Click here to for Adult Routine Preventive Care Recommendations PDF from Massachusetts Health Quality Partners (MHQP- a coalition of physicians, hospitals, health plans, purchasers, patient and public representatives,academics, and government agencies working together to promote improvement in the quality of health care services in Massachusetts).

Additional MHQP preventive care guidelines including Pediatric and Perinatal recommendations can be found here.

Click here for PPACA Covered Preventive Services.

In order to satisfy the Massachusetts Minimum Creditible Coverage standard, a health plan must cover in full (no deductible or copay) all of the services listed in the MHPQ guidelines. In addition, plans must include a $0 annual Wellness visit. The PPACA laws of 2010 essentially duplicate the MHPQ guidelines for eventual enforcement nationwide. Most major carriers in states other than MA are already covering these preventive services.

It should be noted that many preventive tests can also be considered “diagnostic”, under certain circumstances, and then possibly be subject to deductible and/or copays, depending on plan design. For help verifying whether or not a specific test you may need falls under preventive or diagnostic services in your plan, contact us using the form below, or call (413)527-2738.

Mandated in 2010 by an amendment to the 2006 Health Reform laws, tiered network health insurance plans are designed to save money and provide choice to consumers, while incentivizing doctors and hospitals who surpass quality and affordability guidelines. In a tiered network, individuals pay higher or additional copays depending on the pricing tier of the hospital or facility.  Insurers assign doctors and hospitals to tiers using a formula of quality and cost measures. Premium for a tiered network plan must be at least 12 percent below standard plans, often much more. Tiered networks now make up as much as 15 percent of the Massachusetts health insurance market.

“This is a perfect triangle of interested parties—consumers, health plans and providers—and gives consumers a great stake in the reduction of health care cost.” -Barbara Anthony, MA Division of Insurance

Which MA health insurers offer tiered plans?

All of the major MA carriers are now offering tiered network plans, with new plans and modifications occuring regularly. Blue Cross Blue Shield of MA, the largest MA health insurer, also has the most extensive tiered network plans.  BCBSMA launched their Blue Options tiered deductible plan in 2010, and in 2011 they added Hospital Choice Cost sharing as an optional feature for all their HMO and PPO plans.  Fallon Community Health Plan is launching a tiered product for Western  and Central Massachusetts in April, 2012.  Both FCHP and Tufts Health Plan are now offering limited network HMO plans in partnership with Steward Health Care, serving Eastern MA businesses. Harvard Pilgrim is launching a new tiered network called Focus Network- MA, which will be available across most of MA starting in April, 2012.

Why an Employer might consider offering a health insurance plan with hospital tiering:

• Employers have more affordable plan options to choose from while still offering employees robust benefits.
• Members can cut their out-of-pocket costs when they seek care at one of the designated high-quality, lower cost hospitals in the network.
• Members have access to higher cost hospitals, though at higher costs.
• Provides incentives for members to make more educated and cost-effective provider choices

Health insurance tiering sounds confusing, is it worth it?

There have been complaints that tiered networks can be confusing to use, and some doctors and hospitals are frustrated that they are in different tiers for different health plans.  Massachusetts will soon require that health insurers use the same set of quality criteria. But hospital and physician ratings might still vary because insurers will still weigh the criteria differently and because the prices insurers pay for office visits, tests and procedures are not the same.  These issues notwithstanding, we believe that tiered networks are important for business owners to consider when evaluating group health insurance options.

Companies looking to purchase a new group health insurance policy, renew a current policy, or considering a change in coverage should contact Waugh Agency, LLC for a comprehensive comparison of all available plans.

While the constitutionality of the Individual Mandate is the headline issue in this week’s Supreme Court hearings, a lesser understood but fundamental component of the 2010 PPACA health insurance reform laws is also at risk, namely Medicaid expansion.  The PPACA laws mandate an individual obtain coverage or pay a tax penalty (the current MA penalty ranges from $238-$1,212 based on income).  The laws require states to create or expand subsidized and free health insurance plans for low income individuals. The affordable care act also contains provisions wherein the federal government provides additional Medicaid funding to pay for this expansion. In the case before the Supreme Court, the plaintiffs argue that it is coercion to force States to create subsidized health insurance plans and exchanges, or risk losing Medicaid funding from the Feds.

The lower court judge who went the furthest on the broad overhaul, ruling that the whole law should be struck down, nonetheless said he found the challenge to the Medicaid expansion legally unpersuasive. “There is simply no support for the state plaintiffs’ coercion argument in existing case law,” wrote U.S. District Judge Roger Vinson of Pensacola, Fla., in the first decision on the main case now before the Supreme Court.
-Washington Post

PPACA modeled after Massachusetts health reform laws

The Massachusetts model of PPACA has been in place since 2006, so residents here are familiar with the complexities of health insurance reform. However, the fact that 98% of MA residents have health insurance, as well as the lower trending rates in the commercial health insurance market, suggests that health insurance reform is worth the cost.

“I don’t see it as [coercion] at all, I see it as a tremendous opportunity. We know we have poor people who are currently unable to afford private health insurance.”
-Massachusetts health secretary JudyAnn Bigby

One of the main provisions of PPACA is the individual mandate, which requires everyone to purchase health insurance, or pay a tax penalty.  Massachusetts Residents are familiar with this arrangement as our State passed a health insurance mandate in 2006, with penalties being assessed since 2008.

The Justices will take about three months to form their opinion, and announce their ruling in June or July.  With this being a Presidential election year, the Supreme Court may be likely to want to protect itself from politics, and there is growing chatter about one possible way for them to do so.

Several news outlets have been suggesting that the Roberts Court may exercise ‘judicial restraint’, and not rule on the Individual Mandate until 2015.  The possible argument to delay ruling on the individual mandate involves the Anti-Injunction Act, which prevents challenge to any tax until someone pays it and sues for refund.  With the individual mandate not taking effect nationwide until 2014, the argument is that the Supreme Court does not have jurisdiction until 2015 when someone pays the tax and sues.

With the fate of health insurance reform hanging in the balance, and the overwhelming evidence proving that health insurance reform actually does work (MA now has 98% of the population covered, and the rates are starting to trend lower), we are hopeful that fairness, patient protection, and affordability will prevail over politics and scare tactics.

Contact Waugh Agency, LLC to obtain the most affordable group health insurance for your company.

Steward’s fully integrated community care organization serves more than one million patients annually in 85 communities in Eastern Massachusetts.  The plan network includes all of the Steward Health Care system community doctors and hospitals.

Both deductible, and no deductible plan designs will be offered.  The plan, called Steward Community Care, will be available as of April 1, 2012 to all Eastern MA small businesses.

Under the plan, a hospital or physician in the Steward network will deliver clinically appropriate care, with out-of-network care coming from Brigham and Women’s and Massachusetts General hospitals in Boston. Tertiary-level pediatric care will be provided through Mass. General.

Participating hospitals and medical centers:

• Carney Hospital
• Good Samaritan Medical Center
• Holy Family Hospital
• Merrimack Valley Hospital
• Morton Hospital and Medical Center
• Nashoba Valley Medical Center
• Norwood Hospital
• Quincy Medical Center
• Saint Anne’s Hospital
• St. Elizabeth’s Medical Center

Contact Waugh Agency, LLC for complete details, and a no obligation rate comparison.

Under the ACO model, physicians and hospitals are paid on a population based budget rather than a fee per service (as in most HMOs, and PPOs).  The creation of ACOs is a key facet of the 2010 Affordable Care Act, the comprehensive national health reform law that includes the individual mandate, healthcare exchanges, and patient safety programs.

According to this article from the Boston Globe, ACOs  ”will provide financial incentives for health care providers to give better care at lower cost”, which would benefit both patients and providers.  The HHS estimates this pilot program of 32 ACOs will save up to $1.1B in the 19 participating States, over five years.

The Medicare ACO pilot program starts Jan. 1, 2012.  Insurance carriers, and the Federal Government want to bring ACOs into the non-retiree market.  Blue Cross Blue Shield of MA, for example, has been experimenting with an ACO model for one of it’s payment networks since 2008.

Read the full HHS press release.

With 1st Quarter 2012 MA renewals underway, I am seeing moderate increases in most client’s group health premiums, versus last year.  This is inline with the MA Division of Insurance approved “base rates” for Q1 2012.  When these rates were approved by the DOI last month, the average reported increase was 4.8%, with a few carriers coming in much lower. Bear in mind, these are the “base rates”, which are not adjusted for group size, average age, and other demographics.

This article compares the Q1 2012 increase to last year’s, when some businesses saw rate increases “as high as 34 percent”.  That figure is a little misleading, because the maximum DOI allowed base rate increase last year was lower- around 8%- but after demographic and age adjustments, there were certainly companies that saw 30%+ renewal offers in 2011.

It can be frustrating for business owners to read that the State has capped rate increases at 6%, then see their own renewal offers come in much higher.  My agency specializes in obtaining the absolute lowest rates for our clients.  We can often use innovative premium-saving options such as health plans with a built in Health Reimbursement Arrangement, to reduce or eliminate the sting of an increase.

Below is a breakdown of Q1 2012 base rate increases for the major Massachusetts insurers:

Blue Cross HMO Blue (5.9 percent)

Harvard Pilgrim HMO (5.2 percent)

Neighborhood Health Plan (4.3 percent)

Tufts Health Plan (4 percent)

Harvard Pilgrim Health Care (3 percent)

Tufts HMO (2.6 percent)

CeltiCare (2.2 percent)

Fallon HMO (1.5 percent)

Fallon Community Health Plan (1.2 percent)

-figures are from State House News Service

Here is a link to a summary of the report from “The Ultimate MA Health Care Insider Info” blog.

MAIM wants to start by repealing the individual mandate (part of the 2006 law that requires MA residents to obtain health insurance or face tax penalties), then eventually unravel the entire Act Providing Access to Affordable, Quality, Accountable Health Care.  Presumably, they would prefer that the poorest Massachusetts Residents have no health insurance, and clog the ER’s.

I am not saying that I believe there are no problems with the Massachusetts health care system.  However, MA is one of the few states in the country where individuals can receive discounted or free health insurance, based on income.  As a licensed health insurance specialist who has participated in pilot programs with the MA Health Insurance Connector Authority, I work every day with individuals and groups who, if they were in most any state other than Massachusetts, could probably not afford health insurance.

There is also a movement to repeal the individual mandate on a national level, and the U.S. Supreme Court is set to issue a ruling by July, 2012.

link to Herald article

link to article from Masslive.com

link to the Kaiser report

This article from the NY Times discusses the Kaiser study in detail.