Health Insurance

What is the Individual Mandate??

Hi Guys,

We’ve got a special edition v-blog here because, as you may have heard, there’s a lot going on over in Washington about repealing the individual mandate in the proposed tax reform bill.

Now, most folks are probably so confused about what the heck they are talking about and what the implications would be. So today I’m going to simplify some concepts and terms so that you can make your own decisions about what you think would be best for yourself, your family, and/or the People.

*Note- it is actually much more complicated than this but I’m going to keep it very simple for now.

First concept you need to understand is called a Risk Pool.

Risk Pool– the group of people that are in the same insurance plan. By being in that specific insurance plan, or risk pool, you are sharing risk across the other folks in the plan. For example, Medicare is a risk pool because it is one group of people that enter into the insurance plan and receive medical services in return. Other risk pools might be your company, if you work for a really large employer that pays for your health insurance, or a commercial insurance product like a BlueCross BlueShield, for example.

Before we continue, let’s learn more about risk pools by clicking on the photo below!

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Now that you have a greater understanding of risk pools and how they work let’s talk about the Individual Mandate.

Individual Mandate: the requirement that all individuals purchase health insurance or else pay a small penalty for not having health insurance.

*Note- For the 2017 plan year, the fee is calculated 2 different ways – as a percentage of your household income or per person. You’ll pay whichever is higher when you do your taxes. The fee is 2.5% of household income or $695 per adult + $347.50 per child. 

Now, why was the individual mandate built into health reform? In order to combat Adverse Selection, whereby people don’t pay their dues into the system but then when they become sick they purchase and use their health insurance. And don’t forget, all of us get sick at some point in our lives…

Adverse Selection: people who are sick are more likely to purchase health insurance.

So then what effect does removing the individual mandate have?

Cost of Care: when you have less healthy people paying into the system then the cost sharing (premiums, deductibles, etc.) is going to increase for everyone else who is paying into the system.

Let’s use an analogy of an amazing dinner buffet. I live in Los Angeles so I’m going to use delicious Souplantation as my example. Now the Brentwood Souplantation offers their dinner buffet at $11.99 per person for all you can eat. What a great deal! But what happens if people like me who only eat a small salad, soup, and dessert stop coming to Souplantation and people who are severely obese and eat five plates of food start coming to Souplantation? In order to cover their costs, Souplantation is going to have to increase their prices for the buffet for everyone who is coming to the restaurant or risk shutting down the restaurant. Now Souplantation might start charging $19.99 per person. But what if they start losing the business of the healthy people who say you know what, I don’t even eat $19.99 worth of food so it’s not worth coming, and Souplantation starts to lose more of the healthy customers it needs. This leads to…

Market Instability: the inability of health insurance companies to predict their risk pools’ enrollment numbers, risk profiles of those enrolling, and the cost of those enrollees.

Let’s continue on with the Souplantation example. Their customers are turning over like crazy! They’ve increased their prices but now they are getting more heavyset folks and they are having difficulties predicting how much food is going to be eaten and sometimes they don’t order enough and they run out of food, etc. You can see what a mess this has turned into! Now what happens? Souplantation decides to shut its doors and find a new location where the clientele is more predictable with a steady mix of customers who eat a lot and customers who eat a little.

So now that the insurance companies have increased prices and/or pulled out of the market as an option for the people, the third area of impact is coverage.

Coverage: The CBO estimates that due to adverse selection, the cost of care and market instability will increase such that an estimated 13 million people will lose coverage because they won’t have an affordable option for themselves and their families.

Who the heck is the CBO??

Congressional Budget Office (CBO): a strictly nonpartisan (doesn’t take political sides) group of economists and budget analysts who provide objective, impartial analyses of Congress’ proposals. CBO does not make policy recommendations, and each report and cost estimate summarizes the methodology underlying the analysis.

Now I hope I have provided enough of the basics for you to better understand what the individual mandate is and how it works so you can think about it for yourself and not necessarily along political lines!

As always, please let me know if you have any questions or comments and I hope you’re having a wonderful week!

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Health Insurance

Health Insurance 101- Intro to Benefits

Hey Guys and Gals! I’m sure you’ve been waiting in anticipation to learn more about BENEFITS!!

Before we get started, here is the quick recap of the three health insurance essentials so you can see where BENEFITS kicks in.

Three key essentials:

  • Cost Sharing
  • Benefits/Coverage
  • Networks

The gist: you need to find a health insurance plan that includes the BENEFITS, or medical services, that you need with the NETWORK of doctors and hospitals that you want to see with a COST SHARING setup that fits your budget.

Benefits/Coverage: which medical services you can receive that will be covered under the health insurance plan, or in simplified terms, what you get for your $$$.

Benefits that are covered in your insurance plan will range from who is providing the service (midwives, physical therapists, chiropractors, etc.) to where the service is provided (in the hospital vs outside the hospital in a clinic, skilled nursing facility, etc.) to how long the service can be provided (length of hospital stay for having a baby).

And where can you find all these details??

Summary of Benefits and Coverage– remember that document we talked about a couple weeks ago? This document, even though it looks incredibly daunting, is your best health insurance friend because it tells you what is covered and what it will cost! It will feel like reading the ingredients on a nutrition label or your prospectus when investing- it’s not exciting and there are going to be terms you won’t know but use Google and ask friends and read it because IT’S IMPORTANT! 

Key tip to remember: Your COST SHARING is directly related to the size of your BENEFITS and your NETWORK. If you need or want more BENEFITS to be covered by your health insurance plan, and potentially the option of a larger NETWORK of doctors and hospitals, your COST SHARING will go up accordingly.

More Benefits + Larger Network= Cost Sharing (1)

Now many of you have been asking me how to best take advantage of your benefits and my recommendation is this: Take advantage of your free annual preventive visit with your doctor. Most of you should have this with your insurance plan (or should select an insurance plan with one) and it’s important you use it!

Any question about BENEFITS? Comment below and as always…

Cheers to Health and Happiness!

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Prevention

Get Your Flu Shot!

Hi Everyone! Welcome back to Health Care For the People.

‘Tis the season! The flu season that is! And it’s time to roll up those sleeves…

Now, what do you and your family need to know about the flu? Here’s what the Centers for Disease Control and Prevention (CDC), which is our leading agency that conducts and supports health promotion, prevention, and preparedness activities in the United States, has to say!

“Fun” Flu Facts:

  • The flu is contagious! It is spread when someone who is infected has droplets from their nose or mouth that then gets into your nose or mouth. (Think sneezing, coughing, hand-to-hand touching and then touching your face)
  • You may be able to pass on the flu to someone before you know you are sick or while you are sick. Some seemingly healthy people may be able to infect others beginning one day before symptoms develop and up to 5 to 7 days after becoming sick.
  • Typical symptoms include fever, chills, achy muscles, cough, runny or stuffy nose, headaches or a sore throat.
  • Depending on the health state of the individual, the flu can cause mild to severe illness and can even lead to death.
  • Each year, more than 200,000 people in the United States are hospitalized for respiratory and heart conditions illnesses associated with the flu virus.
  • Each year, between 12,000 and 56,000 people die from flu-related complications. These are typically patients who are already sick with a chronic condition such as heart failure or pulmonary disease.

Now let’s address all the silly myths and excuses that people make for not getting the flu shot!

Debunking “Fun” Flu Myths:

  • No, you cannot get the flu from the flu shot! The vaccine you receive is inactivated so the typical symptom you may get is soreness in the arm. And let’s be honest, any symptoms people have from the flu vaccine are much better to deal with than the symptoms caused by the actual flu illness.
  • If you do get flu-like symptoms, it wasn’t because of the vaccine! You may have already been sick when you got the flu shot. Also, you may be sick with another bacteria or virus that is not the flu or is not the strain from the vaccine.
  • The flu vaccine is safe and effective! For more than 50 years, hundreds of millions of Americans have safely received seasonal flu vaccines.

So now it’s time– I’ve gotten my flu shot. Have you gotten yours?!?

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Let me know if this article was helpful and please write any additional comments or questions below!

Cheers to Health and Happiness! 

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Primary Care

Who is your PCP? Part 2- The Primary Care Medical Home

Hi Everyone,

Welcome back to Health Care For the People for today’s post called Who is your PCP Part 2- The Primary Care Medical Home. In part 1 we talked about the importance of having a PCP and now we are going to talk about the Primary Care Medical Home, or what we call in the industry, PCMH.

The Primary Care Medical Home (PCMH) is a model whereby your PCP is the quarterback of your care for the rest of your care team.

What is a care team you ask?

Well for starters your care team is not going to look the same as someone else’s care team.

Depending on your current health state you might have only one doctor, your PCP, or you might have multiple doctors treating different diseases. You might have a mental health provider or a social worker.

If your care is very complex you might also have a care coordinator, which is an individual who is not a clinician but who works very closely with your PCP to coordinate your care between the different providers on your care team.

Potential Members of the Care Team:

  • PCP
  • Specialists
  • Care Coordinator
  • Mental Health Provider
  • Social Worker
  • Pharmacist
  • Hospital-based providers in the event of hospitalization
  • Community providers such as home health or skilled nursing facility staff

As you can see, depending on the complexity of your health situation, it can be really complex and just like anything else in this world Communication is Key! So it’s really important that your PCP (and potentially Care Coordinator) are working to optimally communicate and collaborate on improving your health outcomes.

That’s why we call the PCP your quarterback in the PCMH model. Your PCP is at the center of your healthcare world, looking at you holistically as a patient and serving as your quarterback who is fully knowledgeable in the care you are receiving from all your providers.

If you’re interested in learning more, here is a great link from the Patient-Centered Primary Care Collaborative that has some really helpful graphics:

https://www.pcpcc.org/about/medical-home 

Have any questions about the PCMH model? Feel free to write any comments or questions below and be sure to subscribe to the newsletter!

Cheers to Health and Happiness! 

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