By Jonathan Burroughs
It’s said that people love surprises, but when they come in the form of medical bills, American consumers beg to differ. More than half have gotten a surprise medical bill, according to the National Opinion Research Center at the University of Chicago, and more than half of those surveyed blame the insurance carrier. While occurrences of surprise medical bills flew mostly under the radar for a long time, as high healthcare cost discussions retain center stage, the topic is being widely discussed. It seems to be something that both political parties can agree upon. Most people with health insurance know that they need to check with a provider before using said provider to make sure that healthcare professional is in-network. That’s all well and good, except for those times when they’re incapacitated, as in an emergent situation, and they need care fast, at the closest facility able to receive the care that is needed. Maybe they can’t talk and maybe they have no one with them to advocate; a typical recipe for a surprise medical bill. Another recipe for a big bill: ending up in a facility that is in network, but having a provider care for them who isn’t, a situation that befalls many Americans each year. Of course, it would be ideal if the facility or provider would say, “I’m not in your network,” but at that point, what can a patient really do? We’re Afraid: Very Afraid The Kaiser Family Foundation says that two-thirds of us are “very” or “somewhat” worried about unexpected or surprise medical bills. They occur because of a difference in cost-sharing levels between in-network and out-of-network charges. And they happen when out-of-network providers, who aren’t bound by contracts, bill patients directly for additional charges. The foundation shares that the majority of bills aren’t that big, below the $500 mark, but we’ve all heard the horror stories of exorbitant bills that threaten to bankrupt the unsuspecting patient. Approximately one in five emergency room visits result in a surprise bill. Sometimes patients can negotiate bills much lower and sometimes not. And the process can require hours and hours of time. As Kiplinger advises patients and the medical community can at large, it’s smart to ask if everyone involved in a procedure is in network. Consumers are advised to check out state protections, since some states don’t allow surprise billing. They should never pay that bill before calling both insurer and provider to ask “Why”? and then should ask for itemization. Then, when all else fails, as it frequently does, they should appeal, via the state insurance department’s consumer services or healthcare advocate. Sometimes even that can’t solve the problem. Lawmakers Take Action If it all sounds hopeless for the unfortunate patient, in reality, it often is. President Donald Trump spoke on May 9, 2019, along with a patient who was billed $110,000, even with insurance. “So this must end,” he said then. “We’re going to hold insurance companies and hospitals totally accountable.” On July 17, 2019, the House Energy and Commerce Committee passed an amendment to H.R. 3630, the No Surprises Act. The legislation contains a third-party arbitration clause and will make its way to the House for its next review. It was introduced in mid-May as a discussion draft. Both providers and payers have an opportunity for independent arbitration specifically, says Healthcare Dive, which reported the action early. They can do that, according to the amendment, when the median in-network rate is more than $1,250, a change from previous wording that specified a benchmark payment rateif disputes arose. That term, benchmark, is defined as the maximum amount per member per month that the Centers for Medicare and Medicaid Services will pay a Medicare Advantage organization that delivers traditional Medicare benefits. We Have Choices Other things are happening, and they’re not just wishful thinking. The Senate introduced S.1531, Stopping the Outrageous Practice of Surprise Medical Bills Act of 2019 last May 16. It’s with the Committee on Health, Education, Labor, and Pensions. Lower Health Care Costs Act of 2019, S.1895, that debuted on June 19 includes language about precarious air ambulance bills. Its currently resting on the Senate Legislative calendar and also contains language about keeping costs transparent and tackling the equally hot topic of too-high drug pricing. There’s also H.R. 861, End Surprise Billing Act of 2019; S. 1266, Protecting Patients from Surprise Bills Act; H.R. 3502, Protecting People from Surprise Bills Medical Act; and H.R. 3784, To amend title XXVII of the Public Health Service Act and title XI of the Social Security Act to prohibit surprise billing with respect to air ambulance services, introduced on July 16. Some For, Some Against The issue is made more complex by the fact that states may do things differently in terms of resolving differences between provider claims and insurer reimbursement. As Yahoo! Finance reports, New York and Connecticut utilize independent reviews that cite a database as the benchmark, while New Jersey uses arbitration. And at the root of this, there are no federal regulations — but that is about to change. As expected, opponent and proponents have voiced their opinions about the No Surprises Act. The American Hospital Association says it supports arbitration, America’s Health Insurance Plans says “no” and The ERISA Industry Committee (ERIC) cites “government-mandated baseball-style arbitration in this legislation,” and no longer supports the act. With so many wheels spinning around such a complex topic, one could wonder how long it will take to get through all the layers to bipartisan legislation that gets the job done. Yes, there’s a lot of noise around surprise medical bills, but for the American consumer, it certainly beats the sound of crickets. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success!
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By Jonathan Burroughs
HRAs, or health reimbursement arrangements, are defined as a type of account-based health plan that employers can use to reimburse employees for their medical care expenses. Employer-sponsored health plans cover more than 155 million employees in this country. Enthusiastic administration officials say the plan will give the private insurance market a shot in the arm, and help small businesses offer health coverage to all levels of employees. The healthcare community is calling this HRA expansion. As the National Law Review explains in extensive legal detail, the new law reverses long-standing ACA policy that prevented HRAs or premium payment plans from being used to reimburse premiums paid for individual market coverage. The new HRAs give employees the freedom to purchase insurance in the individual market, from an exchange or not. ‘Your Attention Please’ On June 13, three departments — Health and Human Services, Labor and the Treasury —teamed up to announce the new policy that becomes effective Jan. 1, 2020. Business owners can provide an individual coverage HRA or ICHRA (Yes, another acronym) or an excepted benefit HRA. The HRA experts at PeopleKeep, personalized benefits automation software providers, explain the nuances of these two options this way. The ICHRA allows employers to give employees a set amount of tax-free money each month, to spend on healthcare and/or individual health insurance, and then be reimbursed up to that amount. The excepted benefit HRA mandates that employers offering group health plans offer an HRA that reimburses for dental and vision coverage, along with short-term premiums. The federal government’s announcement says that more than 11 million American workers, which include 800,000 uninsured, will ultimately enroll in HRA plans. That 800,000 number is used again, referring to companies that will likely jump on the HRA bandwagon, with almost 90 percent employing fewer than 20 people. A Brief History of HRAs HRAs aren’t anything really new, hence the current “expansion” label. They were ticking along until 2013 when the IRS wrote guidance with IRS Notice 2013-54 around the Affordable Care Act that cut employers’ ability to offer HRAs. The agency said “OK” to HRAs paired with group health coverage but “no” to a combo of an HRA and individual coverage. In December 2016, enter the qualified small employer HRA or (You guessed it: another acronym) QSEHRA (Some people call it “Q-Sarah.”). It’s great for smaller employers, those with 50 or less on board. The employer can put away money every month for staff to buy their own individual health insurance or spend on necessary medical costs and again, it’s all tax-free. Fast forward to fall 2017, when President Trump’s executive order directed the above three departments to revisit that 2013 guidance so all employers could pair the HRA with individual coverage for their employees. A year later, the 2013 rule was gone in favor of that duo of HRAs we’ve just described — and here we are. Those in Favor Say “Aye” Supporters say that since employers need to provide health insurance as a highly desirable benefit in a tight employee market and that doing so can be expensive, the new HRA alternative is ideal. It doesn’t mandate that an employer choose just one health plan for its entire employee group, which can sometimes be an expensive proposition. Those same employers can also reap tax benefits that big corporations do but can do it a different way with the HRA, which, as noted, excludes premiums from federal income or payroll taxes. On June 14, Brian Blase, special assistant to the president at the National Economic Council focused on healthcare policy, wrote for CNN that “the Obama administration forbade workers in the individual insurance market to use HRAs to pay for coverage — significantly impeding employer flexibility and worker choice. Trump’s new rule undoes this misguided restriction.” He notes that 80 percent of employers that offer insurance only offer one type of plan. He also shares that between 2010 and 2018, the proportion of workers at firms with three to 49 workers covered by an employer plan fell by more than 25 percent. The often controversial yet undeniably influential Blase thinks that HRAs may bolster the individual market by more than 50 percent, yielding more competition that ultimately delivers better choices for consumers. Insiders credit him for getting the HRA rule done and note that, ironically, he’s leaving his job soon. In an opinion in The Washington Post, Avik Roy, president of the Foundation for Research on Equal Opportunity cheers the move, saying it could cause a revolution in the private insurance market. Roy even goes a step further, suggesting the administration require “all newly incorporated businesses seeking the tax break for employer coverage to do so through HRAs.” Those Opposed Say “No” True, under the HRA system, employees do have free rein to choose a plan that works with their budget, which receives rave reviews in some circles, and a thumbs-down in others. So an employee with champagne healthcare coverage taste could go for broke, while another might choose bottom-of-the- barrel coverage which provides the bare minimum and leaves them exposed to a sky-high deductible, as with some catastrophic plans. Short-term or limited benefits plans can expose consumers if the plans discriminate against pre-existing conditions, says the former editor of Modern Healthcare, Merrill Goozner. He sounds the alarm bell about HRAs, calling the move another way to undermine the ACA exchanges. And here’s something not mentioned in that announcement, says Goozner: “Moreover, if an employer no longer offers an employer-provided health plan, an employee that accepts HRA cash could be cut off from receiving premium tax credits on the ACA exchanges.” He says that many employers will get lost trying to understand the detailed parameters around eligibility — it will be Greek to them — which will in fact buff up employment “for insurance brokers and employee benefit consultants.” Joining the “not-so-fast-here” congregation, Larry Levitt, senior vice president of the Kaiser Family Foundation, tweeted about an irony he perceives with the entire situation. He believes HRAs can only fly “if the ACA individual insurance market is stable and attractive,” and as he noted, and we’ve written about here, the current administration has tried on numerous occasions to undermine that market. Finally, Speaker of the House Nancy Pelosi responded with a formal statement, which said, among other things, that “the Trump Administration has worked relentlessly to push families into disastrous junk plans, increase their health care costs and gut their health care protections.” Truthfully, the rules around this new rule are very complicated, experts agree. The Trump administration has adopted what’s been termed an aggressive timeline, and 2020 is just around the corner. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! |
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