Tag: health insurance

Feds Move to Rein In Prior Authorization, a System That Harms and Frustrates Patients

When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.

As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.

But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.

“On at least four or five occasions, she called me up, hysterical,” Roux said.

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.

Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.

Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.

“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.

Read the full article from KHN.

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The Case of the Two Grace Elliotts: A Medical Billing Mystery

Earlier this year, Grace Elizabeth Elliott got a mysterious hospital bill for medical care she had never received.

She soon discovered how far a clerical error can reach — even across a continent — and how frustrating it can be to fix.

During a college break in 2013, Elliott, then 22, began to feel faint and feverish while visiting her parents in Venice, Florida, about an hour south of Tampa. Her mother, a nurse, drove her to a facility that locals knew simply as Venice Hospital.

In the emergency department, Elliott was diagnosed with a kidney infection and held overnight before being discharged with a prescription for antibiotics, a common treatment for the illness.

“My hospital bill was about $100, which I remember because that was a lot of money for me as an undergrad,” said Elliott, now 31.

She recovered and eventually moved to California to teach preschool. Venice Regional Medical Center was bought by Community Health Systems, based in Franklin, Tennessee, in 2014 and eventually renamed ShorePoint Health Venice.

The kidney infection and overnight stay in the ER would have been little more than a memory for Elliott.

Then another bill came.

Read the full article from KHN.

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About 5 Million Uninsured People Could Get ACA Marketplace Coverage Without a Monthly Premium – But They Would Have to Enroll Soon

About 5 million uninsured people across the country could get coverage through an Affordable Care Act Marketplace health plan with virtually no monthly premium if they enroll soon, a new KFF analysis finds.

In most states, open enrollment runs through January 15, with tax credits available to help eligible low- and middle-income people afford coverage. Those tax credits would offset the full monthly premium for the lowest cost plan or plans for millions of uninsured residents, the analysis finds.

Free or nearly-free premium silver plans with very low deductibles are available to all Marketplace subsidy-eligible enrollees with incomes up to 150% of poverty ($20,385 for individuals or $41,625 for families of four enrolling in 2023).  In some cases, there could be a small extra charge – usually no more than a few dollars per month – for non-essential benefits covered by the plan.

In some parts of the country, people with incomes above 150% of poverty can also get free or nearly free silver plans, with somewhat less generous cost-sharing reductions. For example, as can be seen in the interactive map, a 40-year-old making $25,000 per year (184% of poverty) could get a free or nearly free silver plan with a smaller cost-sharing reduction in about 8% of counties, excluding counties where individuals are eligible for Medicaid or Basic Health Program (BHP) plans. Less generous bronze plans with higher deductibles are often available without a premium at even higher incomes.

KFF has an online calculator that estimates the tax credits and premiums available to individuals and families based on their age, income, and location, and maintains more than 300 frequently asked questions about open enrollment, the health insurance marketplaces and the ACA.

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Open Enrollment Period for Health Insurance

Open enrollment for most medical plans, including Medicaid and Medicare, starts November 1st and goes through early to mid-December. This is the time to sign up, renew, or change coverage to best suit your family’s situation. If you wish to estimate how much how health insurance will cost your family without giving any information to a government entity, you can visit the KFF Health Insurance Marketplace Calculator, which provides estimates for health care premiums through marketplaces, aka health insurance exchanges.

For individuals who are on, or expect to be on Medicare, the open enrollment for 2023 is open now through January 15th. If enrolled by December 15, coverage will start January 1, 2023. Medicare is generally for those 65 years or older, but certain younger individuals with disabilities, End-Stage Renal Disease, or ALS can be eligible. For step-by-step instructions on how to sign up for Medicaid or change plans in Medicaid, visit the medicaid.gov or healthcare.gov websites.

For more information on health insurance available through the health insurance exchanges, visit either healthcare.gov or wahealthplanfinder.gov. Medicaid, also known as Apple Health in Washington state, is available through the Washington Health Plan Finder. Many uninsured children, aged 18 and under, who are a part of a low-to-medium income family, are likely to be eligible for free health insurance through Apple Health. A full breakdown of the program and income requirements is available.

Help is available for those who are having a difficult time navigating the health insurance landscape.  Washington Health Plan Finder has step-by-step instructions for applying and navigators to help apply.

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The Average Medicare Beneficiary Has a Choice of 43 Medicare Advantage Plans and 24 Part D Stand-Alone Plans for Coverage in 2023

For 2023, the typical beneficiary has a choice of 43 Medicare Advantage plans as an alternative to traditional Medicare, a new KFF analysis finds. That’s an increase of 5 plans on average from 2022, adding even more choices to the Medicare Advantage marketplace, which is poised to become the dominant way Medicare beneficiaries get their health coverage and care.

In addition, the typical beneficiary has a choice of 24 Medicare Part D stand-alone prescription drug plans for 2023, a second KFF analysis finds, one more than in 2022.

These findings are featured in two briefs released by KFF today that provide an overview of the Medicare Advantage and Medicare Part D marketplace for 2023, including the latest data and key trends. Medicare’s open enrollment period began Oct. 15 and runs through Dec. 7.

Medicare Advantage

More than 28 million Medicare beneficiaries – 48 percent of all eligible beneficiaries – are enrolled in Medicare Advantage plans, which are mostly HMOs and PPOs offered by private insurers. Enrollment is projected to cross the 50 percent threshold as soon as next year.

For 2023, a typical beneficiary has 43 Medicare Advantage plans to choose from in their local market, including 35 plans that offer Part D drug coverage. In total, 3,998 Medicare Advantage plans will be available across the country.

Read the full article from KFF.

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People With Long Covid Face Barriers to Government Disability Benefits

When Josephine Cabrera Taveras was infected with covid-19 in spring 2020, she didn’t anticipate that the virus would knock her out of work for two years and put her family at risk for eviction.

Taveras, a mother of two in Brooklyn, New York, said her bout with long covid has meant dealing with debilitating symptoms, ranging from breathing difficulties to arthritis, that have prevented her from returning to her job as a nanny. Unable to work — and without access to Social Security Disability Insurance or other government help — Taveras and her family face a looming pile of bills.

“We are in the midst of possibly losing our apartment because we’re behind on rent,” said Taveras, 32. Her application for Social Security disability assistance, submitted last fall, was rejected, but she is appealing.

Like many others with long covid, Taveras has fallen through the cracks of a system that was time-consuming and difficult to navigate even before the covid pandemic. People are facing years-long wait times, insufficient legal support, and a lack of clear guidance on how to prove they are disabled — compounded by the challenges of a medical system that does not have a uniform process for diagnosing long covid, according to health experts and disability attorneys.

The Biden administration promised support to people with long covid, but patient advocates say many are struggling to get government help.

The Centers for Disease Control and Prevention defines long covid broadly, as a “range of ongoing health problems” that can last “weeks, months, or longer.” This description includes people, like Taveras, who cannot work, as well as people with less severe symptoms, such as a long-term loss of smell.

Read the full article from KHN.

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A Review of 62 Studies Finds Few Big Differences Between Traditional Medicare and Medicare Advantage on a Variety of Measures

Enrollees in Medicare Advantage Were More Likely to Get Routine Check-ups and Immunizations, While Those in Traditional Medicare Were More Likely to Receive Care in the Highest-Rated Hospitals. Rates of Satisfaction Were Similar Among Both Groups.

With the Medicare open enrollment period set to begin Oct. 15, a perennial decision faced by Medicare beneficiaries is whether to get their coverage through traditional Medicare or the private plans known as Medicare Advantage.

A new KFF review of 62 studies published since 2016 that compares Medicare Advantage and traditional Medicare on measures of beneficiary experience, affordability, utilization, and quality finds few differences that are supported by strong evidence or have been replicated across multiple studies. For example, beneficiaries in both coverage types reported similar rates of satisfaction with their care and overall measures of care coordination.

Notably, relatively few studies specifically examined specific subgroups of interest, such as beneficiaries from communities of color, living in rural areas, or dually eligible for Medicare and Medicaid, making it difficult to assess the strength of the findings or how broadly they apply.

In some areas, however, the research identified noteworthy differences between Medicare Advantage and traditional Medicare, including:

Medicare Advantage:

  • Medicare Advantage enrollees were more likely than those in traditional Medicare to report having a usual source of care. They were also more likely to receive preventive care services, such as annual wellness visits and routine checkups, screenings, and flu or pneumococcal vaccines.
  • Medicare Advantage enrollees reported better experiences getting needed prescription drugs than traditional Medicare beneficiaries overall. However, among beneficiaries with diabetes, cancer, or a mental health condition, findings were mixed.
  • Most studies found that utilization of home health services and post-acute skilled nursing or inpatient rehabilitation facility care was lower among Medicare Advantage enrollees than traditional Medicare beneficiaries, but were inconclusive as to whether that was associated with better or worse outcomes.

Traditional Medicare:

  • A somewhat smaller share of traditional Medicare beneficiaries than Medicare Advantage enrollees experienced a cost-related problem, mainly due to lower rates of cost-related problems among traditional Medicare beneficiaries with supplemental coverage. (But traditional Medicare beneficiaries without supplemental coverage had the most affordability-related difficulties.)
  • Traditional Medicare outperformed Medicare Advantage on measures such as receiving care in the highest-rated hospitals for cancer care or in the highest-quality skilled nursing facilities and home health agencies.

In other areas, though, findings were mixed or showed little difference between Medicare Advantage and traditional Medicare based on multiple studies.

Among the findings:

  • There were generally no differences in the aggregate number of hospital days or average length of stay for common medical admissions.
  • Neither Medicare Advantage nor traditional Medicare consistently performed better across all quality measures.
  • Additionally, two analyses of several measures of beneficiary experience found no differences between the two groups in experiences with wait times and in the share reporting trouble finding a general doctor, being told that their health insurance was not accepted, and being told they would not be accepted as a new patient.

Findings related to the use of other health care services, including hospital care and prescription drugs, and condition-specific quality of care measures varied – likely due to differences in data and methodology across studies.

Interest in how well Medicare Advantage plans serve their growing and increasingly diverse enrollee population has never been higher, as Medicare Advantage, for the first time, is projected to enroll more than half of all eligible Medicare beneficiaries next year, making it the main way that Medicare beneficiaries get their coverage and care. In comparison, just over a decade ago in 2010, 25 percent of the eligible population was in a Medicare Advantage plan.

The Medicare open enrollment period runs through Dec. 7.

The full analysis, Beneficiary Experience, Affordability, Utilization, and Quality in Medicare Advantage and Traditional Medicare: A Review of the Literature, as well as more data and analyses about Medicare Advantage, are available at kff.org.

Care Coordinators: MCOs’ Best Kept Secret

For families who have children with complex health care needs, coordinating all the appointments, medications, and therapies can be difficult. When an individual has several doctors and specialists that they regularly see, the help of a care coordinator can be invaluable. A care coordinator, or patient care coordinator, is a health professional employed by an MCO, or managed care organization, to oversee complex care cases. They can help with getting needed appointments, acquiring resources outside of prescriptions, ensuring that medications are easily available and do not have any interactions, and help families have better peace of mind that all of their medical practitioners are on the same page.

Care coordinators are available to many patients, but they are rarely given as an option to overtaxed patients or patients’ parents. Primary care physicians sometimes recommend a care coordinator to help a patient or family, but as they are not familiar with every aspect of a patient’s life and health care, they will often assume that a family does not need a care coordinator when they would be greatly aided by having one. For those with a strong connection to a primary provider, asking them to request a care coordinator for their healthcare can be an efficient way to start the process. While a primary care physician is often the one to initiate the assistance of a care coordinator, is possible for a patient or their family to request care coordination on their own.

The process for requesting a care coordinator is different through different health care systems. The majority of individuals on Medicaid, also known as Apple Health, have their healthcare covered by an MCO. Calling the MCO’s customer service line is often the first step in getting a care coordinator.  The phone numbers of the five MCO’s that oversee apple health in Washington state are as follows: Amerigroup at 1-800-600-4441, Community Health Plan of Washington at 1-800-440-1561, Coordinated Care of Washington at 1-877-644-4613, Molina Healthcare of Washington at 1-800-869-7165, and UnitedHealthcare Community Plan at 1-877-542-8997.  If you are unsure which MCO is in charge of your healthcare, view our video on Who is in Charge of Your Apple Health Healthcare? If there are problems in getting through to your MCO, you can call the Health Care Authority, that oversees all Washington Medicaid MCOs, at 1-800-562-3022.

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Patients Seek Mental Health Care From Their Doctor But Find Health Plans Standing in the Way

When a longtime patient visited Dr. William Sawyer’s office after recovering from covid, the conversation quickly turned from the coronavirus to anxiety and ADHD.

Sawyer — who has run a family medicine practice in the Cincinnati area for more than three decades — said he spent 30 minutes asking questions about the patient’s exercise and sleep habits, counseling him on breathing exercises, and writing a prescription for attention-deficit/hyperactivity disorder medication.

At the end of the visit, Sawyer submitted a claim to the patient’s insurance using one code for obesity, one for rosacea — a common skin condition — one for anxiety, and one for ADHD.

Several weeks later, the insurer sent him a letter saying it wouldn’t pay for the visit. “The services billed are for the treatment of a behavioral health condition,” the letter said, and under the patient’s health plan, those benefits are covered by a separate company. Sawyer would have to submit the claim to it.

But Sawyer was not in that company’s network. So even though he was in-network for the patient’s physical care, the claim for the recent visit wouldn’t be fully covered, Sawyer said. And it would get passed on to the patient.

Read the full article from KHN.

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