Salary Caps too Low for Medicaid?

August 14, 2012 9:39 PM

Is a $5,000 salary too much for Medicaid?

(AP) MIAMI – Sandra Pico is poor, but not poor enough.

She makes about $15,000 a year, supporting her daughter and unemployed husband. She thought she’d be able to get health insurance after the Supreme Court upheld President Barack Obama’s health care law.

Then she heard that her own governor won’t agree to the federal plan to extend Medicaid coverage to people like her in two years. So she expects to remain uninsured, struggling to pay for her blood pressure medicine.

“You fall through the cracks and there’s nothing you can do about it,” said the 52-year-old home health aide. “It makes me feel like garbage, like the American dream, my dream in my homeland is not being accomplished.”

Many working parents like Pico are below the federal poverty line but don’t qualify for Medicaid, a decades-old state-federal insurance program. That’s especially true in states where conservative governors say they’ll reject the Medicaid expansion under Obama’s health law.

In South Carolina, a yearly income of $16,900 is too much for Medicaid for a family of three. In Florida, $11,000 a year is too much. In Mississippi, $8,200 a year is too much. In Louisiana and Texas, earning more than just $5,000 a year makes you ineligible for Medicaid.

Governors in those five states have said they’ll reject the Medicaid expansion underpinning Obama’s health law after the Supreme Court’s decision gave states that option. They favor small government and say they can’t afford the added cost to their states even if it’s delayed by several years. Some states estimate the expansion could ultimately cost them a billion dollars a year or more.

Many of the people affected by the decision are working parents who are poor — but not poor enough — to qualify for Medicaid.

Republican Mitt Romney’s new running mate, conservative Wisconsin congressman Paul Ryan, has a budget plan that would turn Medicaid over to the states and sharply limit federal dollars. Romney hasn’t specifically said where he stands on Ryan’s idea, but has expressed broad support for his vice presidential pick’s proposals.

Medicaid now covers an estimated 70 million Americans and would cover an estimated 7 million more in 2014 under the Obama health law’s expansion. In contrast, Ryan’s plan could mean 14 million to 27 million Americans would ultimately lose coverage, even beyond the effect of a repeal of the health law, according to an analysis by the nonpartisan Kaiser Family Foundation of Ryan’s 2011 budget plan.

For now, most states don’t cover childless adults, but all states cover some low-income parents. The income cutoff, however, varies widely from state to state.

Most states cover children in low-income families. Manuel and Sandra Pico’s 15-year-old daughter is covered by Medicaid. But the suburban Miami couple can’t afford private insurance for themselves and they make too much for Florida’s Medicaid.

Manuel Pico, a carpenter, used to make more than $20,000 a year, but has struggled to find work in the last three years after the real estate market collapsed. He occasionally picks up day jobs or takes care of the neighbor’s yard. Sandra Pico would like to work full time, but can’t afford to pay someone to watch her 34-year-old sister, who has Down syndrome.

“No matter how hard I work, I’m not going to get anywhere,” Sandra Pico said. “If you’re not rich, you just don’t have it.”

In San Juan, Texas, 22-year-old Matthew Solis makes about $8,700 a year — too much to qualify for Medicaid in that state. Solis, a single father with joint custody of his 4-year-old daughter, said he works about 25 hours per week at a building supply store making minimum wage and is a full-time college student at the University of Texas-Pan American. He aspires to be a school counselor.

He recently sought medical care for food poisoning, visiting a federally funded clinic. But he doesn’t see a doctor regularly because he can’t afford private insurance. The new health law allows young adults to remain on their parents’ insurance until age 26. But that doesn’t help Solis, whose father is uninsured and whose mother died of leukemia when he was 8.

“I voted for him (Obama) because he promised we would have insurance,” Solis said. “I’m pretty upset because I worked for Obama and I still don’t have coverage.”

His governor, Rick Perry, like Pico’s governor, Rick Scott, is rejecting the Medicaid expansion. So Solis too is out of luck unless his circumstances dramatically change.

In all but one of the states where governors are rejecting or leaning against the expansion, the income level that disqualifies a parent from Medicaid is below the federal poverty line. Only in New Jersey, where Gov. Chris Christie has said he’s leaning against the expansion, is Medicaid available to parents with incomes at the poverty line and slightly above. New Jersey will cover a parent making $24,645 in a family of three.

Most states base Medicaid eligibility for parents on household income and how it compares to the federal poverty level, which was $18,530 for a family of three in 2011, the year being used for easier state-by-state comparisons.

In Louisiana, the eligibility cutoff for a working parent is 25 percent of federal poverty, or $4,633 for a family of three. In Nevada, it’s 87 percent of the federal poverty level, or $16,121 for a family of three.

That’s been the range in states where governors are likely saying no to expanded Medicaid.

In contrast, states where governors have said they’ll expand Medicaid are more generous with working parents. The Medicaid eligibility cutoff ranges in those states from Washington’s $13,527 to Minnesota’s $39,840.

To be sure, some states with generous coverage for parents have been forced to cut back. Illinois, facing a financial crisis, ended coverage last month for more than 25,000 working parents. Even so, the state still covers working parents with incomes slightly higher than the poverty line.

The national health law’s Medicaid expansion would start covering all citizens in 2014 who make up to roughly $15,400 for an individual, $30,650 for a family of four.

The federal government will pay the full cost of the Medicaid expansion through 2016. After that, the states will pick up 5 percent of the cost through 2019, and 10 percent of the cost thereafter.

Why would a governor say no?

These state leaders are in favor of smaller government. In principle, they don’t want the federal government to expand — even if that expansion would help their own citizens. Also Medicaid is costly, taking a huge bite out of budgets already. And they don’t want to be on the hook for paying any more of the tab even if it’s years down the road.

“We don’t need the federal government telling us what to do when it comes to meeting the needs of the citizens of our states,” Florida Gov. Rick Scott wrote recently in an opinion piece for U.S. News and World Report. “And we don’t need Washington putting states on the hook for future budget obligations.”

Also, many conservatives view Medicaid as a wasteful, highly flawed program, akin to no health coverage. Many doctors across the country won’t treat Medicaid patients because the payments they receive are so low.

When the Supreme Court ruled that states could opt out of the health law’s Medicaid expansion, it raised the chances for inequity at a time when more Americans have fallen from the middle class into poverty, said Isabel Sawhill, a senior fellow at the Brookings Institution.

“Why should a sick person in Connecticut have access to health care when they don’t in Mississippi and Texas?” Sawhill asked. “We really do have a very high level of poverty as a result of the recession. And the safety net is weaker than ever.”

Medicaid, the nation’s single largest insurer, is a state and federal program created in 1965 as a companion program to welfare cash assistance to single parents. Today, the elderly and disabled cost nearly 70 cents of every Medicaid dollar, not the stereotypical single mother and her children.

What’s largely unknown to many Americans is who is left out of the safety net, said Cheryl Camillo, a senior researcher at Mathematica Policy Research. “A huge chunk of the populace is not covered, even by Medicaid,” she said.

The political rhetoric during a presidential campaign focuses on the middle class and leaves the uninsured working poor largely invisible, said Rand Corp. researcher Dr. Art Kellermann.

“We hear a lot of talk about unemployment and the aspirations of middle-class Americans. But we don’t hear about the consequences of unemployment and the consequences of the collapsing middle class,” Kellermann said. Losing health insurance is one of those consequences.

“It’s like the public just doesn’t want to believe anything else until it hits home,” he said, “Until it’s their own child, brother or parent that got laid off when they were 58, until then, it’s not real.”

 

Kentucky Agency Asks Judge to Drop Contempt Order over Medicaid Lawsuit

Kentucky Agency Asks Judge to Drop Contempt Order over Medicaid Lawsuit

 

The Kentucky Cabinet for Health and Family Services has apologized to a federal judge and is asking him to drop a contempt order against the agency. U.S. Senior Judge Karl Forester held the agency in contempt last month after ruling that the cabinet did not comply with his order to process thousands of requests from Appalachian Regional Healthcare patients who wanted to switch Medicaid managed-care companies.

The issue stems from a lawsuit ARH filed against Coventry Cares, a Medicaid managed-care company that has decided to cut ties with the ARH system.

The Lexington Herald-Leader reports an attorney for the state agency filed a motion on Friday that said the judge’s order wasn’t clear and specific and the cabinet’s failure to abide by it was “inadvertent.”

Medicare fraud busters unveil command center

Medicare fraud busters unveil command center

By By RICARDO ALONSO-ZALDIVAR and KELLI KENNEDY – 1 day ago 

BALTIMORE (AP) — Medicare’s war on fraud is going high-tech with the opening of a $3.6 million command center that features a giant screen and the latest computer and communications gear. That’s raising expectations, as well as some misgivings.

The carpeting stills smells new at the facility, which went live a week ago in a nondescript commercial office park on Baltimore’s outskirts. A couple dozen computer workstations are arrayed in concentric semicircles in front of a giant screen that can display data and photos, and also enable face-to-face communication with investigators around the country.

Medicare fraud is estimated to cost more than $60 billion annually, and for years the government has been losing a game of “pay and chase,” trying to recoup losses after scam artists have already cashed in.

Fraud czar Peter Budetti told reporters on a tour this week that the command center could be a turning point. It brings together in real time the geeks running Medicare’s new computerized fraud detection system with gumshoes deployed around the country. Imagine a kind of NCIS-Medicare, except Budetti says it’s not make-believe.

“This is not an ivory-tower exercise,” Budetti said. “It is very much a real-world one.”

But two Republican senators say they already smell boondoggle.

Utah’s Orrin Hatch and Oklahoma’s Tom Coburn say Medicare’s new computerized fraud detection system, a $77-million investment that went into operation last year, is not working all that well. In a letter to HHS Secretary Kathleen Sebelius, they questioned spending millions more on a command center, at least until the bugs get worked out.

“Institutionalizing relationships through establishing a (command) center may be useful, but if huge sums of money have indeed been spent on a video screen while other common-sense recommendations may have not been implemented due to ‘resource concerns,’ this seems to be a case of misplaced priorities,” wrote Hatch and Coburn. Insiders are telling them the screen alone cost several hundred thousand dollars, the senators say.

The two Republicans may have more than congressional oversight in mind. In an election year, Medicare fraud is an issue with older voters because it speaks to the Obama administration’s stewardship of the program.

Responded Budetti: “Our expectation is that this center will pay for itself many times over.”

Conducting what amounted to her first formal inspection on Tuesday, HHS Secretary Sebelius set the bar high for the command center, nothing less than the end of “pay and chase.”

“Preventing fraud and abuse is what this effort is about,” she said.

The government’s new antifraud computer system aims to adapt tools used by credit card companies to stop theft from Medicare and Medicaid. It was launched with great fanfare last summer. But by Christmas, it had stopped just one suspicious payment from going out, for $7,591. Administration officials say that shouldn’t be the only yardstick, and the system has made other valuable contributions.

Sebelius spoke with three groups of staffers during her visit Tuesday. One group was responsible for developing computer models to query billing data for suspicious patterns; another in charge of investigating data generated by the computer models, looking for mistakes as well as real fraud; and a third handling coordination with law enforcement around the country. The staffers said they expect the coordination to cut the time it takes to investigate suspected fraud schemes from months to days and weeks.

Hatch’s office says development of the computer models has lagged. Command center staffers told Sebelius the first-year goal is to have 40 such computerized anti-fraud queries to sift through millions of incoming claims.

The administration must report to Congress on the antifraud computer system later this year, an assessment that will first be independently reviewed by the Health and Human Services inspector general’s office.

Hatch and Coburn say they have repeatedly pushed the administration for details and “the responses have been polite, but vague.”

Medicare scams have grown into sophisticated networks where crooks file millions of dollars in bogus claims and take off with the money. Sometimes they even manage to flee abroad to countries where the feds can’t touch them.

Reaction to health care decidion

  • Updated June 28, 2012, 1:21 p.m. ET

Americans react to historic health care decision

 

Associated Press

CHICAGO — The mother of two disabled teens called Thursday’s Supreme Court ruling on the health care law wonderful because it bars insurance companies from setting lifetime limits for medical expenses — a big help to her family.

But a retiree on Medicare called it a “sad day” and worries that the law’s new rules coming in 2015 will interfere with treatments doctors can provide.

Across the country, some Americans haven’t been dramatically affected yet by the law, which will take a few years to reach full force. But many others say they have felt its effects already and have strong opinions about it.

___

Name: Becky Morefield

Home: Mahomet, Ill.

Age: 51

Occupation: Stay-at-home mom of two disabled teenagers

Insurance coverage: Private insurance through husband’s employer

As Morefield sees it, the health law allowed her son Tucker to die peacefully at home with private health insurance covering his care.

Tucker, one of three triplets with cerebral palsy, was always the most fragile of the siblings, Morefield said. Five years ago, he maxed out the $1 million lifetime limit in his family’s policy when he went into respiratory failure and was hospitalized for 12 weeks.

Hitting the lifetime limit meant the insurance company would no longer pay Tucker’s medical bills. The state of Illinois picked up the slack through a program for children with special health care needs. But the program put strict limits on certain medical supplies, leading the family to wash and reuse equipment meant for single use.

Tucker’s coverage was reinstated Jan. 1, 2011, because the health law barred lifetime dollar limits on coverage. He lived another 15 months covered by private insurance. At the end, he had doctor visits at home, oxygen and enough pain medication — all care that Morefield said would have been restricted under the state program.

“It was a blessing for us,” Morefield said. “People who’ve not had the ongoing medical things we’ve had don’t understand.”

Morefield reacted to the Supreme Court decision on Thursday, her birthday, with joy. She called it a great gift that will grant her and her husband peace of mind.

“It’s wonderful,” she said.

___

Name: Margo Criscuola

Home: Chicago

Age: 66

Occupation: Education consultant

Insurance coverage: Medicare

Criscuola is worried that a controversial board created by President Barack Obama’s health overhaul will ration health care and also dictate treatments to doctors. She has family members with a rare genetic condition that she said requires experimental therapies.

“I was listening to the radio this morning and heard the news. I think it’s a very sad day for this country, for our medical industry and for our health in this country,” Criscuola said.

“If you have a law that requires doctors’ treatments to be approved on the basis of their general effectiveness and doctors are not permitted to experiment with other kinds of approaches, that makes it very difficult for special diseases like these to be treated.”

The board, called the Independent Payment Advisory Board, is meant to hold down Medicare costs, beginning in 2015. Republicans are targeting the provision for repeal. Criscuola fears the board’s influence will go beyond Medicare and permeate the health care system. The White House has said the board is crucial to holding down costs and is barred by the law from rationing care.

The law also encourages a payment model for hospitals, insurers and doctors called “accountable care organizations,” which Criscuola believes also will limit doctors’ choices in treating patients.

Criscuola has benefited from a provision in the health care law that provides free annual wellness exams to people with Medicare.

“Do I use it? Yeah. Is the benefit I receive from it more than if I had kept the money I paid into Social Security and Medicare payroll taxes and invested it myself? No. It’s considerably less,” she said. “Will it be around in 15, 20 years? Probably not.”

___

Name: Bev Veals

Home: Near Wilmington, N.C.

Age: 48

Occupation: Stay-at-home mom of a 17-year-old and a 20-year-old

Insurance coverage: Coverage under the new law for people with pre-existing conditions

On Thursday morning, waiting for the news, Veals was watching CNN, which initially reported incorrectly that the law had been overturned. She was tense with worry that she would lose her coverage.

“I’m totally, absolutely right now dazed because they first, initially said it had been overturned,” Veals said. “I’m sitting here gasping for breath. … Now they’re saying it’s being upheld.” She added: “It’s a relief.”

The expense of her breast cancer treatments led to bankruptcy and foreclosure for her family over a horrific 10-year period. Finally, it cost so much that she could no longer afford health insurance. She and her self-employed husband decided to drop her from the family’s insurance plan four years ago to reduce their monthly premiums from $1,700 to $400 a month.

She spent the next 27 months uninsured. Then in 2011 she signed up for insurance made possible by the new law. The program helps people who have been turned away by insurance companies because of pre-existing medical conditions. She now pays $377 a month for her insurance with a $1,000 deductible, meaning she pays that much out of pocket before the coverage starts.

“It has only been a little over a year for me, but I can’t tell you the dignity being covered brings,” Veals said. “My biggest fear was I would have to beg for help to cover medical bills. Panhandling to pay a doctor’s bill … not my idea of the American Dream.”

Though raised as a Republican, Veals said her politics are changing.

“As a conservative, I believed if you can’t make your way, you don’t get your way. Now I’ve cost more medically than I will ever be able to make. I’ve changed my political stance because of this,” she said. “It doesn’t do our economy any good when we have so many people having to file for medical bankruptcy.”

___

Name: Carlton Grimmett

Home: Atlanta

Age: 43

Employment: Night security guard at upscale apartment complex

Coverage: Uninsured

Two years ago, Grimmett had a job with good insurance and a wife with diabetes and other health problems. But then his job, doing plumbing and HVAC work at an Atlanta university, was outsourced and he no longer could cover his wife’s medical bills.

His wife had to stop going to the private doctors she was seeing, and her husband tried to get her into care elsewhere. But at other facilities, they encountered paperwork, delays and foot dragging, he said. Her health deteriorated.

“When you don’t have insurance, they treat you different,” he said.

In January 2011, Mary Grimmett started struggling to breathe and was rushed to Grady Memorial, Atlanta’s safety net hospital. She qualified for a program that provides discounted and even free care to uninsured people who qualify. But by that time she had pneumonia (as well as a broken ankle that needed surgery) and was very sick.

She spent two weeks in the hospital and then died of congestive heart failure — a complication of her other illnesses. She was 39.

Today, Grimmett has a job, making $25,000 a year, but he still has no insurance. Under the new health care law, he will be eligible for a government tax credit to help with the cost of buying private health insurance.

That would reduce his estimated annual premiums for health coverage from $5,054 to $1,726. He might have to pay additional copays for doctor visits, but his income would make him eligible for modest subsidies to help with those out-of-pocket expenses.

He is healthy, but the loss of his wife was a tragic lesson in the importance of coverage, he said. When he heard about the Supreme Court ruling from others at a nonprofit where he was volunteering, he said he felt grateful to Obama for helping the poor.

“He’s listening to the voice of Jehovah God,” he said. He added: “I’m grateful for the hope and opportunity to have health insurance, not just myself but all people who can’t afford health insurance. It’s a great thing that has taken place today.”

___

Name: Jim Schreiber

Home: New York City

Age: 26

Occupation: Works for small beverage business

Insurance coverage: Private insurance through his employer

Schreiber’s young and healthy, but still had reason to worry about the Supreme Court decision. He works for a small business and is responsible for switching the company to a new health insurance plan. He has found a plan at a reasonable price, but that price won’t be locked in until August.

Early Thursday, he was concerned that the price would jump with a confusing decision on the health care law, or if the court overturned it. Like many other Americans, he saw contradictory news reports about the ruling and “my heart dropped.”

He repeatedly refreshed the Web pages on his computer screen and, finally, when the ruling became clear, “it was a relief.”

The company is among the 30 percent of businesses with fewer than 10 employees that offer health coverage. Small businesses often pay more for insurance than large companies.

Schreiber is hoping his company can qualify for a tax credit made available by the health care law for small businesses that provide health insurance. The tax credit is one of the most popular ideas in the health law, according to opinion polls, but only about 4 percent of potentially eligible businesses claimed it in 2010.

Before he turned 26, Schreiber was insured for a year on his mother’s health plan because of another provision in the health care law. The law isn’t perfect, Schreiber said, but “it’s a starting point to move forward.”

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AP Medical Writer Mike Stobbe contributed from Atlanta.

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AP Medical Writer Carla K. Johnson can be reached at http://www.twitter.com/CarlaKJohnson

—Copyright 2012 Associated Press

Millions still go without insurance if law passes

Millions still go without insurance if law passes

By TOM MURPHY, AP Business Writer – 4 hours ago 

One of the biggest misconceptions about President Obama’s health care overhaul isn’t who the law will cover, but rather who it won’t.

If it survives Supreme court scrutiny, the landmark overhaul will expand coverage to about 30 million uninsured people, according to government figures. But an estimated 26 million U.S. residents will remain without coverage — a population that’s roughly the size of Texas and includes illegal immigrants and those who can’t afford to pay out-of-pocket for health insurance.

“Many people think that this health care law is going to cover everyone, and it’s not,” says Nicole Lamoureux, executive director of the Alexandria, Va.-based National Association of Free & Charitable Clinics, which represents about 1,200 clinics nationally.

To be sure, it’s estimated that the Affordable Care Act would greatly increase the number of insured Americans. The law has a provision that requires most Americans to be insured or face a tax penalty. It also calls for an expansion of Medicaid, a government-funded program that covers the health care costs of low-income and disabled Americans. Additionally, starting in 2014, there will be tax credits to help middle-class Americans buy coverage.

The Supreme Court is expected to hand down a decision this month on whether to uphold the law completely or strike down parts or all of it. If it survives, about 93 percent of all non-elderly, legal U.S. residents will be covered by 2016. That’s up from 82 percent this year.

Still, millions of illegal immigrants won’t qualify for coverage. This population will account for roughly 26 percent of those who will remain uninsured, according to Urban Institute, a nonpartisan think tank.

And many legal U.S. residents will go without insurance, too. About 36 percent of the population that remains uninsured will qualify for Medicaid but won’t sign up for various reasons. Others likely will make too much money to qualify for assistance but be unable to afford coverage.

Here’s a look at some of the groups that will likely remain uninsured if the law survives:

ILLEGAL IMMIGRANTS

More than 11 million unauthorized immigrants live in the United States, according to the Pew Hispanic Center, a nonpartisan research center. That amounts to nearly 4 percent of the total population. But there are no provisions that address illegal immigrants in the health care law.

They won’t be able to sign up for Medicaid. They won’t be eligible for the tax credits to help buy coverage. And they won’t be able to use online marketplaces that the government will set up in order for people to get coverage in a process that’s similar to buying plane tickets on travel web sites. Those online exchanges, much like the tax credits, will require proof of citizenship.

“They will still need to find alternative ways to seek care because nothing in the law really expands coverage and affordable coverage options for undocumented immigrants,” says Sonal Ambegaokar, a health policy attorney with the National Immigration Law Center in Los Angeles.

The topic is a politically divisive issue. On one side, there are people who say that the government should provide health care for all U.S. residents — legal or not. The other side contends that doing so could take valuable resources away from U.S. citizens.

“Because of the limited supply of health care, we’re almost in a sociological triage,” says Bob Dane, spokesman for the Federation for American Immigration Reform, a national group that calls for stricter immigration laws. “It begs the question, ‘Who do we serve, who do we serve first and who is not entitled?'”

Researchers have found that immigrants tend to use the health care system less than legal residents. Illegal immigrants, in particular, tend to avoid using the health care system until they have to, favoring home remedies first or making cash payments to providers when they need care. That population also is younger, so it generally has fewer health care needs, says Timothy Waidmann, a researcher with Urban Institute.

The think tank, using federal government survey data, estimates that illegal immigrants accounted for an estimated $18 billion of the $1.4 trillion spent on health care in the United States in 2007. That adds up to less than 2 percent of total spending.

Some say excluding illegal immigrants from the overhaul will keep some legal residents uninsured, too. Ambegaokar, the Los Angeles attorney, points to parents who are illegal immigrants but have children who are legal citizens because they were born in the United States.

If the parents are not eligible, they may not know that their kids qualify. And in other instances, if one child is legal and the other is not, the parents may decide not to sign up either to avoid playing favorites.

“The goal is to enroll everybody who is eligible,” Ambegaokar says. “But when you make systems complicated and require proof of ID, you’re going to inevitably keep out people who should be in.”

LOST IN TRANSLATION

Medicaid, which currently covers more than 60 million people, is expected to add about 17 million more people to its program by 2016 if the law is upheld, according to the nonpartisan Congressional Budget Office, which researches budgetary issues for Congress.

But people are still expected to fall through the cracks. That’s because the requirements and process for signing up for Medicaid can be confusing. And while the overhaul aims to make the process easier, it won’t smooth out all the wrinkles.

The problem? Many people don’t realize that they qualify for coverage. And that likely will still be the case, albeit to a lesser extent, after Medicaid expands.

Coverage depends on how someone’s income stacks up to federal poverty guidelines, which can be obscure to the average person. Plus, because income can fluctuate, someone could qualify one year but not the next.

“Regardless of how much outreach you do … you’re never going to get perfect enrollment,” Matthew Buettgens, another Urban Institute researcher, says.

Staying enrolled can be another hurdle. Medicaid recipients have to re-enroll, sometimes more than once a year. They can be dropped if they miss deadlines, submit incomplete forms or if paperwork doesn’t catch up with them after they move — something poor families tend to do more frequently than the average American household.

Leeanna Herman learned this when an unexpected $300 doctor bill arrived in the mail. The Bakersfield, Calif., resident was pregnant and unemployed and didn’t know her government-funded health coverage had lapsed.

“I was freaking out,” says Herman, 23, who went a month without coverage because she missed the deadline to re-enroll. “How do you expect me to pay that?'”

Experts say online applications and electronic verification of income levels and other things will make this process easier. But deadlines will still matter and some people don’t have easy access to the Internet. And there will still be some people who simply won’t enroll.

“There will always be that segment that says, ‘Aw, the heck with it, I will just wait until I get sick and go to the ER,'” says Stephen Schilling, CEO of Clinica Sierra Vista, a nonprofit that has a network of 27 community health centers in California.

Schilling expects to still see a lot of uninsured patients at the nonprofit group’s health centers even if the law is upheld. The center sits in an agricultural area in California’s San Joaquin Valley, populated with migrant workers and saddled with an unemployment rate of around 15 percent.

It cares for about 60,000 uninsured people annually, thanks in part to grants and a sliding fee scale for patients based on their family size and income. Schilling says he still expects between 20,000 and 40,000 uninsured patients if the overhaul is implemented.

LIVING IN THE GAP

The overhaul calls for tax credits to help middle-class Americans buy coverage. But some people who make too much money to qualify for the tax credits may have a hard time finding an affordable option for private health insurance

The subsidies can pay a large chunk of the insurance bill. For instance, a 40-year-old person who makes $50,000 in 2014 and needs coverage for a family of four might receive a government tax credit of more than $8,000.

That would cover more than 70 percent of the premium, or the cost of coverage, according to a subsidy calculator on the nonprofit Kaiser Family Foundation’s website. Of course, that estimate depends on the type of coverage the person choses, where they live and whether they can get coverage through work.

But the tax credits will go to people with incomes up to 400 percent of the federal poverty level, or $44,680 for an individual this year. People just above that level may have a hard time finding affordable health insurance.

Angela Agnew Laws worries that she might remain uninsured like she has been for the past eight years even if the health care law is upheld.

Laws, who lives in Leesburg, Va., runs a small business that cleans and maintains commercial buildings. She hopes her income will climb to about $60,000 by 2014, which would be too high for tax credit help.

A plan that offers more than just basic protection against big medical expenses could cost as much as $10,000 annually for Laws. She could find less extensive coverage for a lower premium, but that may only save about $1,000.

Laws, 58, figures that she’ll remain uninsured if she can’t find an affordable coverage option that fits a monthly budget already crammed with payments of $1,203 for rent $530 toward her car.

“It’s a scary prospect for me,” she says.

Ohio eases access for Medicaid-eligible patients

Ohio eases access for Medicaid-eligible patients
By Ann Sanner
The Associated Press
Posted Jun 06, 2012 @ 03:00 AM

COLUMBUS — State officials are hoping to more easily grant uninsured pregnant women and children in Ohio access to health care services under Medicaid, if they are likely to qualify for the program that provides coverage to the poor and disabled.
A pilot program slated to start next week would let certain health care providers in Ohio presume the patient’s eligible for Medicaid after an initial screening test. Children and expectant mothers would have to prove residency and provide other biographical details. The patients then could access the Medicaid-funded services immediately for 60 days while they apply for the program.
Determining whether a person is eligible for the Medicaid program can take as long as 45 days, state officials said. Case workers must evaluate applicants against more than 150 separate categories to make eligibility determinations.
The state wants to ease that enrollment time by allowing certain health care providers to presume Medicaid eligibility for children and pregnant women, the state’s Medicaid director said Tuesday. That way, patients will get the medical services they need faster and could be on a healthier path sooner.
In general, potential beneficiaries do get served by some health care providers, but the delay in their Medicaid eligibility prevents them from getting prescriptions and any needed follow-up care, said Ohio Medicaid director John McCarthy.
“What we’ve done is change that,” McCarthy told reporters at the news conference in Columbus.
The state has been doing a limited version of presumptive eligibility for children, but that could only be granted at county job and family services offices, limiting the effectiveness for individuals with immediate medical needs.
Under the pilot program, providers could perform an eligibility check and grant immediate medical assistance to both children and pregnant women where they receive their health care.
A test run for the presumptive eligibility program will start at Nationwide Children’s Hospital in Columbus, MetroHealth System in Cleveland and the Community Action Committee of Pike County.
The state hopes to expand the pilot program statewide by January.
About 2.2 million Ohioans are enrolled in Medicaid. Roughly 1.2 million are children, and 30,000 are pregnant women, McCarthy said.

Analysis – Supreme Court Ruling

Obamacare Collapse Would Put Employers In Charge

by The Associated Press

WASHINGTON April 24, 2012, 01:12 pm ET

WASHINGTON (AP) — If the Supreme Court strikes down President Barack Obama’s health care overhaul, don’t look to government for what comes next.

Employers and insurance companies will take charge. They’ll borrow some ideas from Obamacare, ditch others, and push even harder to cut costs.

Here’s what experts say to expect:

— Workers will bear more of their own medical costs as job coverage shifts to plans with higher deductibles, the amount you pay out of pocket each year before insurance kicks in. Traditional insurance will lose ground to high-deductible plans with tax-free accounts for routine expenses, to which employers can contribute.

— Increasingly, smokers will face financial penalties if they don’t at least seriously try to quit. Employees with a weight problem and high cholesterol are next. They’ll get tagged as health risks and nudged into diet programs.

— Some companies will keep the health care law’s most popular benefit so far, coverage for adult children until they turn 26. Others will cut it to save money.

— Workers and family members will be steered to hospitals and doctors that can prove that they deliver quality care. These medical providers would earn part of their fees for keeping patients as healthy as possible, similar to the “accountable care organizations” in the health care law.

— Some workers will pick their health plans from a private insurance exchange, another similarity to Obama’s law. They’ll get fixed payments from their employers to choose from four levels of coverage: platinum, gold, silver and bronze. Those who pick rich benefits would pay more.

“Employers had been the major force driving health care change in this country up until the passage of health reform,” said Tom Billet, a senior benefits consultant with Towers Watson, which advises major companies. “If Obamacare disappears … we go back to square one. We still have a major problem in this country with very expensive health care.”

Business can’t and won’t take care of America’s 50 million uninsured.

Republican proposals for replacing the health care law aren’t likely to solve that problem either, because of the party’s opposition to raising taxes. The GOP alternative during House debate of Obama’s law would have covered 3 million uninsured people, compared with more than 30 million under the president’s plan.

After the collapse of then-President Bill Clinton’s health care plan in the 1990s, policymakers shied away from big health care legislation for years. Many expect a similar reluctance to set in if the Supreme Court invalidates Obama’s Affordable Care Act.

Starting in 2014, the law requires most Americans to obtain health insurance, either through an employer or a government program or by buying their own policies. In return, insurance companies would be prohibited from turning away the sick. Government would subsidize premiums for millions now uninsured.

The law’s opponents argue that Congress overstepped its constitutional authority by requiring citizens to obtain coverage. The administration says the mandate is permissible because it serves to regulate interstate commerce. A decision is expected in late June.

The federal insurance mandate is modeled on one that Massachusetts enacted in 2006 under then-Gov. Mitt Romney. That appears to have worked well, but it’s unlikely states would forge ahead if the federal law is invalidated because health care has become so politically polarized. Romney, the likely Republican presidential nominee, says he’d repeal Obamacare if elected.

That would leave it to employers, who provide coverage for about three out of five Americans under age 65.

“With or without health care reform, employers are committed to offering health care benefits and want to manage costs,” said Tracy Watts, a senior health care consultant with Mercer, which advises many large employers. “The health care reform law itself has driven employers, as well as the provider community, to advance some bolder strategies for cost containment.”

First, employers would push harder to control their own costs by shifting more financial responsibility to workers.

Data from Mercer’s employer survey suggests that a typical large employer can save nearly $1,800 per worker by replacing traditional preferred provider plans with a high-deductible policy combined with a health care account. “That is very compelling,” said Watts.

It won’t stop there. Many employers are convinced they have to go beyond haggling over money, and also pay attention to the health of their workers.

“As important as it is to manage the cost of medical services and products, and eliminate wasteful utilization, there has been a strong recognition that ultimately healthier populations cost less,” said Dr. Ian Chuang, medical director at the Lockton Companies, advisers to many medium-size employers. His firm touts programs that encourage employees to shed pounds, get active or quit smoking.

Employer health plans were already allowed to use economic incentives to promote wellness, and the overhaul law loosened some limits.

A Towers Watson survey found that 35 percent of large employers are currently using penalties or rewards to discourage smoking, for example, and another 17 percent plan to do so next year. The average penalty ranges from $10 to $80 a month, but one large retailer hits smokers who pick its most generous health plans with a surcharge of $178 a month, more than $2,100 a year.

Overall, one of the most intriguing employer experiments involves setting up private health insurance exchanges, markets such as the health care law envisions in each state. Major consulting firms such as Mercer and Aon Hewitt are developing exchanges for employers.

As under the health care law, the idea is that competition among insurers and cost-conscious decisions by employees will help keep spending in check. Aon Hewitt’s exchange would open next January, with as many as 19 companies participating, and some 600,000 employees and dependents.

“The concept of an exchange does not belong to Obamacare,” said Ken Sperling, managing the project for Aon Hewitt. “We’re borrowing a concept that was central to the health care law and bringing it into the private sector. Whether the law survives or not, the concept is still valid.”

Competition cuts down Medicare fraud

AP NewsBreak: Competition cuts down Medicare fraud

By RICARDO ALONSO-ZALDIVAR, Associated Press – 2 minutes ago 

WASHINGTON (AP) — A yearlong experiment with competitive bidding for power wheelchairs, diabetic supplies and other personal medical equipment produced $200 million in savings for Medicare, and government officials said Wednesday they are expanding the pilot program in search of even greater dividends.

The nine-city crackdown targeting waste and fraud has drawn a strong protest from the medical supply industry, which is warning of shortages for people receiving Medicare benefits and economic hardship for small suppliers. But the shift to competitive bidding has led to few complaints from those in Medicare, according to a new government report.

The report found only 151 complaints from a total population of 2.3 million Medicare recipients in the nine metropolitan areas, including Miami, Cincinnati and Riverside, Calif.

As a result, the program is expanding to a total of 100 cities next year, along with a national mail order program for diabetes supplies such as blood sugar testing kits. Eventually the whole country will participate.

Medicare traditionally has struggled to manage medical equipment costs. Officials say the program often paid more than private insurers for comparable equipment and was vulnerable to fraud by unscrupulous suppliers ordering expensive but unneeded products for unwitting beneficiaries.

By shifting to competitive bidding with a limited number of approved suppliers in each area, Medicare will save nearly $26 billion from 2013-2022, the government estimates, and reduce costs for seniors without cutting benefits.

“What we see is that costs are lower and there is no impact on the health status of our beneficiaries,” said Jonathan Blum, deputy administrator for Medicare. “This gives us very strong confidence that we can expand the program. To us, this is a clear success.”

The home-care supply industry sharply questioned that conclusion.

“With respect to the number of complaints (the report’s) information is downright laughable,” said Walt Gorski, a senior lobbyist for the American Association for Homecare. “It defies logic.” The group represents suppliers of home health equipment, ranging from oxygen to hospital beds.

The industry says hundreds of economists at academic institutions around the country have concluded that Medicare’s competitive bidding model is flawed and could lead to shortages or force beneficiaries to use less desirable cut-rate equipment.

In its report, Medicare said it closely monitored the health of beneficiaries likely to use home equipment in the nine areas involved with the competitive bidding experiment. It then compared the results to data for beneficiaries in other similar areas where competitive bidding has not been instituted yet. Using yardsticks such as emergency room visits and nursing home admissions, it found no significant differences.

“We have not seen any change in health status or access to services once the program went into place,” said Blum.

The report said the Medicare consumer hotline received 127,466 calls from beneficiaries about the competitive bidding program during 2011, less than 1 percent of the total volume of calls received. Most involved routine matters, such as locating a supplier.

Medicare defined complaints as dissatisfaction that could not be resolved by a call center operator. It registered 151 complaints for the year, the vast majority in the first six months of the program. Only six complaints were logged in the last three months of the year.

Medicare also called a sample of beneficiaries in areas where there was a sharp drop the quantities of supplies ordered for diabetes testing and for sleep apnea machines. The report said “in virtually every case” the beneficiary reported having more than enough supplies on hand, often several months’ worth.

“This would suggest that beneficiaries received excessive replacement supplies before they became medically necessary,” according to the report

The nine metropolitan areas involved in the experiment were Charlotte-Gastonia-Concord (North Carolina and South Carolina); Cincinnati-Middletown (Ohio, Kentucky and Indiana); Cleveland-Elyria-Mentor (Ohio); Dallas-Fort Worth-Arlington (Texas); Kansas City (Missouri and Kansas); Miami-Fort Lauderdale-Pompano Beach and Orlando (Florida);, Pittsburgh; and Riverside-San Bernadino-Ontario (Calif.).

Nine categories of medical equipment are included in the program: oxygen supplies, standard power wheelchairs, complex power wheelchairs, mail-order diabetic supplies, tube-feeding supplies and equipment, sleep apnea machines and equipment, hospital beds, walkers, and certain types of mattresses.

The major components of the $200 million saved last year were $59 million from oxygen supplies and equipment, $51 million from mail-order diabetic supplies and nearly $40 million from power wheelchairs and similar devices.

Oregon reforms healthcare

Reforming healthcare: Oregon steps well past federal model March 6, 2012
By JONATHAN J. COOPER, Associated Press
SALEM, Ore. (AP) — Pregnant with her seventh child and desperate to kick a meth addiction, Madeline Hutchinson turned to a program from the local Medicaid provider that connected her with a mentor and other support that she said helped her get off drugs.
Emmanual, now 2, was born healthy.
“We need mentors. We need advocates,” Hutchinson said. “We need someone that’s going to come along and say, `This baby needs to be clean. And we’re going to show you how.”‘
There’s a smattering of preventative care programs like this around Oregon, and not just for addicted mothers. But there hasn’t been a statewide push — until now.
Oregon Gov. John Kitzhaber last week signed a law that will create new regional entities, called coordinated care organizations, which will be able to spend money on programs like the one Hutchinson credits with turning around her life.
Kitzhaber says the plan will improve care, reduce costs and serve as a model for the rest of the nation.
But critics say that if the program works, more people will use health care benefits and costs will rise.
The coordinated care organizations will be responsible for looking after Medicaid patients in their area. Local organizations will determine their exact models.
But each will be a holistic approach that addresses every aspect of health — mental, medical and dental — with a focus in particular on people with mental illnesses, addictions or chronic conditions like diabetes, heart disease, asthma and kidney failure.
The idea is to target the costliest patients and provide up-front care that can prevent emergency room visits and other expensive interventions, and thus save Medicaid a lot of money.
Oregon has long been a pioneer in finding new approaches to health care, and Kitzhaber — a former emergency room doctor who is passionate about overhauling the system — believes the new law could solve several problems.
Officials say that if all 50 states adopted Oregon’s changes, the federal budget would save more than $1.5 trillion over the next 10 years — more than Congress’ failed “super committee” was trying to save over the same time period.
“I’m convinced … the federal government is going to have to do something drastic about the cost of health care,” Kitzhaber said. “And it’s not going to be driven by how you keep people healthy. It’s going to be driven by how do you keep from defaulting on the national debt, which is two completely different conversations.”
Long before the Oregon Legislature passed the law in February, Kitzhaber took his idea to Washington, D.C., to present it to Obama administration officials, and he caught their attention.
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And the ability to usher in widespread cost savings across the health care system will depend on whether the program can expand beyond Medicai Oregon, there’s no guarantee that other states with different cultural and political environments would see the same results.
Oregon state Sen. Fred Girod, a conservative Republican and a dentist, said he doesn’t think the plan would actually save money because he says i consumption of health care.
“Are we going to get more for less?” Girod said in a committee hearing. “I’ve been in the Legislature for a long time, I’ve been promised that I don’ times and I have yet to see it.”
Proponents dismiss the CBO report, saying their plans go far beyond the limited experiments that were studied, and point to data from projects in elsewhere that more closely align with their plans.
A state-commissioned report found that significant savings were possible from eliminating duplicated tests, preventing hospitalizations and other Oregon’s changes will focus on the neediest, costliest patients. Many of them are on both Medicare, primarily for the elderly, and Medicaid, prima
Various funding streams from all levels of government for mental, physical and dental care will be pooled into a global budget. Each coordinated c a share of that budget and will have broad authority to spend the money as it sees fit. Successful organizations will be rewarded with additional ca
Local officials around Oregon have already begun setting up coordinated care organizations in various parts of the state, and some are expected to on July 1.
Supporters of the new law say a project in central Oregon shows that it can work.
After identifying 144 patients who were frequently visiting the emergency room — at least 10 times in a year — a group of health providers found th health conditions and more than half had no primary care provider who could treat simple disorders outside the ER.
By creating care plans, assigning case managers to help them navigate the health care system and embedding mental health providers at the docto room visits were reduced by 49 percent in six months.
Robin Henderson, a psychologist who is director of behavioral health services for the hospital in Bend, Ore., says the program has promise, “It’s an philosophy to start to look at how you care for the whole person.” (Copyright 2012 by The Associated Press. All Rights Reserved.)

$375M Fraud Lasted 5 Years

$375M Health Care Scheme Went Unnoticed for Years
By NOMAAN MERCHANT
DALLAS go.com
The Texas doctor accused of “selling his signature” to process almost $375 million in false Medicare and Medicaid
claims went unnoticed for half a decade by a fraud detection system that some critics say is broken.
Authorities say Jacques Roy and six others indicted for health care fraud certified 11,000 Medicare beneficiaries
through more than 500 home health providers over five years. Those numbers would have made Roy’s Medicare
practice the busiest in the country. But an investigation into Roy and his business practices didn’t begin until about a
year ago, officials said.
The federal agency that administers Medicare has two sets of contractors: one to pay claims and another evaluating
those claims for fraud. U.S. Health and Human Services investigators have found that health officials often have a
hard time tracking the work of contractors that are supposed to detect Medicare fraud — estimated by some to reach
$60 billion annually.
Federal officials who announced the indictment against Roy and six others in Dallas acknowledged the problems
with the system. They contend they have improved data analysis and are working to move away from having to “pay
and chase” offenders.
Others say Medicare is still very vulnerable to fraud.
“It’s a trust-based system that is ripe for the picking by criminals,” said Kirk Ogrosky, a Washington, D.C., attorney
at the law firm Arnold & Porter and a former top health care prosecutor at the U.S. Department of Justice.
Roy, 41, a doctor who owned Medistat Group Associates in DeSoto, Texas, faces up to 100 years in prison if he’s
convicted of several counts of health care fraud and conspiracy to commit health care fraud. Six others, including the
owners of three home health service agencies, are also charged.
Roy’s attorney, Patrick McLain, said he had yet to review much of the evidence but Roy maintained his innocence. A
detention hearing for Roy in federal court was delayed until Monday.
More than 75 of the agencies that used Roy’s signature to certify claims also have had their Medicare payments
suspended.
Some of those indicted alongside Roy are accused of fraudulently signing up patients or offering them cash, free
groceries or food stamps to give their names and a number used to bill Medicare. Medicare patients qualify for home
health care if they are confined to their homes and need care there, according to the indictment. U.S. Attorney Sarah
Saldana said some people supposedly eligible for home care were found working on their cars outside.
Roy is accused of signing off on paperwork for home health services and pocketing much of the fraudulent billings.
Health and Human Services Inspector General Daniel Levinson described Roy’s billing on Tuesday as “off the
charts.” But it was missed for years by Palmetto GBA, the contractor that paid the home health agencies using Roy’s
signature, and Health Integrity LLC, the agency tasked with catching any irregularities.
A spokesman for BlueCross BlueShield of South Carolina, which owns Palmetto, referred questions about its fraud
procedures to the federal Centers for Medicare & Medicaid Services. Officials at Health Integrity did not return a
phone message.
CMS health insurance specialist Carmen Irwin said a screening process is intended to investigate complaints, but it
can be difficult to immediately pinpoint a single doctor’s signature being used so often.
“We’re paying a home health agency,” Irwin said. “We’re not necessarily looking at how many claims are for one
physician because we’re not necessarily paying a physician on a home health claim.”
A report by the HHS inspector general’s office issued in November highlights problems with the contractors charged
with weeding out fraud. The contractors reported their findings in different ways and sometimes provided
incomplete data, the report found. Some of the information turned out to be inaccurate. Inspectors said “the
inconsistencies and lack of uniformity we identified” could prevent effective oversight.
Patrick Burns, spokesman for the advocacy group Taxpayers Against Fraud, credited HHS for hiring Peter Budetti,
CMS’ deputy administrator for program integrity, to upgrade its systems. But Burns said the department still had no
excuse for missing obvious problems.
“You can’t have 11,000 bills from a single doctor if you’re the number one home health provider in the nation,”
Burns said. “You can’t see that many patients. It’s not physically possible.”