Lunch and Learn - Official Launch!

Your lunch hour is longer than this OHA meet up so grab your munchies and spend a few minutes to get more acquainted with the fast changing world of healthcare insurance and how it affects you and all those around you. This will benefit employers, those in HR who handle benefits, consumers, medical providers and others.  The Zoom format sessions will only last 30 minutes once a month starting September 28th at 12pm noon. There will be 15 minutes of presentation followed by 15 minutes for anyone to ask questions. Subjects will change each month. A core mission of OHA is to constantly educate the public and those who work with and serve Connecticut residents. We'll make further announcements via social media and this newsletter.  Follow us on Facebook.

 Here is the link to the Zoom session so put it on your calendar.

Struggle to Control Medical Costs Continues and Fails

There is bad news for consumers and small businesses. The Connecticut Insurance Department has approved health insurance rate increases averaging 5.6 percent for the individual market and 6.7 percent for the small group market. In approving the increases, the department reduced rates requested by insurers by 35 percent for the individual market and by 48 percent for the small group market – so if not for the efforts of the Insurance Department, things could have been worse.

The fact that the Insurance Department had to make big cuts to some of the requested rates does not inspire confidence that the carriers have all the tools they need to hold down medical costs.  The carriers are right that high medical prices are driving premium hikes.  But that just leads to the question of why the carriers are not able to negotiate better prices.  Specific high-cost healthcare providers like hospitals and drug makers in future years should be summoned to the rate hearings to justify the prices they are demanding.  Justifying these underlying medical prices in public is especially urgent in our new high-deductible world, where most consumers have to pay all of their own non-routine medical expenses, at whatever price is negotiated by their insurance companies.

Even with the cuts, the approved requests are high.  For instance, it is hard to see why UnitedHealth Group’s Oxford plans need rate hikes of 10 percent, or nearly three times some of their competitors.  If Oxford is having trouble negotiating fair rates with its healthcare providers, this is something that the public and state policymakers need to know about.  If our insurers are not able to negotiate fair, sustainable medical prices, this is something state regulators or the legislature can help with.

We pay more than twice as much for healthcare as all other wealthy countries, and the difference is that our overseas economic competitors have some kind of periodic public-private partnership process where healthcare providers and drug makers are required to justify their prices.  Insurers in Connecticut need the same kind of public-private partnership to give them the negotiating muscle that they need.   The annual rate hearing process is a perfect place for Connecticut to catch up to the rest of the world, and provide the support our insurance companies need to hold powerful high-cost providers like hospitals and drug makers accountable for the high prices they are demanding.

Here is a link to a broader story including comments from other state leaders:
https://ctmirror.org/2021/09/10/insurance-department-approves-rate-hikes-for-2022-though-not-as-large-as-carriers-sought/

Here is a link to the final rates:
https://portal.ct.gov/-/media/CID/1_RateFilings/2022-Initial-Rate-Filings-Chart.pdf

Important Insurance Committee Forum on Controlling Drug Prices
September 24 from 12:00PM to 3:00PM

Legislative Forum: “Consolidation, Private Equity, and Drug Prices in Health Care Costs”

Sponsored by CT Rep. Kerry Wood, Co-Chair, Insurance and Real Estate Committee

Join nationally recognized experts and Connecticut state legislators for a compelling discussion of how hospital and other health provider consolidation and drug prices affect the cost of healthcare in our state.

Link to agenda, Zoom, and YouTube information: https://www.cga.ct.gov/2021/insdata/oa/pdf/2021OA-00924-R001200INS-OA.pdf

 

Legislation Update: Public Act 21-9
 

During the 2021 legislative session, the General Assembly passed a bill preserving a number of telehealth mandates that had been established by the Governor’s pandemic-era executive orders.  Public Act 21-9 extends the sunset date for the following mandates through June 30, 2023.
 

• Telehealth providers are required to determine whether a patient’s health coverage includes coverage for the telehealth services being provided. 
• In-network telehealth providers are allowed to utilize any communication technology recognized as appropriate by the Office of Civil Rights of the U.S. Dept. of Health and Human Services.  In addition, DSS/HUSKY providers may be permitted to deliver covered telehealth services via audio-only technology.  
• Telehealth providers are prohibited from charging facility fees for telehealth services.
• Telehealth services provided to uninsured patients are limited to Medicare rates.
• Telehealth providers are prohibited from balance billing for telehealth services for insured patients.
• Insurers are required to cover telehealth services to the same extent that such services are covered in-person.
• Insurers are required to pay for telehealth services at the same rates as covered in-person services.

OHA: We're in YOUR Corner

OHA Stands with Emerging Tech
A consumer who had been diagnosed with prostate cancer called OHA for help with an appeal of his health plan’s decision to deny coverage for a cancer classifying genomic test.  The test is called the Prostate Decipher and it had been ordered by his urologist to assist with treatment planning.  The insurance carrier denied coverage on the basis that it was “investigational and not medically necessary.” 

OHA collected clinical information from the patient and his doctor and reviewed the medical literature on the subject.  Clinical studies showed that the test is an emerging practice and that it classifies the type of prostate cancer which is helpful when selecting the most appropriate treatment option.   The Insurance Carrier stood by its decision and upheld the denial upon appeal.   Unfortunately, the decision was final and binding.  Despite the increasing use of the Prostate Decipher test, patients who will benefit from this type of cancer classifier do not have coverage for the test through their health plan.  Only those who are willing, and able, to pay the $5000 price of the test will benefit from the Prostate Decipher cancer classifier test results.  

In this case, the bioscience facility appreciated that the patient had taken the time to appeal.  They believe patient appeals will help in the long run to have this eventually become a covered test.  The bioscience facility thanked OHA for its efforts and significantly reduced the amount of the bill to demonstrate their appreciation to the patient for having appealed the insurance carrier’s adverse ruling.


Never Take "NO" as a Final Answer
The parent of an 8-year-old girl who was receiving occupational therapy at Creative Development, LLC., contacted OHA for help when their health insurance carrier decided these services were “no longer medically necessary” and coverage was stopped.  OHA collected clinical information from the child’s parent and healthcare provider and wrote an appeal which demonstrated the reasons why occupational therapy was the most appropriate intervention to help with the types of challenges that were occurring.  The health plan’s decision to deny the requested services was upheld on appeal.  But as in the case for any clinical judgements (i.e., medical necessity denials), the patient had the right to have the health plan’s decision reviewed by an independent, external medical reviewer.  At this level of appeal, the denial was overturned so that coverage would be allowed.  The family saved $1,500 by having exercised their right under the law to appeal the insurance carrier’s denial of coverage.

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OHA has saved consumers tens of millions of dollars since the agency was launched - and we've become a trusted resource and consumer advocate on all matters of healthcare insurance here in Connecticut and on developments in Washington, D.C. that can affect us. We share these changes and information  in many ways - social platforms like our page on Facebook and Twitter, press conferences and via this newsletter. If you know somebody who is not getting this newsletter on a regular basis - or is only getting it because it's shared with them - OHA invites one and all to join our exclusive email list. Sign up for the newsletter here.