Wellness vs the Unwell

One of the benefits granted under the Affordable Care Act was the coverage requirement for wellness services.  This means that certain screenings such as colonoscopies and mammograms were to be regularly performed at no cost to the consumer. 

An interesting loophole is being exploited.   Insurers have determined that if a screening indicates that the patient has an underlying health issue that was uncovered during the regular screening, that the purpose of the screening was diagnostic.  This means it would not be covered under the wellness provisions of your policy.

What this means is that if you go in for your mammogram and it is determined that you have breast cancer the news you get is: “You have breast cancer. Oh, and, that “free” mammogram; you are now going to have to pay for it.”

So, you can either pay your co-pay or fight the charge.  But, oh yes, you have cancer, so maybe fighting with the insurance company is not on the top of your priority list.


Update on Exchange Prescription Drug Coverage

 As time passes, it is becoming clear that policies purchased from an exchange will require more and more time from policyholders and their doctors to monitor payments and to meet new responsibilities which have become a prerequisite to being reimbursed. 

Prescription Drug Coverage

If you have an exchange policy, the days of having your doctor call in a prescription and then you going to the pharmacy of your choice and picking it up are becoming a thing of  the past.  Exchange policies are unlikely to offer open access to drugs used regularly. 

Insurance companies are implementing ”utilization management controls” which must be complied with in order for you to receive reimbursement for your prescription drugs.  This means that patients and their physicians must complete additional paperwork to demonstrate appropriate use of the drug being prescribed.  By doing this, drug companies can limit access to specific medications and, more importantly, reduce costs.  

Doctors are now being asked to fill out additional, complex paperwork to get their patients covered by their insurance companies.   If physicians do not comply with new and confusing utilization requirements, patients may not be able to get the drugs their doctor says they need. 

Worse, consumers will have to pay for the cost of controlling costs.  Copayments and co-insurance fees for drugs increased an average of 34 percent under ACA. Greatest impact was felt in the cost of brand-name drugs and specialty drugs.

 ‘Analysis from Avalere Health concluded that consumers purchasing insurance through the exchanges are twice as likely to face utilization management controls on prescription medications compared to people with employer-sponsored coverage.   Patients who use brand-name, cancer or mental health drugs are more likely to encounter this problem under PPACA.  For example, fifty one percent (51%) of brand-name mental health meds have special controls on the exchanges, compared with only eleven percent (11%) on the employer-based market.’  (Source: Rx hurdles high under some PPACA plans, By Kathryn Mayer, March 24, 2014 Benefits Pro Magazine)

Raising the Minimum Wage will Decrease Eligibility for Obamacare Benefits

People earning the current minimum wage have significantly benefited from the expansion of “Obamacare”.  A large number of those low income wage earners are single women with children.  Because of the Affordable Care Acts’ expansion of Medicaid eligibility, these women have been able to get healthcare for themselves and their families.

The President is now pressing to increase the minimum wage; and, he is moving to expand eligibility for overtime.  By expanding the minimum wage and increasing overtime payments, the President may actually be hurting those people who were formerly helped by the Affordable Care Act..

The unintended consequence of raising wages for people who have obtained health services through an exchange is that those very people may no longer be eligible for the subsidies or the benefits they received.  If their wages increase too much, they may be put over the threshold for Medicaid eligibility and lose their benefits.   If this wage increase goes into effect after the sign up deadline passes, those people will not be able to get health insurance coverage to replace their Medicaid coverage until 2015.

By expanding the minimum wage to $10.10 per hour, if a person works 40 hours per week, their annual income would be $21,008.  Previously, at $7.25 per hour, the federal minimum wage, the same person working 40 hours per week would earn $15,080.  Under the ACA’s expansion of Medicaid, any person earning $7.25 per hour and the family members they were financially responsible for would be eligible for Medicaid. By raising the wage to $10.10, a single person would no longer be eligible for Medicaid.  If a single mother of one makes more than $21,707, she and her family is no longer eligible for Medicaid.  (Note: In some states, like California, the Medicaid threshold was increased to 138% of the poverty level vs. the federal standard of 135%; but, in this care, the effect would be no different.) 

Increasing wages for people who have already sought subsidized coverage based on current wages has another unintended consequence.  If their actual income exceeds the estimated income their subsidies were based on, they will be responsible for repaying the difference between the lower subsidy they would get at their new higher wage and what they actually got.  The IRS is responsible for enforcement.  Failure to return the money can lead to garnishment of wages, attachment of bank accounts; the penalties are quite severe. 

The registration deadline could be extended to accommodate those whose increased wages make them ineligible for Medicaid.   However, moving people from Medicaid to an exchange policy significantly increases their cost of care. Not only do they have to pay for their coverage, but they are now responsible for co-pays, etc.  Increasing income also impacts one’s eligibility for subsidies and out of pocket costs they will be responsible for. 

Now that healthcare is directly tied to wages, we must be thoughtful about the interconnectedness.