Health Care Costs and Spending in New York State

New Report: "Health Care Costs and Spending in New York State" New York's health care spending overall and per capita are among the highest in the  nation. The State's health care spending has accelerated over time and is projected  to further increase in coming years, outpacing both inflation and overall economic  growth. A new NYSHealth-funded chart book, "Health Care Costs and Spending in New  York State," pulls together a compendium of information on health care costs,  spending, and payments based on existing State and national research. Prepared by  Health Management Associates, the slides in this online chart book synthesize a wide  range of data into an easy-to-use resource that covers the impact of rising costs,  drivers of spending growth, variations in spending, and the relationship between  quality of care and spending. It illustrates trends over time, highlights regional variations  within the State, and contrasts New York with the nation and other states. Readers  are encouraged to download and use these slides in their own presentations. Access the chart book.

NY State of Health - Starting Today, Customer Service Center is Open

NY State of Health lets you shop for, compare, and buy a health plan  online, in person or over the phone.  We offer expert “helpers” for  every step of the process.  Starting today, trained representatives  are ready to answer questions and provide information to  consumers and small businesses. You can reach NY State of Health by calling us toll free at  1-855-355-5777. Customer Service hours of operation are: Monday – Friday 8am - 5pm You are among the first to learn that our Customer Service  Center is now open!  If you have questions about health plans, financial assistance,  or anything else about NY State of Health please call our  Customer Service Representatives at 1-855-355-5777. NY State of Health will expand its hours and begin enrolling  New Yorkers in health plans starting on October 1, 2013, but  you can call us now to learn more or you can visit our website  at http://nystateofhealth.ny.gov/ Thank you for your interest in NY State of Health.  We'll send you more updates soon. NY State of Health The Official Health Plan Marketplace nystateofhealth.ny.gov 1-855-355-5777

Did You Know: Dental PPO Balanced Billing?

Dental Benefits: What is Balanced Billing? 

 

 

This year, once a month, Council Services Plus will be bringing you tid-bits of helpful and interesting facts and information about insurance. 

  

Last month we discussed Dental Benefit Maximums; so keeping with that theme, this month we

we'll focus on another term that often is associated with dental benefits: PPO Balanced Billing.

Many times employees choose a dentist that may not participate in the "network" of dentists approved by the plan offered by the employer. Many dental plans offer out-of-network benefits and still pay claims submitted by dentists that do not participate with that plan. If your plan has out-of-network coverage (usually associated with Point of Service (POS) or Preferred Provider organization (PPO) plans) you need to be aware of the fees charged by that dentist, and what your plan deems as reasonable and customary (R&C) charges that they will pay for.

When you use a participating (or preferred) provider, that dentist has agreed to accept the company's R&C fees as the basis for their billing. For example, if a filling R&C fee is $100, then the participating dentist must charge that for a filling. If your coinsurance is 80%, then you pay $20 (20% of $100) and the company pays $80.

 

Let's now assume you go to a non-participating provider and they charge $150 for the same filling. The insurance plan will still base the amount they pay at 80% of R&C ($100) and you must pay the "balance" of the bill due to the non-participating dentist. Under this situation, your cost is $70 ($150-$80). You can see why you may "prefer" to see a "preferred" provider in a PPO plan to help keep your costs down. 

Help Your Employees Cover the Cost of Healthcare

CS Plus Now Offers Access to Affordable, Comprehensive Voluntary Benefits for Your Employees In a stressful time, specified disease insurance can help protect your employees and let them concentrate on what matters most. The American Cancer Society reports that cancer costs Americans nearly $230 billion annually, and much of that is considered indirect or hidden costs not covered by major medical plans (Loss of wages, deductibles/coinsurance, travel expenses, lodging/meals, child care, etc).  CS Plus now offers your employees access to Specified Disease Insurance for Cancer from Colonial Voluntary Benefits (underwritten by The Paul Revere Life Insurance Company). This type of policy pays specific benefits for cancer diagnosis and treatment.

Specified Disease Insurance for Cancer Plan Benefit Includes: Wellness benefit - Payable for one of the specified cancer screening tests performed. Bone marrow donor benefit - Payable if you donate your bone marrow to another person who has been identified as a match to your bone marrow type. Inpatient benefits - Payable for hospital-related services such as hospital confinement, ambulance, air ambulance and full-time nursing services. Treatment benefits - Payable for cancer treatments such as radiation and chemotherapy, anti-nausea medication and medical imaging. Surgical procedures benefits - Payable for surgery performed to treat cancer, including reconstructive surgery and anesthesia. Transportation and lodging benefits - Payable if you must travel to receive cancer treatment. Extended care benefits - Payable for extended care services such as home health care, hospice and skilled nursing care Rates starting as low as $13.75 per month, per employee. For More Information Please Contact: Licensed Account Representatives Kristie Hood at  (877) 501-4277 x129, khood@councilservicesplus.com; or Eric Laughlin at x128, elaughlin@councilservicesplus.com

Employer Notice of Health Insurance Exchange to Employees – Delayed

Employer Notice of Health Insurance Exchange to Employees – Delayed

The Departments of Labor, Health and Human Services, and U.S. Treasury issued new guidance on January 24, 2013 delaying the requirement that employers notify all employees about the existence of the new health insurance exchanges.

Originally scheduled to take effect by March 1 of this year, the notice requirement has been put on hold until late summer or early fall of 2013. A new effective date has not yet been determined. Once a new effective date is announced, it is expected that employers will be required to distribute the notice to all existing employees, as well as to new employees upon hire.

The Department of Labor may issue model language for employers to use in satisfying the notice requirement.

It is expected that the notice must include:

       A description of what Exchanges are, what they provide, and where employees can go to find more information about them;

       Information regarding available tax credits if the employer doesn’t provide minimum essential coverage and the employee purchases health insurance on the Exchange; and

       A statement that employees who purchase coverage on the Exchange may lose any employer contributions and that these contributions may be excludable from employees’ income when they file their Federal income tax

We will keep you informed when new guidance becomes available.

Please visit our Health Reform page often for the latest information and updates

How Are You and Your Clients Impacted by Health Care Reform?

How Are YOU and Your Clients Impacted by Health Care Reform?

Health care reform is intended to overhaul the health care system, expand affordable coverage, change insurance rules and create an online marketplace (exchange) in each state for the individual and small group markets.

Health care reform will affect individuals, families, businesses, physicians, hospitals and health insurance carriers.

Some aspects of the law are already effective and others will be phased in over the next few years. Regulations will continue to be issued as implementation of the health care reform law is not yet complete. To help you understand the law, the most important provisions and dates are outlined in a new brochure (PDF), "How are YOU Impacted? An Employer's Guide to Health Care Reform."

To request printed copies of the brochure, please contact your Account Consultant and reference form number B-4280.

View Brochure (PDF) >>

Comptroller Thomas P. DiNapoli's Weekly News

Comptroller Thomas P. DiNapoli's Weekly News

DiNapoli Finalizes Fiscal Monitoring System

State Comptroller Thomas P. DiNapoli announced Monday his office has finalized plans to implement a statewide fiscal monitoring system that would publicly identify local governments experiencing financial strain.

DiNapoli: Inappropriate Payments Cited In Kingston Audit

The city of Kingston made $23,000 in improper payments to employees for unearned leave time, according to an audit released Thursday by State Comptroller Thomas P. DiNapoli. As a result of the audit, former fire chief Richard Salzmann was arrested and charged by Ulster County District Attorney D. Holley Carnright with offering a false instrument for filing in the second degree, a class A misdemeanor.

DiNapoli: Empire BlueCross BlueShield Paying Hospitals Windfalls For Special Medical Items

New York State health insurance provider Empire BlueCross BlueShield has routinely allowed hospitals to charge excessive amounts for special medical items such as implants, drugs and blood, because they did not sign agreements to limit reimbursement for those items, according to an audit of the New York State Health Insurance Program released Friday by State Comptroller Thomas P. DiNapoli.

DiNapoli: Utica Facing Continued Fiscal Challenges

The city of Utica continues to struggle with recurring budget gaps and has nearly depleted its fund balances, according to a fiscal report issued Tuesday by State Comptroller Thomas P. DiNapoli. The report is the latest in a series of fiscal profiles on cities across the state.

Comptroller DiNapoli Releases Municipal Audits

New York State Comptroller Thomas P. DiNapoli Thursday announced his office completed audits of:

the Big Flats Fire District No. 2; the Golden Glow Volunteer Fire Company, Inc.; the Lincoln Fire District; and, the Village of Richmondville.

Comptroller DiNapoli Releases School Audits

New York State Comptroller Thomas P. DiNapoli Thursday announced his office completed audits of:

the Hadley–Luzerne Central School District; and, the Hyde Park Central School District.

Making Sense of Health Care Reform for Your Nonprofit

NYCON's insurance subsidiary Council Services Plus (CS Plus) offers info, resources and direct insurance assistance to nonprofits across NYS. CS Plus only works with nonprofits, and has brought over $1 million in savings to nonprofit clients. Visit www.councilservicesplus.com for more info or e-mail.

Health Care Reform: Are You Prepared? The United States Supreme Court largely upheld President Obama's health care law, the Affordable Care Act in a mixed decision. The court's ruling, seen as one of the most significant in decade, is a crucial milestone for the law, allowing almost all of its far-reaching changes to roll forward. The decision did significantly restrict one major portion of the law: the expansion of Medicaid, the government health-insurance program for low-income and sick people. The ruling gives states more flexibility not to expand their Medicaid programs, without paying the same financial penalties that the law called for. The legislation for the Patient Protection and Affordable Care Act (PPACA) will impose significant new responsibilities on employers, some of which are already effective. While further guidance is expected on the application of these requirements, the following provides a summary and timeline of key provisions of the PPACA. As employers look ahead to the implementation of the PPACA, CS Plus will be providing additional updates to provide clients with compliance strategies in connection with various components of the new law. Summary of the Affordable Care Act The Affordable Care Act (umbrella term for the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010) was passed by Congress in March 2010 to overhaul the health care system, expand affordable coverage, change insurance rules and create an online marketplace (exchange) in each state for the individual and small group markets. Most U.S. citizens and legal residents will be required to have health insurance in 2014. Those without coverage would pay a tax penalty based on household income to be phased-in starting in 2014. Federal subsidies will be available to assist those who cannot afford to purchase coverage. Large employers (50 or more full-time employees) will be required to "pay or play" starting in 2014. Qualifying small employers (no more than 25 employees) are eligible for a tax credit for offering coverage beginning in 2010. The tax credit increases in 2014 if employers buy from the exchange, and then phases out in 2016. How Health Reform will Impact Businesses The Patient Protection and Affordable Care Act (PPACA) impacts businesses in several ways - from the types of benefits offered under insurance plans, to the ways employers conduct their businesses. Some provisions are already in effect and more will be implemented over the next several years. General Impacts on Employer-Provided Coverage There are several mandates from the Patient Protection and Affordable Care Act (PPACA) already in effect. View the Timeline below for more information on timing of provisions. Some of the key mandates are below. Grandfathering - "Grandfathering" allowed some plans to be exempt from some Health Care Reform provisions. Lifetime Limits and Annual Limits - Law prohibits imposing annual limits on Essential Health Benefits and any lifetime dollar limits. Medical Loss Ratio (MLR) Reporting - A Medical Loss Ratio or MLR is the percentage of premium dollars insurers spend to provide covered medical services and improve the quality of health care for their members. No Pre-Existing Conditions Exclusions - As of September 2010 there are no pre-existing exclusions for children under age 19. Beginning in 2014, this provision applies to everyone, including adults. Patient-centered Outcomes Research Fee - The Patient-Centered Outcomes Research Tax, also known as the Comparative Effectiveness Research Fee, is a fee paid to the government to fund Patient-Centered Outcomes Research Institute (PCORI) research. Preventive Services - The Patient Protection and Affordable Care Act of 2010 (PPACA) requires health plans to cover designated preventive services without any member cost sharing. Summary of Benefits Coverage - The Departments of Health and Human Services, Labor and Treasury recently issued final regulations requiring health plans to provide a SBC and Uniform Glossary that clearly explain benefits and coverage within a standardized template with uniform language. W-2 reporting - PPACA contains a requirement for employers to report the cost of health coverage under an employer sponsored group health plan on an employees W-2 form. The cost includes both the cost paid by the employer and contributions from the employee. Women's Preventive Services - The Patient Protection and Affordable Care Act (PPACA) requires health plans to cover designated women's preventive services without cost sharing for the member. Cost-sharing includes deductibles, copayments and coinsurance. Some of the benefits and services outlined in the women's preventive guidelines are already included within the existing PPACA preventive services requirements. Establishment of Health Insurance Exchanges On April 12, 2012 Governor Andrew M. Cuomo issued an Executive Order to establish a statewide Health Exchange. State-established health insurance exchanges must begin to operate on January 1, 2014. The Exchanges are virtual marketplaces that allow individuals and eligible employers to purchase health insurance. Initially in 2014, only employers with up to100 employees can purchase insurance for their employees through the Exchange. Prior to 2016, states can limit the size to businesses with up to 50 employees. Beginning in 2017, states can allow employers with more than 100 employees to purchase health insurance for their employees through the Exchange. How Does Health Care Reform Affect Small Businesses? In addition to the key provisions outlined, it's important to know that small businesses already have an opportunity to qualify for: Small business tax credits - In an effort to help small employers offer affordable coverage to their employees, the Patient Protection and Affordable Care Act provides for tax credits for qualified small employers. These credits began in 2010. The credits increase in 2014, but are only available for coverage purchased on an Exchange. The small group tax credit sunsets in 2016. Timeline It will take several years for changes to be enacted and regulations written. However it's important to begin to understand what will be happening in the near future versus long term changes. To view a larger image of the timeline, CLICK HERE.

If you have any questions regarding this update, please contact Anthony DeCicco, Account Executive, Group Benefits at adecicco@councilservicesplus.com; or by phone at (877) 501-4277, ext 123.

NYS has authority to review and approve health insurance rates

The Central NY Business Journal reported that the New York State Insurance Department again has the authority to review and approve health-insurance premium increases before they take effect.

Gov. David Paterson signed the bill allowing the reinstatement of the power today.
Since 2000, New York had regulated health-insurance premiums under a "file and use" law that "significantly" limited the state's ability to disapprove premium increases and allowed the insurance industry to regulate itself, the governor's office said in a news release.

The new law requires health insurers and health-maintenance organizations (HMOs) to make an application to the Insurance Department to implement premium increases.
The department would review the rate-increase applications, as well as the underlying calculations, to ensure that the rates are justified and not excessive, the governor's office said.

The law would apply to all rate increases taking effect on or after Oct. 1, 2010.
In addition, the legislation will immediately require health insurers and HMOs to spend more of every premium dollar they collect on medical claims.

In particular, the law raises the "medical-loss ratio," or the percentage of premium spent to provide medical care, from 75 percent to 82 percent for small businesses and from 80 percent to 82 percent for individuals.

In a statement released Tuesday night, the New York State Conference of BlueCross BlueShield Plans expressed "complete disappointment" over what it calls "government-imposed price controls." Read more here.

AG: New Information Can Help Consumers with Health Care Costs

In Rochester on Tuesday, New York Attorney General Andrew Cuomo announced a reform to the consumer reimbursement system for health care. The state is creating a non-profit is called FAIR Health, an research group headquartered at Syracuse University. The University of Rochester, Cornell University and the University at Buffalo are also part of the group.

Cuomo says FAIR Health will provide an independent system to help consumers find out how much they'll have to pay for health care procedures."

Before the patient goes to the doctor, the patient could say I'm getting reimbursed $140 dollars, is that the right amount?'," Cuomo says. "The doctor will know what they'll be reimbursed. That will be done on a web site operated by this company. Before you leave your house, you punch in your procedure code and you'll know exactly what your reimbursement rate is going to be."

Cuomo says the independent company will set reimbursement rates for out-of-network procedures.

Cuomo say a nearly $1 million settlement with health insurers across the country will fund the new system.

Area hospitals to use report to help guide their future plans

The Olean Times Herald reported that a recent report on what consumers think about health care in Western New York is seen by local hospital administrators as a valuable tool.

The report, "Reaching for Excellence: Community Vision and Voices for Western New York Health Care," polled more than 1,700 people from throughout eight Western New York counties. The report reflects what people want in the future from the health-care system and critical needs that currently are not being addressed.

Timothy J. Finan, president and CEO of Olean General Hospital, and Eva Benedict, president and CEO of Jones Memorial Hospital in Wellsville, both said the report will be a significant part of their future planning on how to make a more patient-centered health-care experience.

The report is a collaborative effort of the Community Health Foundation of Western and Central New York, the John R. Oishei Foundation, The P2 Collaborative and The University of Buffalo Regional Institute. It is the first to conduct such an intensive, widespread and continuing process for engaging and amplifying the consumer perspective, said Ann F. Monroe, president and CEO of the Community Health Foundation.

The report identified five critical areas that consumers felt needed to be addressed: Making a human connection, losing the hassle factor, helping patients understand, making healthy choices and increasing access to care.

Mr. Finan called the report significant and said that it amplified what Olean General knew intuitively about people's perception of the health-care system. The report will help administrators at Olean General and Bradford Regional Medical Center develop a strategic plan as the hospitals soon come together under the Upper Allegheny Health System, he said.

"As we embark upon a strategic plan for the new Upper Allegheny Health System this will be very important information that will factor into the process," he said.

Ms. Benedict said that Jones Memorial will use the information for its own strategic planning.

"We certainly welcome and need that consumer input and their perceptions to help us guide where go in the future," she said.

The report is the result of two years of information gathering. Nearly 115 meetings were held to discuss the future of Western New York health care. Read more here.

Health Care Forum Set for Thurs and Friday

The Buffalo News reported about the People’s Pharmacy, Joe and Terry Graedon, who offer health information on home remedies, prescription drugs and saving money.

Their health advice column runs Tuesdays, Wednesdays and Thursdays in the Life & Arts section of The Buffalo News, and their radio show is aired nationally on public radio.

“People think of us as the ‘Pill People,’ said Joe Graedon during a recent phone interview. “We are either talking about prescription or over-the-counter drugs, dietary supplements, herbs, home remedies. We’re talking about stuff—that for the most part—you swallow or smear.”

It may come as a surprise, then, to hear the Graedons speak off-topic Friday, when they present the keynote address during the P2 Collaborative Conference at the Buffalo Niagara Convention Center.

“The real question here is: ‘How do you motivate yourself to make those lifestyle changes?’” said Joe Graedon.

With more than 200 member and partner organizations, the P2 Collaborative brings together health care providers, patients and insurers. The initiative— dedicated to improving the health of people in Western New York— is funded by sources including the John R. Oishei Foundation, the New York State Department of Health and the Robert Wood Johnson Foundation. Read more here.

Seminar at a glance
When: 7:30 a. m. to 6 p. m. Thursday and 7:30 a. m. to 2 p. m. Friday
Where: Buffalo Niagara Convention Center
What:Spend two days with national health experts learning how to improve health care in Western New York.
Keynote Luncheon Address: “Taking Charge of Your Health” with Joe and Terry Graedon from “People’s Pharmacy” at noon Friday. Cost $50. To register, visit: http://tinyurl.com/p209lunch.
Event Schedule: For information and fees, visit http://www.p2wny.org/.

Community Health Foundation Implements Health Insurance Survey

The Buffalo News reported that when 1,700 Western New Yorkers were questioned by local health care reformers, their top concerns centered around how they are treated by medical professionals and how to get broader access to care.

In Washington, the top concern is how to pay for changes in a system that consumes an astounding 17 percent of gross domestic product—far more than any competitor nation—without covering everyone and with no commensurate benefit for the extra money.

That disconnect underlines the health care crisis of 2009, where patients worry about quality, politicians worry about costs, and conservatives try to use both concerns to kill reform—again.
That’s why it’s noteworthy that controlling costs was not among the top five concerns that came out of 114 community meetings to hear what Western New Yorkers want.

That may be because many on public programs or who have good employer coverage don’t feel costs very directly, said Ann F. Monroe, president of the Community Health Foundation of Western and Central New York, one of the organizers of this unprecedented project. Read more here.

Area small businesses back ‘public option’ in health insurance

The Buffalo News featured an article about an informal survey by an advocacy coalition that found small business owners in New York state overwhelmingly support the idea of a “public option” as part of a national health insurance reform effort, and are willing to pay to make “quality, affordable coverage” available.

The survey by New York Small Business United for Health Care reported that 73 percent of the business owners surveyed preferred a proposal with a public, government-run alternative to private insurance, versus 19 percent favoring an expansion of private market options.

The owners said they are willing to pay a portion of their payroll towards supporting such an option, with 64 percent saying they would pay at least 4 percent to 7 percent to “guarantee quality affordable coverage for themselves and employees.” Read more here.

Webcast Your Brain Surgery? Hospitals See Marketing Tool

The NY Times explored the increasing use of online marketing tools in hospitals. As the article relates:

The point of Shila Renee Mullins’s brain surgery was to remove a malignant tumor threatening to paralyze her left side.

But Methodist University Hospital in Memphis also saw an opportunity to promote the hospital to prospective patients.

So, a video Webcast of Ms. Mullins’s awake craniotomy, in which the patient remains conscious and talking while surgeons prod and cut inside her brain, was promoted with infomercials and newspaper advertisements featuring a photograph of a beautiful model, not Ms. Mullins.

This time, Methodist did not use billboards as it has with other operations, deeming this procedure too sensitive. But its marketing department monitors how many people have watched the Webcast (2,212), seen a preview on YouTube (21,555) and requested appointments (3).

“The goal is to further our reputation as well as to educate the community, who will ask their physicians about our care,” said Jill Fazakerly, Methodist’s marketing director.

Faced with economic pressures and patients with abundant choices, hospitals are using unconventional, even audacious, ways of connecting directly with the public. Seeking to attract or educate patients, entice donors, gain recognition and recruit or retain top doctors, hospitals are using Twitter from operating rooms, showing surgery on YouTube and having patients blog about their procedures.

They consider the methods inexpensive ways to stand out in an era of reality TV and voluminous medical information available online.

Some ethicists and physicians say the practices raise questions about patient privacy and could paint overly-rosy medical pictures, leaving the hospitals and patients vulnerable if things go awry.

Jeffrey P. Kahn, a University of Minnesota bioethicist, sees “value in demystifying medical care,” but said this “creates an aura of sophistication and high-tech ability” that may not represent “quality of care at a hospital.”

“Do we really want to treat health care like other consumer goods?” he asked.

Tony Cotrupi, a health care marketing consultant, said hospitals “have come to marketing dragging and kicking, but because things are so competitive they have to.” Patients “used to go like sheep wherever the doctor sent us,” he said, and spent “more time researching what kind of toaster to buy.”

“But now, you have the curious consumer,” Mr. Cotrupi said, “and hospitals are doing all they can to open up the kimono.”

Henry Ford Hospital in Detroit uses Twitter from the operating room.

Bill Ferris, the hospital’s Web services manager, said that during an operation to remove a man’s kidney tumor, the surgeon, Dr. Craig Rogers, worried that the unexpectedly large tumor would require total kidney removal.

“Gosh, this is big,” Dr. Rogers said. “Could I have picked a harder case for this?” So an observing chief resident tweeted: “Dr. Rogers is saying because the tumor is large he may have to do a radical (total) nephrectomy.”

Then, “some bleeding needed to be controlled,” but “we just tweeted right through it,” Mr. Ferris said. Other Twitter-casts included a hysterectomy and a craniotomy, during which the hospital posted video on YouTube and photos, and the surgeon would “literally scrub out for an hour and twitter.” Hospitals say patients give consent and are not compensated.

Mr. Ferris said: “One concern is what happens if something goes wrong — you’re making this public in a very real-time way. Our general plan is we would gently take a break from the twittering if the situation became very dire. You don’t necessarily want to be tweeting that somebody might be dying on the table, and God forbid the patient’s family learns about it that way.”

Methodist Hospital records an identical surgery on another patient, so if “something unforeseen happens and you need the camera to cut away from the surgery, you can fall back on your previous surgery,” Ms. Fazakerly said.

E. Haavi Morreim, an ethicist at the University of Tennessee College of Medicine, said “If you don’t show the bad along with the good, people can end up misinformed or with excessively optimistic expectations.”

More than 250 hospitals now use YouTube, Facebook, Twitter or blogs, said Ed Bennett, Web strategy director for the University of Maryland Medical System. Read more here.