What If Someone DOesnt Have Health Insurance In 2014

If someone who can afford health insurance doesn’t have coverage in 2014, they may have to pay a [fine]. They also have to pay for all of their health care.

 

The fine is sometimes called the "penalty," "individual responsibility payment," or "individual mandate."

When the uninsured need care

When someone without health coverage gets urgent—often expensive—medical care but doesn't pay the bill, everyone else ends up paying the price.

 

That's why the health care law requires all people who can afford it to take responsibility for their own health insurance by getting coverage or paying a fine.

 

People without health coverage who pay the fine will also have to pay the entire cost of all their medical care. They won't be protected from the kind of very high medical bills that can sometimes lead to bankruptcy.

The fine in 2014 and beyond

The penalty in 2014 is calculated one of 2 ways. You’ll pay whichever of these amounts is higher:

• 1% of your yearly household income. (Only the amount of income above the tax filing threshold, $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average yearly premium for a bronze plan.

• $95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.

The way the penalty is calculated, a single adult with household income below $19,650 would pay the $95 flat rate. A single adult with household income above $19,650 would pay an amount based on the 1 percent rate. (If income is below $10,150, no penalty is owed.)

 

The penalty increases every year. In 2015 it’s 2% of income or $325 per person. In 2016 and later years it’s 2.5% of income or $695 per person. After that it's adjusted for inflation.

 

If you’re uninsured for just part of the year, 1/12 of the yearly penalty applies to each month you’re uninsured. If you’re uninsured for less than 3 months, you don’t have to make a payment.

 

Learn more about the individual shared responsibility payment from the Internal Revenue Service.

Enroll by March 31, 2014 and you won’t have to make the individual shared responsibility payment

If you enroll in a health insurance plan through the Marketplace by March 31, 2014, you won’t have to make the payment for any month before your coverage began.

 

For example, if you enroll in a Marketplace plan on March 31 your coverage begins on May 1. If you didn’t have coverage earlier in the year, you won’t have to pay a fine for any of the previous months of 2014.

If you pay the fine, you're not covered

It's important to remember that someone who pays the penalty doesn't have any health insurance coverage. They still will be responsible for 100% of the cost of their medical care.

 

After open enrollment ends on March 31, 2014, they won't be able to get health coverage through the Marketplace until the next annual enrollment period, unless they have a qualifying life event. Learn more about qualifying for coverage outside Open Enrollment.

Minimum essential coverage

To avoid the penalty you need insurance that qualifies as minimum essential coverage. If you're covered by any of the following in 2014, you're considered covered and don't have to pay a penalty:

• Any Marketplace plan, or any individual insurance plan you already have
• Any employer plan (including COBRA), with or without “grandfathered” status. This includes retiree plans
• Medicare
• Medicaid
• The Children's Health Insurance Program (CHIP)
• TRICARE (for current service members and military retirees, their families, and survivors)
• Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA), and Spina Bifida Health Care Benefits Program)
• Peace Corps Volunteer plans
• Self-funded health coverage offered to students by universities for plan or policy years that begin on or before Dec. 31, 2014

Other plans may also qualify. Ask your health coverage provider.

What kinds of health insurance don't qualify as coverage?

Health plans that don't meet minimum essential coverage don't qualify as coverage in 2014. If you have only these types of coverage, you may have to pay the fine. Examples include:

• coverage only for vision care or dental care
• workers' compensation
• coverage only for a specific disease or condition
• plans that offer only discounts on medical services

Exemptions from the fine

Some people with limited incomes and other situations can get exemptions from the fine. Learn about exemptions from paying the fine.

Here's How Much People Are Really Paying for Health Insurance

Plenty of data-hounds have been crunching numbers on health insurance premiums lately, based on the prices insurance companies quote on healthcare.gov and state marketplaces. Online brokerage EHealth (EHTH) has today published something new: a look at the prices people are actually paying to buy policies through its site.

 

Rather than just look at the rates insurers are offering, EHealth’s price index shows the average monthly premium of all the plans its customers purchased over the previous two weeks. Here’s a screenshot showing the index since October:

 

 

 

These are premiums for individual policies across the U.S. People buying on EHealth can’t get federal subsidies, so customers are bearing the full cost of the premiums.

 

The curve shows that people who signed up early bought the most expensive policies, paying more than $350 per month in October and early November. They probably represent pent-up demand from people with preexisting conditions who—before Oct. 1—couldn’t get insurance or could buy policies only at sky-high prices. For people with preexisting conditions who know they’re going to need medical care, it makes sense to buy more generous policies with higher premiums.

 

The price of the average policy purchased on EHealth declined through the fall and leveled off at the start of January. It has consistently been a few dollars above $270 for a month.

 

Will the average price drop further as we get closer to the March 31 open enrollment deadline? That’s when young people and other healthy procrastinators are expected to buy coverage in the largest numbers. A healthier group that expects fewer medical costs in the year ahead might seek out plans that trade lower premiums for higher deductibles.

10 Tips For Buying Insurance In 2014

2014 marks the biggest change in health insurance since Medicare. For the first time ever, health insurance is mandatory for most Americans under age 65. The biggest change is that those people with pre-existing medical conditions will now be able to buy quality health insurance without fear of being declined, or facing a surcharge or a waiting period for pre-existing conditions that won't be covered.

 

The second biggest change is that those who earn less than 400 percent of the federal poverty level -- $45,000.00 for individuals or $95,000.00 for families of four -- will now be able to qualify for premium discounts on health insurance costs. The requirement to qualify for the discount is that insurance must be purchased on one of the new health insurance exchanges, aka marketplaces.

 

1. Work with a knowledgeable health insurance agent.

Eliminate about 80 percent of the difficulties of buying insurance online. A good agent can help you navigate the exchange site, help you determine whether you qualify for a discount and, if you do qualify, help you choose from among the various plan options and even help you enroll. They will be able to answer your questions as they come up. Best of all, having an agent help you doesn't cost a dime extra.

 

2. Don't buy insurance on an exchange if you don't qualify for a discount.

Insurance companies that participate in the exchange in most cases offer many more options for qualified health insurance beyond what they make available on the exchange. You can go to individual insurance company websites to see what each company has available. Or, you can have your agent do that for you (see Tip 1).

 

3. Work with an insurance agent to plan health coverage for your family if dependents aren't covered adequately by your employer plan.

If you have dependents covered under your group health insurance plan at work, unless the employer is paying for some of the cost, work with an insurance agent who will help you determine if you can get better coverage for less money on your spouse and/or children. Chances are if you have employer paid group insurance on yourself, you won't be eligible for an individual plan. But that doesn't preclude your spouse and children from having one, especially if the employer doesn't contribute anything toward dependent coverage costs.

 

4. Before choosing a health plan, be sure the doctors are "in network" and you can see specialists without a referral.

Less costly plans often don't let you see specialists without a referral from your primary care doctor.
 

When you are considering plans, don't just choose the cheapest. Pay attention to who is and is not in network. About 90 percent of the time, it probably won't make a difference. But, that 10 percent can be a life-and-death situation.
 

In Minnesota where I'm from, the gold standard of choice is the Mayo Clinic. I won't pick a plan myself or recommend a plan that doesn't include the right to go there without begging for a referral.

 

5. Hire an expert insurance agent or consultant to audit your insurance program.

Look for someone to make sure that all the major risks in your life are well-protected – for risks such as major lawsuits, major damage to or destruction of your residence, premature death, long-term disability and, of course, major medical expenses.
 

An expert can help you identify where the gaps are and recommend custom endorsements to plug those gaps. I have done several hundred audits over the years and typically find at least 15 to 20 coverage shortfalls or inconsistencies.

 

6. Protect your income with long-term disability insurance.

Some employers provide it. However, benefits that you receive while disabled usually are taxable income. So, if the benefit is 60 percent of your salary, you will be lucky to yield 45 percent after taxes.
 

Unless you can live on that 45 percent, contact your employer. Request that the company include the premiums it pays you for long-term disability insurance in your taxable income. By doing this, you will have paid income taxes on the relatively small premiums so that if you become disabled, you can collect those benefits tax-free.
 

If your employer can't or won't do that for you, buy a supplemental individual policy that will cover at least the income taxes that you will have to pay on your group benefits.
 

If you don't have coverage at work, talk to a knowledgeable agent to help you qualify for and buy a privately owned long-term disability insurance policy. Because you're buying this policy with after-tax dollars, benefits will always be tax-free to you!

 

7. Buy an umbrella liability policy to cover insurance gaps in your primary policies.

All umbrella car or homeowners insurance policies cover lawsuits. Typically, these policies will provide a base layer of coverage, usually $300,000 or $500,000 per claim. Then, if you're sued for more than those limits, an umbrella policy will pay excess amounts up to the umbrella limit of $1 million or more.
 

The real advantage of an umbrella policy is that it will defend and pay some judgments against you from personal lawsuits not covered by your primary auto or homeowners policies.
 

Never worry about the price of an umbrella policy. Instead, focus on whether it is broad enough to cover those uncovered risks in your life not covered by auto or homeowners insurance.
 

Here are just a few examples of lawsuits not covered by auto or homeowners insurance that can be covered by the right umbrella policy:

• Damage to rental cars in the U.S. or abroad.
• Injuries you cause to a water skier while renting a powerboat on vacation.
• Liability that you agreed to in a contract such as a wedding reception contract, making you responsible for all injuries and/or property damage caused by wedding guests.
• Injuries you cause to a co-worker while driving a company-furnished car.

 

8. For a townhouse or condo unit, be sure you get the "deductible assessment coverage."

The rates for condominium master policies have been on the rise. To keep the premiums affordable, many associations have opted for higher deductibles of $5,000, $10,000 or even $25,000. Not only does that keep the premiums affordable, it also minimizes the number of claims made against the master policy, which helps keep the rates low.
 

Here's the problem: If the loss is caused by you from, say, a kitchen fire or dishwasher overflow, or is confined to your unit, most associations will require you to pay the deductible on the master policy.
 

"No problem," you say proudly. "I have loss-assessment coverage on my homeowners unit-owner policy." Virtually all laws on assessment coverage limit deductible assessments to $1,000. If that wasn't enough bad news, it also requires that the assessment be against all unit owners.
 

The bottom line is that you will need to get a relatively new coverage -- separate coverage -- called "deductible assessment" coverage. Find out what your association master policy deductible is and buy deductible assessment coverage for that amount from your insurance agent.
 

9. If your home is for sale, watch out for vacancy exclusions.

With the housing market in the dumpster the past few years, this common problem has arisen. A couple buy a new home before their existing home sells. They move into the new house, leaving the old house empty. Three months later, vandals break into the old home, have a wild party and completely trash the place, causing $50,000 in damage, and the owner has no coverage.
 

Homeowners policies exclude glass breakage and vandalism damage if the house has been vacant, that is without enough furniture to be lived in, for 60 days or more. There are high-risk policies you can buy to cover a vacant house, but the coverage is watered down and the premiums are three to four times greater than what you've been paying for homeowners insurance.
 

The better way to keep your homeowners policy and still have vandalism coverage is by keeping enough furniture in the house so it can be lived in, such as a kitchen table, a couch and a lamp in the living room, and one bed.

 

10. For all of your insurance needs, pick an insurance agent with great expertise.

What most people don't realize is that you can get an insurance expert for the price of an intern. Since all agents work on commission, an agent with a lot of experience costs exactly the same as a less knowledgeable agent.
 

The biggest mistake that people make when they buy insurance is that they shop based on price and end up with the agent who gave them the best quote, often with very little expertise. In fact, they would be much better off coverage-wise and price-wise if they shopped for the expertise of an agent first, then had the expert design insurance coverage with the right specifications and had the expert shop for that coverage.
 

Shopping for the best price first leaves you with a good deal but the wrong coverage. Shopping for expertise first leaves you with a competitive price for the right coverage.

When you have a serious claim, which choice would you make?

CHEERS TO 2013!

NEW YEAR RESOLUTION:   Getting Your Insurance Coverage in Order for 2014   There is not a lot of time to think about insurance during the hectic rush of the holidays, but as you ring in the New Year, it is a good idea to evaluate your insurance coverage. The National Association of Insurance Commissioners (NAIC) offers these tips and reminders to help with your review.

Homeowners/Renter's Insurance This is a great time to update your home inventory and make sure your homeowners or renter's policy is up-to-date. While the decorations are out of storage, take some photos or video of your baubles. Do not forget to make note of any antique items and their value so you can talk with your insurance agent to ensure that they are properly covered. If you are starting a home inventory from scratch, the NAIC's free smartphone app, myHOME Scr.APP.book, takes some of the headache out of the process. Download the app from iTunes or Google Play. You can also download a paper version here.   Now that you have opened all your gifts, remember to add them to your home inventory, too. Include as many details as you can and take a photo of each item. Most basic home insurance policies have standard limits for big-ticket items like electronics, art, jewelry or sporting equipment. You may need special coverage, so be sure to call your agent as soon as possible to discuss changes for your policy.   If you want to review your insurance policy or declarations page before talking with your agent, take a look at this consumer alert to help understand the terminology.   Auto Insurance Winter can be a challenge for all drivers. Whether you are trying to escape the weather for someplace warmer or just preparing for the first drive to work in the snow, there are a few insurance items you should review.   To make sure you are winter-ready, check your auto insurance policy. Here is a quick reference on how to read your declarations page.   Make sure your coverage is appropriate for your life situation. Liability is the part of the policy that pays for any injury or damage if you cause an accident. If your liability insurance is too low, it is possible that you could be sued for any damages above your liability limits.   Also take a look at your deductibles for comprehensive and collision coverage. This is the amount you will pay if your car is damaged or totaled without fault of another driver. Raising or lowering this amount can affect your premium.   Before hitting the road, make sure you have a copy of your insurance card and your insurance agent or company's number in the car. It is also a good idea to have a way to record details of an accident if you are in one. The NAIC smartphone application WreckCheck walks you through the process of gathering information following an accident. You can then email your notes directly to your agent. Download the free app from iTunes or Google Play.   Health Insurance Many families recently went through the open enrollment process for their health insurance at work or Medicare Open Enrollment, which means you may have new insurance cards and paperwork coming in the mail. It is a good idea to get all this information together before winter illness or accidents happen.   Make sure to check your provider lists to verify visits to your doctor and any specialists are still covered by your policy, as in-network or preferred provider lists change from year to year. Also read through your documents and make note of your copays for in-network and out-of-network providers so you are not surprised later.   When you're planning a vacation away from home, check with your insurance carrier to identify urgent care centers and hospitals that accept your insurance coverage near your destination and along the way. Be sure to ask your carrier about applicable co-pays and deductibles if care is needed.   Click here for the explanation of some of the terms you may find on your health insurance paper work.

Connecticut is only state enrolling more in private insurance than Medicaid under Obamacare

Connecticut is the only state in the country in which more people have applied for private coverage than Medicaid through the health insurance exchange, an exchange official said Tuesday.

 

James Wadleigh, Access Health CT’s chief information officer, said the state’s exchange has taken more than 11,000 applications for individual and small-business coverage. About 6,000 are for private insurance customers, and about 4,700 will receive Medicaid.

 

As part of the health law commonly known as Obamacare, the Medicaid program in Connecticut and many other states will expand Jan. 1 to cover more adults without minor children. In addition, exchanges like Access Health are selling private insurance plans that, for many people, are expected to come with discounted premiums, subsidized by the federal government.

 

A major reason for Connecticut’s unique balance of applicants, Wadleigh said, is that the state began expanding Medicaid in 2010, shortly after the health law passed. That means fewer people are becoming eligible for Medicaid in Connecticut than in other states.

 

Connecticut currently provides Medicaid coverage to adults without minor children earning up to 56 percent of the poverty level. As of Jan. 1, that level will rise to 138 percent. Officials expect that will add between 55,000 and 60,000 more people to the program. (For adults with minor children, the income limit for Medicaid is already higher, and that will remain largely unchanged.)

 

Wadleigh reported the state’s enrollment trends during a meeting Tuesday morning of the state’s Health Care Cabinet.

 

Of the private insurance customers so far, 27 percent have selected “gold” plans, which have the highest premiums but pay the highest share of members’ medical costs. The majority, 55 percent, have selected the midlevel “silver” plans, while 16 percent have chosen “bronze” plans, which have the cheapest premiums available to most customers but leave them with higher expenses if they seek medical care.

 

Two percent of the customers chose catastrophic plans, which are available to people under 30 and carry low premiums but high out-of-pocket costs for most medical care.

 

Wadleigh said that of the people signing up for coverage, 19 percent are between ages 18 and 34. He did not say whether that referred to people signing up for Medicaid and private insurance, or just private insurance. Figures released last month showed that most of the young enrollees were signing up for Medicaid.

 

Access Health also provides coverage options for small businesses, but that portion of the exchange’s activity has been smaller than expected, Wadleigh said.

 

People can sign up for private insurance through Access Health through March 31, but the deadline for getting coverage that begins Jan. 1 is Dec. 15. Lt. Gov. Nancy Wyman asked whether there has been talk of extending the application deadline for getting coverage that takes effect Jan. 1. Wadleigh said there has been talk of doing that, including during a conference call with the White House last week, but said there's been nothing definitive.

Your guide to Obamacare: Frequently asked questions about the Affordable Care Act

This FAQ provides expert answers to the key issues about exchanges, enrollment and more.

Americans have many questions about Obamacare. Here are the answers to some of the most common ones.

Here are answers to some frequently asked questions about the exchanges.

 

Q. Who can buy on the marketplace? Can I buy on the exchange even if I am not eligible for subsidies?

A. The exchange can be used by individuals, families and small business owners who have 50 or fewer employees.

Q. If I have insurance from my employer, do I have to do anything?

A. You don't have to, but if you choose to do so, you can drop your employer's coverage and buy a plan from the exchange.

Keep in mind, depending on the type of employment coverage available to you, you might not qualify for certain savings offered by the exchanges.

Q. Can I buy insurance through the marketplace if I already have a serious health problem?

A. Yes. The amount you pay for a health plan will not be affected by your health status.
This means that you can't be charged more because of your health problem.

RELATED: YOUR GUIDE TO OBAMACARE: AFFORDABLE CARE ACT TO OPEN OCT. 1
It also means you will not have to wait to get the coverage you need.

Q. If I have Medicare, can I purchase a plan on the exchange?

A. Yes, but you can't get help paying for it.
Also, getting extra coverage on the exchange may not make sense.
That's because Medicare will be your main coverage, but you would still have to pay for a full health plan at New York State of Health.

Talk about this with an exchange helper to figure out the right strategy for you.

Q. Some groups are exempt from being required to have coverage. Who are they?

A. The categories include people who would have to pay more than 8% of their income for health insurance, people with incomes below the threshold required for filing taxes, those who qualify for religious exemptions, members of Indian tribes, undocumented immigrants, and people who are incarcerated.

Some Small Businesses Choose to Self-Insure

NorthBay Adventure is just the kind of small business that could be expected to buy medical insurance for workers under health act rules taking effect in 2014. But Executive Director George Comfort says that's not likely to happen.

Instead, NorthBay became self-insured last year, paying most workers' health costs directly, a practice more typical of large employers. The decision to self-insure was about free choice, savings and what's best for his company, Comfort says.

But others see it as a threat to the Affordable Care Act. As more small employers such as NorthBay avoid the act's requirements through self-coverage, small-business marketplaces intended to cover millions of Americans could break down and become unaffordable, they say.

"What you've got is basically a loophole for the small employer to get out of the ACA requirements," says Robert Laszewski, a Virginia-based consultant and former insurance executive.

To employees, medical self-insurance looks like a regular health plan. Self-insured employers pay for most worker health costs directly, though they contract with an insurer or other company to administer claims. The employers also buy coverage known as stop-loss for claims exceeding a certain amount. Brokers say a growing number of firms see such plans as low-cost alternatives to conventional coverage, as they're exempt from ACA requirements such as insurance taxes and specified benefits.

NorthBay, which is based in Maryland and delivers outdoors education to sixth-graders, saves some 45% on self-insured health costs for its 60 or so covered employees compared with the price of regular coverage, Comfort says. "We have a very young workforce," Comfort says. "Our average age is at or below 30. We have a very healthy group."

But if too many small companies take a similar route, insurance plans for small businesses will be stuck with older and sicker members, say policy scholars.

Under some conditions, such a dynamic could drive up the cost of traditional insurance by as much as 25%, says Matthew Buettgens, a researcher at the Urban Institute.

"If it becomes too easy to self-insure, you're inviting employers to choose one kind of coverage if their workers are healthy and a different kind of coverage if they're sick," says Mark Hall, a law professor at Wake Forest University.

Facing a conundrum

That undermines a basic feature of the exchanges: the "community rating" that obligates insurers to offer similar prices to all comers, spreading the cost of care among well and sick alike. In a worst-case scenario, small employers will self-insure when workers are healthy, avoiding community rating, then immediately buy price-controlled coverage on the exchanges if someone is gravely ill.

Health-act advocates especially worry that firms with fewer than 50 employees will self-insure. Those companies aren't required to offer policies under the health law, but many are expected to buy in online marketplaces, called exchanges, scheduled to open in October.

However, self-insurance might be the only way some struggling employers can afford medical coverage, says Michael Ferguson, chief operating officer at the Self-Insurance Institute of America, an industry group.

Even so, he disputes the notion that firms and stop-loss companies can "cherry pick" the system by self-insuring only when workers appear healthy. Even young people have accidents and get sick. He says companies often know less about employees' health than they think.

"The idea about employers gaming the system is just a canard," he says.

The key to self-insurance for small companies is stop-loss coverage, which often kicks in when medical costs per worker are as low as $10,000 or $20,000, limiting the employer's risk almost as well as a regular plan.

Brokers report brisk sales of self-insured plans and this backstop stop-loss coverage. "Last year, we saw a huge uptake of self-funded or partial self-funded business," says David Fear, a Roseville, Calif., consultant who helps brokers and agents issue stop-loss coverage.

The average size of self-insured companies that Fear handles is between 25 and 30 workers, he estimates. His business for firms with fewer than 100 employees doubled in the last year, he says.

A booming business

At BSI Strategic Consulting, a Fresno, Calif., firm that helps small companies self-insure, "our business has more than doubled in the last six months," says CEO Lawrence Thompson. "There's a lot more interest in self-funding than I've seen in the last 32 years."

At insurance giant Cigna, self-coverage for small employers grew by a fifth last year, says Julie McCarter, vice president of product development for Cigna Select, which sells medical stop-loss coverage and claims processing.

"A lot of it comes down to what's going on in Washington," says Donald Drelich, CEO of D.W. Van Dyke, a Connecticut insurance consultant. "People are seeing the cost of insurance rising because of the things that are being added (under the ACA), so they're exploring other possibilities."

Self-coverage is exempt from premium taxes, which are estimated to raise prices from 2% to 4%, as well as from the health law's "essential benefit" and community rating rules. Employers such as NorthBay's Comfort say that gives them the flexibility to tailor plans for their workers.

Officials in some states are trying to limit self-coverage. California, Rhode Island and Minnesota are considering legislation that raises the point at which stop-loss insurance kicks in, reducing or eliminating small firms' ability to self-insure.

Two years ago then-New Jersey Commissioner of Banking and Insurance Thomas Considine warned stop-loss insurers to cease "selectively marketing" to small employers with young workers. He pledged to issue regulations prohibiting the practice but, following industry protests, they were never published.

Last month, the self-insurance institute formed an alliance with the National Retail Federation and other business groups to oppose such measures. If the idea behind the ACA is to increase health coverage, such groups ask, why would anybody want to limit small businesses' ability to offer self-insured plans?

"To the employers, it looks like health insurance, it feels like health insurance, and it's less costly," says David Burton, general counsel for the National Small Business Association. "Do you want to set up a situation where an IBM or a GM can be self-insured — or even a small company with 100 or 150 employees — and the smaller guys don't have that option? I don't see the logic in that."

Gov. Malloy Talks Mental Health Claims

Malloy Announces Plan to Reduce Insurance Denials

for Mental Health Services

The Connecticut Insurance Department and the UConn Health Center are collaborating to help families struggling to get mental health treatment paid through their insurance, according to Gov. Dannel Malloy.

Malloy said the department and the health center are developing a “user-friendly ‘claims tool kit’” for policyholders and providers, including out-of-network providers who operate on cash basis.

The goal, according to a news release from Malloy’s office, is to reduce the number of insurance denials.

“No one should have to overcome mountains of red tape when they are trying to access mental health services,” Malloy said. “This collaboration allows us to leverage the respective expertise of the Insurance Department and the UConn Health Center to put in place a common-sense approach to what can be a profoundly frustrating process. I commend the Insurance Department and the Health Center for their commitment to improving mental health care access for residents.”

Access to mental health services is part of the governor’s multi-prong plan to reduce gun violence in response to the massacre at Sandy Hook Elementary School in Newtown in December.

“It’s been the Department’s observations that incomplete or incorrect information, coding errors, and other documentation issues are often the cause of claims denials requiring multiple appeals. We don’t want families having to fight to get the care they need,” Deputy Insurance Commissioner Anne Melissa Dowling, who oversees the Department’s health insurance initiatives, said.

Malloy said the claims tool kit, which should be complete this summer, is the first in a series of behavioral health projects the Insurance Department and Health Center are undertaking to assist consumers and providers.

Connecticut Races To Reach Uninsured, Open Health Insurance Marketplace

HARTFORD, Conn. — In the nation’s insurance capital, the hunt to find uninsured people and get them enrolled in the state’s new online health insurance marketplace has already begun.

Officials working for Access Health CT, created under the federal health law, have collected names of more than 1,300 people needing coverage at recent town-hall meetings across the state. This spring and summer, they plan to use booths at festivals and street fairs to gather thousands more. Come fall, they’ll also pay community groups and small businesses, such as barbers and beauticians, in New Haven, Bridgeport and other cities with high uninsured rates to reach out to people and sign them up for coverage on the spot.

The marketplaces open nationwide Oct. 1 and are key to the health law’s expansion of coverage to millions of individuals and small businesses.  In Connecticut – one of 16 states slated to run its own marketplace, also called an exchange – the goal is to sign up 220,000 people by next March, or two-thirds of the state’s uninsured. That’s ambitious considering that only a third of the uninsured nationally are expected to enroll in the first year.

“We are on a mission to make history,” Access Health CEO Kevin Counihan said in an interview at his downtown office that looks out at UnitedHealthcare Center and the golden dome over Aetna’s corporate headquarters.

Looking around his headquarters, where 25 staffers work alongside employees from private contractors, including Deloitte Consulting and KPMG, he said, “It’s not Groundhog Day here.”

‘Connector On Steroids’

From 2006 to 2011, Counihan was chief marketing officer for the Massachusetts Health Insurance Connector Authority, which attracted national attention because it helped the Bay State achieve near universal health coverage and become the model for the federal health law. Massachusetts also won kudos for its marketing to the uninsured, which included advertising at Fenway Park during Red Sox games.

Those experiences prepared him for his current challenge, which Counihan describes as “the Connector on steroids.” He said the Connecticut exchange is a more ambitious start up because it must be a one-stop shop for both private coverage and Medicaid, and because of the federal law’s extensive insurance reforms.

As in Massachusetts, Counihan and Access Health have had to balance the sometimes conflicting interests of health insurers, hospitals, doctors and other providers, employers, insurance agents and consumer advocates. Ellen Andrews, executive director of the Connecticut Health Policy Project, a consumer group, predicts the private plans offered by Access Health will be too expensive for many people, even those with subsidies to defray the costs. At least half of the people buying policies in the marketplaces are projected to qualify for subsidies.

“We are concerned the standard plan is very expensive,” she said, citing the exchange board's decision to use the state’s most popular small group plan as the basis for the benefits required of every policy sold in the exchange. Most state exchanges did the same thing to reduce disruption in the insurance market.

Health plans begin to submit their prices to the exchange next month for coverage that begins in January.

Andrews said Access Health’s decision not to negotiate rates with insurers initially -- as Massachusetts does -- will also result in higher prices.

Small business groups say they share that concern. “Relying on the carriers to be able to bring plans into the exchange with no structures to challenge price is just plain irresponsible,” said Kevin Galvin, chairman of Small Business for a Healthy Connecticut.

Exchange officials say they opted against negotiating with carriers initially because they did not want to dissuade any from participating, said Jason Madrak, chief marketing officer. Five insurers, including all the major carriers in the individual and small group markets, plan to participate.

A Public With High Expectations, Little Patience

Despite such criticisms, Connecticut has advantages over other state exchanges.

That’s because it started more than two years ago with more than $100 million in federal grants. And the state’s small size means it can more easily pinpoint outreach efforts. Most of the uninsured are in a handful of cities including Hartford, New Haven and Bridgeport, and the exchange knows which neighborhoods to find them in from Census reports.



Access Health CEO Kevin Counihan



As the nation’s insurance capital, the state may have less of a challenge convincing people of the value of health coverage, Counihan said. Being the wealthiest state in terms of per capita income should also help.

While the exchange will advertise on television, newspapers and billboards, the focus will be on working with community health centers and other providers to identify the uninsured when they seek health care, Madrak said. The group will also work with local chambers of commerce to get the word out to small businesses. Nearly 10 percent of Connecticut residents are uninsured.

Part of Counihan’s job these days is managing expectations. “It won’t be perfect on Day One,” he said, recalling how the introduction of Medicare’s prescription drug benefit in 2005 ran into many snags although it was ultimately successful.

Compared to the Connector’s launch, Counihan said the public has higher expectations and less patience. “People on the left want to see this fail so they can say, ‘Another reason for a single payer system,’ and people on the right want it to fail so they can say, ‘Big government does not work.’”

Counihan said the online exchange may have fewer features than originally envisioned – for instance, quality ratings of insurance plans -- so it gets done on time. Though he has help from some of nation’s largest consulting firms as well as from his former boss at the Connector, Jon Kingsdale, he knows the buck stops with him.

“It’s a tough, lonely job,” said Counihan. “I’ve never had so much coming at me at the same time.”

He said an Obama administration official recently asked him what he could offer to help, and he replied, “’Give me another year.”

That was not an option.

Anthem Responds To Criticism Over Psychotherapy Reimbursement

Anthem Blue Cross and Blue Shield in Connecticut responded to criticism by doctors groups that the insurer isn’t paying for psychotherapy when it is provided in conjunction with other medical services.

Wallingford-based Anthem, the state’s largest health insurer, said the American Medical Association published significant changes and updates to the procedure codes associated with behavioral health services, which took effect Jan. 1.

These code changes do not set behavioral health provider reimbursement,” Anthem spokeswoman Sarah Yeager said in a prepared statement. “In compliance with federal law, Anthem implemented the code changes and adopted new fees to match to the new codes. Anthem sought to preserve the level of payment that behavioral health providers were receiving before the code changes.”

Anthem was criticized Thursday by three doctor groups — the Connecticut Psychiatric Society, the American Psychiatric Association and the Connecticut State Medical Society — which claim Anthem responded to the annual change in medical-billing codes by covering only visits for an evaluation or management of medical issues, and not psychotherapy as a separate equal category when provided during the same visit.

The most recent version of “current procedural terminology,” or CPT, medical-billing codes take effect Jan. 1 each year, and psychotherapy has been isolated as a separate service in the past, but with different codes.

“These practices are both unethical and illegal,” the American Psychiatric Association’s chief executive Dr. James H. Scully, Jr., said in a prepared statement. “We worked very hard to enact mental health parity laws, and it is now clear that Anthem is seeking a way to avoid compliance. We are not prepared to allow them to skirt their obligations under the law.”

Anthem’s spokeswoman, Yeager, said, “We believe that our provider reimbursement rates for behavioral health services are appropriate, in compliance with applicable laws, and allow our members to continue to have access to mental health services which we recognize are critical to overall health. All applicable behavioral health services, including psychotherapy services, continue to be covered in accordance with our members’ benefit plans.”

CT Among Leaders in Health Insurance

HARTFORD - Connecticut is far ahead of other states in designing a health insurance exchange, a long-awaited option for people stuck in the expensive individual health market or who have no health insurance.

Major decisions on the exchange are being made now to have it up and running by October 2014 when open enrollment will take place until March 2015.

 

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Connecticut Among Leaders in Developing Health Insurance Exchange