I feel remiss in not posting to my blog for some time.  I will be adding to the blog with regularity in the near future.

There was a significant ruling put out by The Obama administration.  HHS formed a commission to come up with what an essential benefits set would be as it relates to health insurance policies governed by the PPACA/ACA starting in 2014.  The administration’s commission could not decide what benefits should be included and what should not be included.  If they included all the benefits being lobbied for by patient and provider groups the cost of the resulting insurance premiums would have bankrupted the Federal Government.  On the other hand if HHS and the commission were to exclude some of these benefits, these same groups would cause significant damage to the chances for re-election of the administration.

So what did they do?  They punted to the states to make those decisions. Please read the article below to see how the states will be required to make those decisions.  Dave Wiest, CBC…President…EMEX Benefit Systems

HHS Issues Essential Health Benefits Bulletin on Benchmarking

Gives States Greater Flexibility in Determining What’s Covered Under New Exchange Plans in 2014

On December 16, 2011, the Department of Health and Human Services (HHS) issued a bulletin outlining proposed policies and the approach it intends to pursue in rulemaking for defining Essential Health Benefits (EHB). Per the Patient Protection and Affordable Care Act (PPACA), beginning on January 1, 2014, non-grandfathered Individual and Small Group plans offered inside and outside the Exchanges must cover the EHB.  In addition, PPACA prohibits the use of lifetime and annual limits on the dollar amount of EHB.

In developing the regulation, HHS stated that its aim is to balance comprehensiveness, affordability, and State flexibility. It is, therefore, proposing to allow each State to select an existing health plan as a “benchmark” to establish the services and items included in the Essential Health Benefits package for 2014 and 2015.

States will choose from one of four health insurance plan options as a benchmark:

• the largest plan based on enrollment in any of the three largest small group products in the State
• any one of the three largest State employee health plans
• any one of the three largest Federal employee health plan options
• the largest HMO plan offered in the State’s commercial market

HHS will propose that the default for States choosing not to set a benchmark will be the small group plan with the largest enrollment in the State. For 2016 and beyond, HHS would reassess the proposed benchmark process.

The bulletin did not address cost sharing, e.g., deductibles, copayments, and coinsurance, which will be covered in future guidance. Cost-sharing rules will determine the actuarial value of the plan. It also does not address how this state-by-state approach is to be applied to the ban on lifetime and annual limits for plans that cover people in multiple States.

However, the bulletin did reaffirm that Essential Health Benefits must include items and services within the following 10 benefit categories:

(1) ambulatory patient services,
(2) emergency services,
(3) hospitalization,
(4) maternity and newborn care,
(5) mental health and substance use disorder services, including behavioral health treatment,
(6) prescription drugs,
(7) rehabilitative and habilitative services and devices,
(8) laboratory services,
(9) preventive and wellness services and chronic disease management, and
(10) pediatric services, including oral and vision care.

Resources
HHS encourages public input on this proposal.  Comments are due by January 31, 2012 and can be sent to:  EssentialHealthBenefits@cms.hhs.gov

Dave’s Blog

www.emexbenefits.com

dwiest@emexbenefits.com

881 Meander Court
Medina,  MN 55340
Phone: 763-478-9050

Toll Free 877-478-EMEX (3639)
Fax: 763-478-9014
Cell:  952-239-7374
W7602 Wallin Drive
Minong, WI 54859
715-466-4105

Hello All

It has been quite some time since I have written in my blog and as such, I will be pontificating quite a bit in the next few days.  A lot has happened in the last couple of months.  First, I would like to give you a rundown of what is happening in the ACA Exchange world.

Only 13 of the 50 states have passed exchange bills.  In addition, two others already had exchanges (Mass and Utah).  Of the exchanges that now exist, my favorite is Utah both for selfish reasons and for the purpose of the exchanges to begin with.  The Utah exchange has 120 plans available and uses the existing agent community to enroll people in the various plans.

At this time, the Utah exchange is only available to employees of small business. It does not incorporate government subsidies for paying coverage for low-income individuals.  Instead, at this time it has been set up as a “defined contribution” model.  This means that the employer decides how much if any money they are willing to contribute toward the cost of coverage and then the employee decides which plan they wish to buy.  If there is a balance that needs to be paid then the employee pays the difference.  You can imagine the difficulty people have in choosing between 120 different plans.  This is where the professional agent comes into the picture.  Instead of having state employees on the phone with an employee or the employee online by themselves choosing a plan, Utah pays a commission on the sale enrollment and service of these policies.  These well-trained agents have a vast amount of experience enrolling people in health plans, so Utah decided not to recreate the wheel.

The Utah exchange utilizes the company “Bswift” as their vendor for software and exchange management.  The entire Utah exchange has two employees and a board of directors that govern the plan.  My understanding is that the state of Utah spent $50,000 setting up their exchange.

Will the Utah exchange ultimately be successful?  I believe it will be but only time will tell.  In the meantime, Utah has a system that is beginning to make inroads and has not spent millions of unavailable tax money in their experiment.

Here is a link to a YouTube video on the Utah exchange done by PBS.   http://www.youtube.com/watch?v=VHPZ4JDkU94

Dave Wiest
President
EMEX Benefit Systems

Hello All

Yesterday as I was watching the news and reading reports on the new debt limit increase I finally realized why I get so incensed with the term REVENUE when used by politicians.

All of us in business and the general public have used the word revenue in a positive manner.  We all try to increase out revenues through increased manufacturing, sales, service or productivity increases.  It is in all our interests to increase “revenues”.  It connotates hard work and having productive fruitful work lives.

Now in the interest of sounding more positive the government has hijacked the word “REVENUE” and tried to make it sound as if they are doing something productive in raising “REVENUES”.  This type of diversion from the truth and reality irritates me.  In my opinion, it is a dishonest representation of the truth.

What is really on the minds of government and its bureaucracies is further taxing the revenues of honest hard-working people.  The government does not exist on revenues it exists on taxes and its ability to convince the public that it should give up their hard-earned revenues in favor of unearned government taxes.  So instead of the individual who earns the revenue being in charge of their revenue the government raises taxes in an effort to self perpetuate itself and continually expand its reach into unproductive inefficiently run endeavors which are passed off as essential services.

In the last few days, I have heard several well-known celebrities, one of which was Matt Damon, pontificate that all those that do well should pay more to the government.  Since that is their opinion then I would suggest that they open up their checkbook and write a check to the government of their choice.  Nothing prevents sending money to the government and it would certainly increase their “REVENUE”.

The government reminds me of an uncle of mine that came for a couple of weeks and stayed for a year.  He helped out around the house but his living expenses were covered by detracting from the revenue I generated by working every day during that year.  Do not get me wrong I loved my uncle and I felt an obligation to provide for his basic needs when he could not or would not but I doubt he would have called my hard work his revenue.

Dave Wiest
President
EMEX Benefit Systems

Hello All

I just received an article written by a friend and colleague Dave Racer.  In his article he spoke of his efforts a couple of years ago in obtaining a CPAP (continuous positive airway pressure) machine to treat his sleep apnea. He talked about how a lease cost $200 a month for 10 months at which time he assumed the machine would lease again the 2^nd and succeeding years.  He was able to buy the machine up front for $1350.  I commend dave for his efforts.

Anyone with a high deductible plan in which the deductible exceeds the cost of the goods or services they need should go through this same effort which would save all of us money within the health care system.  And in fact would help keep the cost of health insurance down.

Now I would like to give you an idea of what an agent can do for you to help to keep these costs even lower.  I should say up front that I also have sleep apnea and have been using a CPAP machine since 1998.  I should also say that sleep apnea contributes to heart disease and to strained relationships not to mention the lack of quality sleep with those that necessarily are required to sleep in the same room with someone who has sleep apnea.

CPAP machines are typically given to a patient under a lease purchase arrangement.  The new machines are expensive and the insurance carrier does not want to pay for a machine only to find out that the patient cannot tolerate that particular machine or any type of CPAP machine.  Therefore they pay a higher rate for the lease purchase than to buy it outright.  The result is a lower overall cost to the insurance company as well as better profits for the durable medical company.

So what happens to the CPAP machines that get turned back in before the lease purchase is finished?   I asked myself that question after about two years of using my CPAP that was paid for by the insurance company on a lease purchase.  I began making calls to friends and acquaintances in the durable medical equipment business to find out what happened to these “slightly used” machines.  I was told that they are cleaned checked out and repaired if necessary and offered for sale.  I asked the price and was told between $100 and $300.  Interesting huh!

As a result of this revelation I have arranged for over 20 used machines to be sent to various clients and friends saving many thousands of dollars.

Last week the used CPAP machine I have at our cabin finally gave up the ghost after 7 years of faithful service.  Since I already paid the out of pocket maximum in claims under my policy this year and my policy allows for a replacement every 5 years I got a new machine with a lot of new features on it and it cost me nothing.  It is a bad way of looking at things, but let’s face it, we all do what is best for us and our own pocket books.  In addition to the new machine, since my insurance won’t pay for a backup machine I got in touch with my friend that owns a durable medical equipment company and bought a back up used machine for $100 (it had 1000 hours on it about 4 months use).  Now I have all my needs taken care of for $100 instead of the $1350 Dave paid for his single machine.

Knowing the system and how it works can help you save money.

If any of you need a CPAP machine call me and I will help you get your machine.

Dave Wiest
President
EMEX Benefit Systems

Hello All

Headline April 12,2011.  The Missouri Democrat Attorney General files a
friend-of-the-court brief supporting the 26 states that received a ruling in Florida Federal Court ruling the individual mandate in the ACA law unconstitutional.  To read the article follow the following link.  Dave Wiest

Missouri’s Democratic AG splits with Obama over PPACA
By Reuters
April 13, 2011

http://ebn.benefitnews.com/news/missouri-democratic-ag-ppaca-2712028-1.html?ET=ebnbenefitnews:e1403:1624114a:&st=email&utm_source=editorial&utm_medium=email&utm_campaign=EBN_inBrief_041411

Hello All

Part of the ACA (Affordable Care Act) was to require employers with more than 50 employees to provide a voucher to their employees equal to the highest contribution level the employer makes.   That employee can then take that money and buy their health insurance through the exchange using employer provided money.

Part of the new budget for 2011 that shows 38 billion in cuts also eliminates this “Free Choice Voucher”.  If the President signs it into law this provision will be gone.

While it does not do away with penalties it does make it easier to maintain the integrity of an employer’s group health plan.  The “Free Choice Voucher” could have contributed to anti-selection by the fact that group plans for employers over 50 employees are composite rated based on the losses and age and other demographics of the group.  The individual exchange will most probably have age rating.  This would cause young people to abandon the group for lower cost exchange premiums.  The employee would then be allowed to keep the difference in premiums for themselves thereby causing a higher premium for the remainder of the group whose average age and claim base increased do to lack of participation by the young healthy employees.

Dave Wiest
President
EMEX Benefit Systems

Hello all

We all are wondering what the Federally mandated exchange plans through the state exchanges look like.  Well maybe not you but I sure am!

The Kaiser Foundation just ran an article projecting what these plans might look like.  There are 4 mandated plans, Bronze, Silver, Gold and Platinum.  I have included the link for you to read the article.

In the article it projects that these plans will all have high deductibles based on their actuarial values.  It also shows the percentage of people in the US that are currently enrolled in plans with deductible of at least $1,000.*

http://www.kff.org/pullingittogether/What-Conservatives-Won-In-Health-Reform.cfm

Dave Wiest
President
EMEX Benefit Systems

INSURED MEDICAL REIMBURSEMENT PLANS

Hello All

Some of you have “INSURED MEDICAL REIMBURSEMENT PLANS” in place.  The writing of new plans was suspended by ACA regulations in 2010.  HHS removed the discrimination language temporarily in December of 2010 therefore new plans can now be written.  These plans allow a company to reimburse claims for selected people within the company without running afoul of discrimination rules.  This is a valuable tool for recruitment and retention of key employees.  It is not known how long this reprieve will last so “GET EM WHILE THEY”RE HOT” and call us for an explanation and a quote.

Dave Wiest
President
EMEX Benefit Systems

Hello All

I have been asked several times what effect the Tax Relief Act that was passed in the waning days of 2010 would have on “me”.  Most of you have probably had contact with your accountants and have already seen some form of summary on the law.  If you have not.  Here is a link to a very good summary and analysis of the bill.  It consists of 14 pages and is quite informative.

http://emexbenefits.com/Tax%20Relief_Job%20Creation%20Act%20of%202010.pdf

Dave Wiest
President
EMEX Benefit Systems

Hello All

In recent weeks there has been a bill proposed to implement the “Exchange” in Minnesota (HF479).  This bill consists of a minimalist approach to the exchange requirement mandated to the states by the Obamacare legislation.  This bill is designed with as much private market protections as the Obamacare law allows.

Some staunch conservatives don’t want any bill creating an exchange to be passed.  They reason that since the Federal Court in Florida ruled the individual mandate to be unconstitutional and the law to be unseverable that the entire law is unconstitutional and cannot be enforced. The judge did not however formally enjoin the Federal government from continuing to implement the law.  Judge Roger Vinson has been asked formally by the Obama administration to specify whether they can continue the implementation process that they have already begun.  We should have an answer to this question in the next few weeks.

On the surface I would agree.  I abhor the idea of the exchanges and the costs involved in the implementation of such a requirement.

I think that any good plan includes dealing with the law as it is and working toward completely eliminating the law and implementing real reform that concentrates on the cost of healthcare and inequities in the system.  With this in mind hopefully the Federal government will be enjoined from implementation and the Supreme Court will strike down the law.  We cannot expect in Minnesota, since Mark Dayton is our governor and we have DFL attorney general, that we will follow suit with Florida and Alaska in refusing to implement, according to the law’s timeline, Obamacare.  I also do not believe that Governor Dayton will return the federal money sent to MN to establish the Exchange as Wisconsin, Florida, and Vermont have done (all Republicans).

In addition, if HF479 is not passed, Governor Dayton may decide to implement an exchange designed by him and his staff as five other governors’ have done with no input from their legislature.

To me designing these programs with a minimalist approach is like having seatbelts in your car.  We hope we will never need them but we have little control over what other drivers may do.  We need to drive our cars and we must protect ourselves and our loved ones to the best of our abilities.

Without these protections we leave ourselves open to disaster.

Please call your state representatives and senators to voice your support for HF479.

Dave Wiest
President
EMEX Benefits