Source: California Association of Underwriters (CAHU), www.cahu.org

AB 1150 (Lieu)
Insurer & HMO Health Plans Employee Performance Goals for IFP Policy Rescissions
This bill prohibits compensation of a person or entity employed by, or contracted with, a health care service plan or a disability insurer, from being based on, or related in any way to, the number of contracts, policies, or certificates for health insurance that the person or entity has caused or recommended to be rescinded, canceled, or limited, or the resulting cost savings to the health plan or insurer. It also prohibits a health care service plan and disability insurer from setting performance goals or quotas, or providing compensation to any person or entity employed by, or contracted with, the health care service plan or insurer, based on the number of persons whose health plan or insurance coverage is rescinded or any financial savings to the health care service plan or insurer associated with rescission of coverage.

AB 1203 (Salas)
Non-Contracting Hospitals Who Do Balance Billing if HMO Patients for Post-stabilization
Prohibits a non-contracting hospital from billing an enrollee of a health plan licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene) for post-stabilization care following an emergency, unless one of the following apply: a) the hospital is unable to obtain the name and contact information of the enrollee’s health plan; or, b) if the patient (or the spouse or legal guardian) refuses to consent to transfer to a facility contracted with the health plan after stabilization.  A patient is defined as"stabilized" or that "stabilization" has occurred when, in the opinion of the treating provider, no such material deterioration of the patient’s condition is likely to result from, or occur during, the release of the patient, as provided.

Requires the following written notice to be provided to such patients:
"You have received emergency care at a hospital that is not a part of your health plan’s provider network. Under state law, emergency care must be paid by your health plan no matter where you get that care. The doctor who is caring for you has decided that you may be safely moved to another hospital for the additional care you need. Because you no longer need emergency care, your health plan has not authorized further care at this hospital. Your health plan has arranged for you to be moved to a hospital that is in your health plan’s provider network.  If you agree to be moved, your health plan will pay for your care at that hospital. You will only have to pay for your deductible, copayments, or coinsurance for care. You will not have to pay for your deductible, copayments, or coinsurance for transportation costs to another hospital that is covered by your health plan. IF YOU CHOOSE TO STAY AT THIS HOSPITAL FOR YOUR ADDITIONAL CARE, YOU WILL HAVE TO PAY THE FULL COST OF CARE NOW THAT YOU NO LONGER NEED EMERGENCY CARE. This cost may include the cost of the doctor or doctors, the hospital, and any laboratory, radiology, or other services that you receive."

According to the author, recently, there has been a growing trend whereby hospitals are acquired and subsequently cancel all existing contracts of the previous ownership, including health plan contracts. In the absence of a contract, a hospital is able to charge higher rates. The author points to several instances where the hospitals have made no contact with the patient’s health plan and insurer. The author indicates that this often means that the hospital bills charged to patients and their health plans are much higher and than previously contracted rates before the change in ownership. According to the author, this practice leads to "balance billing" which is when non-contracting providers bill patients for the difference between the provider’s billed charges and the amount that a health plan actually pays to the provider.

AB 1894 (Krekorian)
Mandate for HIV Testing Benefits
This bill requires, on or after January 1, 2009, every health plan and every insurer that issues, amends, or renews an individual or group policy of health insurance, which covers hospital, medical, or surgery expenses, to provide coverage for human immunodeficiency virus (HIV) testing, regardless of whether the testing is related to a primary diagnosis. It also specifies, in the case of health insurers, that it is within the sole discretion of the insurer as to the provider of the test with which it chooses to contract; and that reimbursement is to be provided according to the principles and policies of the insurer.

SB 1168 (Runner)
One-Year Continuation of Student Dependent Coverage for Medically Necessary Reasons
This bill provides that a health plan or insurer who provides coverage for a dependent child who is over 18 years of age but younger than the limiting age and enrolled at a postsecondary educational institution may not terminate that coverage if the child takes a medically necessary leave of absence from school. This bill limits this coverage to a period of the lesser of 12 months or the termination date of the policy from when the leave of absence begins.

The Association of California Life and Health Insurance Companies (ACLHIC) supports the bill because it allows a student suffering from a treatable medical condition that renders him/her unable to continue as a full-time student to continue on their parents’ health insurance coverage for up to one year while they are being treated for their medical condition and not able to sustain full-time student status.

After the recent release of a few different healthcare surveys regarding Consumer Driven Health Plans (CDHP) and their “modest” impact on benefits cost trend, I have been fielding calls from benefit managers seeking my opinion on CDHPs. As a result, I thought it would be wise for me to blog some of my answers and observations on these topics.

• CDHPs and “High Deductible” health plans are not the same thing.
• Large or “jumbo” self insured employers have the most to gain (financially) by introducing a CDHP, but only if they entice or force a sizeable enrollment in the plan.
• A CDHP shifts costs from employer to employee by increasing deductible/out of pocket costs and making participants responsible for managing their healthcare purchases.
• When voluntarily offered, CDHPs typically attract the young and healthy.
• A CDHP all by itself does not improve the health of its participants.
• Plan design, wellness incentives, access to cost and outcome information and communication tools are “key” elements to a robust CDHP offering. 

 For small to mid-size employers:

• A CDHP with all the bells and whistles does not exist in a fully insured environment, although a few insurers have “modified” CDHP offerings with some tools.
• If your rates are “pooled” or “book rated”, there is no improved financial impact with insurance carriers for having a healthier or wiser population.

While this is not a comprehensive write up on CDHPs, I believe it answers some of the recurring questions I receive.

While standing in line at retail store this holiday season, I observed what I thought was a phenomenon only seen in “feel good” movies. A shopper was looking for a specific product that the retailer did not have in stock. Rather than trying to sell a different item, the sales clerk immediately recommended a competing retailer. The clerk knew the competition had stock on hand and described the exact location in the store where it could be found.

A few days later, I witnessed a second occurrence of this phenomenon at a different establishment. This was “old school” retail service, was it making a comeback? I thought this type of service ended with the 50’s.

These two observations caused me to reflect on my experiences in the benefits industry as both a purchaser and a service supplier. Had I ever referred a prospect to the competition or myself been referred elsewhere?

While acting as a benefits manager earlier in my career, I do not recall ever being referred elsewhere. It was quite the contrary. Those calling on me always seemed to have the cure for what ailed me, or at least that is what their sales pitch wanted me to believe. Often after conducting a little discovery, it was obvious that there was not a match.

Was this just a case of an overzealous salesperson or a misunderstanding about my needs? Having walked a mile or two in the salesperson’s shoes, it was apparent that their need to meet their quota was put ahead of my organizations need.

How can these time burning encounters be avoided? Those of us in service provider roles need to apply the same sales discipline these retailers demonstrated by walking away from business that does not fit our core delivery model. We cannot be everything to everyone.

On the other hand, employers need to be more specific with the services they desire and the requirements for providers. Collectively, we need to eliminate unnecessary RFPs and succinctly articulate our needs or our abilities to meet those needs. Who knows, in 2007 one of us may be referring you to our competition.