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keep calm kick blue cross


Blue Cross and Blue Shield of Louisiana agreed to participate in the health exchange for the A.C.A.  While La. did not create a state exchange, their policies were available on the federal exchange.  Now at this point I’m pretty sure that we all know that one of the things with the A.C.A. is that insurance companies cannot discriminate against anyone that has a pre-existing condition.  So, if you are an insurance company and you see that people with HIV/AIDS are starting to enroll in your healthcare plans you need to find a way to, shall we say, “discourage” them from doing so, since we know that treating PLWH (People Living with HIV/AIDS) can cost some serious money.  With plans purchased on the healthcare exchange, the most an individual can be responsible for in a calendar year is $6350 for the individual.  Anything after that, again in a calendar year, is picked up by the insurance company.  Now, $6350 is a goodly chunk of change for an individual to be responsible for, but for an HIV+ individual, I’m guessing that number can be reached rather quickly.  So what to do with those damned HIV+ folks if you are an insurance company who can’t deny them coverage based solely on their health condition?  You are going to look for any and every way you can to try to stop covering them and BCBS-LA found a way in a directive sent out by CMS, the Centers for Medicare and Medicaid Services, a part of DHH.

Back in November of last year, CMS sent out a directive concerning third-party payments because of the possibility of fraud.

The November 2013 directive warned “hospitals, other health care providers and other commercial entities” not to accept third-party payments because of fraud risks, just months after the agency told insurers that they could accept Ryan White funds “to cover the costs of private health insurance premiums, deductibles and co-payments”

Soon, I’m sure heads were bent towards each other in Baton Rouge as BCBS-LA folks said “this is sooo great because now we have an excuse to kick those PLWH folks off our rolls”.  You see, some PWLH are able to get part or all (I’m not sure) of their health insurance premiums paid by Ryan White Act funds.  Part of the monies from the Act are given as grants to the states and the states in turn can give the grants to local organizations and those local organizations can, in turn, use the money to help pay for insurance premiums for folks.

Part B grants fund core medical services and support services. Core medical services include outpatient and ambulatory health services, ADAP, AIDS pharmaceutical assistance, oral health care, early intervention services, health insurance premium and cost-sharing assistance, home health care, medical nutrition therapy, hospice care, home and community-based health services, mental health, outpatient substance abuse care, medical case management, and treatment adherence services.

So, the “thinking heads” at Blue Cross said “aha, we have our out!” and issued this statement:

“In no event will coverage be provided to any subscribers, as of March 1, 2014, unless the premiums are paid by the subscriber (or a relative) unless otherwise required by law,” Blue Cross Blue Shield of Louisiana spokesman John Maginnis told Reuters.

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One of the things the Affordable Care Act was supposed to do was to encourage “competition” among the health insurance companies.  It was believed that opening up the markets would cause more companies to enter into an area and compete for the business of (for now) individuals.  So how has that worked out?  Apparently not so well in rural or or smaller market areas.

In an article in the NY Times, evidence is coming forward showing that rural areas or smaller towns are not benefiting from the opportunity to have competition in the marketplace.

While competition is intense in many populous regions, rural areas and small towns have far fewer carriers offering plans in the law’s online exchanges. Those places, many of them poor, are being asked to choose from some of the highest-priced plans in the 34 states where the federal government is running the health insurance marketplaces…

In the counties that are using the federal exchanges, approximately 58 percent of them only offer plans from one or two insurers.  In 530 of those counties there is only one insurance company participating.  Experts say there are a number of reasons for this lack of companies participating in the exchanges:  medical costs are high, one company has “cornered” the market and hospital systems are resistant to efforts to lower prices.  John Holahan, a fellow at the Urban Institute said: “I think that all else being equal, premiums will clearly be higher when there’s not that competition.”  And that can be seen in two examples cited by the Times piece.

In Wyoming, two insurers are offering plans at prices that are higher than in neighboring Montana, where a third carrier is seen as a factor in keeping prices lower.

In an even more glaring example, the Times cites the issue in Florida:

In some cases, competition varies markedly across county lines. In Monroe County, Fla., which includes the Florida Keys, two insurers, Cigna and Florida Blue, offer plans on the federal exchanges. In neighboring Miami-Dade County, there are seven companies, including Aetna and Humana, two of the nation’s largest players.

I can also say that in the Jefferson County region of Alabama (Birmingham) there are only two companies participating in the federal exchange:  BCBS of Alabama and Humana.  Now when you go to and enter in the information for Birmingham it give you a list of twelve health plans, but they are plans offered only by the two companies mentioned and the list includes the various Bronze/Silver/Gold/Platinum varieties of the four plans, five if you count the catastrophic plans limited to those under 30.  It also includes several types of plans including PPOs and HMOs, but again only by those two companies.  If there had been a 3rd company offering policies would that have affected any downward pressure on the costs?  Going by the example of Wyoming and Montana above, there’s a good chance it would.  The Times piece also points out that most of the counties with only one insurer are mostly concentrated in the South, although other states with scarce competition include Maine, West Virginia, North Carolina and Alaska.  There is a handy-dandy graphic of the breakdown that you can see here.    The Times piece also cited an example from Georgia:

In rural Baker County, Ga., where there is only one insurer, a 50-year-old shopping for a silver plan would pay at least $644.05 before federal subsidies. (Plans range in price and levels of coverage from bronze to platinum, with silver a middle option.) A 50-year-old in Atlanta, where there are four carriers, could pay $320.06 for a comparable plan. Federal subsidies could significantly reduce monthly premiums for people with low incomes.

Another area that the A.C.A. was going to attempt to lower costs for consumers was with the “multistate plans”.   The multistate plans were basically a sop to those on the left who wanted a single-payer option.  The multistate plans would be devised by O.P.M, the Office of Personnel Management and was meant to resemble the plans offered under the Federal Employees Health Program.  Under FEHBP there are probably anywhere from ten to twenty plans a Federal employee can choose from when you include local plans, HMOs and the like.  “The law created what are called multistate plans, in which a private carrier offers insurance in the marketplaces of multiple states under contract with the federal government.”  As you can see from the link above under multistate plans, not every state decided to offer those plans and where they did offer the plans they may not have made that big of a difference:

In Orange County, Ind., the silver plan offered through Anthem Blue Cross and Blue Shield’s multistate plan is the same price — $487.11 for a 50-year-old — as another Anthem silver plan offered in the marketplace.

Now the Times piece does not mention whether both of those plans offer the exact same benefits.  Hell, the plans aren’t even the same from state to state.  Here is the offering from BCBS in Louisiana:

Blue Cross and Blue Shield of Louisiana $1500, a Multi-State Plan

Blue Cross and Blue Shield of Louisiana $2000, a Multi-State Plan

And here are the multistate plans from Kentucky:

Anthem Blue Cross and Blue Shield Gold DirectAccess, a Multi-State Plan

Anthem Blue Cross and Blue Shield Silver DirectAccess, a Multi-State Plan

The Louisiana plans don’t even mention if they are a silver and gold plan or what.

For now, let’s call the competition aspect of the A.C.A. a work-in-progress.  We are only in the first year and after the insurance companies have a year under their belt the competition aspect of the Act may improve.

This is an open thread.

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