Obama signs Medicare bill changing how doctors get paid

For LA Times story by Noam M. Leavy see

  • Instead of annually ignoring a reimbursement system that by this year threatened to cut physician fees by more than 20%, lawmakers finally put a new payment system in place that gives physicians an annual 0.5% increase over the next four years.
  • In 2019 performance-based financial incentives begin for physicians, rewarding doctors whose patients get better.
  • The Children’s Health Insurance Program (CHIP) is extended until 2017, as well as funding for Community health centers serving more than 23 million low-income folks.

Unfortunately the usual pander-to-the-base prohibition on using federal dollars for abortion is included in the bill.

Long-term Care Policies Sold Decades Ago Are Becoming Costlier

The LA Times reported on March 27, “‘Insurers that sell these products lose money on them,’ says Vincent Lui, a life-insurance analyst at Morningstar. ‘So they’re raising prices and also trying to get out of the business right and left.’ Four of the five largest providers — including Manulife and MetLife — have either scaled back their business or stopped selling new policies, according to Moody’s. The largest provider, Genworth Financial, continues to offer them yet has struggled under the weight of rising costs.”

“The rate for staying at a nursing home has gone up an average of 4% every year for the last five years, according to Genworth’s annual survey. In 2014, the median bill for a shared room topped $6,000 a month. ‘They were making their best estimates at the time. They just turned out to be wrong,’ says Shachar Gonen, a Moody’s analyst who covers the industry. ‘If insurers knew full well what they were getting into, they probably would have priced their policies much higher. So who knows if the long-term insurance business would have ever started.'”


Read the full story here.

Patient Advocacy Takes Off

The LA Times reported on April 6, “These patient advocates — also called medical billing advocates or claims assistance professionals — have been around for decades. But the field has taken off in recent years as patients face higher out-of-pocket medical costs and the healthcare system becomes increasingly difficult for the average person to navigate.

‘People just don’t understand what’s on their bill. The language is written in medical terminology. Sometimes clients just want a translation,’ says Maureen Lamb, a medical billing advocate and chief executive of Medical Bill Support in Holderness, N.H.

Larger organizations and an estimated 300 independent advocates practice nationwide, according to the Alliance of Professional Health Advocates, an advocate trade group.

There is no uniform training or licensing requirements for advocates or specific type of service they offer.

A host of organizations provide education and support to advocate professionals, many of whom are former nurses, attorneys or medical coding professionals. Some are certified in medical bill coding by organizations such as the American Academy of Professional Coders and the American Health Information Management Assn.

Private advocates may charge by the hour, with rates ranging from $75 to $150. Some work on retainer or charge a flat project fee. Another common practice is to take a percentage of the savings they achieve.

Increasingly, employees have access to these services on the job for free as part of their work-based benefits. More than half — 52% — of employers with more than 500 workers offer the service, as do 27% of companies with 10 or more employees, according to the 2014 national employer health plan survey by consulting firm Mercer.”

Resources and links

Here is how to find a patient advocate or medical bill specialist.

Check at work: Many large and mid-size companies offer medical advocate services. Check with your human resources department.

Hire one yourself: There are organizations with lists to search for advocates in your area.

AdvoConnection directory:

Medical Billing Advocates of America:

Health Proponent:

Read the full story here.

Kaiser fined $28 million for failing to provide timely MRI

See LA Times story here:

By the time Kaiser finally approved an MRI for 23 year old Anna Rahm, a cancerous tumor grew so large that doctors amputated her leg, half of her pelvis and part of her spine.

Kaiser has also recently been fined millions for failure to provide mental health benefits in a timely manner; according to the LA Times article by Stuart Pfeifer, Kaiser mental health workers accused the company of failing to provide enough therapists, forcing some patients to endure lengthy and potentially dangerous waits for treatment.

2016 open enrollment period announced by HHS

On February 20, the Department of Health and Human Services (HHS) issued final regulations on the 2016 Notice of Benefit and Payment Parameters. The regulations address a variety of Patient Protection and Affordable Care Act (PPACA) benefit provisions for 2016 affecting both the group and individual markets. While HHS clarified a few items from the proposed rule – namely the open enrollment period, minimum value, and medical loss ratio – many of the provision requirements remain the same. Here is an overview.

Open Enrollment Period
For the 2016 calendar year, the open enrollment period for non-grandfathered policies in the individual market, inside and outside the Marketplace, will run from November 1, 2015 through January 31, 2016, with various plan effective dates depending on when an individual enrolls.

Essential Health Benefit Benchmark Plans
It is confirmed that states may select new benchmark plans for 2017, based on plans available in 2014.

2016 Cost Sharing Limits
The 2016 maximum annual out-of-pocket limits are confirmed at $6,850 for individual coverage and $13,700 for family coverage. Additionally, the out-of-pocket limit for individual coverage applies to all enrollees, even if they are enrolled in family coverage. For example, if the plan has an individual out-of-pocket maximum of $5,000 and a family out-of-pocket maximum of $10,000, then if any family member’s out-of-pocket maximum reaches $5,000, services for that particular family member will be covered at coinsurance.

Reduced Maximum Annual Limitation on Cost Sharing
Individuals with household incomes between 100-200 percent of the Federal Poverty Level (FPL) have a reduced maximum annual limitation on cost sharing for self-only coverage of $2,250. Individuals with incomes between 200-250 percent FPL have a reduced maximum annual limitation on cost sharing for self-only coverage of $5,450.

Minimum Value Standards
The final rule establishes new standards by which employer-sponsored plans meet the minimum value requirement. HHS now requires employer plans to provide “substantial” coverage of inpatient and physician services. This will apply to employer-sponsored plans on the effective date of the final notice, and these plans will not meet minimum value unless they provide this specific coverage. Separate further guidance is expected to provide more clarification around the definition of “substantial.”

Rate Reviews
Premium rate increases in the individual and small group markets of 10 percent or more (or above a threshold specified by a state) triggered at the “plan-level” will be reviewed by state regulators or HHS to determine whether they are reasonable. This is a change from the previous requirement that was triggered at a “product level.”

Issuers seeking the increase are required to publicly disclose the proposed increases and the justification for them. Beginning with rates filed in 2016 for coverage effective on or after January 1, 2017, rate increases will be subject to review by HHS.

Reinsurance Fee
The final rule confirms that the 2016 Reinsurance Fee is $27 per person. In addition, self-funded group health plans that do not use a third-party administrator will be exempt from making reinsurance contributions in the 2015 and 2016 benefit years.

The final rule also confirms that self-insured expatriate plans are also not required to make reinsurance contributions for the 2015 and 2016 benefit years.

Medical Loss Ratio (MLR) Program
The final rule clarifies that Federal and State employment taxes should be included in premium for the MLR and rebate calculations. In addition, subscribers of non-federal governmental or other group health plans not subject to ERISA must receive the benefit of MLR rebates, or a rebate distribution, within three months of receipt of the rebate by their group policyholder, just as subscribers of group health plans subject to ERISA do.  This provision is effective January 1, 2016 for the 2016 MLR reporting year, which must be submitted in 2017.

2016 Federal Marketplace User Fee
The user fee paid by insurers that offer plans on the federally facilitated Marketplace is confirmed at 3.5 percent of monthly premiums, consistent with previous guidance.

Compliance Standards for Federal Marketplace
Under the final rule, HHS has the authority to approve and oversee vendors that provide training to agents and brokers in federally facilitated Marketplaces. HHS may recognize the successful completion of a Marketplace training program by agents and brokers. To become an HHS-approved vendor, the organization must demonstrate that it meets specified criteria outlined on the application process established by HHS.

HHS is also finalizing the proposal to extend the good faith compliance policy for Qualified Health Plan (QHP) issuers participating in federally facilitated Marketplaces. In addition, the final 2016 Letter to Issuers in the federally facilitated Marketplace was published, which provides key guidance for issuers seeking to offer plans in this Marketplace.

There are many other details confirmed in this final rule. A fact sheet on the final rule is available on the Centers for Medicare and Medicaid Services (CMS) website. Read the CMS Fact Sheet

How to set up a Security Freeze on your credit report


If you are very concerned about becoming a victim of fraud or identity theft, a Security Freeze (also known as a Credit Freeze) might be right for you.

Placing a freeze on your credit report will prevent lenders and others from accessing your credit report entirely, which will prevent them from extending credit. With a Security Freeze in place, even you will need to take special steps when you wish to apply for any type of credit.

Because of more stringent security features, you will need to place a Security Freeze separately with each of the three major credit reporting companies if you want the freeze on all of your credit files. A Security Freeze remains on your credit file until you remove it or choose to lift it temporarily when applying for credit or credit-dependent services.

Placing a protective freeze for a child can prevent fraudulent accounts from being opened with your child’s identity. If you are the parent/legal guardian of a minor or medically incapacitated consumer and reside in an eligible state, you may have the right to request a Protected Consumer Freeze.

Reasons for a Security Freeze

  • You want maximum control of your credit
  • You are concerned that you might become a victim of fraud/ID theft
  • You are a victim of fraud/ID theft
  • You won’t need to apply for credit in the foreseeable future
  • You are the guardian of a minor or medically incapacitated consumer who won’t need to apply for credit in the foreseeable future


  • Until you choose to lift it permanently or temporarily
  • Until the minor becomes an adult
  • Until an authorized request is made to permanently remove the freeze

How to implement a Security Freeze
Visit each of the three major credit reporting companies – TransUnion, Equifax and Experian

Scam email campaigns targeting Anthem members in wake of cyber attack

Members who may have been impacted by the cyber attack against Anthem should be aware of scam email campaigns targeting current and former members.  These scams, designed to capture personal information (known as “phishing”) are designed to appear as if they are from a health plan and the emails include a “click here” link for credit monitoring. These emails are NOT from Anthem.

  • DO NOT click on any links in email.
  • DO NOT reply to the email or reach out to the senders in any way.
  • DO NOT supply any information on the website that may open, if you clicked on a link in email.
  • DO NOT open any attachments that arrive with email.

Anthem is not calling members regarding the cyber attack and are not asking for credit card information or social security numbers over the phone.

This outreach is from scam artists who are trying to trick consumers into sharing personal data. There is no indication that the scam email campaigns are being conducted by those that committed the cyber attack, or that the information accessed in the attack is being used by the scammers.

Anthem will contact current and former members via mail delivered by the U.S. Postal Service about the cyber attack with specific information on how to enroll in credit monitoring. Affected members will receive free credit monitoring and ID protection services. 

For more guidance on recognizing scam email, please visit the FTC Website:

Cyber Attack Impacting Anthem Members

I want to let you know that we have just become aware that Anthem, Inc., the parent company of Anthem Blue Cross, is the victim of a highly-sophisticated cyber attack. Anthem has informed us that its member data was accessed, and information about our clients could be among the data.

We are working closely with Anthem to better understand the impact on its members. Here is what we do know:

  • Once Anthem determined it was the victim of a sophisticated cyber attack, it immediately notified federal law enforcement officials and shared the indicators of compromise with the HITRUST C3 (Cyber Threat Intelligence and Incident Coordination Center).
  • Anthem’s Information Security has worked to eliminate any further vulnerability and continues to secure all of its data.
  • Anthem immediately began a forensic Information Technology (IT) investigation to determine the number of impacted consumers and to identify the type of information accessed. The investigation is still taking place.
  • The information accessed includes member names, member health ID numbers/Social Security numbers, dates of birth, addresses, phone numbers, email addresses and employment information, including income data. Social Security numbers were included in only a subset of the universe of consumers that were impacted.
  • Anthem is still working to determine which members’ Social Security numbers were accessed.
  • Anthem’s investigation to date shows that no credit card or confidential health information was accessed.
  • Anthem has advised us there is no indication at this time that any of our clients’ personal information has been misused.
  • All impacted Anthem members will be enrolled in identity repair services. In addition, impacted members will be provided information on how to enroll in free credit monitoring.

Anthem has created a website –, and a hotline, 1-877-263-7995, for its members to call for more information, and has shared the attached Frequently Asked Questions (FAQs) that further explains the cyber attack. Read Anthem’s FAQ here:

Please feel free to contact me if you have any questions.

Michael Grodsky, Principal
Artist Insurance Services
phone: (323) 293-6800

5 tips to prepare for last-minute ACA enrollments

With less than two weeks until the end of the Affordable Care Act’s Feb. 15 open enrollment period, Artist Insurance Services offers these five tips to help prepare for purchasing health insurance.

1. Do a full assessment of your current health care needs.
Being able to assess what is important to you and your families will make it easier to sift through the plan options in the exchange. Do you require specialists for a known health ailment? What are your current prescription drug needs?

2. Have your 2013 tax filing information ready and available. (This tip applies only to folks with subsidized plans obtained through Covered CA).
Your 2013 tax filing will be important in order to gauge what, if any, health care subsidies you may be available to take advantage of in 2015.

3. Make a full list of your current doctors.
You’ll want to check with your doctor’s office to ensure they are considered “in network” for any of the potential plans you are considering selecting.

4. For those already enrolled previously in the exchange, do you need to increase or decrease coverage?
Having the right health care plan that best fits your individual needs is essential, says NASE. Paying for an oversized plan that provides many bells and whistles you haven’t utilized in the past – and will be unlikely to use in the future – may be a good place to start cutting costs.

5. Establish a realistic budget that includes health care costs.
‘Nuf said.

P.S.:  The same plans at same prices are available off-exchange, plus additional plans and carriers that are not available through Covered CA. If you don’t qualify for premium assistance, you may be better off avoiding Covered CA altogether. Dealing with Covered CA has been a bureaucratic nightmare of epic proportions for many folks.

To book an open enrollment phone call, click this link:

Blue Shield signs agreement with Cedars-Sinai

Effective March 1, 2015, Blue Shield of California has signed a new agreement with Cedars-Sinai Medical Center for Individual and Family Plan PPO plans. This includes on- and off-exchange Platinum, Gold, Silver, and Bronze plans.

With this agreement, Blue Shield’s IFP PPO members will also have access to Cedars-Sinai Medical Group and Cedars-Sinai Health Associates. Additionally, members will have access to other Cedars-Sinai Medical Center identified independent physicians.

Cedars-Sinai health insurance information page: