Stupidest Idea of the Year: An Early Frontrunner

Long Term Care insurance (LTCi) is arguably the single most complicated product we sell (tied perhaps only with Disability Income plans). It has a lot of moving parts, a very specific market niche, and is easily misunderstood. Underwriting is particularly involved because, unlike, say, life insurance, there can be multiple claims of varying degrees. The tax implications can be confusing and complicated, particularly for business owners. There are different ways that carriers count off their elimination periods, and how they price and define shared plans. And so on.

So naturally, Rocket Surgeon Paul Forte, CEO of some outfit called Long Term Care Partners L.L.C, thinks it would be a grand idea to market LTCi plans through Exchanges modeled on the ever-so-successful 404Care.gov site.

Really!

One can see why he'd like that to happen: his company is the admin for two major Federal insurance programs, and one can never have too much of that sweet, sweet gummint largesse. That they would no longer feel the need for, oh, agents or underwriting is just icing, really.

Wait, what?

No, seriously:

"Allowing some medical underwriting could hold down costs without leading to a rate spiral, and keeping costs low could help make a big exchange sustainable even without the help of a mandate."

Yes, he's proposing the "Affordable Long Term Care Act" - because we've seen just how successful the ACA has been in reducing costs, not to mention folks' access to actual care.  And did you notice that interesting little turn of phrase: "help of a mandate?"

Remember when we were warned, during the initial SCOTUS fight, that if the government can force us to buy health insurance, they can force us to buy anything? That was dismissed as silly then.

Still sound silly now?

Didn't think so.

But wait, there's more:

"Forte would further reduce costs by putting the LTCI exchange system under the jurisdiction of the federal government, not state governments"

Yes, because Lord knows that the Feds are well-known for reining in costs and keeping to a tight budget. Heck, I bet he could reduce the cost of Long Term Care insurance by 3000%.

And what about that whole direct-to-the-public marketing scheme? Let's unpack that a bit:

"Those objecting to what they think will be lost by foregoing the services of live agents should recognize that the ALTCIP would not be geared to high-net-worth individuals, but rather to moderate-income persons seeking better value"

Well first, Mr Genius, high net worth folks already have plans in place, and many can afford to self-insure. They're also likely to have easy access to loads of expert advisors and financial planners. Long Term Care coverage is specifically geared towards middle class folks who don't have that kind of access, and to whom, for example, the Partnership Program is a real boon (does he seriously think that high net worth individuals worry about Medicaid spend-down?). These are exactly the kinds of folks who need agents to help them understand the difference between, for example, service and calendar days.

There is literally nothing positive or useful in this proposal; it is simply an embarrassingly naked attempt to grab a few more DC dollars, and to further damage the middle class.

Wonder if he thanked Ms Bell for the free advertising.

Health Wonk Review: VD edition is up...

VD as in Valentine's Day. Peggy Salvatore has a new blog (WooHoo!), and this week's eclectic round-up of health care policy and polity.

It's chock full of great posts - Sweet!

I can't wait!

In email from HHS:

[click picture to embiggen]

And because I'm a giver, here's the link to register. Have fun, and try not to trash the place, m'kay?

Another 1,000 Words on ObamaCare

Hello, This is Peggy

Do you ever wonder who is actually on the other end of the line when you call hc.gov? What kind of training

do they have? Am I getting the right answer? If not, can I call back and ask for Peggy?

"You can call HealthCare.gov three different times and get three different answers," - USA Today

Well that's refreshing. At least they are honest about it.

Being locked out of one's account can be extremely frustrating, especially for some of the low-wage workers who have very limited time to deal with their insurance, navigators said. But some of the problems — such as lapses in insurance coverage for sick relatives — can infuriate people.

Call-center workers have become much more proficient at unlocking consumers' accounts this year, which remains an issue because many people forget their passwords, user names or both, said Cardenas. Last year, the workers would tell people to just create new accounts, which tended to create more confusion and is a particularly bad idea this year for those re-enrolling, she said.

Considering you can't get a subsidy without going through goodluck.gov I would say getting locked out of your account is a major concern.

So, who you gonna call when you have a problem?

Ronnell Nolan, who heads Health Agents for America in Baton Rouge, said she and some of her members long suspected call-center workers weren't giving them their own names. Nolan recalls dealing with someone who went by what sounded like the same name as actress Halle Berry. Turns out, they don't use their own names — and it's with good reason, said CMS spokesman Aaron Albright,

Representatives use aliases and won't disclose their location .

So much for transparency in government.

Buckeye Medicaid Dumping

Glancing into his crystal ball in 2009, co-blogger Mike had some harsh words for the folks running Medicaid:

"Why has Medicaid failed to protect the poor? Medicaid is the government program expressly established to provide adequate medical insurance for the poor. Why is it not doing so? Why has our government left so many of the poor without access to medical insurance?"

Flash forward 5 years or so, and we find that not much has changed:

"Medicaid could dump 500,000 Ohioans in 6 months ... All are poised to lose benefits for failing to submit information needed to confirm that their household income falls within Medicaid eligibility guidelines."

And of course, this redounds negatively on Gov Kasich's (foolish) decision to expand the program, multiplying the effects.

So what's the problem?

There are several, actually:

First, all of these folks are required to "re qualify" annually; that is, to prove that their economic woes haven't let up. That they failed to do so is, ultimately, on them. But the state, having initially approved them does have an obligation to remind them of this requirement. The traditional method is via snail mail, but some of these "Some problems ... may have been caused by apartment numbers being placed above recipient’s names on envelopes, preventing them from being delivered."

Oops.

And the notices, written (as is appropriate) in English, went to at least some folks who "speak other languages." I would say that's their problem, not the taxpayers'. And up to a third of the notices were returned as "undeliverable."

Lovely.

Talk about burying the lede, though:

"About 2.9 million poor Ohioans receive Medicaid."

Given that the state is home to just shy of 12 million people, has it occurred to someone in charge that having 25% of your population on Medicaid might indicate just a wee little problem?

Way to go, Guv.

[Hat Tip: Co-blogger Bob V]

Anthem Hacking - Perspective

In comments to one of our previous posts on this topic, Co-Blogger Bob makes a terrific point:

"Not taking anything away from Mandiant as they are the "A team" when it comes to tracking down hackers ... Most companies do very little when it comes to cybersecurity and many (mo st?) have probably been hacked and just don't know it."

This morning, the Wall Street Journal reported that "Anthem Inc. stored the Social Security numbers of 80 million customers without encrypting them." On the face of it, this seems pretty unconscionable.

But is it?

I reached out to several of our carriers, and to AHIP (America’s Health Insurance Plans), which represents (most of) the carriers. I had but one question:

"Is this an egregiously unusual oversight, or industry standard?"

That is, is Anthem an outlier here, or do most carriers leave that kind of information unencrypted? The folks at AHIP were kind enough to send me a copy of the HHS regs on the subject, but also told me that they'd not surveyed their members on it, so can't tell me whether or not this is SOP.

I'm still waiting to hear back from my carriers, and will update this post as appropriate.

JUST IN from Anthem:

Members who may have been impacted by the cyber attack against us should be aware of scam email campaigns targeting current and former members.  These scams, designed to capture personal information (known as “phishing”) are designed to appear as if they are from a health plan and the emails include a “click here” link for credit monitoring. These emails are NOT from us.

• DO NOT click on any links in email.
• DO NOT reply to the email or reach out to the senders in any way.
• DO NOT supply any information on the website that may open, if you clicked on a link in email.
• DO NOT open any attachments that arrive with email.

We are not calling members regarding the cyber attack and are not asking for credit card information or social security numbers over the phone.

Friday LinkFest

So, several items that, while blogworthy, don't seem to merit their own dedicated post:

■ As we've already seen, the future of health care CO-OPs is, at best, rocky. At the Employee Benefit Advisor, Bruce Shutan looks under the hood, and notes that "it captured nearly a quarter of the total enrollment for all 23 consumer-operated and oriented plans known as CO-OPs operating in 24 states," all on a "shoe-string" budget. Bruce has some thoughts on how this will play out as we go forward..

■ FoIB Holly R tips us to this tidbit of tantalizing info:

"The White House cyber czar may have had personal information leaked in the recent Anthem data breach."

That breach, news of which is still evolving, may end up "touching" a lot more folks than originally believed.

■ As we've noted many times, wine (especially the reds) have been linked to several positive health effects. Turns out, that IPA you were drinking last Sunday may also help:

"[B]eer also confers some health benefits, according to a new study, which found a compound within can ward off dementia and other cognitive decline."

L'chaim!

Obamacare Enrollment Update

The folks that brought us Obamacare and a non-working website like to keep those who are interested up to

date on the latest score. The latest installment for week 10 of the Obamacare open enrollment saga goes like this.

Since Open Enrollment began on November 15, almost 7.3 million consumers selected a plan or were automatically re-enrolled through the HealthCare.gov platform, which includes the Federally Facilitated Marketplace (FFM), State Partnership Marketplaces and supported State-Based Marketplaces. - HHS

7.3 million selected a plan or were re-enrolled.

Sounds a lot like the stimulus reports about jobs created or saved.

Selecting a plan does not mean actually applying for coverage. Nor does it mean the premium was paid. In DC-speak it means window shopping.

The same is true for the automatic re-enrollment.

Until you actually PAY for your policy you don't have coverage.

Isn't it odd how they fail to count the number of people that actually LOST health insurance because of Obamacare?

Anthem Hacked [UPDATED]

Picking up on where Bob left off ...

As you've no doubt already heard, hackers were able to gain access to Anthem's systems, and access the personal information of both clients and employees (it's not clear whether "employees" include independent agents/brokers who represent the carrier). All told, it appears that over 80 million folks were affected.

To its credit, Anthem sent out an email last night addressing the problem:

To our valued business partner:

Safeguarding your clients’ personal, financial and medical information is one of our top priorities, and because of that, we have state-of-the-art information security systems to protect your data. However, despite our efforts, Anthem was the target of a very sophisticated external, cyber attack. These attackers gained unauthorized access to Anthem’s information technology (IT) system and have obtained personal information from our current and former members such as their names, birthdays, member ID/Social Security numbers, street addresses, email addresses and employment information, including income data. Based on the information we know now, there is no evidence that banking, credit card, medical information (such as claims, test results, or diagnostic codes) were targeted or compromised.

Once the attack was discovered, Anthem immediately made every effort to close the security vulnerability, contacted the Federal Bureau of Investigation (FBI) and began fully cooperating with their investigation. Anthem has also retained Mandiant, one of the world’s leading cybersecurity firms, to evaluate our systems and identify solutions based on the evolving landscape. [ed: emphasis added, see below]

Anthem’s own associates’ personal information was accessed during this security breach. We join you in your concern and frustration, and we assure you that we are working around the clock to do everything we can to further secure your clients' data.

Anthem will individually notify current and former members whose information has been accessed. We will provide credit monitoring and identity protection services free of charge so that those who have been affected can have peace of mind. We have created a dedicated website (www.AnthemFacts.com) where members can access information such as frequently asked questions and answers. We have also established a dedicated toll-free number that both current and former members can call if they have questions related to this incident. That number is: 1-877-263-7995. As we learn more, we will continually update this website and share that information with you.

We want to personally apologize to you and your clients for what has happened, as we know you expect us to protect your information. We will do everything in our power to make our systems and security processes better and more secure, and hope that we can earn back your trust.

Sincerely,

Ken Goulet
President, Commercial and Specialty Business

Erin Hoeflinger
Ohio Plan President
 
Regarding Mandiant and cyber-remediation: on the one hand, this seems very much like closing the barn door. On the other, at least they recognize their vulnerability, and are seeking to mitigate and minimize it. One suspects that Mandiant (and its competitors) will be very busy going forward, as other insurers take stock of their own potential weak spots.

UPDATE: FoIB Holly R catches this from Bloomberg:

"... hackers obtained data on tens of millions of current and former customers and employees"

And asks: "How former?"

Good question, disturbing implications.

Blue Attack

Anthem Blue Cross policyholder data hacked. Possible 37 million affected.

The information accessed during the "very sophisticated attack" did include names, birthdays, social security numbers, street addresses, email addresses and employment information, including income data, the company said. - Yahoo News

Taxes, Shmaxes

Thanks to Moe Lane, we have this little gem:

"Consumers who received too much in federal tax credits ... got a reprieve of sorts from the Internal Revenue Service this week. Although they still have to repay ... excess subsidies, the IRS won’t ding them with a late payment penalty if they don’t repay it by the April 15 tax deadline."

Which is nice for them, but creates a problem:

"The Equal Protection Clause of the 14th amendment of the U.S. Constitution prohibits states from denying any person within its jurisdiction the equal protection of the laws."

So what's the problem?

Well, suppose you owe taxes on something (other than the subsidy clawback), and fail to pay on time: you're still subject to fines and interest. But for the special snowflakes that "miscalculated" their subsidies, well, no worries, mate.

Of course, it's not really a problem at all, at least according to the Obamastration:

"White House Press Secretary Josh Earnest described reports that millions of Americans would be getting tax bill because of Obamacare as "inaccurate" just days after the Treasury Department estimated that 6 million Americans will pay about $2 billion in individual mandate taxes this year."

Left hand meet right hand.

Sheesh.

Guest Post: The Force(d) is with You

From time to time, we host guest posts from esteemed colleagues and other bloggers. These are typically for insurance-related matters that fall outside our own particular wheelhouse. Today, we're pleased to bring you this post from Dennis Wall,  an elected member of the American Law Institute, author of several legal and risk-related books, and proprietor of the Insurance Claims And Issues blog.

If you've ever bought a house, you know that the lender requires you to insure it. Sometimes, folks let their coverage lapse, and the lender then obtains its own coverage, "forcing" it onto the property (and the homeowner). Today, Dennis explains the implications in this economy:

The “Great Recession” of 2008-2009 has caused a lot of harm. No harm has been felt more keenly than by people involved with residential mortgages and home loans.

During the six years leading up to the Great Recession, or from 2002-2007, mortgage debt rose nearly as much as it had since the United States was founded. Household mortgage debt rose an average of $60,000.00 during those same six years, or about $10,000.00 each year for each home in the United States. That is also the time when the once-standard 30-year fixed rate mortgage with a 20% down payment was no longer the mortgage loan of choice. [Findings from report of the Financial Crisis Inquiry Commission. THE FINANCIAL CRISIS INQUIRY COMMISSION FINAL REPORT, January, 2011].

A forensic investigation over three years, including research into publicly available federal court electronic filings, reveals clearly that many business practices have deliberately been kept secret concerning the sale, maintenance and monitoring of mortgages. In particular, the practices of a small number of insurance companies offering force-placed insurance to lenders has dramatically driven up the price of lender force-placed insurance or LFPI.

LFPI is insurance which protects the lender’s interest in the borrower’s collateral. It is “collateral protection insurance” in the sense that it is insurance which protects only the collateral.

Kickbacks and other alleged premium add-ons drive up the price of lender force-placed insurance. Some call the process “reverse competition” or “pay to play.” LFPI premiums are paid by the borrowers and not by the lenders. That is, the premiums for LFPI are paid by homeowners and not by the banks. A three-year review of federal court files reveals that the only complaints which survive in court are the complaints in which the homeowners complain about the extra charges added on to the monthly premiums they pay.

The notion that lenders force-place insurance only when borrowers do not meet their obligations, is largely a myth. It is far more likely that lenders will force-place insurance and let the homeowners oppose it if the homeowners can. To the contrary, homeowners make their monthly mortgage payments for the most part – until they no longer can make the payments including the added burden of premiums for “pay to play” force-placed insurance. Then the lenders and their agents foreclose, and the mortgage machine starts all over again.

Thanks, Dennis! And look for his new book, “Lender Force-Placed Insurance,” due out this Spring.

One Decade Down, Next to Go

It is humbling to consider that today marks our 10th Blogiversary. Well over 7,000 posts and millions of views, numerous awards and links from the New York Times, Wall Street Journal, Forbes, Fox and others.

And, of course, the very best co-bloggers on the 'net.

But most important: our terrific, engaging and interested readers.

Thank you all for 10 great years - and now on to 20!

And speaking of Medicaid...

As Bob recently noted, Indiana has become the 28th state to climb on board the  Medicaid expansion train (wreck). He also pointed out that there's already a shortage of providers willing to take on Medicaid patients.

Wonder why?

Well, our friend Dr Val has a pretty graphic answer:

Click on over to read the whole story (and definitely check out the comments).

Another Installment of: That's NOT how it works

It seems like only a  week ago that we referenced our 2nd ever post - wait, it was a week ago that we did that! And here we are again, talking about insurance fraud. And this one's a doozy:

"Irina Vorotinov has been charged by ... with defrauding Mutual of Omaha Insurance Company of more than $2 million in life insurance proceeds by falsely claiming that her former husband had died."

Turns out - Spoiler Alert! - the ex- was, in fact, very much alive, and caught on film years after his alleged death.

Ooops.

Super(bowl) Health Wonk Review is up

Our favorite health care economist, Jason Shafrin, hosts this week's festive round-up of health care policy and polity. It's cold outside, so come in and warm up with some great reads.

Popcorn State Expansion

On February 1, 2015 Indiana will become the 28th state to expand Medicaid. Good news (I suppose) for

those under 138% of the FPL. No more insurance premiums.

But you may have trouble finding a doctor. This is nothing new nor indigenous to Indiana. Medicaid participants in all states have trouble finding doctors willing to take them as new (or even old) patients.

About 765,600 Hoosiers lacked insurance in 2013, according to the Kaiser Family Foundation. The state has estimated more than 300,000 Hoosiers — or 56 percent of those newly eligible for Medicaid — could enroll in the first year and more than 400,000 would sign up during the second year. - Indy Star

Agents that wrote Obamacare subsidized plans on those under 138% of the FPL can probably expect to lose those clients ....... and the revenue.

How is the expansion funded?

The federal government pays for 100 percent of the cost through 2016. That declines gradually to 90 percent by 2020, assuming Indiana's waiver is extended past three years. Indiana's share — estimated to be about $1.6 billion between 2015 and 2021 — will be paid for through the state's existing cigarette tax and from a tax on hospitals.

Funded by the federal government, which doesn't have any money.

And funded by smokers and hospitals.

Increasing the cost of cigarettes probably isn't bad in the big scheme of things but taxes on hospitals will increase the cost of health care. How is this a good thing?

So, what is a Hoosier any way? I have heard it comes from "Hoosier mama" which I suppose is a version of "Yo mama".

Regardless, I wonder if this is a good thing or not.

Some thoughts on subsidies

So, been having a bit of a Twitter-tussle with a well-regarded friend and colleague. At issue is the future of ObamaTax subsidies as we look forward to the resolution of Burwell/King/Halbig.

Which got me to thinking: Why we're having this discussion at all? After all, President Obama explicitly promised us that, under the ObamaTax, premiums would decrease 3000%, and that we would have comprehensive, affordable coverage.

If this were truly the case, then why would we need bribes subsidies in the first place? After all, who wouldn't want cheap, useful insurance coverage? Why would we need to be cajoled, nay, forced into buying it if it was such a great bargain?

And if, as Mike pointed out years ago, the folks in DC actually did their jobs, would we need to be expanding Medicaid?

Thought not.

Tuesday Spindle-clearing

In no particular order:

■ Coming as a surprise to no one who's been paying attention:

"A quarter of firms that that had offered insurance to their employees last year were canceling their health plans this year, and another 25% said they planned to do so next year."

This in Michigan, and focused on smaller companies not (yet) subject to the Employer Mandate. Talk about blizzards...

■ Could treating Alzheimer's really be this simple?

"Researchers say they’ve developed a nasal spray that could potentially improve memory and other mental capabilities for the more than 5 million Americans suffering from Alzheimer’s disease."

It's still a long way off (and currently being tested only on those with mild cases), but sounds promising.

■ Almost 5 years ago, we wrote about a "Lifespan Calculator:" an online widget that purported to predict how many days one had left. It appears that the technology is improving:

"A test to determine if elderly patients will die within 30 days of being admitted to hospital has been developed by doctors to give them the chance to go home or say goodbye to loved ones."

Corrected for accuracy:

"A test to determine if elderly patients will die within 30 days of being admitted to hospital has been developed by doctors to encourage them onto the Liverpool Pathway."

There, better.

■ But hey, "middle class:"

"I’m sorry sir,” the polite Healthcare.gov customer-service agent said. “There’s nothing I can do. You’re either going to have to enroll in Medicaid or you’re going to have to pay the full health-insurance rate.”

The problem, of course, is that the gentleman in question had the misfortune to fall within the one category for which the ObamaTax was supposed to work, but never quite has. As a grad student, he wasn't worried about his next BMW, but neither was he worried about his next meal. Couple that with the problem that, if one is eligible for Medicaid one is not eligible for a subsidy, and one begins to see the problem.

I really like the author's take on this, by the way: "Call me crazy, but in my book Medicaid is a last resort, not a first option."

It's so easy to forget that this is no game, no theory; it hurts real people, every day.

DC's Best Kept Secret

What with all the reports of how well Open Enrollment v2.0 has been going, it's no wonder the folks in charge want to keep this under wraps:

"It will cost the federal government – taxpayers, that is – $50,000 for every person who gets health insurance under the Obamacare law"

But that's only the tip of the proverbial iceberg:

"It will take $1.993 trillion, a number that looks like $1,993,000,000,000, to provide insurance subsidies ... and to pay for a massive expansion of Medicaid and CHIP"

But hey, worth it to provide universal health insurance coverage.

Wait, what?

"The best-case scenario described by the CBO would result in 'between 24 million and 27 million' fewer Americans being uninsured in 2025, compared to the year before the Affordable Care Act took effect."

So after 15 years and $1,993,000,000,000, they still won't have everyone covered?

Gee, sure glad they passed it to find out...

(And notice, one has to go to the UK press to find this)

Solution for Austerity Cuts in Health Care

If your government is running out of money and cutting services to balance the budget, what

do you do?

Elect a liberal.

Greece has been teetering on bankruptcy for years thanks to too much government and too many social give away programs. All that is about to change as a result of this weekends election

In Greece’s biggest hospital, the Evangelismos Hospital in Athens, conditions were worse than those I have seen in developing countries.

The moment the hospital doors open on ‘emergency’ days, people flood in. The collapse in official primary and community health care services means everyone who needs healthcare comes to A+E - whether for a major accident, medication for a long term condition or to get their child immunized. Staff told me that serious trauma cases often have to wait hours for X-rays and treatment due to understaffing and that, if too many cases come in at the same time, people die before they can be treated. - Open Democracy

The "austerity program" has saved the country but at what price? 

The government had closed all the polyclinics then reopened some recently but with only 30% of the doctors that they need. Whereas previously there had been 150 doctors providing services to the district, there were now only 50. A polyclinic for a population of 400,000 people had no gynaecologists, no dermatologists, and only two cardiologists.

 “We want our doctors back” – said one of the volunteers I spoke to. Thousands of doctors have left the country. Those that remain – including senior hospital doctors - earn about €12,000 ( $13,400 US) a year.

The good news?

Greater access to health care (presumably).

The bad news?

Eventually Greece will run out of money (again) and they are back to square one. There is no free lunch.

CoOpportunity assumes room temp

Last month, we reported on the travails of Iowa's CoOpportunity Health, a start-up recently taken over by Hawkeye State regulators. FoIB Josh Archambault tips us that they've now been shuttered:

"Iowa’s insurance regulator plans to shut down insurer CoOportunity Health, marking the first failure of one of the nonprofit cooperatives created under the Affordable Care Act."

T'won't be the last.

P&C Files: That's *NOT* How It Works!

[click pic to embiggen]

[Hat Tip: DoIB Sarah S]

Flashback Friday

Our 2nd ever post here was a recap of the "Top Insurance Swindlers" of Ought-four. It was a rogues gallery that included a "greedy granny" and an arsonist pastor, among others (no mention of the apocryphal cigar owner). In fact, you'll notice an edit dated earlier this month: a business owner had emailed me requesting that I modify an entry because - ten years on - it was adversely affecting her business.

Fast forward a decade, and we have the truly inspirational story of an entire family of (alleged) insurance fraudsters:

"Authorities said the ensuing probe uncovered a decades-long pattern of questionable insurance claims ... Six other people, including her husband, two children and daughter-in-law, also face charges."

Bet Thanksgiving dinner is a hoot.

Obamacare with Thin Crust or Thick?

Next time you order a pizza think about Obamacare. The same folks that brought us lower health insurance

premiums and better coverage are helping us make better choices when it comes to pizza.

The FDA finalized an Obamacare-mandated rule in November that requires restaurants to display calorie information on their menus. However, there appears to be some confusion over what the FDA calls a “menu.”

I J Review

A menu is what the server hands you in a restaurant.

But it can also be a web page, advertising flyer, clip and save coupon .........

To make matters more complicated,

Considering that Domino’s customers can customize their own pizzas, there is an endless number of possible combinations of toppings, each of which has a different calorie count. Liddle said a low-ball estimate of combinations Domino’s offers is 34 million. Pizza Hut has 2 billion possible combinations.

Maybe pizza's should be broken down into 4 simple categories.

Bronze, silver, gold and platinum.

That would simplify everything.

Medicaid and Long Term Care

Many folks continue to believe - erroneously - that Medicare will cover most (if not all) of their long term care needs. It won't. But Medicaid probably will, if you lack the assets to self-pay.

Unfortunately, this requires that one "spend down" one's assets, accumulated over a lifetime of toil. To qualify for assistance from Medicaid to cover long term care expenses, one is allowed to keep only a small amount of cash, a home and a car, maybe a few baubles.

The good news is that buying a Partnership-qualified long term care insurance plan, one may offset some of that spend down, and keep more assets.

And, as local ElderCare Law guru Michael Millonig informs us via email this morning:

"Level of Assets That Spouses of Medicaid Recipients May Keep Rises for 2015 ... [For example] If a couple has $100,000 in countable assets on the date the applicant enters a nursing home, he or she will be eligible for Medicaid once the couple's assets have been reduced to a combined figure of $52,000 -- $2,000 for the applicant and $50,000 for the community spouse."

Click on through for more details.

Is Healthcare.gov really just a massive voter data collection tool for DNC? [UPDATED]

[Scroll down for update]

Seeing how Obama has abused the IRS and voter registration this isn't such a stretch:

"Daoudi's company — Catchpoint Systems— came across some 50 third-party connections embedded on HealthCare.gov. They attracted attention because such connections can slow down websites. They work in the background, unseen to most consumers.

The AP was able to replicate the results. In one 10-minute visit to HealthCare.gov recently, dozens of websites were accessed behind the scenes. They included Google's data-analytics service, Twitter, Facebook and a host of online advertising providers."

A list of 9 million potential voters who "benefited" from government largess along with their facebook and twitter friends would be very valuable come Get Out the Vote time.  

UPDATE [HGS @ 1/21/15]: And it gets worse:

"... healthcare.gov – the flagship site of the Affordable Care Act, where millions of Americans have signed up to receive health care–is quietly sending personal health information to a number of third party websites."

Including Doubleclick.net, Twitter and even Youtube.

Hey, if you like your privacy, you can keep....

A Giveaway is Now a Threat

As open enrollment creeps across the finish line in year two, many organizations that support Obamacare are changing their marketing plans. The first year and the opening of this year focused on the ever popular "giveaway" model. It came in two parts.

1. Give people something for free. From free birth control to free preventive care people should sign up for health insurance because these benefits wouldn't cost anything. Never mind the fact that doctors and pharmacies aren't really giving this stuff away.

2. Explain that Government thinks this is important for you to have insurance so they are paying the majority of your premiums. Never mind the fact that if your income is above $20,000 to purchase a Silver Level plan you will pay 5% of your income for it. Never mind the fact that cheap insurance means high out-of-pocket costs for health care.

Now comes the third marketing campaign:  Explain the consequences of not buying insurance. The dreaded and unpopular individual mandate and the tax you have to pay for not buying government approved health insurance with free stuff in it. Never mind the fact that you are being taxed to help pay for parts one and two above.

Yep, that should do the trick.

Everything Old is New (Again)

Way back in the early days of this blog, we reported on a seasoned citizen who chose a life at sea as her Long Term Care plan:

"On our October cruise on Royal Caribbean lines, there was an elderly lady who actually resided on the ship 'Voyager of the Sea ... She told us that it was just more financially feasible to do this than living in an assisted-living home and was much more fun"

So it was with a sense of deja vu that I read this item this morning:

"Lee Wachtstetter, an 86-year-old Florida widow ... sold her five bedroom Fort Lauderdale area home on 10 acres and became a permanent luxury cruise ship resident ... has been living on the 1,070-passenger vessel longer than most of its 655 crew members — nearly seven years."

One interesting tidbit: in our original story, the traveling senior reported spending over $200,000 a year; by contrast, Mrs Wachtstetter seems to have scored quite the bargain at a little over $160,000 annually.

Sweet Sailing, Mama Lee!

Counting down the ObamaTax

As you've no doubt seen all over the news, once Open Enrollment v2.0 is over next month, folks who failed to take advantage of it and are still uninsured will (likely) be subject to a fine penalty tax. Many (most?) folks believe that the tax is a mere $95 this year and, for some people, this may well be the case. But it's actually just a minimum; the actual rate (this year) is 1% of income:

"TurboTax, an online tax service, estimated that the average penalty for lacking health insurance in 2014 will be $301."

On the one hand, that's a lot more than $95, but on the other, it's likely less than one month's premium, especially for folks who don't qualify for a subsidy.

Just for grins and giggles, I took an average person (age 35) living in the Mid-West and ran some quotes. I chose Anthem because, let's face it, Blue Cross is ubiquitous and, in many markets, the 800 lb gorilla. My hypothetical client, of course, eschews tobacco.

The least expensive plan available cost $253, and includes a maximum potential out-of-pocket (MOOP) liability of an additional $6,400 if he has a bad year. But assuming that, like most folks, his expenses are generally a flu shot and maybe a generic prescription (available for $4 at many retailers), this doesn't seem like such a good deal. It would take less than two months to be "in the hole" vice "going naked."

Now let's back up a bit and consider his younger brother, aged 28: he's eligible for a "Catastrophic" Plan (not to be confused with an HSA-compliant one), which comes with a MOOP of $6,600, and costs $180 per month. Again, a couple of months into it, and he's well past the $301 fine penalty tax, too.

Bottom line: why would anyone think that this is an efficient incentive?

Sold Out

In an unusual move, Community Health Alliance has pulled their product off the exchange in Tennessee.

Community Health Alliance has pulled its health insurance plans off the federal marketplace because it hit its enrollment goals.

Knoxville-based Community Health Alliance, a nonprofit consumer operated and oriented insurance provider, or co-op, hit its enrollment goals in the first two months of open enrollment. It stopped offering plans on the exchange Jan. 15.

No carrier has ever done this before (pulling a product in mid-year). Is this the first of many or simply an anomaly?

Health Wonk Review: Welcome to '15 edition now up

Vince Kuraitishos hosts this week's eclectic round-up of the first wonky blog posts of the New Year.

MVNHS© In The News

Since it's been a while since we've reported on the Much Vaunted National Health Service©, seems like it's a good time to catch up:

1 - Co-blogger Bob alerts us to this alarming news:

"More than 3,000 operations have been cancelled by the NHS in the first two weeks of [December] as an "unprecedented demand" takes its toll."

Here's the deal: When something is "free" (or, more precisely: perceived as free) then more folks are going to want it. After all, why would anyone in their right mind leave money (or health care) "on the table?"

It also points out that nationalized health care schemes do nothing to rein in demand, and by extension, cost.

2 - FoIB Peter K explains why the folks mentioned above may have been lucky to have been put off:

"A six-week-old baby was killed by her bipolar mother after she stuffed pages from the Bible into the infant's mouth, while supposedly in the care of bungling NHS staff."

What difference which book was used seems irrelevant and unhelpful; the important information here is that careless (overworked?) staff allowed such a person unfettered, unsupervised access to a vulnerable patient in their charge.

Could it happen here? Of course, but the difference is that this seems to be a pattern for MVNHS© folks:

"Other fatal errors by the Cambridgeshire and Peterborough NHS Trust included the shocking loss of records detailing an attempt by Lovemore in 2006 to smother her first child."

And that was just this one family.

Oy.

A Timely Reminder

It's 2015, and that means:

"The employer mandate applies to applicable large employers with 50 or more full-time employees and full-time equivalents. It requires applicable large employers to either offer full-time employees and their dependents minimum essential coverage that is affordable and meets minimum value requirements, or risk paying an excise tax (penalty). 

Employers with 100 or more full-time employees and full-time equivalents, and employers with 50-99 full-time employees and full-time equivalents who do not qualify for transition relief, will need to comply in 2015."

Shorter: The (Evil) Employer Mandate is now in effect.

Note that smaller groups (under 50) are (so far) exempt. So again we ask: how would you like to be Employee #51 on the company totem pole?

Bob G vs "Survey Says!"

FoIB Bob Graboyes takes to the pages of US News to explain why judging the success (for certain values of "success") of the ObamaTax, based on ubiquitous and often self-selecting surveys, is destined to be disappointing:

"The phrasing of questions matters a great deal. Individuals surveyed may answer a pollster’s question dishonestly for a variety of reasons, or they may answer incorrectly because they don’t actually know whether they have qualifying insurance coverage."

Or maybe they think their better half took care of it. Doesn't really matter: you know the old saw about lies, damn lies and...

Bob wants to know just one simple thing: Why must we rely at all on these consumer surveys? They are subjective and prone to bias (both intentional and inadvertent). Surely there must be a better way?

And indeed there is. But you'll have to read his article to see what it is.

(It's worth it)

Bucks, Ducks and Luck

Congratulations to The Ohio State Buckeyes for their impressive route of the University of Oregon Ducks last night in Texas. While most of us here in Buckeye country are busy celebrating the win, one regional retailer is licking its wounds:

"Ohio-based Morris Furniture Company is now on the hook for upwards of $1.5 million in refunds to customers ... The promo promised refunds to customers who purchased at least $1,999 in furniture a ... if OSU won the championship game by at least seven points."

Which, by golly, they did.

So the chain is on the hook for an estimated $1.5 million dollars. That's the bad news. The good news is that they took a page from Chicago's World Furniture Mall, about which we wrote some 8 years ago:

"[The store] promised that if the Bears shut out the Packers in the season opener at Lambeau Field in Green Bay, Labor Day weekend shoppers would get their furniture free."

Which is what happened. Fortunately, the owner had purchased a "Special Event" policy for just such an occurrence, and was out only the price of the plan. So, too, the Ashley's folks "did work with a third-party company that underwrote the promotion."

Smart move.

Frustrating Client Tricks

First off, let me be clear that it's the client (and myself) that's frustrated. It's just that kind of situation:

Mary is divorced, and has custody of her teenaged son.She is responsible for his health care expenses, but her ex- is supposed to provide health insurance. Unfortunately, he is not terribly reliable: he is frequently unemployed (and uninsured), and he doesn't always let Mary know whether or not their son's actually covered.

In order to alleviate the stress of that inconsistency, Mary has always kept her son on her insurance. Due to some recent employment woes, she purchased a subsidized ObamaPlan from the Exchange.

A few weeks ago, her ex- contacted her to let he know that he'd found new employment, and that he and their son would become active on the new group plan on February 1. This presents her with something of a dilemma:

Once her son is on the group plan, he is no longer eligible for a subsidized plan. And according to Mary, she will also lose her subsidy (although she can keep the plan itself). Since I came into the picture after she'd already gone through the 404Care.gov subsidy eligibility hoops, I really can't confirm this, so I've just taken her at her word.

She also knows, from previous experience, that she really needs to keep her son on her plan, lest her ex- bail on the insurance requirement (yet again).

She asked her agent about what to do, and he referred her to me (this happens with some regularity).

I turned to my trusted posse (a group of colleagues around the country who are both expert and high integrity) for advice. I had a pretty good idea of what was going to happen here, but really wanted some additional input, especially regarding issues I might have missed.

Colorado Health Insurance Insider's Louise Norris came through in a big way.  Louise confirmed my belief that Mary "can't keep her son on a subsidized exchange plan. You can't get subsidies at all if you're even eligible for employer-sponsored coverage that is deemed affordable under the ACA rules (and unfortunately, because of the family glitch, they only look at the cost of coverage for the employee when they determine whether a group plan is affordable, regardless of whether dependents are being added to the plan or how much it would cost to add them)."

Louise also mentioned that Mary shouldn't lose her own subsidy just because Junior came off, but again, I  came in after she'd done that calculus, so I'm going to leave that lie (I have no idea how she completed the process).

Ultimately, it appears that the only way that Mary can resolve her dilemma is to drop her ObamaPlan and buy a new policy off-Exchange, one that will cover both her and her son. I pointed out to her that this solution has its own challenges; for example, having two plans in place often leads to Coordination of Benefits issues between the two carriers. She told me that she's done this before (where she kept him on both the ex-'s and her own plans) to no ill effect.

I am not satisfied with this solution, yet it appears that it's the only viable one if she wants to know that her son always has some insurance in place.

Still, better than nothing, one supposes.

Paying Medical Bills

A recent blog post by health care business consultant and policy expert David E. Williams suggests that medical bills are not paid because people do not understand them (as cited in a recent report by the Consumer Financial Protection Bureau). He then admits that “[e]ven though I’ve been working as a healthcare business consultant for more than 20 years, I don’t understand my bills either” and then lists several reasons for this misunderstanding. With all due respect to David, let's dissect this:

1) Providers send bills while insurance claims are still pending, so I don’t understand whether I’m being asked to pay the right amounts

In today’s modern medical offices, even those without EMR (electronic medical records), practices have Practice Management software which electronically bills insurance companies through organizations called clearing houses. When the provider receives the Explanation of Benefits (EOB) from the insurance carrier, the payment or if the patient owes is entered into the software and then a bill for the patient is generated based on the information from the insurance company. A provider would not bill while an insurance claim is pending as the software is not designed to generate a bill before the insurance information is entered. When you are billed by the provider, it is the correct amount.

2) Explanations of benefits from my health plan aren’t timely and aren’t informative. The services described sound completely generic and are hard to trace back to the provider bill

Your EOB should match the bill you receive from your physician’s office. Also, after the visit you the patient should receive a statement detailing your services, both the ICD-9 and CPT codes you were charged, the amount of money charged by the physician and any payment you made, such as a co pay or co insurance.

3) We now have a high-deductible plan and are being asked to pay more by our providers, but I’m not confident that providers are correctly taking into account our out-of-pocket maximums on an individual and family basis

As a medical practice manager, I am astounded that someone that purports to be a health care advisor would make such an inflammatory statement about medical providers. Going back to point one, the provider bills only after receiving the information from the insurance company on the patient’s portion. It is not any provider's responsibility to keep track of a patient’s deductibles, that is the patients responsibility and it is between the patient and the insurance company.

4) Providers aren’t coding claims in line with the Affordable Care Act or insurance company rules, resulting in incorrect out-of-pocket amounts

Mr. Williams then cites another post in which he discusses the “free” services to be offered by the provider, such as preventive care annual physical or the “free" screening colonoscopy. This is an oft misunderstood aspect of medical care: these services *can* be paid at 100% *provided that* the exam is purely a review, and there are no diagnostics, tests, labs etc. The minute you say, “by the way doc, my arm hurts when I do this”, it is no longer a preventive exam, it is now diagnostic and your deductible and/or co-pays will apply. Now, the logical question is, isn’t talking to the doctor about things that hurt the whole reason for seeing a doctor? Yes it is, but hey I didn’t make up the rules, I only follow them. So providers are not incorrectly coding, we are coding what actually happened.

5) Few providers (at least around here) allow online payments. I have to either call the office during work hours or mail in a check –both a hassle

Really, David? Many (most?) banks now allow for on-line bill-paying, no reason you can't set that up to pay for health care, as well. Heck, if you're on an HSA-compliant plan (as it appears you might be), you could even pay those bills from your HSA account.

This article is a rehash of every complaint I have heard in my 15 years working in health care. Why is paying your doctor any harder than paying your cable bill or your credit card bill? It is an expense you incurred of your own free will when you went to see your doctor. You know that you will receive a bill, especially with the average deductible north of $2500, and yet each patient is always surprised when the bill arrives in their mail box: “Is this the correct amount?” or “Have you billed my insurance company?” or “The doctor said he wasn’t going to bill me. My favorite is “I don’t think I should have to pay: 1) for my healthcare, or 2) such a high amount”. I have heard every excuse and reason not to pay a medical bill, and in my experience the provider is correct 90% of the time.

OPM @ HHS

Hey, it's a great gig:

"HHS executives spent $31 million taking 7,000 first class and business class flights between 2009 and 2013, including 253 trips for which a one-way ticket cost more than $15,000."

Which comes as less-than-great news for us proles.

Results Are In And It Isn't Pretty

Early Obamacare results from the carrier side are looking ugly. An Assurant financial statement is revealing for the first 9 months of 2014.

A 3rd quarter loss of $17M might not seem like much but you have to factor in a couple of things.

Assurant is a relatively small player in the individual health insurance market. The $17M loss contrasts with a $6M net operating gain for the same period a year earlier.

Then there is this ..........

Net operating loss in third quarter 2014 was driven by increased claims from Affordable Care Act (ACA) qualified policies. Results reflect estimated recoveries from the ACA riskmitigation programs.

Note: In 2014, ACA risk-mitigation programs designed to reduce the potential adverse impact to individual health insurers from health care reform provisions went into effect. Assurant Health is eligible to participate in the risk-adjustment and reinsurance programs. As of Sept. 30, 2014, estimated recoveries under these two programs totaled $257 million. 

If not for the "taxpayer bailout" the losses would have exceeded $274 million.

I think Assurant and the other carriers should send us a thank you note.

Publication 5187

Have you studied IRS Publication 5187? That's the one that explains IRS Forms 1040-A, 8962 and 8965.

Essentially, if you purchased your Obamacare plan through hc.gov and received a subsidy when it comes time to file your 2014 income taxes there are a few extra things you will need.

Publication 5187 explains all this.

Page 5 of 5187 explains your obligations under the Shared Responsibility Provision in Obamacare. Kind of has a Socialist ring to it doesn't it? Shared responsibility .........

Pages 6 & 7 explains situations in which you may be exempt from your shared responsibility. Be sure to check those out. You may have bought insurance because you thought you had do but didn't.

The next 14 pages give examples of how to calculate your tax liability and repayment limitation in case you underestimated your income and got more than your appropriate share of responsibility. We can't have anyone getting greedy with their government hand out, can we?

And just in case you still don't understand how this Obamacare shared responsibility works, you are also directed to review IRS Publications 17, 974, 5172, 5185, 5182, 5156, 5120, 5121 and 5093.

Of course all of these are available in English and Spanish.

And if you missed any of this, here is a video summary.

Kill the 40 Hour Bill

Today the House of Representatives will vote on a bill to repeal the definition of full time employment status from Obamacare. Under the law, employers with 50 or more employees are now required to provide health insurance benefits to their employees who work more than 30 hours per week. The House bill (and accompanying Senate bill) would increase the threshold to the traditional full time definition of 40 hours per week. Passing this bill would be a huge mistake.

By passing this legislation, Republicans are providing supporters of the law with cover and ammunition. It allows them to claim that Republicans are pro-big business and anti-middle class while also accusing them of wanting more people to be uninsured.

It also will reduce the number of people who oppose the law. Every time Republicans chisel away a piece of Obamacare it makes an anti-Obamacare group less likely to oppose the law (hint: device manufacturers). The Obama Administration knows this - It's why many of the unpopular provisions of the law didn't begin until 2014. Even then the administration has continued to delay unpopular provisions time and time again.

A better solution would be to let employers and their employees "feel the pain." An employer who chooses to offer insurance and avoid the penalty can do so and play within the legal requirements of the law. Offering the minimum coverage and charging the maximum allowed under the law is a good start. Employees need to understand what Obamacare defines as affordable and good insurance under the law. For the employer who doesn't offer insurance they would then be subject to the tax imposed on them by the law. Make no mistake, the result here is that in many cases the employer will simply pass along this tax to their employees in the form of lower wages.

Republicans will be better served by focusing on how this will financially impact people when it's fully implemented. They should point to all of the unpopular provisions that the Obama Administration delayed. They should ask the constituents they serve what the financial impact would be if they had to pay 9.5% or more of their income for insurance. They should ask what impact employers will face if they can't afford to offer insurance. They should ask employers where the $2000 per employee penalty will come from.

Allowing this atrocity to run its course isn't the ideal solution. But for the average American the only way to understand just how bad this law really is means that they must feel the pain - and that is best felt when it hits their pocketbook.

If you like it, you can('t) keep it

Healthcare economist Robert Book has a very personal tale of ObamaTax woe:

"I am self-employed, and I have several significant pre-existing conditions ... who was supposed to be able to get insurance under the new system."

Turns out - surprise! - that he was lied to. That is, he relied on the word of ObamaTax proponents, including that of the President himself, that he could simply go to the 404Care.gov site, punch a few buttons, and be enrolled.

I heartily recommend reading the whole thing, but the takeaway is breathtakingly simple, and alarming:

"A few days later I got a letter from “The Marketplace” ... congratulating me for selecting a plan, and reminding to to pay my premium as soon as I got a bill from the insurance company."

Problem is, he never received the bill, because his newly-chosen insurer never received notice that he had, in fact, signed up. In theory, HHS sends a notice (ANSI 834 form) to, say, Anthem that Bob Smith has chosen them as his carrier, and needs to add him to their records, send out a bill and an ID card, etc. What seems to be happening is that this last, crucial step is either delayed or, in many cases, not happening at all.

So you have any number of folks who think they've signed up for insurance who really haven't. And since this is the gummint, good luck holding those (ir)responsible to account.

Just another broken promise, apparently.

Here We Go Again

Minnesota health insurer PreferredOne bails on the Obamacare individual health insurance plan market

leaving 30,000 people in a lurch.

The Minnesota health plan offered some of the lowest premiums in the country and captured 60 percent of the state's roughly 55,000 new Obamacare enrollees. But those premiums were too low, it turns out, to cover the medical care and other expenses of all those new customers. In the fall, PreferredOne steeply hiked rates for 2015 and dropped out of Minnesota's Affordable Care Act marketplace entirely, saying it was “not sustainable" to continue.  - Business Week

The problem?

They didn't charge enough.

See a pattern here?

And More 404Care.gov Tricks

And the hits, they just keep on coming. From email:

[click to embiggen]

Warm, fuzzy.