This is an example of one Ohio company adjusting how they administer coupons people use at the pharmacy. The program helps make sure members’ out-of-pocket cost for prescription drugs are properly applied to deductibles and maximum out-of-pocket amounts.
The benefit of the coupon is easy to grasp. Someone on an expensive brand medication can obtain it at low or no cost.
The problem can be that the carrier processes it as a paid claim and the member never pays what the plan requires. There are reasons both employers and carriers want real out of pocket to be met by the member.
The carriers now are adjusting and working on ensuring that the member is not given credit or given a reimbursement for something they never paid for personally. Members can use the coupons, but the carrier will credit only what the member actually paid.
This seems like a reasonable solution. It will likely become a normal way coupons are processed.
Bob Laszewski is an insurance health industry expert we regularly track to stay up to speed on the national healthcare picture. His typically even-handed analysis has been consistently the most accurate of any of the opinion leaders we follow. Here’s how Laszewski summed up the primary reason for our country’s runaway healthcare costs during a recent interview broadcast on the national news program Full Measure in a segment entitled Zombiecare:
“The healthcare establishment has been getting unlimited dollars from government, from employers, from consumers. They built this incredible infrastructure now that’s very expensive. And the only way we’re going to make healthcare more affordable is to deal with all this infrastructure we’ve got and get it to an efficient place.”
When asked how we address this infrastructure problem, here’s the pragmatic Laszewski take:
“We’re going to have to do it over many years. In the private sector and the public sector, we’re going to have to put them on a diet. It really is the prices we charge. We’re going to have to, in real terms, ratchet those back so that hospitals and doctors understand there’s going to be less money in the years to come.”
During the interview Laszewski addressed several things related to the current status of health insurance and the Affordable Care Act. Among the items he addressed:
The Individual Mandate and Paying the Penalty
“The law technically says that you have to have health insurance. If you don’t have health insurance, you will pay a fine. But the Trump administration has told the Internal Revenue Service, who is in charge of collecting the fines, that when people file their tax returns, if they refuse to say whether they have health insurance or not, the IRS should not pursue them. You technically have to pay it. Your accountant’s probably going to tell you, you technically have to pay it, but it’s not being enforced.”
ObamaCare as Zombie Care(because a Zombie is the walking dead)
“Obamacare is still there, it’s still walking around. It’s still selling health insurance plans to people. But it has no chance in its present form of ever offering affordable and attractive health insurance. And more and more people are just exiting it and going uncovered because they can’t afford it.”
Our takeaway from all this? Be smart. Stay incredibly vigilant. Take full advantage of every tool we have at our disposal to do the best we can to help our clients control costs and navigate the turbulent healthcare waters.
There’s still no clear big picture path anywhere in sight.
To watch the entire interview or to read the full transcript, go here.
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- Tom Barrett
- October 11, 2017
- affordable, affordable care act, confusion, cost, costs, coverage, employers, health plans, healthcare, healthcare reform, hospitals, insurance, medical, Obamacare, penalties, trends
- 0 Comments
Perhaps this is early but you can file it.
IRS Announces HSA-HDHP Limits for 2018
Who knows where the federal healthcare regulations are going, but if the Republicans (and the President) pass anything it will likely affect the group market by:
- Removing the cost share regulations
- Reduce the reporting requirements
- Allow carriers to create more types of plans
We will report on those types of things when/if the Senate releases their proposed version of a new healthcare bill .
Medicare can be tricky when it is coordinating with Group Health Coverage.
This is especially true when Medicare enrollees WAIVE Part B coverage, thinking that they don’t need it because they have Group Health Coverage.
Our message to those people is BE CAREFUL. You must be certain that if you waive Part B coverage that you are not opening yourself up to claims exposure.
Never assume that a Group Health Plan will step in and cover claims.
Since CMS clearly states that the INDIVIDUAL is responsible to know (not the employer nor the insurance company) the Medicare coordination with other coverage, it is critical to be careful and do the research.
Here are some examples where things get tricky:
- When an employer has fewer than 20 employees, Medicare is primary. With some insurance companies they do not even pay claims if Medicare does not approve. If one does not enroll in Part B, that means NOTHING is approved by Medicare. Translation: Costs that would have gone to Part B are not approved by Medicare and not approved by the insurance company. This is a big problem.
- When an employer has fewer than 100 employees, Medicare that is DUE TO DISABILITY is primary. The same rules apply.
- When someone is on COBRA and Medicare, Medicare is primary no matter how many employees the employer has. If the member on COBRA waives Part B, they face potential liability. People could easily assume that the rules would be the same as when they were active on the plan (vs COBRA), but that would be a mistake.
While we at BBG will help our clients get the right answer and try to fix things if someone has assumed the wrong thing, we urge everyone who is Medicare eligible to engage to find the right answers. We are not responsible for errors in Medicare enrollment, but we can be a resource for assistance.
No one should assume that waiving Medicare Part B coverage will be just fine. Getting the right answers and keeping the documentation is critical if you waive Part B.