Tag Archives: health insurance coverage


When a Penalty Is Not a Penalty

The Affordable Care Act requires most Americans to buy qualifying health insurance coverage. Fail to comply with this mandate, and there’s a financial penalty waiting for you come tax time. But when is a penalty not a penalty? When is a mandate not a mandate? Hey, kids, let’s do some math.

The penalty for going uninsured in 2016 is $695 per adult and $347.50 per child, up to a maximum of $2,085 or 2.5% of household income, whichever is greater.

To determine the cost of coverage, we’ll use the second-lowest Silver plan available in a state. That’s the benchmark used to calculate ACA subsidies, and in 2015 Silver plans were roughly 68% of policies sold through an exchange. Even more important, I found a table showing the cost of the second-lowest cost Silver plan for 40-year-olds by state, but I couldn’t find a similar table for other levels.

The least our 40-year-old could spend on the second-lowest Silver plan this year is $2,196, in New Mexico; the highest premium is $8,628, in Alaska. The median is $3,336. Divide the penalty by the premium, and you get 32% of the cheapest premium and 21% of the median premium. Put another way, paying the penalty saves our 40-year-old  consumer $1,500 in New Mexico and more than $2,600 in the mythical state of median.

I did find a table showing the national average premium a 21-year-old would pay for a Bronze plan: $2,411.  In this situation, the $695 penalty amounts to just 29% of the policy’s cost, a savings of more than $1,700.

The purpose of this post is not to encourage people to go uninsured. I think that’s financially stupid given the cost of needing health insurance coverage and not having it. And, personally, I support the individual mandate. I also understand the political obstacles to establishing a real penalty for remaining uninsured.

However, I also believe the individual market in this country is in trouble. (More on this is a later post). Adverse selection is a contributing cause to this danger. The individual mandate is supposed to mitigate against adverse selection. The enforcement mechanism for that mandate, however, is a penalty that, for many people, is no penalty at all.

That’s not just my opinion. That’s the math.

A version of this article was originally posted on LinkedIn.

Health Insurance Exchange Scam Alert: Beware of Fake Websites

The Identity Theft Resource Center (ITRC) has growing concerns regarding the potential for new scams concerning the implementation of the Health Insurance Exchange (HIE) websites as part of the Patient Protection and Affordable Care Act (also known as Obamacare). These exchanges are currently online with enrollment due to start on October 1st.

According to the Act, each state must implement insurance exchanges. These exchanges are to serve as online marketplaces (websites) for consumers to compare rates and make choices about which health insurance coverage is best for them. Each state has the ability to determine the best way to manage these exchanges in order to meet the needs of their uninsured residents.

The open enrollment period for these exchanges begins on October 1, 2013. There have already been some predictions that there will be “bugs and glitches,” to quote President Obama, during this process. IT professionals are already voicing concerns regarding the ability to handle the amount of traffic anticipated on the first day of the rollout. However, no one is talking about ensuring that consumers actually know and understand where to go in the first place.

There is huge potential for misinformation and misunderstanding with this new insurance exchange program. Consumers will now be mandated (or face a penalty come tax time) to purchase health insurance if they don’t have existing coverage. The official website, www.healthcare.gov will be used by the majority of the states. But 17 states have opted to manage their own unique exchange with a different URL. This has the potential to cause much confusion for consumers. While it may appear that this information would easily be located via an internet search, our experience was that the official website was not easy to locate. In fact, when we searched for “health insurance exchange official websites” (rather than “website”) the websites for the 17 states that have their own unique URLs appeared, but www.healthcare.gov did not appear on the first page.

From our experience with scams and fake websites, we believe it would be extremely easy for scammers to create multiple websites that will trick consumers into thinking that it is either the federal health exchange website or one of the alternative state websites. Without known and reliable sources, there exists a great opportunity for gaming of the Internet search engines to attract consumers to websites intent on harming them by eliciting the fraudulent collection of personal identifying information (PII). There is a need to present factual information about which websites represent the accredited websites for the new insurance exchanges.

While there is a comprehensive list of insurance exchange websites on www.healthcare.gov, we are concerned that consumers may not find their way there in the first place. Already our searches indicate that there are organizations using keywords such as “Obamacare” and “Health insurance exchange” in the paid advertising section that are not the official insurance exchange websites. While these websites may not be scams, our concern is that it will only be a matter of time before imposter websites intent on real consumer harm surface.

This concern has a historical basis. The Fair Credit Reporting Act (FCRA) requires each of the Credit Reporting Agencies (CRAs: Experian, Transunion, and Equifax) to provide consumers with one free credit report annually. Confusion still exists between www.annualcreditreport.com, which is the court-mandated website hosted by the credit reporting agencies that actually provides annual free credit reports to consumers, and other websites that offer free credit reports or free credit scores such as www.freecreditreport.com, hosted by one of the credit reporting agencies. Soon after the creation of the original mandated website, dozens of look-alike websites were created. Consumer protection organizations, including the Federal Trade Commission, continue to educate consumers about this to this day (Consumer Information: Free Credit Reports) even though the mandated free website was launched in December 2004.

With the operational launch of these new insurance exchanges just a few short months away, consumers will be scrambling to comply before the January 1st, 2014 deadline. We already stated that we expect consumers to use search engines to locate the particular website they are supposed to use, and that the searches are inconsistent. With that knowledge, will regulators put provisions in place to identify, deter, monitor and address imposter websites? Or do they presume that the existing regulatory or enforcement provisions will deter those who create malicious fake websites intended to capture the personally identifiable information of consumers? Information provided to a fake insurance exchange website could be used to commit identity theft and other frauds.

There will be two types of imposter websites that will require redress. Not all imposter websites are created equal. There are differing levels of harm depending upon the type of imposter website consumers discover. There are legitimate businesses cutting corners and engaging in misleading tactics to secure new business and there are outright scam websites, whose intention is to secure personally identifiable information for malicious use.

Phishing and smishing could eventually come into play.

In 2012 “Imposter Scams” ranked 6th (out of 30) in the list of most complained about fraud events according to the FTC Consumer Sentinel Report. The 82,896 complaints represented 4% of the total complaints received by the FTC.

This category is defined by the FTC as “complaints about scammers claiming to be family, friends, a romantic interest, companies, or government agencies to induce people to send money or divulge personal information.” Complaints included the following: Scammers posing as friends or relatives stranded in foreign countries without money, scammers claiming to be working for or affiliated with government agencies, and scammers claiming to be affiliated with a private entity (a charity or company).

By far, the largest subtype of scam was regarding government agency imposters, with over 43,000 of the total in that category. Previous years’ statistics indicate that year over year, government imposters were the most complained about subtype: 47,454 in 2011 and 49,321 in 2010.

This demonstrates that the scammers continue to find impersonating the government to be a lucrative enterprise. Since this is a new program, even those consumers who normally know not to click on strange links in emails or respond to unknown senders of text messages, may feel compelled to respond and potentially share their personally identifiable information via these means. Why should we believe that the health care exchanges will be immune to this kind of impersonation?

If past behavior is an indicator, we can be sure that there will be financial harm to at least some of these victims.

The Internet Crimes Complaint Center (IC3) 2011 report states that it received approximately 39 complaints per day regarding FBI impersonation email scams. IC3 presented a total loss for this type of impersonation scam (via phishing emails) as over $3 million dollars. This number is just for the complaints that the IC3 received and does not take into account all the unreported losses.

A fundamental part of the Identity Theft Resource Center’s mission is to serve as a relevant national resource on topics such as this. In an effort to provide consumers with the important information they need about potential insurance exchange scams, the Identity Theft Resource Center has developed a scam alert and posted additional information on its website to help educate consumers.

The Identity Theft Resource Center is hopeful that there will be strong and coordinated efforts to educate consumers as to the authentic websites for these exchanges. As they differ from state to state, universal messaging will be difficult to coordinate. Of course, there will be glitches, and as with any new process, we will only discover what these are when the actual user experience is reviewed. However, these efforts need to take place now.

Implementing International Medical Providers Into The U.S. Workers' Compensation System, Part 3

This is Part 3 of a multi-part series on legal barriers to implementing international providers into Medical Provider Networks for workers’ compensation. Previous articles in the series can be found here: Part 1 and Part 2. Subsequent articles in the series will be forthcoming soon.

Heather T. Williams agrees with critics, that medical tourism is a trade-off for consumers, allowing them to opt-out of increased regulation in favor of fewer restrictions and greater cost savings. Factors unique to the medical tourism industry will help preserve the quality of patient care and insulate patients from the regulatory pitfalls critics fear. Williams points to the benefits of medical tourism as providing patients with substantial cost savings, due in part to lower labor costs overseas.43

The cost savings in the context of inflated health care costs in the U.S. indicates why patients are driven abroad to seek medical care. How much of a cost savings medical tourism offers patients can be seen in how much hospitals charge for major surgical procedures such as cardiac surgery, partial hip replacement, knee replacement, and rhinoplasty. A hospital in India charges $4,000 for cardiac surgery, compared to $30,000 in the U.S. Hospitals in Argentina, Singapore or Thailand charge $8,000 to $12,000 for a partial hip replacement that would otherwise cost twice that much here. Singapore and Indian hospitals charge $18,000 and $12,000 respectively for knee replacement that normally cost $30,000 in the U.S. Finally rhinoplasty that costs $4,500 in the U.S. costs only $850 in India.44

Though all patients can benefit, medical tourism’s cost savings are more likely to benefit those with inadequate health insurance coverage.45 Lower-middle-class individuals, who typically have sufficient means to pay for reduced-price care out-of pocket, will benefit most from medical tourism.46 This is a point to bear in mind with regard to workers’ compensation, as many claimants are generally lower-middle-class.47

Medical tourism disproportionately benefits uninsured or underinsured individuals,48 but they are not the only ones benefitting from cost savings from medical tourism.49 Self-insured employers and private insurance companies have begun integrating medical tourism into their policies. It is attractive to small businesses as well.50 Medical tourism is expanding as self-insured employers and insurance companies have integrated medical tourism into their policies.51 For instance, Blue Ridge Paper Products of Canton, North Carolina sought to send an employee overseas for gallbladder and shoulder surgery.52 They offered him 25% of the savings, but the United Steelworkers prevented them from doing so and union workers were removed from the pilot program.53 54

State governments, looking to save money anyway they can may accept medical tourism for their state employees. A bill introduced into the state legislature in West Virginia in 2006, (H.B. 4359), would have encouraged state employees covered by the Public Employees Insurance Agency (PEIA) to utilize Joint Commission International accredited foreign hospitals, receive travel reimbursements for themselves and a companion, and participate in the savings with a cash rebate.55 56 The bill is still pending in the House Banking and Insurance committee.57

Large HMOs and health insurance companies have established plans to allow patients to obtain low-cost services overseas.58 BlueShield and Health Net of California, United Group Programs of Boca Raton, and BlueCross and BlueShield of South Carolina have offered such plans for travel to Mexico and Thailand for treatment.59 The effect of financial incentives on American’s willingness to travel for medical care is evident in a 2007 nationwide telephone survey of a representative sample of 1,003 Americans in which 38% of uninsured and one-quarter of those with insurance would travel abroad for care if the savings exceeded $10,000. One-quarter of uninsured, but only 10% of those with insurance would travel if savings were between $1,000 and $2,400. Fewer than 10% would travel to save $500 to $1,000, and no one would do so to save $200 or less. This represented a potential market share of 20-40 percent for non-urgent major surgery.60 61

Medical tourism is fast becoming a feature of American health care. In the next few years, more and more Americans will be going overseas for medical care. It is only a matter of time before medical tourism’s mark is felt on another arena of American health care — workers’ compensation.

43 Williams, 611.

44 Herrick, 8.

45 Williams, 614.

46 Ibid, 614.

47 Juan Du and J. Paul Leigh, “Incidence of Workers Compensation Indemnity Claims Across Socio-Demographic and Job Characteristics,” American Journal of Industrial Medicine, 54 (2011): 758-770. The study suggests that low socioeconomic status was a predictor of reporting workers compensation claims, but did not include income levels; although it is possible to extrapolate from the data presented that the subjects were generally lower middle class or working class.

48 Williams, 614.

49 Ibid, 615.

50 Ibid, 615.

51 Ibid, 615.

52 Boyle, 43.

53 Ibid, 43.

54 Williams, 616.

55 Ibid, 44.

56 Nicolas P. Terry, “Under-Regulated Health Care Phenomena in a Flat World: Medical Tourism and Outsourcing,” Western New England Law Review, 29, no. 29 (2007) 427.

57 West Virginia Legislature website, (2006).

58 Williams, 616.

59 Boyle, 44.

60 Herrick, 2.

61 Arnold Milstein and Mark Smith, “Will the Surgical World Become Flat?,” Health Affairs, 26, no. 1 (2007): 138.

The Insurance Rate Public Justification & Accountability Act – Does It Get To The Real Problem?

A recent press release states, “The California Secretary of State announced today that a ballot initiative to require health insurance companies to publicly justify and get approval for rate increases before they take effect has qualified for the 2014 ballot.” The release goes on to state, “the initiative would require health insurance companies to refund consumers for excessive rates charged as of November 7, 2012 even though voters will not vote on the initiative until a later ballot.”

The President of Consumer Watchdog stated, “Californians can no longer afford the outrageous double-digit rate hikes health insurance companies have imposed year after year, and often multiple times a year. This initiative gives voters the chance to take control of health insurance prices at the ballot by forcing health insurance companies to publicly open their books and justify rates, under penalty of perjury. Health insurance companies are on notice that any rate that is excessive as of November 7th 2012 will be subject to refunds when voters pass this ballot measure.” This effort was supported by State Senator Dianne Feinstein and California Insurance Commissioner David Jones.

Is there more to the story? Is there something else we should be considering? Is it really this obvious that this is solving a major concern or problem?

As with most sensational statements, there is far more to consider as it relates to the affordability of health insurance. As a professional actuary for more than 41 years, I am afraid there is far more to this story than has been described by the proponents of this initiative. The remainder of this article will address some of the most obvious issues.

Do Carriers Intentionally Price Gouge Their Customers?
Although there always seems to be exceptions to the norm, carriers set rates based upon their historical costs and a reasonable projection of what might happen in the future. These rates are developed by professional actuaries who are subject to Guidelines for Professional Conduct that govern their analysis and review methodologies.

Rates are not made subjectively, but rather based upon extensive analysis of what costs have been. Actuaries spend endless hours reviewing the claims experience, analyzing utilization and cost levels, developing estimates of inflationary trends, analyzing operating costs and carefully projecting what future rates will need to be in order to cover costs and produce needed margins. When prior rates are inadequate, premium rates are increased on particular plans to avoid losses.

This process is very systematic and based upon detailed actuarial analyses. This process is not arbitrary or capricious, but can be challenging for some product lines. I know of no competent carrier that intentionally tries to gouge its customers, but rather the opposite. Carriers work hard to find ways to provide the greatest value to their customers and keep rates as low as possible.

Why Do Premium Rates Go Up So Much?
There are many reasons why rates increase but the most prevalent reason is the high cost of health care. Most of the premium goes to pay health care bills. Under health care reform at least 80% – 85% of the premium goes to pay for health claims. The carrier has little control over these costs other than their efforts related to negotiating discounts and in the impact of their care management activities. The carrier is subject to the prices charged by health care providers. Hospitals charge what they want to charge and carriers try to keep these down by negotiating and maintaining discounts from billed charges.

Since the government sponsored programs pay deeply discounted prices for Medicaid and Medicare members, sometimes below actual cost of care, the carriers are subject to a significant cost shift, paying prices much higher than their governmental counterparts. When providers increase their prices, carrier costs automatically increase. Other than the limited impact of regulation on prices for Medicaid and Medicaid patients, there is no oversight of what providers charge for their services. The fear by providers of the pending impact of health care reform and how it will expand the Medicaid population has resulted in some dramatic increases in provider charge levels to carriers.

In addition to the increases in provider costs, premium rates increase for other factors which include:

  • Aging: as members age, their costs increase as much as 1.5% – 2.0% per year
  • Selection bias at time of lapse: there is a strong tendency for a bias in lapsed or terminated members. The healthier members tend to lapse more quickly than others since they are more easily able to find alternate coverage. This tends to increase average costs about 1% – 1.5% per year, especially on individual and small group coverage.
  • Impact of underwriting: As individuals are reviewed by carriers for medical conditions at time of enrollment, more healthy individuals are enrolled. As time passes, the impact of this underwriting selection wears off and as a result the average costs increase by as much as 2% – 3% per year.
  • Deductible leveraging: As costs have increased over the years, individuals have preferred higher deductible programs to keep their costs down. Effective trend rates are higher on higher deductible programs based upon a concept known as deductible leveraging, even though the underlying trend is identical to that for a lower deductible program. For example the effective trend for a $3,000 could be a third larger than for a lower deductible. For example, for an underlying trend of 10%, the leveraged trend for a $3,000 deductible is 13.2% or 3.2% greater than what is expected.
  • Utilization trend: In addition to changes in what providers charge, the actual rate by which patients consume services is higher each year, by as much as 1% – 1.5% per year. Some services increase more rapidly.
  • Unit costs vs. CPI: National CPI statistics for health care are based upon a common market basket of services and do not reflect a reasonable norm from which to expect health care services to follow. Recent CPI statistics show a general economic trend of no more than 3%, with their medical statistics showing 5% – 6%. Carrier trends have been even higher for many reasons including the above factors.

The Unique California Situation
In most states the insurance commissioner has the authority to regulate rates carriers use for some of their products. Historically in California, the commissioner’s authority was somewhat limited. They required filing of some rates, but did not have the authority to stop a carrier from using a proposed rate or rate increase. They were able to exert some pressure, many times strong pressure, to stop a carrier from large rate increases, but if a carrier wanted to proceed they usually had the right to do so.

In recent years, the department resorted to some public pressure, some negative PR, and essentially threats to the carriers. The proposed initiative gives them the “authority” to do something meaningful, not just veiled threats. So as far as that is concerned, it is good to give more real enablement to do something meaningful to hold all carriers accountable for their actions. I do not believe there is any real concern about carrier behavior, at least among the major players.

The Real Issue
It’s always better to deal with the real cause of the problem, not just undesirable symptoms. If headaches are caused by a brain tumor, it is better to fix or remove the tumor, not just take a stronger pain killer. If the Insurance Rate Public Justification and Accountability Act is to fix the healthcare cost problem, then it is taking action on a symptom of the problem, not the real cause.

As discussed above, there are multiple reasons why health insurance premiums increase. Regulating the carriers alone doesn’t solve any of the underlying problems. It restricts the behavior of one of the middlemen. It doesn’t get to the core problem. It definitely will have an impact, but if not kept in check, will create perhaps even greater problems, potentially driving some carriers out of the market and perhaps transferring more of the problem to additional government bureaucracy.

Although the author is not a big fan of increased government regulation, some regulation or legislation focused on the prices providers are able to charge for services might be more beneficial. At least the major driving force of premium rate increases would be more stable and controlled which would keep premiums more in line.

Proposed Solution
Although fraught with additional challenges, my favorite solution to the provider charge driver is a shift from today’s system which has different prices for different payers to a system where all payers pay the same price (i.e., called the all-payer system). No matter what type of coverage a person has, the carrier/administrator would be charged the same price. This means that there would be no bias against government payers vs. private sector payers. This would increase the cost for the government for Medicaid, but would substantially reduce what the private sector pays.

Our firm’s analysis shows that setting the prices at Medicare payment levels for all patients would actually be a close proxy for a reasonable price. Private sector prices would drop in most markets by 15% – 17%. Medicaid prices would be increased to a reasonable Medicare payment level. Providers would have no reason not to take any patient since each patient brings the same revenue.

This would also level the playing ground for managed care plans and carriers since network differences would be eliminated. The plans could compete on more important items such as care management effectiveness, clinical efficacy, comparative effectiveness, and quality of the provider network.

Under this approach, Medicare would be the agency essentially regulating the reasonableness of prices. Significant administrative costs would be eliminated from both the carriers and the providers.

There would be a cost to the various states for raising the price they have to pay for Medicaid beneficiaries since they often have to pay 50% of the cost of these patients. Some of this could be offset by some increased federal payments from the savings generated in the system.

Bottom Line
California’s proposed initiative is interesting but probably not as big of a deal as it could be. Here’s hoping for some “real” legislation that could save more of us more “real” dollars and eliminate some of the administrative costs of the current system.