The insurance industry is highly regulated. This makes sense since its actions have such important consequences in our everyday lives.
When the ACA (Affordable Care Act, often called Obamacare) was introduced, I was delighted to hear so much discussion about the health care system. Congressional hearings stretched out over a year. President Obama gave a lengthy speech to Congress explaining his vision and the foundations of the legislation.
After months of public hearings and debate, Democrats accepted more than 160 Republican amendments to the bill. It was an arduous process, but the good news was that people were now talking about and learning more about our health care delivery and financing systems. We knew that the legislation was complex and clearly imperfect, but the insurance industry had been at the table during the process and was clear on the path it needed to follow.
This is in stark contrast to the situation we are facing today. After voting 60 times to repeal the ACA at costs estimated near $100 million one would assume there was a replacement plan ready to be proposed. Since the election, Republicans in the House proposed the AHCA (American Health Care Act). Republican Senators are working in secret on their own version with a goal of passing the bill before the July 4th recess. I don’t see how it can be passed before the recess.
Insurance companies are required to file rates by June 21st for 2018. In California they are filing two sets of rates: one if the rules don’t change and one based on what they perceive might be the new rules!
To expect such an important industry (representing almost 1/6 of our economy) to function under this type of uncertainty is unconscionable. Every American is in some way touched by the health insurance industry. I feel like Congress is playing a game of “chicken” with the healthcare of Americans. While the individual market only effects about 7% of the population, the ACA effects more than just the individual market.
The Trump administration continues to fund the Cost Sharing subsidies that help the working poor, but threatens each month to stop the funding. These subsidies help the middle class families earning up to 400% of the Federal Poverty Level. More uncertainty.
The MediCal/Medicaid population is walking the same tightrope. Community health centers are unable to budget when it is unclear how or if they will be reimbursed for providing care. In Shasta County this is particularly problematic. There are about 65,000 MediCal beneficiaries in Shasta County- 1 out of every 3 citizens. We must acknowledge that we live in a poor community whose long term health is dependent on this program.
Fortunately, we have Partnership Health managing our MediCal population and Shasta Community Health Center as the cornerstone of providers. Both organizations are efficient and proactive. Full disclosure: I serve on the Board of SCHC. In serving on this board, I have become acutely aware of the needs of this population and how it is served.
As of my press deadline, the final Senate bill has not been released. I implore our readers to follow this very closely. In its House form, it was not at all comprehensive and left many issues unaddressed, purportedly with the intent of incremental reform. The problem being that the bill also repealed the ACA. Therefore, it was not incremental reform, it was simply creating chaos in the markets.
While we wait for this to be sorted out, I am reminding our readers of a new California law that is effective 7/1/2017.
This new state law protects individuals from receiving unexpected “surprise or balance” medical bills from an out-of-network doctor when receiving non-emergency services at an in-network facility such as a hospital, clinic, lab, imaging center.
When a patient uses a network facility, they should no longer have the surprise of finding out that one of the providers is not a member of the insurance plan.
When individuals go to an in-network facility for care but receive services from an out-of-network doctor, they only have to pay their in-network cost-sharing amount that counts toward the annual deductible and annual out-of-pocket maximum limits according to their health plan.
If for any reason the out-of-network doctor receives payment that is more than the allowed in-network cost-sharing, the out-of-network doctor must refund the overpayment within 30 days of receipt.
P.S. Blue Shield of California is sponsoring the Wisdom Study, a five-year research study, to improve how women are screened for breast cancer. The two approaches are an annual mammogram and a personalized mammogram schedule based on the woman’s risk. To see if you qualify: wisdomstudy.org