Undetermined Issues

[stuy119]

So we're proceeding to 2011, and no caps are allowed on certain items of health plans. In speaking today with an attorney who deals with benefits plans (solely), she raised a few interesting points I had not considered.

1. Clients are prepping their plans for 2011. Nothing has been said as to whether or not there are caps on IVF and other reproductive issues. There are Supreme Court cases that say that reproductive rights are a guaranteed right, so there is precedent for making these uncapped. Yet there has been no determination on this so companies can design their programs.

2. Third-party independent claims review has not established the "independence" of the claim reviewers.

3. Much like reproductive issues, DME is a benefit that is to remain uncapped. Companies that have a large union presence are facing quite a bit of issues with this, since moving from a capped benefit covered at 100% (regardless of the dollar limit) to an uncapped benefit covered at anything less than 100% constitutes a reduction in benefits - which is not allowed according to CBA regulations.

And those are just small issues which have yet to be resolved. Needless to say, there is going to be a whole lot more of this going on over the next 3 years. She said the law was obviously written by those with no experience in either business or insurance.

Not that we didn't already know that.

 

[somarco]

Valid points, but the impact on total claims is most likely negligible.

When AIDS made the news carriers reacted and quickly adjusted morbidity factors in anticipation of large AIDS related claims . . . that never materialized.

AIDS then, as now, affects a relatively small portion of the population. The impact on claims is minimal.

IVF can be expensive, running $30,000 on average. This amount, while significant involves only a small portion of the population. In states where it is mandated, and keep in mind that insurance is still regulated at the state level, the premium increase is 3 - 5%.

I suspect as we move forward under Obamacrap there will be plenty of surprises which will only serve to fan the fires of those calling for a repeal of this expensive boondoggle.

 

[ABC]

These are really interesting points.

I would be surprised if the IVF had that big of impact on premium. I would guess it would be under 2%. Now on small group it could have a huge impact. When I was writing group biz in Illinois they had a state mandate IVF. I lost a case I was bidding on because they had an on going IVF case. What was interesting was the network discounts were huge on those procedures compared with a state that did not have the mandate. If IVF coverage goes as any other illness we will see deep network discounts and more providers.

On the Independent claims review a handful of states already have a process for this. It will be interesting to see how the other states set their up. ON a large group side if you lose the grandfather status you better make dam sure your are addressing this issue with the re insurance contract.
I do not see how a personal appeal process is going to turn down that experimental therapy that saved a child life.

The 3rd issue on the uncapped DME I have not run into. So the attorney is stating that the group would lose their gandfather status or a violation of the union contract?

There are firms in DC that write these bills that employ mainly young people that just graduated.

We are just seeing the tip of the iceberg

 

[stuy119]

It's the issue of having to deal with a potential fine for being "out of compliance," more than dealing with a cost issue.

On the DME stuff, it's either accept the potential claims or break the contract. They'll likely accept the potential of the claims rather than need to re-negotiate, but it goes to show just how asinine this bill is and how far reaching it is with no regard to the operations of the businesses who organize and pay for this. The DME is just 1 of 100 examples that are out there.