pay your premiums (mandated or voluntarily) ... but denial of claims & treatment will continue?

[thotzRthingz]

Healthcare bills lack protections against treatment denials, experts say

"There are going to be a lot of denials," said insurance industry analyst Robert Laszewski, a former health insurance executive. "I am not setting insurance companies up to be villains. But we are telling them to bend the cost curve. How else are they going to bend the cost curve?"

- source: http://articles.latimes.com/2009/oct/19/business/fi-patients19

Yes, the article is dated last October... so, after at least six months of this sort of dire warning, did the "VICTORY" fix this (or did we just MANDATE payment of premiums, for continued denials of treatments & claims)?

[HereSince1628]

1. We'd all sort of like to know how it will work. I get the feeling

that it'll be many years until we do.

[thotzRthingz]

4. I look forward to working hard on a plethora of FIXES (as promised) ... when & where do we begin?

[ixion]

2. "did we just MANDATE payment of premiums, for continued denials of treatments?"

Yep, they did.

[thotzRthingz]

3. not to mention... COST control (premiums, co-pays, deductibles will continue to rise)

[quiet.american]

5. If you can find your way to DU, why can't you find your way over the interwebs to the info you need?

This link has EVERYTHING you need to know about HCR as it pertains to the bill just passed:

Affordable Healthcare for America Act:
http://www.speaker.gov/newsroom/legislation?id=0361

(And by the way, the answer is "No.")

[thotzRthingz]

7. surely you do not expect me to accept some politician's rhetoric? if you think

what you are being told (per the link you provided) is true... show me, in the legislation's language (i.e., section / paragraph) just how "denial of claims and treatments" is being addressed. I'm not talking about DENIAL OF INSURANCE POLICIES here. I'm talking about: denial of filed claims (by those who HAVE, or will have, health insurance), and denial of requests for specific treatments (you know, the sort of thing which has occurred, is occurring, and will continue to occur... daily).

[quiet.american]

8. "....politician's claims...."? The link provides ALL the "language" you could ever want.

If you're really more interested in the truth of the matter, rather than pushing the claim you're making, you can take the time to look this up in the bill. It's there at the link, and maybe then *you'll* post the language back to us.

[HughMoran]

11. not interested

You know that.

[stillwaiting]

9. They'll be able to deny claims based on "fraud".

Just. Like. They. Do. Now.

They purposefully don't screen applications very well so that they have an out when they need to drop their "customers" when they get really sick.

It's part of their business model apparently.

I remember watching the CEO's in front of Stupak admitting that they did not screen applications as part of the application process because it would cost too much or some such crap.

Funny how there is NO emphasis in the media on how important it is to keep letter perfect records of your health care records and what the consequences could be if you don't. They don't want you to so that they can profit the most off of you. That is the unfortunate truth.

[quiet.american]

14. It "was" part of their business model. It's what they *were* free to do.

One of the immediate benefits of the bill ("immediate" meaning six months from now) is that insurance companies will not be able to do what you've described - drop your coverage. If they want to claim fraud, the burden of proof will be on them; in the meantime, the consumer will still receive coverage and treatment until the time they can prove it. Which, if they're scamming, they won't be able to.

[hack89]

32. But they can deny treatment without dropping coverage

they are more than happy to take my money and give me nothing in return. How does this law change that? It doesn't as far as I can see.

[tomber]

12. depends

The bill requires the appointed commissioner to determine the details of the minimum policy coverage. People will pay premiums on this coverage but it will still be a minimum coverage policy that will not include everything and will probably only cover 70% of the bill leaving the individual responsible for 30%. This is pretty standard for a minimum coverage bill. The government will subsidize your premium payments if you qualify but it will not pay your bills and will not cover you for things that the policy does not cover.

[quiet.american]

15. Amended to add, the government does offer cost-sharing beyond the premium.

And there is an Essential Benefits Package determined not by the commissioner, but is detailed in the bill itself.

[tomber]

16. what page or section

is that on in the bill? I must have missed it.

[quiet.american]

25. I believe it's page 252 in the House bill; further links:

(Reference starts on page 3)
http://edlabor.house.gov/documents/111/pdf/publications/AHCAA-DETAILEDSUMMARY-102909.pdf

White House charts of premium and cost-sharing across the House, Senate and Proposal:

[tomber]

26. subsidies

Those rate charts are for subsidies to help people pay the premiums. Do you have any more info on the details of coverage not determined by the commissioner aside from the general requirements of what must be included like no preexisting and no lifetime caps etc...?

[quiet.american]

28. It actually is for cost sharing, too -- here --

From my first link:

MAKIING COVERAGE MORE AFFORDABLE::

Affordability credits. Provides financial assistance for premiums and cost sharing for individuals and
families with incomes up to 400 percent of the federal poverty level (FPL). Affordability credits are offered
on a sliding scale such that premiums range from 1.5 percent of income at the lowest tier to 12 percent at.... etc, etc.

Look at what the title of the second table from the WH says:

"Reduced cost-sharing"

Page 252-253 of the House bill has a section for premium and a section for cost-sharing (I cite the House bill because it lays it out more specifically, but the WH figure has the Senate cost-sharing percentages):

SEC. 343. AFFORDABILITY PREMIUM CREDIT.
(a) IN GENERAL.—The affordability premium credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in an amount equal to the amount (if any) by which the reference premium amount specified in subsection (c), exceeds the affordable premium amount specified in subsection (b) for the individual, except that in no case shall the affordable premium credit exceed the premium for the plan.

3 SEC. 344. AFFORDABILITY COST-SHARING CREDIT.
4 (a) IN GENERAL.—The affordability cost-sharing
5 credit under this section for an affordable credit eligible
6 individual enrolled in an Exchange-participating health
7 benefits plan is in the form of the cost-sharing reduction
8 described in subsection (b) provided under this section for
9 the income tier in which the individual is classified based
10 on the individual’s modified adjusted gross income.


Not exactly sure about your question, but here's the link to one-stop shopping on this - bill texts, summaries, implementation timelines, etc.
http://www.speaker.gov/newsroom/legislation?id=0361

[notadmblnd]

6. well, insurance companies will now have to pay between 80-85% of what they

take in, back out. logically, one would think that there would be less denial of claims.

[Statistical]

10. Insurance companies profits are already much less than that.

The 85% medical loss rate is good PR headline but meaningless.
Insurance companies could DOUBLE profits and still meet those guidelines.

http://www.google.com/finance?q=NYSE:CI&fstype=ii

Take Cigna for an example.

In 2009 they had revenue of $18.4 billion yet only had an operating income of $1.8 billion (roughly 10% of revenue). Profits were even less $1.3 billion.

[notadmblnd]

17. I didn't write the law, I'm telling you what it is.

Why do you have sympathy for insurance companies?

[Statistical]

20. I don't.

I am simply saying the "cap" is meaningless.

Insurance profits are LESS than the cap.

It would be like say you make $50,000 a year. Your boss comes to you with "bad news". He is going to cap your compensation to less than $385,000 a year. Would that really hurt you? Would it affect your take home pay in any way? Is it likely to affect your take home pay at any point in the next decade?

Insurance companies could REDUCE the amount of money they spend on paying claims and still meet the "cap".

[pundaint]

30. What was their loss ratio, because that, and not operating income are what we

are discussing.

[GinaMaria]

34. They claim to do that now

Does the bill mandate how they calculate this or will they keep calculating the way they have been? If the latter, then nothing changed on what they pay out.

[thotzRthingz]

13. Here's a very specific example... for the "true believers" who wish to take-up this challenge:

Background:

I met and talked with Dawn Smith, as she traveled from GA to PA to confront CIGNA's CEO about her being denied specific life-saving treatment. No less than three respected doctors in the Atlanta area said she should pursue said treatment... but CIGNA repeatedly DENIED her access to same.

Dawn had health insurance. Dawn paid her premiums, co-pays, and deductibles, FOR YEARS... yet she was being denied treatment which three doctors had lobbied FOR, on her behalf. Here's a bit more of Dawn's story: http://www.itcouldhappentoanyone.com

Dawn Smith is not alone... these sorts of DENIALS take place all the time (some for less serious conditions, some for conditions which are just as serious and urgent).

Challenge:

Going back to my OP ... and the question posed therein ... are you now telling me, and more importantly ... are you telling Dawn Smith that her treatment can no longer be DENIED by her insurance company (as a result of this recent "historic victory")? Furthermore; if you are wrong in your assumption, will YOU pay for Dawn Smith's treatment (and hold CIGNA accountable for their continued DENIAL)?

[proud2BlibKansan]

19. Yes that is illegal under this bill

They really should have called it health insurance reform. The bill does more to reform the insurance industry than health care.

[thotzRthingz]

21. fair enough reply, although section/paragraph of the legislation has not been cited...

I presume you are referring to a $100/day FINE which is proffered as a penalty for non-compliance by the insurance companies?

My question then becomes: will that really serve as a deterrent? Also, at what point will "denials" (not of insurance policies, but of claims & treatments) become acceptable (if at all)? For example:

Will they be able to deny your 15th quadruple bypass (absurd yes, but it illustrates the point)?

On one side, your doctor will say a procedure is necessary... on the other side (at the ins. company's end), someone needs to approve the claim/request (think of that as serving the purpose of preventing fraud). IOW: someone/somewhere must decide WHEN TO PULL THE PLUG... elsewise cost of medical care is prohibitive (i.e., we simply run out of money... then CARE gets denied to everyone).

[quiet.american]

23. The provision that comes to mind for Dawn's circumstances is the subsidized high risk pool

I see she met with Congressman John Lewis, and I've heard him and many others during the debate cite circumstances like hers as examples of why healthcare reform is urgently needed.

I couldn't watch all the links at the link you posted, however, I was looking for exactly the reasons CIGNA gave for rejecting her claims, to match them with provisions in the bill that would prohibit them from doing that now.

In the meantime, though, it seems to me that like "Natoma," Dawn would be a prime candidate to go into the high risk pool to get the treatment she needs, and there is also funding in the bill to establish an external appeals process for those in Dawn's circumstances.

Looking at her story, it's impossible to understand how someone like that reprehensible CIGNA CEO sleeps at night.

[thotzRthingz]

24. Reprehensible indeed! See Dawn's letter (linked herein) to CIGNA's CEO for "denial" reasons...

http://www.itcouldhappentoanyone.com/my-letter-to-cignas-ceo

The DEATH & DENIAL PANELS (of which the REPUKES have made such a fuss)... were already "out there"... let's hope that a $100/day FINE is sufficient to put an end to such practices!

[quiet.american]

31. What an eloquent letter from her. And what's worse is that CIGNA sent her routine, generic denials.

One other thing that comes to mind that's in HCR is the Essential Benefits Package which would not allow CIGNA to make the determination that her treatment was "medically unnecessary."

Also, insurance companies pulling stunts like CIGNA would be blocked from participating in the Exchange(s), and since they love money so much, that should a very real incentive to stop this kind of sociopathic behavior. Just despicable.

But in the short term, it really looks to me that Dawn would be eligible for the subsidized high risk pool.

[eridani]

37. States already have high risk pools which offer perfectly useless trash

It doesn't mean jackshit that premiums are subsidized if co-pays and deductibles are ridiculous.

[NNN0LHI]

18. You are quoting an insurance industry hack to make your point?

Something is funny here.

Don

[thotzRthingz]

27. I try to take both sides of any argument, to heart, it helps me to better understand those with whom

I find myself in opposition (sometimes I even adopt some of their points of view, tossing out other points of view as unreasonable). Not many people know that, about me... likely even fewer care for my approach... but, that's who I am (and why I am a registered-INDEPENDENT).

Of course it is also very likely that many here, @ DU, would prefer me not to post... and I presume the MODS will make the decision as to whether or not I can stay (until such time, I'll just continue to be me).

Have a nice day.

[Dawgs]

22. AGAIN, this is the start of health care reform; not the end.

Work to fix anything you don't like and stop wondering if this bill isn't perfect.

[pundaint]

29. Well be sure to let us know if some reform happens.

[freddie mertz]

33. Meanwhile, some are actually claiming we now have health CARE as a RIGHT.

What a sick, cruel, pathetic joke that is.

[GinaMaria]

35. maybe

that will be where the change is truly born. When people believe health care is a right and have expectations of that right, the demands on politicians will increase. The best thing we can do is keep talking about health care as a right, like speech and assembly. When people believe their god-given rights are being violated, they will stand up. Exactly why Fox keeps promoting the idea that progressives are for rights that are not god-given and therefore not rights but privileges.

I get your point about some who promote this bill as something it isn't and was never going to be, but I also see an opportunity in that falsehood to create a new reality. Yes. Health care is a right and the more people who believe it, the closer we are to public run health care available to anyone who wants it.

[freddie mertz]

38. I appreciate your optimism.

Looks like it will be a long fight.

Too bad the president blocked even the smallest discussion of the merits of single-payer this time out.

We have to think long term, and beyond this current administration.

[OneBlueSky]

36. that's one of the two ways corporations increase shareholder profits . . .

by reducing expenditures (which, in the case of health insurance, means payouts for benefits -- and large deductibles) . . .

the other way they make money is by increasing income (in the case of health insurance, the premiums charged to policyholders) . . .

anyone believe they'll stop milking either just because Congress tells them to? . . . they OWN Congress!!! . . .