JustCare

Tag: CHIP

  • CMS rule would make prior authorization easier for people in most federal programs, except Medicare Advantage

    CMS rule would make prior authorization easier for people in most federal programs, except Medicare Advantage

    People in Medicare Advantage plans–the private health insurance plans that offer Medicare benefits–contend with multiple challenges to getting care, including restricted networks of doctors, high deductibles and copays, and prior authorization rules. Healthcare Dive reports that the Centers for Medicare and Medicaid Services just issued a rule that would make prior authorization easier for people with Medicaid, people in state health insurance plans and people in the CHIP program beginning January 2023. For some incomprehensible reason, the rule does not apply to people in Medicare Advantage.

    As you might expect, the hospitals, doctors and patients generally like the proposed rule. It would standardize and speed up the approval process for the delivery of health care services and medicines, reducing the burden on them. It would means shorter delays in the delivery of care.

    But, the providers do not understand why it does not include Medicare Advantage plans. Why shouldn’t they be part of a CMS rule that standardizes data-sharing? They cover millions of people. Not having them included only complicates matters for providers and makes it harder for older adults and people with disabilities enrolled in Medicare Advantage to get care.

    What’s problematic about the new rule is that it gives health plans–except for health plans in the state health insurance exchanges–as long as seven days to make a decision about whether to authorize a standard procedure. Even when the procedure is urgent, the insurers have three full days.

    Why should health insurers have so much power to delay care and jeopardize people’s health, even in an urgent situation? The American Hospital Association has asked that the timelines be changed to three days in non-urgent situations and 24 hours in urgent cases.

    Health insurers, for their part, are not happy with the rule whatsoever. Prior authorization allows them to delay care. At times, it deters people from getting care altogether. Anytime that care is delayed or foregone, the insurers do not spend money and profit.

    The new policy also requires insurers to let hospitals and doctors know why they are denying authorization. The insurers complain that the burden is all on them.

    The health insurers don’t have much of an argument. They claim “distraction” from containing the pandemic. They also claim that the comment period is too short to enable them to comment appropriately. They say it violates the Administrative Procedures Act.

    It’s all hogwash, but that doesn’t mean that the health insurers won’t be able to wield their enormous power to undo the rule. The question is whether the health insurers are more powerful than the doctors, the hospitals and the patients. Most likely yes, since they have more resources.

    The rule would force more electronic interoperability among providers and insurers. For all kinds of reasons, the improved ability to exchange data is important.

    Here’s more from Just Care:

  • Who’ll lose health care after ACA repeal?

    Who’ll lose health care after ACA repeal?

    Later this month, Republicans in Congress plan to repeal large portions of the Affordable Care Act (ACA), aka Obamacare. The consequences for the health and financial security of tens of millions of Americans will be severe. Who’ll lose health care after the ACA is repealed? In a post-Obamacare world, access to care will be in jeopardy for tens of millions of working Americans whose employers don’t offer them coverage as well as for non-working Americans between jobs, unemployed or with pre-existing conditions.

    While the ACA did little if anything to restrain the growing cost of health care, it required that health insurers both provide coverage to anyone wishing to buy it and cover essential benefits. It also put a cap on insurer profits and administrative costs. Once Republicans repeal the ACA, there’s every reason to expect that insurers will once again 1) refuse to cover people with pre-existing conditions or charge them unaffordable premiums, 2) sell plans offering inadequate health coverage, and 3) take greater profits, raising premiums, copays and/or deductibles.

    In a post-Obamacare world, comprehensive health insurance will be unaffordable or unavailable to a large portion of non-elderly Americans. The Kaiser Family Foundation projects that 27 percent of people under 65 have pre-existing conditions that would lead health insurers to deny them coverage. In 11 states, three in ten nonelderly Americans will not be able to buy health insurance. Those states are West Virginia (36%), Mississippi (34%), Kentucky (33%), Alabama (33%), Arkansas (32%), Tennessee (32%), Oklahoma (31%), Louisiana (30%), Missouri (30%), Indiana (30%) and Kansas (30%).

    Pre-Obamacare, 52 million Americans could not buy health insurance because of their pre-existing conditions. And, millions more Americans were underinsured, with inadequate coverage to meet their health care needs if they developed costly or complex conditions.

    A new report from the Urban Institute projects that 58.7 million Americans will be uninsured by 2019, more than double the number of uninsured today, 28.9 million. In 2019 alone, the federal government will spend $109 billion less on health care.

    • About 9.3 million people will lose the government subsidies the ACA offers and will no longer be able to afford coverage.
    • Nearly 13 million people will lose Medicaid or coverage through CHIP, the Children’s Health Insurance Program.
    • Many employers will stop covering their workers once they are no longer required to do so.

    And, while Republicans are saying that they may keep the ACA subsidies in place until they pass a replacement plan, it’s more than likely that a large number of health insurers will stop offering coverage in 2018.  Insurers will fear attracting too many people with costly conditions once Republicans repeal the ACA’s mandate that most everyone have health insurance.

    The full consequences of the ACA repeal for people with Medicare are less clear but not good. The ACA extended the life of the Medicare Trust Fund 12 years. It also reduced Medicare Part D prescription drug costs. Moreover, once the ACA is repealed, Medicare premiums are likely to rise as more people under 65 go without coverage and forego needed care before becoming Medicare eligible.

    The smartest and most cost-effective solution to this brewing health care crisis would be to expand Medicare to everyone in America, a solution most Americans support. In the meantime, please sign this petition to tell Congress: Hands off Medicare.

    Here’s more from Just Care: