Fall 2016 healthcare coverage update

What you need to know about healthcare plan changes affecting your coverage

MEDICAL CARE is expensive. You, or whoever ever pays the bill, may feel like a worm on a fishing hook. Right now, there’s a lot of squirming going on.

Major insurers like UnitedHealthcare and Aetna Inc. have scaled back insurance offerings for 2017. And Florida Attorney General Pam Bondi is joining a legal challenge of the proposed $37 billion merger of Aetna and Humana Inc., a challenge involving seven other state attorneys general, the District of Columbia, and the U.S. Department of Justice Antitrust Division.

Aetna is the third-largest health insurer; Humana is the fifth. Both have been competing for seniors’ business as providers of Medicare alternatives and insurers on public exchanges created by The Affordable Care Act, according to a lawsuit filed in U.S. District Court for the District of Columbia.

The lawsuit alleges the merger would result in “loss of competition and harm to consumers” in 364 counties, nine of them in Florida. That includes Polk, Manatee, Sarasota, Broward, Charlotte, Duval, Martin, St. Johns, and St. Lucie counties.

Aetna Chief Executive Officer Mark Bertolini, in a recorded video at the Aetna website, says: “We are prepared for this. We have a strong case [. . .] The overall strategy of being in the local community, helping people in their homes stay healthy and out of the healthcare system, and achieve their overall ambitions for health is still the same.”

In a written statement, Florida Medical Association President Ralph Nobo, Jr., a Bartow obstetrician/gynecologist and a Polk County Medical Association member, applauded Bondi’s decision, saying it is important “to foster a more competitive marketplace that will operate in the patient’s best interest.”

“If approved, the merger would further empower a combined Aetna/Humana to contract with fewer physicians, limit choice for patients, increase wait times for referrals, and increase premiums,” Nobo states.

Dr. Sergio Seoane, a Lakeland family medicine physician who heads the Polk County Medical Association, agrees that the merger would raise “significant competitive concerns in many markets, especially Florida and Polk County.”

“A decrease in competition in health insurer markets is not in the best interests of patients or physicians. This goes against the fundamental nature of a free market,” he asserts. Because Polk is situated between the large metropolitan areas of Tampa and Orlando, he says the merger could give Polk “even less choice with the likely outcome of paying much more for less.”

As of May, the Florida Office of Insurance Regulation had received 11 requests for the federal Health Insurance Marketplace, the same number as this year. In August, it was in the process of reviewing company offers and rates for the 2017 year and did not have specific company information available, according to an office spokeswoman.

However, Jacksonville-based Florida Blue is offering coverage in every county and remains committed to the Affordable Care Act and Florida Marketplace, a Florida Blue spokeswoman says.

Open enrollment in the federal Marketplace starts Nov. 1 and runs through Jan. 31, according to healthcare.gov.

Here’s what you need to know to deal with other healthcare changes that may affect your bottom line:

MEDICARE IS NOW PENALIZING HOSPITALS — up to three percent of their total payment for eligible discharges — when too many people are readmitted. According to the U.S. Department of Health and Human Services, the Hospital Readmissions Reduction Program gives hospitals an incentive to lower readmissions. The real problem is that hospitals can’t turn anyone away because they can’t pay, Dr. Seoane points out, so Medicare is shifting the cost onto insurers. The penalty is an excuse not to pay, in Dr. Seoane’s opinion. “It’s bad for everybody,” he adds. “You can’t keep cutting reimbursement and expect nothing to happen.” Ultimately, healthcare providers are being penalized for the patient’s behavior, Dr. Seoane says. “The healthcare system can’t keep you healthy if you can’t follow directions,” he continues. “You can’t stop emphysema if people smoke.”

At Lakeland Regional Health Medical Center, they are working to reduce readmissions by improving education within the community. For about a year, they have been developing Congregational Health Partnerships to assist faith groups with their desire to help their congregation members stay healthy and out of the hospital or emergency department while succeeding at home. “Our approach is: this is the right thing to do,” says Dr. Daniel Haight, the hospital’s vice president of community health.

Dr. Haight says the community can help a patient avoid readmission by ensuring he or she has a follow-up doctor’s appointment and prescribed medications. Patients should understand their health condition, how it has changed since their hospitalization, and the warning signs of a problem that may result in them being readmitted to the hospital.

He says that patients should ask their care providers what is their main problem, what they need to do, and why it is important, as the National Patient Safety Foundation recommends.

INSURERS MAY REFUSE TO PAY for your prescription, so it helps to pay close attention to what’s covered and what’s not. Let your doctor know quickly if you have a problem paying for a prescription, or suspect you will later on, Dr. Haight says. If switching drugs isn’t a good idea, you may be able to fi le for an exception and have the medication covered. You never want to stop taking a medication due to cost and not share that with your doctor. You may end up sicker and back in the hospital.

THE AFFORDABLE CARE ACT has made significant gains in broadening coverage for women, improving maternity coverage, closing loopholes because of pre-existing conditions, and expanding preventative services. But you still should read the fine print. A study by the National Women’s Law Center says certain coverage still may be excluded, such as genetic testing and the treatment of conditions stemming from non-covered services.

Dr. Seoane says discrimination exists for both males and females. He cites as an example the fact that a woman can get Medicare coverage for an artificial breast while a man can’t get coverage for a penile implant.

PEOPLE SHOULD OPEN AND CAREFULLY READ any mail from Medicare, Medicaid, and their healthcare providers, advises Dr. Haight. If they don’t, they may be automatically enrolled for a Medicare alternative, a Medicare Advantage program, they never chose. And, they may find their doctor is excluded.

This is because insurers offering Medicare and non-Medicare health plans are allowed to enroll current members into their Medicare Advantage plan when they become eligible for Medicare. Folks have a 60-day window to opt out of the plan. Once coverage is in effect, it may be a while until they can cancel it.

The “safest thing” to do is confer with Serving Health Insurance Needs of Elders, known as SHINE, or the Centers for Medicare/Medicaid Services for free unbiased help in choosing the type of Medicare they want, Dr. Haight suggests.

You can get more information by calling 1-800-963-5337 or by visiting floridashine.org.

Pointing out that Medicare Advantage is not Medicare, Dr. Seoane advises folks to be cautious. “You’re giving a private company the right to manage your insurance on behalf of the federal government,” he explains. “They have to offer all the same benefits — and a little bit more.”


article by CHERYL ROGERS

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