APPRISE: Older Adult Health Insurance Counseling, Allegheny County, Pennsylvania

Older Adult Health Insurance Counseling

APPRISE

APPRISE 412-661-1438 or APPRISE@fswp.org.
APPRISE offices are open Monday through Friday from 9:00 a.m. to 4:00 p.m.
SeniorLine 412-350-5460, toll-free 1-800-344-4319, TTY 412-350-2727 or SeniorLine@alleghenycounty.us
APPRISE is a free health insurance counseling program designed to help Pennsylvanians, age 60 years and older. APPRISE volunteer counselors are specially trained to answer consumer questions and offer education about Medicare, HMOs, long-term care insurance, supplemental insurance, and Medicaid benefits. APPRISE services are free, objective and completely confidential.
APPRISE counselors are available to assist an individual in the following ways:

Determine if a Medicare HMO is right for the individual by explaining the way Medicare HMOs work.

Understand Medicare benefits by explaining what services are covered under Medicare Parts A and B and the Medicare Summary Notice.

Select a Medigap insurance policy by explaining the benefits in each plan and providing a list of companies that sell these plans.

Obtain assistance to pay for prescription drugs through government and private programs that offer this service, and explain the eligibility requirements and how to apply.

Find government programs that will pay Medicare deductibles, co-payments, and Part B premiums and assist consumers with the paperwork.

Understand long-term care by explaining eligibility requirements for government long-term care programs and explaining private long-term care insurance and how to select the best policy.

APPRISE services are free and all information is kept completely confidential. To contact a counselor, contact the APPRISE coordinator at 412-661-1438 or APPRISE@fswp.org. For general information on this and other services for older adults, you may contact the DHS AAA SeniorLine at 412-350-5460, toll-free 1-800-344-4319, TTY 412-350-2727 or SeniorLine@alleghenycounty.us.
Pennsylvania Health Law Project (PHLP)
PHLP 1-800-274-3258 works to overcome barriers to accessing health care coverage and services. They provide:

Health Insurance Coverage, Department of Human Services, Allegheny County

What Do PPACA Standards Mean for Employers’ Health Plans? | Towers Watson – Towers Watson

Large employer and self-insured plans

Employers with 101 or more employees may not purchase coverage for their employees through the state insurance exchanges, at least until 2017.⁶ Employer plans need not cover all 10 essential benefits or classify their plans into actuarial value tiers. Nevertheless, the PPACA requires large-employer-insured plans and all self-insured plans, whether offered by large or small employers, to meet similar standards for benefit generosity and plan affordability:

Actuarial value: Under the PPACA’s employer pay-or-play mandate, employers with 51 or more full-time employees must offer at least one plan with an actuarial value of at least 60% or face potential penalties. Employees of large firms that fail this “minimum value” standard may become eligible for federal premium assistance tax credits to buy coverage in the exchanges. When employees qualify for these credits, the employer must pay a penalty of $2,000 per full-time employee or $3,000 per full-time employee receiving a premium assistance tax credit, whichever is less. Large firms that do not offer a health plan to all full-time employees also face a penalty of $2,000 per full-time employee.⁷

“Core” benefits: Most plans offered by large employers already include benefits similar in scope to the 10 statutory essential health benefits, but the law does not require large-employer-insured plans or any self-insured plans to satisfy this standard. The Internal Revenue Service (IRS) has proposed basing actuarial value calculations for these plans on four “core” categories of health services: physician and midlevel practitioner care, hospital and emergency room services, pharmacy benefits, and laboratory and imaging services.⁸ The four core categories include 95% of the charges covered by a benchmark plan with broad coverage.⁹ In practical terms, this difference is likely to have little material impact on actuarial value estimates.

Employer premium contributions: Employees of large firms that offer coverage meeting the minimum value standard are not eligible for premium assistance tax credits or cost-sharing subsidies in an exchange unless their share of the employee-only premium in the employer’s lowest-cost plan exceeds 9.5% of family income. Employers whose coverage does not meet this affordability standard must pay the same financial penalty as firms that fail the minimum value requirement. The IRS proposed regulation applied the affordability standard only to single coverage, but the final regulation suggested that future guidance will address family affordability. The regulation could make nonemployee family members eligible for premium tax credits where the self-only coverage is affordable but the family coverage is not.

How do current employer plans compare with exchange standards?

Figure 1 depicts key cost-sharing provisions for prototypical plans that might be offered in the four exchange tiers in the individual market. These plan designs are largely similar to plans that employers currently offer with the exception of the bronze plan, which has considerably higher cost sharing than most current employer plans. The $3,000 deductible is about $1,100 higher than the average deductible for an account-based health plan (ABHP) in 2010.¹⁰ The PPACA might cap deductibles for all employer-sponsored plans at $2,000 (see sidebar), potentially making it difficult for employers to design a plan with a 60% actuarial value.¹¹

Figure 1. Prototypical health plans in each exchange tier

What Do PPACA Standards Mean for Employers’ Health Plans? | Towers Watson – Towers Watson

Who Will be Uninsured After Health Insurance Reform? – Robert Wood Johnson Foundation

The ACA would reduce the number of nonelderly people without health insurance by 28 million—from 18.9 to 8.7 percent.

Of the 23 million still uninsured, 40 percent would be eligible for, but not enrolled in, Medicaid or the Children’s Health Insurance Program (CHIP). A further 22 percent would be undocumented immigrants.

The majority of those uninsured—19 of the 23 million—would be nonelderly adults:

Thirty-seven percent—mostly young singles without dependents—would be eligible for Medicaid, but not enrolled.

Twenty-five percent would be undocumented immigrants.

Sixteen percent would be exempt from the individual mandate because they would not have an affordable insurance option.

Eight percent would be eligible for affordable subsidized coverage in the health benefit exchanges.

The remaining 15 percent—most higher-income families with dependents—would likely be subject to the mandate, having an affordable private insurance option despite not qualifying for a subsidy.

Who Will be Uninsured After Health Insurance Reform? – Robert Wood Johnson Foundation

Michigan’s Approach to Medicaid Expansion and Reform — NEJM

Five core principles are evident in Michigan’s approach to expanding and reforming Medicaid under the ACA. First, the state must achieve sufficient savings to offset its contributions for the Medicaid expansion when federal funding drops from 100% to 95% in 2017 and to 90% in 2021. Medicaid coverage of some state-financed health services, including mental health and prison health programs, is expected to result in approximately $200 million in savings for the state budget in 2014. If the state’s costs are not offset by such savings, Michigan will withdraw from the Medicaid expansion in 2017 or later years. But current projections indicate that the state’s cumulative savings should cover the additional costs through 2027.5

Second, Michigan will introduce financial incentives for new Medicaid enrollees to control their use of health care services and to maintain healthy behaviors. For 150,000 new enrollees with incomes between 100% and 133% of the federal poverty level, cost sharing amounting to as much as 5% of their annual income (approximately $580 to $775 for a single adult) is slated to begin 6 months after Medicaid enrollment. After 48 months of Medicaid coverage, cost sharing for these new enrollees will increase to 7% of their annual income, or they can choose to enroll in subsidized private insurance offered through the state’s health insurance exchange. A system resembling health savings accounts will be created for individuals or their employers to deposit funds to cover copayments for health care services. Cost sharing can be reduced to 2% of annual income for new enrollees who demonstrate that they engage in healthy behaviors.

Third, the state will enroll newly eligible adults in private health plans rather than in traditional fee-for-service Medicaid. Health plans will be eligible for financial bonuses for effectively managing enrollee cost sharing required by the state and for achieving cost and quality targets. Health plans will also be directed to implement value-based insurance design by varying cost sharing according to the clinical value of services provided.

Fourth, Michigan’s new law addresses health care delivery by requiring that new enrollees have access to primary care and preventive services. New enrollees will also be offered the opportunity to complete advance directives for end-of-life care when they enroll in Medicaid — part of a broader state initiative to encourage residents to express their preferences regarding end-of-life care.

Fifth, Michigan’s new Medicaid law enhances the state’s capacity to monitor the costs and quality of health care. The Department of Community Health, which oversees the Medicaid program, will assess opportunities for improving the Medicaid program and make Medicaid data available to outside vendors that can help participating health plans to pursue innovations in the program. The Department of Insurance and Financial Services will evaluate the effect of the Medicaid expansion on private insurance premiums in the state; some reduction in these premiums is anticipated.3,5 A new Health Care Cost and Quality Advisory Committee will be created to promote greater transparency with respect to the costs and quality of care.

Michigan’s Approach to Medicaid Expansion and Reform — NEJM

Final Word On Obamacare Coverage: Cheaper Than Expected

It’s the definitive look at the insurance market with less than a week to go until the marketplaces open for enrollment.

"We’ve done a pretty good job of getting affordable options on the shelves," Jeanne Lambrew, deputy assistant for health policy to Obama, told reporters Tuesday in advance of the report’s public release. "That is success that we’ve gotten to the point where we can say that."

On average, people will have a choice of 56 different insurance plans — depending on which state you live in, though, that figure could range from seven (in Alabama) to 106 (in Arizona). The average number of insurers in a state is eight, though that again ranges from one to 13 in different states.

As for premiums, before tax credits kick in, they will average 16 percent below the Congressional Budget Office’s original estimates for a silver-level plan (which covers 70 percent of costs). The number of insurers in a state is directly tied to how low premiums will be, Lambrew noted. Arizona, with an average of 106 plans to choose from, had the second-lowest average premiums for a 27-year-old adult: $166 a month. Wyoming, with an average of 16 plans, had the highest average premium at $342 a month.

But then the tax credits take effect. Those knock the premium for that 27-year-old, projected to earn $25,000, down to $145 in most states. For a family of four making $50,000, the credits take the premium price down from more than $1,000 in some states to $282.

The numbers before and after tax credits drop even further for bronze-level plans (which cover 60 percent of costs), often below $100 on average when tax credits are accounted for. White House officials routinely note a recent study that found 6 in 10 uninsured Americans will be able to purchase coverage for less than $100 a month.

Some might still find it preferable to pay the individual mandate penalty ($95 for the year or 1 percent of their income, whichever is greater), as Kaiser Health News reported Tuesday.

Final Word On Obamacare Coverage: Cheaper Than Expected

Primary Payer Status Affects Mortality for Major Surgical Operations

This is the famous “Medicaid is worse than no insurance” study. It’s worth jumping to the full study and reading the Discussion section, as the authors do a pretty good job of pointing out why Medicaid patients, like the uninsured, are so darn sick and do so poorly in the health system. But, it does not say what they (the Right) think it says!

CONCLUSION

In this study, we conclude that Medicaid and Uninsured payer status confers increased risk adjusted in-hospital mortality compared with Private Insurance for major surgical operations in the United States. Medicaid is further associated with higher postoperative in-hospital complications as well as the greatest adjusted length of stay and total costs despite risk factors or the specific major operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US patients.

Primary Payer Status Affects Mortality for Major Surgical Operations

What is Medicaid’s Impact on Access to Care, Health Outcomes, and Quality of Care? Setting the Record Straight on the Evidence – Issue Brief | The Henry J. Kaiser Family Foundation

Finding #1: Having Medicaid is much better than being uninsured.

Consistently, research indicates that people with Medicaid coverage fare much better than their uninsured counterparts on diverse measures of access to care, utilization, and unmet need. A large body of evidence shows that, compared to low-income uninsured children, children enrolled in Medicaid are significantly more likely to have a usual source of care (USOC) and to receive well-child care, and significantly less likely to have unmet or delayed needs for medical care, dental care, and prescription drugs due to costs.³ ⁴ ⁵ ⁶
The research findings on adults generally mirror the patterns for children. A synthesis of the literature on the impact of Medicaid expansions for pregnant women concluded, “…the weight of evidence is that expansions led to modest improvements in prenatal care use, in terms of either earlier prenatal care or more adequate prenatal care, at least in some states and for some groups affected by the expansions.”⁷ Mothers covered by Medicaid are much more likely than low-income uninsured mothers to have a USOC, a doctor visit, and a dental visit, and to receive cancer screening services.⁸ Nonelderly adults covered by Medicaid are more likely than uninsured adults to report health care visits overall and visits for specific types of services; they are also more likely to report timely care and less likely to delay or go without needed medical care because of costs.⁹ Projections from a recent analysis show that, if Medicaid beneficiaries were instead uninsured, they would be significantly less likely to have a USOC and much more likely to have unmet health care needs; except for emergency department care, their use of key types of services would also drop significantly. At the same time, their out-of-pocket spending would increase dramatically – almost four-fold on average.¹⁰ Other research provides evidence of increased access to care and health care utilization for previously uninsured low-income adults who gain Medicaid coverage under state expansions of eligibility.¹¹

Keep reading! (link below)
What is Medicaid’s Impact on Access to Care, Health Outcomes, and Quality of Care? Setting the Record Straight on the Evidence – Issue Brief | The Henry J. Kaiser Family Foundation

JAMA Network | JAMA Internal Medicine | Medicare Payment for Cognitive vs Procedural Care: Minding the Gap

Importance Health care costs in the United States are rising rapidly, and consensus exists that we are not achieving sufficient value for this investment. Historically, US physicians have been paid more for performing costly procedures that drive up spending and less for cognitive services that may conserve costs and promote population health.

Objective To quantify the Medicare payment gap between representative cognitive and procedural services, each requiring similar amounts of physician time.

…

Results The revenue for physician time spent on 2 common procedures (colonoscopy and cataract extraction) was 368% and 486%, respectively, of the revenue for a similar amount of physician time spent on cognitive care.

Conclusions and Relevance Our analysis indicates that Medicare reimburses physicians 3 to 5 times more for common procedural care than for cognitive care and illustrates the financial pressures that may contribute to the US health care system’s emphasis on procedural care. We demonstrate that 2 common specialty procedures can generate more revenue in 1 to 2 hours of total time than a primary care physician receives for an entire day’s work.

JAMA Network | JAMA Internal Medicine | Medicare Payment for Cognitive vs Procedural Care: Minding the Gap

JAMA Network | JAMA | Views of US Physicians About Controlling Health Care Costs

Physicians’ views about health care costs are germane to pending policy reforms.

Objective To assess physicians’ attitudes toward and perceived role in addressing health care costs.

…

Results A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” …

JAMA Network | JAMA | Views of US Physicians About Controlling Health Care Costs