Thursday, July 31, 2008

Charter Oak/HUSKY/PCCM update

DSS Comm. Mike Starkowski met with the Appropriations and Human Service Committees yesterday delivering a 72 page program update. The big news (from our perspective) is that the PCCM concept paper, drafted by a working group of DSS staff and advocates (including the CT Health Policy Project), will be submitted to the legislature next week. The committees will then hold a public hearing on the draft plan, and approve, reject or modify it. In response to a question from Rep. Villano, the Commissioner also announced that the per-member-per-month payment to Primary Care Providers in PCCM will be $7.50, not $5 as was previously reported. The working group had recommended $7.50 after animated negotiations. The bad news is that PCCM may not start until Jan. 1st. Legislators urged DSS to do everything possible to have it ready as another option at the same time that consumers have to choose between HMOs.

There was a great deal of discussion about the 24% increase in rates to the HUSKY/Charter Oak HMOs that seemed “awfully high” to Sen. Harp, with the committees asking DSS to get back to them with more detail. Sen. Harris and others asked about the lack of providers in the new HMOs’ panels. DSS says the HMOs are actively recruiting providers and the plans will pay the out-of-network costs for care to members through November. Legislators expressed concerns that if out-of-network services are not paid at reasonable levels, consumers may still have difficulty accessing care. The Commissioner emphasized that no consumers will be defaulted into any plan until November 25th and the current ASO arrangement, that by all accounts is working well and possibly saving money, will continue until at least the end of the year.

Overall, the committee members expressed a lot of frustration with DSS – in delays to implementing programs, selectively cutting legislative priorities, and numbers that “change every time we meet”. Rep. Merrill said, “We will keep having hearings until we get answers.”
Ellen Andrews

Wednesday, July 30, 2008

Troubling Charter Oak call

We’ve received calls from many consumers about Charter Oak – and it is a good option for some. However yesterday we got a troubling call on our Consumer Helpline (888) 873-4585. Leslie Dmowski called the Charter Oak application number to find out how to apply. She was injured in a car accident and can no longer work. She has applied for disability and is now paying for COBRA – a considerable burden on her family when she is without an income. When she called Charter Oak, she was told she was not eligible because she has insurance coverage. She was told nothing about the financial hardship exception. DSS has stated that if someone is now paying 10% or more of their income for health coverage, they do not have to drop coverage for six months to qualify for Charter Oak. Leslie is paying over 20% of her family’s income for coverage. Thankfully she called us, told her about the financial hardship exception, and sent her an application.

She also waited a long time on the phone after calling Charter Oak and got lost in the phone tree before she spoke to an actual person who was rushed and not helpful. She wanted to make sure that callers know not to press any numbers at the phone prompts to get a real person.

Leslie’s troubles point out a common problem with translating policies to the real world. We at the CT Health Policy Project have been very concerned about the six month uninsured requirement for Charter Oak – we feel it is unfair to people like Leslie who are sacrificing to pay for coverage now and it is bad public policy – excluding those who need health care is an odd way to build a health care program. We advocated with DSS and the legislature to remove the six month exclusion. Policymakers decided not to change it, but assured us that there would be generous exceptions. However it really doesn’t matter how fair the policies are on paper when they don’t get translated to the real world Leslie and her family live in. Advocates have to be especially vigilant – our job is only starting when we get policies passed in Hartford. And policymakers should be realistic when designing programs.
Ellen Andrews

Thursday, July 24, 2008

What would you tell her?

I just returned from a wonderful trip visiting family. While I was there, I ended up in a conversation that put me in an awkward situation, given my job. I was talking with one of my sisters and some of her friends, about half of whom are uninsured. One friend, who is a self-employed 39 year old, asserted, “I don’t believe in health insurance.”

“How’s that?” I asked, preparing myself to tout the importance of health insurance and primary health care.

The friend said that certainly the cost of health insurance is prohibitive, but her main concern was that you can’t be sure of what you’re getting when you pay your premiums. If you have pre-existing conditions, insurers will likely not cover costs associated with those. If you are diagnosed with some unrelated but expensive condition, insurers will likely fight having to cover those costs. She continued. The small print may exclude a number of common events or conditions. And, you may still have an absurdly high deductible or burdensome co-pays.

I was deflated. She’s right…particularly for people who would be finding their insurance as individuals and especially for those who are unable to afford a Cadillac insurance plan on their own.

Insurance is important, but only when it really protects its clients. Too often, we get calls at the Consumer Health Action Network (toll-free in Connecticut at 888-873-4585) from people who have upheld their side of the insurance contract only to find that the insurance companies have built in loopholes that exclude their conditions or key parts of their treatments, or that their “insurance” is not insurance but simply a Medical Savings Account, which offers little in the way of negotiating power to reduce the cost and nothing in terms of offsetting the cost itself.

As I listened to my sister’s friend, I thought about the calls I’ve taken from people here in Connecticut who have seen significantly higher costs than benefits to having health coverage. In order to convince these people (and my sister’s friend) that health insurance is an important and worthy expense, there must be more meaningful standards for what’s covered, clearer explanations of coverage, and better cost controls. Short of either this kind of regulation or of a system that provides truly universal health coverage, we will always have people who forego preventive care, rely too heavily on safety-net providers, and take their chances that they’ll stay healthy enough. That approach is not good for them and it’s not good for our society.
Connie Razza

Wednesday, July 23, 2008

HUSKY/Charter Oak health plan rates up 24% from last year

After accounting for the impact of dental and prescription drug carve outs, the capitated rates paid to the three HUSKY HMOs – Aetna, AmeriChoice (United) and CHN – are 24% higher than the capitated rates paid to the plans last year before November. This is according to an analysis done July 17th for DSS by Mercer obtained by the CT Health Policy Project through a Freedom of Information request. The 24% rate increase includes a 13.1% increase due to programmatic changes (coverage for HPV vaccines, routine dental exams by PCPs, eligibility expansions, etc.) that some advocates and analysts take issue with. Along with medical trend and case mix adjustments, the rate hike also includes a 5.3% or $36.7 million increase for “negotiations” with the plans. $36.7 million is significantly more than the increase in physician fee-for-service payment rates last January – the first in twenty years. It is important to note that the budget, agreed to by both the legislature and the administration, allowed for a 2% rate increase to the plans.
Ellen Andrews

Friday, July 18, 2008

Mr. Lembo goes to Washington

Yesterday State Health Care Advocate Kevin Lembo testified at a Congressional hearing on health insurance company abuses -- post claims underwriting and policy rescissions. That’s when an insurance company cancels a policy after consumer has been paying premiums faithfully, sometimes for years, and they get sick. The company, when faced with mounting claims, looks back into the patient’s history for reasons to cancel. A consumer who joined Kevin on the panel was cancelled after sustaining back injuries from a mountain bike accident because her husband had previous back problems. It is amazing that this was legal in CT until Kevin’s office advocated to change the law. Unfortunately it is still legal in other states, but hopefully Congress will help change that. We are very fortunate to have our State Health Care Advocate, and now Congress knows how lucky we are as well. Read Kevin’s blog on his odyssey into the Beltway.
Ellen Andrews

Thursday, July 17, 2008

Concerns about new Charter Oak $100,000 annual cap

On Monday, Time magazine posted a story called “Low Health Insurance Caps Leave Patients Stranded.” The article exposes the real impact of caps as low as $1 million on individuals and families who face very serious illnesses. This issue is particularly important as the new state Charter Oak Health Plan rolls out. On the day it was launched we learned that the plan now includes a $100,000 annual cap on services, in addition to the $1 million lifetime cap.

According to the article, “Only 1% of employer-offered group plans – the largest health insurance segment – had caps as low as $1 million last year, according to a survey by the Henry J. Kaiser Family Foundation. But 22% had caps of less than $2 million, and some want to see all these relatively low maximums eliminated.”

The article outlines several cases – a leukemia patient, a child with a virus attacking her heart, another child in need of a heart transplant. In two of these cases, the families surpassed the caps within a year of diagnosis.

People with long-term conditions may not exhaust their benefits in one year, but can clearly see the cap approaching. The National Hemophilia Foundation told the reporter, “People with hemophilia can spend more than $200,000 a year just on drugs that prevent internal bleeding.” If they have any other medical needs, they could reach their cap even more quickly.

Sometimes people call the Consumer Health Action Network (888.873.4585) to get help with choosing an insurer. We always encourage people to weigh their options carefully and to check with the Office of the Healthcare Advocate (866.466.4446) to make sure that the plans they are considering are reputable. We are adding to our list: consider the lifetime coverage cap and any annual caps. Consumers should weigh the advantages and limitations of Charter Oak before signing up.
Connie Razza and Ellen Andrews

Wednesday, July 16, 2008

Health First Authority update

Today’s Health First Authority meeting was uneventful. Sharon Langer from CT Voices for Children gave a primer on Medicaid and SCHIP. David Parrella from DSS gave an update on Charter Oak and the HUSKY transition (the same slides he used for Friday’s Medicaid Managed Care Council meeting). DSS has developed a concept paper for an 1115 Affordable Choices waiver to cover Charter Oak, HUSKY, and SAGA and submitted the paper to CMS. DSS refused to share the concept paper with the Authority. Discussion topics included client churning (no answers about why), rate increases (too little, too late), the spending cap (how it restricts the state from accessing federal money), and affordability standards (CT is less generous to uninsured consumers than Massachusetts). There was a presentation by Paul Lombardo of the Dept. of Insurance on MA’s health reforms and by Paul Grady of Mercer on value-based purchasing. Materials from the meeting are online. The next meeting is Sept. 11th at 9am.
Ellen Andrews

Tuesday, July 15, 2008

Medicaid Managed Care Council update

We got a first look at the HUSKY HMOs’ provider networks at Friday’s Medicaid Managed Care Council meeting and it wasn’t good. CHN, which has been a part of HUSKY from the beginning, has robust panels of providers across the state. However, the two new HMOs – Americhoice (United) and Aetna – have a long way to go. As of July 11th CHN had 2,109 primary care providers available to serve HUSKY consumers, while Aetna Better Health had 367 (190 of those are in New Haven County), and Americhoice had only 140 primary care providers statewide. Both Aetna and Americhoice each have a county with only two primary care providers taking HUSKY and Charter Oak patients. And the HMOs are still in negotiations with hospitals for contracts.
We also learned that undocumented immigrants are not eligible for Charter Oak, even the unsubsidized portion of the program. We learned more about how cost sharing the in the program works – the out-of-pocket maximums are on top of the deductibles and copays. Many on the Council were concerned that the state is still at financial risk for behavioral health and drug costs under Charter Oak. Sen. Harp noted that during budget negotiations this spring, HUSKY expenditures were down significantly – suggesting that the state was saving considerable sums without capitation. CMS has asked for that analysis – how much the state spent before and after the state removed capitation in November. DSS also stated that they have no intention to respond to the state’s budget deficit by proposing cuts to HUSKY or Charter Oak.
Ellen Andrews

Thursday, July 10, 2008

CT’s Health Partnership bill featured in NY Times article

Today’s NY Times includes an article outlining proposals to make health coverage more affordable for small businesses. Small companies pay 18% more than large businesses for the same coverage. The recent CT Healthcare Partnership bill proposing to open the state employee pool to small businesses was vetoed by the Governor; however she indicated that she wants to work with legislators next year to craft a bill she can sign. The article also applauds CT for earlier legislation that added some fairness and stability to rate setting for small businesses. CT Comptroller Nancy Wyman is quoted, “This is not an easy problem to solve. We know it.”
Ellen Andrews

Wednesday, July 9, 2008

Sinking or Swimming in the High-Risk Pool?

On the front page of the New York Times this morning, I saw an article that highlights a problem with proposals to model a new component of national healthcare coverage on states’ high-risk pools. Earlier this year, I had been looking at the Connecticut High-Risk Pool (created by the Connecticut Health Care Act of 1975).

What it is? Connecticut High Risk Pool is managed by the Health Reinsurance Association (composed of all private insurance companies and HMOs that offer health insurance in CT) and offers a comprehensive healthcare plan to eligible Connecticut residents who cannot get other coverage because of pre-existing conditions. State law caps HRA rates at 125% -150% of standard insurance rates.

Who it “serves”? Connecticut residents between 19 & 65 and their dependents can be eligible for the high-risk pool. The Health Reinsurance Association offers several plans, but the range of cost is largely covered by two closely related examples:
· The special Low-Income Portability TAA Plan costs a 45 year-old male $317.63 per month; a 45 year-old female would pay $395.40 a month.
· The same plan for a non-low-income individual costs $972.53 per month for a 45 year-old male and $1210.65 for a 45 year-old female.

In my opinion, the high-risk pool is dangerous because it appears to offer safety-net coverage, while actually being priced out of reach of the very people who most need it. While the new Charter Oak Health Insurance program may help cover many Connecticut residents who would earlier have had no option but the high-risk pool or no coverage, the program’s co-pays and deductibles may still bar our state’s sickest residents from participating.
Connie Razza

Monday, July 7, 2008

Book Club -- Sway

I just finished Sway: The Irresistible Pull of Irrational Behavior by Ori and Rom Brafman. A fascinating book that details the psychological forces that keep us from making good decisions. There are dozens of great examples, but my favorite is the “twenty dollar auction”. One the first day of class, a Harvard business school professor plays a game with his students auctioning off a twenty dollar bill. The highest bidder gets the bill, but the second highest bidder also has to pay his bid and receives nothing. Bargain hunting students quickly move the bidding up to $12 or $16, when the contest slows down and only the two highest bidders continue. At $17 for instance, the second highest bidder can spend another $2 and go to $18 hoping to win the bill or risk losing his entire $16. The students “roar with laughter when the bidding passes $20”; the record is $204. The professor has never lost money in the game; all proceeds go to charity. Students are caught “chasing the loss” – the deeper the hole, the more they dig. This illustrates loss aversion, one of several psychological forces that drive our irrational behavior. Thankfully, the authors do not just describe these traps, but provide guidance to avoid them – critically important in policymaking. For more book reccomendations, go to the CT Health Policy Project Book Club.
Ellen Andrews

Wednesday, July 2, 2008

Family Values - a small but significant gap in Connecticut’s health care system

There are a number of people who cannot get healthcare coverage in Connecticut no matter where they turn: Documented immigrants over 65 years of age who have had green cards for less than 5 years. The people affected by this gap are often parents who have come to be with their children and help raise their grandchildren.

This morning, the Consumer Health Action Network hotline (toll-free 888-873-4585) answered a call from a daughter who had brought her 70-year-old parents to Connecticut. They both have had their green cards for 3 years. She has tried many avenues to get healthcare coverage for them.
· Most private insurers will not look twice at the application when they learn that her parents are over 65 years old. One company that did consider the couple came back with a monthly premium of $1400 for one parent, for coverage that would not address any pre-existing conditions.
· Medicare requires that immigrants hold their green cards for 5 years before they are eligible for coverage.
· Medicaid does not cover anyone over 64 who isn’t eligible for Supplemental Security Income, doesn’t receive Medicare, or hasn’t spent a significant amount on medical expenses already.
· The new Charter Oak Health Plan is designed for 19 to 64 year olds and does not make exceptions to those parameters.

It’s a small gap, frankly, but an important one to fill. Models exist for how to fill this gap (for instance, our neighbor to the South, New York). Let’s get to it and make sure that we make sure that as many of the currently uninsured will be able to get healthcare coverage.
Connie Razza

Tuesday, July 1, 2008

COBRA calls to Consumer Network Helpline

In the past three weeks, the Consumer Health Action Network (888-873-4585) has received a number of calls about COBRA. COBRA (which stands for the Consolidated Omnibus Budget Reconciliation Act) is the federal law that allows workers and their dependents to continue group health coverage at their own expense after employer coverage ends because of termination, reduced hours, and other reasons. This trend is disturbing because it indicates at least one if not more of several problems:
· More Connecticut residents are losing their jobs;
· Employers don’t know their obligations under COBRA; and/or
· Employers are counting on their employees not knowing their rights under COBRA.

The program is complicated, but here are some basics:
· In Connecticut, all employers are covered by COBRA law.
· Employees are eligible for COBRA insurance when they retire, quit, are laid off or fired for anything other than gross misconduct, or have reduced hours.
o Employees are covered up to 18 months under the federal COBRA law. If the employee is between 62 and 65 and eligible for COBRA, Connecticut law requires the employer to offer COBRA coverage until the person reaches 65 (when Medicare starts), regardless of the number of months involved.
· COBRA insurance will also cover surviving, divorced, or separated spouses; dependent children; or dependent children who lose their dependent status under their parent’s plan.
o Depending on the reason for loss of coverage under an employer plan, spouses and dependent children may be eligible for COBRA benefits up to 36 months.
· Retirees can qualify for COBRA if their former employer files for bankruptcy.

COBRA coverage can be expensive, especially for people who have just become unemployed, but it is an important option for people to keep coverage through transitions. It is critical that everyone know their rights.
If you have questions about COBRA, go to or call the Consumer Health Action Network Helpline toll-free in CT at 1-888-873-4585.
Connie Razza