republican “Plan” Actuarially Feasible?

Louise — Mon, 14 Oct 2013 16:54:40 -0000

Thanks Bob. Just to clarify, I'm not sure whether the actuaries believe that the increased enrollment will be skewed more towards healthy people or sick people - just that there will be more people in the health insurance pool overall. The individual mandate is expected to increase enrollment, and actuaries have certainly taken this into consideration when they priced the 2014 policies. They probably also have some pretty good predictions for what the overall health status of the new enrollees will be, although everything will likely be easier to predict after a year or two of increased enrollment.

Re: Government Shutdown: Is The Republican “Plan” Actuarially Feasible?

bob.hertz — Sun, 13 Oct 2013 09:55:57 -0000

As usual Louise Norris has a very good post
One comment struck me -- she believes that insurance carriers are pricing their products on the assumption that the individual mandate will bring them millions of healthy insureds.
I hope that is true for the sake of insurance rates. But I can also envision a scenario where those who are older and in failing health are the first to sign up for the ACA. The history of federal insurance plans is one of big big claims in the first year. If the govt backs up the insurers with risk adjustment money. that will help. But I still worry about 2nd year premiums.