Yesterday, the White House outlined new regulations which require health insurance carriers to provide coverage for many preventive care measures at no cost to policy subscribers. These preventive care measures include dozens of screenings and laboratory tests like blood pressure, diabetes, cholesterol, HIV, and cancer screenings, routine vaccinations, well-visits for infants and children, and prenatal care. Counseling to decrease obesity and stop smoking must also be offered free of charge. The complete list of tests and screenings was compiled by the United States Preventive Services Task Force, an independent panel of health experts.

Preventive Services Now Free For the Insured

The new regulations will apply to new health plans beginning coverage after September 23, 2010 as well as to existing plans that make major changes after this date. Secretary of Health and Human Services Kathleen Sebelius estimates this change will affect 10 million Americans with individual and family health insurance and 31 million Americans in new employer-sponsored plans next year. In most instances, the task force has detailed how frequently a screening should be performed. Where the task force hasn’t specified a service’s recommended frequency, they ask health insurers to use “reasonable medical management techniques to determine the frequency.” Though these tests must now be offered to subscribers at no cost, insurance carriers will still be allowed to charge patients for treatments related to conditions detected after a screening.

The benefits of utilizing preventive services are real: Secretary Sebelius noted in a press conference for the release of these regulations that 100,000 deaths annually could be prevented if patients effectively used colorectal and breast cancer screenings, flu vaccines, counseling on smoking, and counseling on aspirin therapy to prevent heart disease. Unfortunately, it’s estimated that Americans use preventive services at only half the rate recommended by physicians and experts. Consumers need to take advantage of the preventive services that will be more widely available (and free!) as a result of these new regulations. Now there should be no excuse for those with individual and family or employer-sponsored coverage for whom these tests are free to take responsibility for their own health by getting screenings.

Secretary Sebelius also announced the task force is now compiling a list of preventive services that carriers must offer for free to women to supplement the services already required, including genetic counseling for women with family history of breast cancer, counseling to promote breast-feeding, and osteoporosis screenings. A controversy is on the horizon already with regard to this second list of women’s services. The Planned Parenthood Federation of America has argued publicly that insurance plans should be required to cover contraceptives without co-payments, a proposition pro-life groups will undoubtedly oppose.

Ladies, it’s a fact that our health needs are different than those of men.  Due to our genetic make-up, there are many other health concerns that we must consider when choosing our health insurance plan.  The future is unpredictable, so it is important that we get coverage for all our current and potential future conditions.

Questions all women should ask about their health insurance coverage

1. Does my health insurance plan cover health screenings recommended annually for women?

It is recommended that women have annual mammograms, cervical cancer screenings, and osteoporosis screenings beginning at a certain age.  There are others important annual tests, but these tests are specific to women. The law requires that health insurance companies offer coverage for one annual mammogram for women 40 and older to prevent breast cancer.  Most states mandate that insurance companies cover an annual cervical cancer screening, such as pap smears.  Also, health insurance companies are required to offer coverage for annual osteoporosis screenings since they are necessary for health maintenance.  Osteoporosis tests begin around age 60.

2. Does my health insurance company cover specialty doctor visits?

Most health insurance companies cover for your OB/GYN services.  But it is important to check your health insurance plan to see what costs and treatments are covered because some are excluded from insurance.  For example, sterilization is rarely covered by health insurance companies.

3. Will my pregnancy be covered by health insurance?

Today, the average cost of having a baby is over $6000. Health insurance companies will most often cover doctors office and hospital visit expenses (with a small co-payment).  But there’s a catch: you must have health insurance before you get pregnant! Women who are already pregnant are considered “high-risk” candidates and it will be much more difficult to get coverage.  Other things you may want to check with the insurance company is if they offer coverage for services during your pregnancy (associated with the pregnancy but not the typical office visits) and prescriptions for possible depression. Even if you don’t needs these, better safe than sorry!

4. What if I need infertility treatments? Is that covered?

Infertility insurance is limited, but you’re not out of luck.  There are 14 states with mandates for health insurance coverage of infertility treatments.  If infertility treatments are not specifically excluded form your insurance plan, you can get coverage.  If needed, get a copy of your plan from your health insurance provider.  Otherwise, infertility treatment coverage is also offered by private insurance companies.

5.  Does my health insurance cover all of my prescription drugs?

There are many prescription pills specifically for women, such as contraceptive pills.  Generally, contraceptives have not been covered by health insurance companies in their plan. But, each insurer is different.  It is important to ask your provider because they may offer contraceptive coverage.

6. Is there coverage for treatment against diseases common to women?

Women are at a higher risk for osteoporosis, breast cancer, cervical cancer, and many others.  It is important for women to take preventative measures in their healthcare as well as have insurance for their expenses.  Vaccines are common preventative measures, such as Gardasil, a vaccine to prevent HPV and cervical cancer.  Many insurance companies cover this preventative vaccine because it reduces the chance of future medical conditions. However, check with the health insurance provider you are considering before making the final decision.

It is important to get coverage before you become ill.  Difficulty arises with health insurance coverage if you are already ill because the insurers many consider it a pre-existing condition.  Or some companies may offer coverage for office visits and pharmacy charges, but have you on a waiting list for any other treatment coverage you may need.

Approximately 47,000 Arizona children will be dropped from coverage when Governor Jan Brewer signed their new budget as of this past Thursday, March 19th, according to the New York Times. Arizona state leaders claimed that they were facing a $2.6 billion shortfall as of 2011.
The Children’s Health Insurance Program, or CHIP is a program in which parent’s use if their household income is too high to qualify for Medicaid however too low to buy insurance plans on the open market.
The Governor explains that more cuts into health insurance may be faced if voters to do not agree to approve a referendum in May which will raise sales tax by one cent for three years.

Medicaid for childless adults will also be expected to end, leaving 310,000 more individuals uninsured.

If you are an Arizona resident and want to view your health insurance options, visit our Arizona state specific page.

As of June 1, 2010, certain Medicare supplement plans will be phased out and new ones will be added. Plans E, H, I and J will no longer be for sale as mandated by the National Association of Insurance Commissioners. In its place, Plans M and N will now be added. Additionally, Plans C and F must be sold by all carriers who offer Plan A. According to Medicare.gov, if you already have or buy Plans E, H, I, or J before June 1, 2010, you can keep that plan for the course of the year.

Medicare Plan N will include copayments for doctor appointments as well as emergency room care. Therefore, the monthly premium will be 28% lower than Plan F, according to the Tuscon Citizen Online. Plan N is recommended for healthy individuals because of the $20 copay for doctors visits; Plan F may be the better choice for those who expect frequent doctor visits.

Those who choose Medicare supplement Plan M can split the Medicare Part A deductible with the insurance company 50/50 to lower monthly premiums. This should be around 15% lower than supplement Plan F, according to EzineArticles.

Medicare supplement Plans N and M do not cover Medicare Part B.

Carriers have been given until this date to change their plans. AARP, or UnitedHealthcare is now the first carrier to release their rates. Plan N’s premium is announced at $86.27.

In addition, Medicare plans will now offer a hospice benefit while at-home-recovery and preventive care will be removed.

For more information, visit our Medicare Supplement Plan N page and Medicare Supplement Plan M page.

Molina Healthcare is expanding to five more states: Idaho, Louisiana, Maine, New Jersey, and West Virginia.  This was the result of a merger for Molina to take over Unisys Corporation’s Health Information Management (HIM) business, according to Hispanic Business Online.  These 900 employees will now work for Molina Healthcare, enabling Molina to go to a state Medicaid agency and offer processing information and eligibility, disease management programs and enrolling patients as well as a nurse advice line.  Molina said they can “do a hybrid where it’s not really an HMO product but we can deliver some of the HMO services to state patients.”  Today, 1.45 million members are served by Molina.  The deal will end by the first half of the year.

From: Hispanic Business News

To view Molina Healthcare plans, visit our Molina Healthcare page.

According to HarriesburgAmerican.com, the Mississippi Health Advocacy Program released a program as of February 19, 2010 to help parents with the application process of CHIP (Children’s Health Insurance Program). The program is called Health Help for Kids and it is designed to provide assistance and resources to parents who are in need of CHIP, a Medicaid program for Mississippi’s children, used in cases where parents’ income is too high to qualify for Medicaid, but too low to cover the cost of individual insurance.

Cuts may be ahead for TennCare, Tennessee’s Medicaid program, according to the Wall Street Journal Health Blog. In attempts to offset the cuts to TennCare, Tennessee hospitals may ask to pay higher taxes on hospital revenues, though the rate right now is unclear. The WSJ blog forsees cuts at the federal levl, if Medicaid cuts on the state level persist.

The hospital tax, according to Tennnesean.com, expired in 1994, when TennCare was created. Though these cuts would save the state approximately $380 million, they would really be costing Tennessee as much as three times more in federal aid. Hospitals have estimated around $526 million in state and federal funding this year and according to Craig Becker, the president of the Tennessee Hospital Association, some state services and hospitals will disappear, which is why the new tax is being proposed.

Tennessee is not the only state facing Medicaid costs. According to the Virginian-Pilot, rising health care costs and a growth in the number of Medicaid patients have increased the government’s obligation to pay over $750 million within the past two years. New Hampshire and Wisconsin as well may see state-level Medicaid cuts, according to a post in KaiserHealthnews.org.

In Maggie Mahar’s post yesterday, Medicaid Needs More Than A Short-term Fix, she highlights the dire straits most state Medicaid programs are in (for example, despite a Medicaid enrollment increase of 18 percent over the past year in Arizona, the state has stopped enrolling children).

Medicaid is an out of control program that is bankrupting state and federal governments. The befits are similar to those of private insurance, but for free. The program will not allow copayments to change behavior, but without them, the systems are falling apart. Here in Connecticut, if you take a ride down to Bridgeport of Yale New Haven hospitals on a Friday afternoon and check out the ER you will see how jammed it is. Services for a majority of these people will be performed without so much as a copay. Even a copay of $5 could make a significant difference to the program. As head of Health Net Medicaid, I was sued regularly for trying to implement such ideas, but if something doesn’t change, these programs will continue to go bankrupt.

Health Plan One spoke to National Public Radio recently and focused on rules around preexisting conditions and insurability. I thought it would be appropriate to be very specific about how health insurance companies view preexisting conditions, what they do with them,  how we can help you get health insurance, and why the system works the way it does.

Health insurance companies are in the business of, in fact, issuing “insurance” policies. Insurance means that a company will assess a person’s risk and then set a price of insurance, commensurate with that risk. To the extent that insurance companies do a poor job at assessing risk, they will not be in business very long, as claims will quickly outrun premiums. In fact, the average insurance company posts 3% of premiums in after tax profits and therefore does not leave a large margin for error.

Insurance companies typically do not want to insure chronic diseases such as diabetes. They also do not want to insure undiagnosed conditions or imminent surgeries. So, for example, if someone has hurt their knee and needs a $5,000 operation, an insurance company will not offer a $200 policy so that person can pay for his or her $5,000 operation. What they will do is say they will not insure that knee but will insure the rest of that person’s health needs, or they will say get if that person gets his or her knee fixed, then 6 months later he or she will be eligible for health insurance. Health insurance companies do not want open ended risks that they cannot assess.

So, how should someone seeking health insurance with a medical condition proceed to purchase health insurance? First question is do you qualify today for individual insurance? At Health Plan One, we can quickly review your health status and tell you what company would potentially offer you health insurance. Or we may tell you that you should review alternatives. Depending on your state and situation, alternatives may include a COBRA plan, a sole proprietor plan, or a HIPAA plan. Certain states like MI, NY, NJ, MA, and others have guaranteed issue plans: they may be a bit more expense but anyone can qualify for these plans. In other states, like CT and NH there are high risk pools, or plans that although expensive but anyone can qualify for.

Again, the ability for health insurance companies to accept all comers regardless of health status requires that everyone participates in the pool. It also requires that health insurance companies are allowed to allocate costs commensurate with risk. For example, age is a big determinant of your health risk: a 5 year old child typically requires much less care than a 60 year old male. Insurance companies will charge that older male 4 to 5 times the premium of the younger male. This may seem unfair to the 60 year old, but it seems awfully fair to the child. Unfortunately, the insurance market needs to allocate prices according to risk profile or it won’t work. Take NY, for example where age rating is not allowed and regardless of age you pay the same price. A PPO policy costs $1,500 dollars per month. This happens because everyone pays the same rate regardless of age. The younger people will ultimately opt out of the insurance pool, viewing it as unfair and too expensive. If the 18 year old opts out because it’s too expensive, then it gets a little bit higher for everyone, and ultimately, the price will reflect a 64 year old male and almost everybody will opt out of the insurance pool.

So how do we deal best with an insurance market that demands we allocate risk appropriately? High risk pools are an excellent way. People buy insurance to guard against future risk not current risk, so you can take the really high risk people and put them in a high risk pool and protect healthy people in an insurance market that reflects the actual cost of insuring against a future event you will have a highly functioning insurance market. Taxes or some other mechanism must be issued to subsidized to the high risk pool, although if everyone has insurance, over time the need for that high risk pool will diminish.

The Connecticut Consumer’s Guide to 2010 Medicare Advantage

Open enrollment season for Medicare Advantage plans began Thursday, November 15.  Over the next few weeks, health insurance companies will be communicating with seniors about their 2010 Medicare Advantage plan offerings.  Whether you’re just turning 65 or you already have a Medicare plan, understanding the different options and choosing the right plan can be a daunting task.

Medicare is divided into three main categories – Original Medicare, which is managed by the federal government, and Medicare Advantage and Medicare supplement – or Medigap – plans, which are offered through private health insurance companies.

Original Medicare is composed of three sub-categories – Part A, which covers hospital expenses, Part B which covers doctors’ expenses, outpatient care and some other medical services not covered under Part A, and Part D, which covers prescription drugs.  Costs vary for each of these.  While Part A is usually provided with no monthly premium, Part B premiums are usually about $100 per month, except for higher-income individuals and Part D premiums range from $40-100 per month based on the drug plan you choose. There is a 20% coinsurance for Original Medicare and the current Part B deductible is $135. It is unclear whether or not this will increase for 2010.

In addition to enrolling in traditional Medicare, seniors may also choose to add benefits through Medicare Advantage or Medicare supplement plans.  Since Original Medicare has deductibles and coinsurance, seniors may purchase a supplement plan to pay a portion or all of those out-of-pocket costs. Alternatively, they may opt to enroll in a Medicare Advantage plan – choosing between HMO, POS and PPO plan types.  Typically Medicare Advantage plans offer more extensive benefits than Original Medicare, including annual physical exams and routine hearing and vision exams, at additional low monthly premiums, although they usually require physician and hospital copayments.  Medicare Advantage plans typically include a Part D drug plan.

Is Medicare Advantage the Best Option for You…?

Choosing Between an HMO or PPO/POS Plan

HMO, POS and PPO plans differ primarily by cost and network, so it pays to invest time in deciding what you want and what you can pay when making your final decision.  While HMOs may have the lowest monthly premiums, plan members may only be able to access care from their carriers’ network, except in the case of emergency care.  And, while some Medicare HMO plans may have no monthly plan premium and include a Part D drug plan, it may have significant hospital and surgery copays.  Often, the most popular Medicare Advantage HMO plans cost between $100-150 in monthly premiums and have no or low inpatient hospital copays.

For seniors who do not want to be restricted by a limited HMO network, such as those individuals who travel a lot, a Medicare PPO or POS plan might be a good alternative (PPO and POS plans are equivalent). While these plans often offer the same overall benefits as HMOs, higher monthly plan premiums and greater cost-sharing for out-of-network services allow greater flexibility in accessing health care. Seniors insured under a PPO/POS plan are not restricted by a network.

While there are private fee for service – or PFFS – plans available in 2009, they are not covered here as they tend to more expensive than other Medicare Advantage plans and are being phased out after 2010.

What’s Different from 2009

Seniors living in Connecticut will be able to choose from many Medicare Advantage plans, including 23 from the major carriers.  With Anthem’s reentry into the Connecticut market this year, competition will certainly be tough, particularly in Fairfield, Hartford and New Haven counties, where most major carriers have a significant number of plan choices.

Both Health Net and ConnectiCare will be offering four HMO plans and two PPO/POS plans to residents in all Connecticut counties.  Aetna is offering three HMO plans and two PPO/POSs for seniors living in Fairfield, Hartford, Litchfield and New Haven counties.  Anthem is offering four HMOs for Fairfield, Hartford and New Haven counties, while United Healthcare is offering one PPO to residents in all Connecticut counties and an HMO only in New Haven County.

In 2009, ConnectiCare had one of the most popular HMO plans in Connecticut, prompting many Health Net HMO members to switch carriers last year.  Smaller premium and low or no out-of-pocket increases for Health Net’s 2010 HMOs make these plans quite competitive this year. However, it is worth noting that both the ConnectiCare and Health Net HMO networks do not extend outside of Connecticut for its Medicare Advantage members.

For residents in Fairfield, Hartford and New Haven counties, Anthem and Aetna also have highly competitive plan options. Aetna’s plans are also available in Litchfield County and its Medicare Advantage members can access Aetna’s network nationwide.

For seniors interested in a PPO/POS plan, Health Net introduced a new plan, which features a low monthly premium and comparable copays to other PPO/POS plans offered in the state. ConnectiCare remains a strong choice, with its competitively priced POS plans. With moderately low physician and hospital copays, the Aetna’s PPO plan and ConnectiCare’s POS plan also may be good options.

Eligibility for Financial Assistance

State Assistance Programs

If you cannot afford Medicare premiums, you may qualify for state assistance. Depending on what state you reside in, you could have one or more options. In Connecticut, seniors who qualify have the option of enrolling in ConnPACE, a program designed to help seniors in paying for prescription medications.

ConnPACE is a state funded prescription drug assistance program for Connecticut’s senior citizens and people with disabilities. ConnPACE covers most prescriptions, insulin, and insulin syringes. Out of pocket expenses for ConnPACE are a $30 annual application fee and a $16.25 copay for each prescription medication.

You are eligible for ConnPACE if you have been a Connecticut resident for at least 6 months, you are 65 years or older or a disabled person over the age of 18, you are not receiving Medicaid benefits, you do not have an insurance plan paying for all or some of each prescription on a continuous basis and you have an adjusted gross income of less than $25,100 for a single person and $33,800 for married people.

Or You May Consider a Medicare Supplement Plan?

Medicare supplement options may certainly be described as an alphabet soup of coverage, ranging from Plan A to Plan J.  Like Medicare Advantage, Medicare supplement plans are sold by private insurers but these plans are primarily designed to help individuals fill payment gaps.

While these plans typically have higher monthly premiums, Medicare supplement plans pay your share of the costs of Medicare-covered services thus eliminating or reducing out-of-pocket payments, including co-insurance, deductibles and Part A and B premiums.  These are separate from Medicare Advantage, employer- or union-sponsored group coverage, Veterans Administration benefits or TRICARE for military personnel and their families, so come with no value-added benefits.  Enrollees would have to purchase a stand-alone Part D drug plan, as none are offered as part of these plans.

While many smaller insurers offer Medicare supplement plans in Connecticut, two plan options from major insurance carriers are worth considering based on their monthly premiums – UnitedHealthcare/AARP Plan J ($184/month) and United of Omaha Plan F ($190/month).  Enrollees would have to purchase a stand-alone Part D drug plan, as they are not offered as part of supplement plans.

In 2010, there will be a few changes to Medicare supplement. Two new plans, M and N, are going to be added. It is believed that these plans will have lower premiums and involve more cost-sharing. They should be introduced by June 2010.

How Should I Decide?

With so many options available to seniors in Connecticut, it may be difficult to identify the one plan that is best for you.  Earlier, we discussed price, which in the case of Medicare supplement plans, should guide your decision since benefits are identical.  While some states do allow for different pricing based on age and gender, Connecticut does not.

For Medicare Advantage Plans, the quality and breadth of the physician and hospital networks, as well as value-added benefits, should also be taken into consideration.  Are you sure your physician is in your plan’s network?  Does your physician admit to hospitals that also are in the carrier’s network?  For example, if your physician only admits to Norwalk Hospital in Fairfield County, it may be worth noting that only one health plan has Norwalk Hospital in its Medicare Advantage network.  The size and quality of an insurer’s network is not critical for individuals purchasing Medicare supplement plans because there are no networks tied to these plans.

In addition to ensuring that your prescription medication is covered under a Part D or Medicare Advantage plan, you need to know what tier your health insurer has placed your drugs in, as different pricing tiers will impact your out-of-pocket costs.

Important Dates

• November 15 – Open enrollment season begins
• December 31 – Open enrollment season ends
• January 1 – Changes made during open enrollment period take effect
• January 2 to March 31 – If you are not satisfied with your Medicare Advantage Plan, you may still switch plans up until this date. You can only make one change after December 31 and you may not add or drop Medicare Part D.

Professionals Here to Help

For more information or to answer questions regarding specific plans, in addition to any concerns regarding Part D drug coverage, please visit www.medicaresolutions.com or www.healthplanone.com or call 1-877-270-0612.