INSURANCE

What health care can I get if I retire before 65

October 7, 2021 by Staff Reporter

Question: G.D. in Batavia: If I retire before Medicare kicks in, what are my health insurance options?

A: Although most people consider 65 to be the standard retirement age in the U.S., did you know that the average actual retirement age is younger? According to GoBankingRates.com, it’s age 63 in Ohio and Indiana, and age 62 in Kentucky. This means the average retiree in the Tristate spends at least two to three years in retirement before they’re eligible for Medicare. So, this is an excellent question that likely impacts thousands of our neighbors.

Your first move should be to check with your employer. A 2019 Kaiser Family Foundation survey found that, while not common, almost 3 out of 10 employers do offer retirees coverage. If it’s not available, you’re married and your spouse is still working, see if you can join their plan. Retirement typically counts as a “qualifying’ life event,” meaning you’re eligible for a special enrollment window.

If neither of those options are feasible, you can explore plans offered on the public marketplace by the Affordable Care Act (online at healthcare.gov). In some cases, if your retirement income is low enough, you can qualify for a subsidy. If you don’t qualify, be prepared for the possibility of sticker shock. You could also consider buying a health plan directly through an insurance company (known as “private” insurance). In this case, we recommend working with an insurance broker or using a comparative website such as GoHealth or eHealth.

Electing to use COBRA insurance for up to 18 months is also a possibility, but just be aware: This option can also be quite expensive because you’re paying your full premium with no employer assistance. Another idea is to pick up a part-time job that includes health benefits. Examples include Lowe’s, Starbucks, Costco and UPS.

The Allworth Advice is to do your research. All these options come with different coverage, availability and costs. Plus, a lot depends on how long you need to bridge the gap between when you retire and when you become Medicare-eligible at age 65.

Q: Roger from Florence: My son is 22 and thinking about changing jobs and only has about $3,000 in his current 401(k). Since it’s not that much, can he just leave that with his soon-to-be former employer?

A: He likely won’t be able to do this. In most cases, if an employee leaves and their 401(k) account balance is less than $5,000, the employer won’t permit that account to stay in their plan.

This means your son has two options: He can either cash out the money or take it with him. We don’t like the idea of cashing out because he’ll have to pay taxes and a 10% early withdrawal penalty. So, instead, he should consider rolling that money over into an IRA. Just be sure he tells his employer to make it a “direct” rollover and has the check made payable to the IRA custodian – he’ll avoid paying taxes or penalties on the transfer using this method.

Here’s the Allworth Advice: Your son should be proud that he’s managed to save $3,000 for retirement so far. And that’s what he needs to keep in mind – this money is for retirement. It may not seem like a lot right now, but if he sets it aside in an IRA and doesn’t touch it (or, even better, adds to it), it will have a chance to keep growing.

Every week, Allworth Financial’s Amy Wagner and Steve Sprovach answer your questions. If you, a friend or someone in your family has a money issue or problem, feel free to send those questions to yourmoney@enquirer.com.

Responses are for informational purposes only, and individuals should consider whether any general recommendation in these responses is suitable for their particular circumstances based on investment objectives, financial situation and needs. To the extent that a reader has any questions regarding the applicability of any specific issue discussed above to his/her individual situation, he/she is encouraged to consult with the professional adviser of his/her choosing, including a tax adviser and/or attorney. Retirement planning services offered through Allworth Financial, an SEC Registered Investment Advisor. Securities offered through AW Securities, a Registered Broker/Dealer, member FINRA/SIPC. Call 513-469-7500 or visit allworthfinancial.com.

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Barro says raising health care costs for unvaccinated employees not ‘a great road’ to go down

September 6, 2021 by Staff Reporter

Columnist Josh Barro says that charging employees who are not vaccinated against the coronavirus more for health insurance is not “a great road” to go down.

Barro made the comment on Hill.TV’s “Rising” on Monday, as the panel was discussing Delta Airlines’ recent decision to subject unvaccinated employees enrolled in the company’s health care plan to a $200 monthly surcharge.

“I don’t think it’s a great road to go down,” Barro said.

Barro says that while he supports getting more people unvaccinated, such a move is a bad idea because healthcare laws in the nation are designed to delink pricing from health risks. He added that there are other things that can be identified besides coronavirus vaccines that can incurs the risks of filing health insurance claims.

“I think that there are a lot of things you can inquire into where people make choices that affect their health status,” Barro said. “And I think we have good reasons for not wanting that to flow through into the pricing.”

“And so… I think this is a step down a road that we don’t want to go down,” he continued.

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Local dentist and health insurance company teams up to giveaway 200 free food boxes – CIProud.com

September 6, 2021 by Staff Reporter

Casa de arte

Police confirm one person dead after shooting on Wayne Street WMBD

News / 2 days ago

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Letter: Deny insurance claims by those who refuse vaccines | Letters

September 5, 2021 by Staff Reporter

Anyone who thinks that having insurance for their car, or house, or even their health, will automatically indemnify them from any loss they might sustain, has probably never had a claim.

Insurance companies routinely dispute claims if the insured is at fault in causing the damage, or has done something to disqualify themselves from coverage. For example, if you have insurance on your house and it burns down, you don’t collect if you’re the one who set the fire. Or, if you intentionally cause an accident with your car, it is unlikely that your insurance company will pay for the damage.

So, I’m curious: How long will it be before health insurance companies refuse to cover the claims of those who test positive for Covid-19 when they appear at hospitals and require treatment after they have refused to be vaccinated?

While many of us believe that the assertion of “individual rights” is just a smokescreen for a misguided political statement, even if there are some for whom it is an honestly held belief, they must understand that rights come with responsibilities. As our health care system is burdened to the breaking point, and care is rationed because there are no beds for the man or woman with the heart attack or the burst appendix, shouldn’t the “defender of individual rights” be told that they’re on the hook for the cost of their care?

After all, why should the society they seem to care so little about bear the burden of their choice? Maybe if we put a price tag on their expression of individualism, we’ll find out just how much they value it.

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For Tribal Members in Oklahoma, Medicaid Expansion Improves Access to Specialty Care

September 4, 2021 by Staff Reporter

“This worked out perfectly,” she said. “We would not have been able to continue to see Dr. Ward and continue care with him if we didn’t have Medicaid expansion.”

For Jonathan Martin, 37, his family of five in Park Hill, Okla., lost their health insurance after he was laid off from his job in March because of the pandemic. Soon after, Mr. Martin, a diabetic, contracted Covid-19 and nearly died following a weeklong stint in the hospital with pneumonia and weakening kidneys.

His wife, Adrian Martin, 30, said her husband recovered but the mental strain that the virus had caused left him needing behavioral health treatment. He was afraid to leave his home for fear of catching the virus again and dying, she said. Without insurance, Ms. Martin said, they were unable to find him the help he needed in the tribal health care system, which she said had a long waiting list for such care.

After qualifying for Medicaid expansion, Ms. Martin was able to obtain the free coverage for her family and get her husband into therapy.

“It is a relief to know that if something happens again,” she said, “I won’t be worrying about trying to find a way to get my husband treated.”

Dana Miller, the director of tribal government relations at the Oklahoma Health Care Authority, said the state had been working with its tribal partners to enroll as many people into the program as it could, especially in its most rural and remote communities. Those who earn less than 138 percent of the federal poverty level — currently about $18,000 a year for an individual or $36,000 for a family of four — are eligible.

“Some folks in rural areas don’t have access to internet or a computer and they need help on filling out documentation,” Ms. Miller said.

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HHS, Labor, and Treasury Departments Defer Enforcement of Transparency in Coverage and No Surprises Act Requirements | Goodwin

September 3, 2021 by Staff Reporter

The No Surprises Act and Transparency in Coverage final rules go into effect January 1, 2022. Implemented as Titles I and II of Division BB of the Consolidated Appropriations Act, these rules are intended to protect patients from surprise medical bills and increase transparency by requiring certain health care facilities and insurers to disclose certain information. The U.S. Departments of Health & Human Services, Labor, and Treasury are jointly charged with implementing specific sections of the No Surprises Act and Transparency in Coverage final rules. On August 20, 2021, however, these agencies jointly announced through an FAQ published on HHS’s website that they are deferring enforcement of certain requirements from the final rules.

One of the No Surprises Act’s final rule’s requirements is that certain health care providers and facilities must provide a good faith estimate of an individual’s expected charges for health care items or services, if the individual is enrolled in a health plan and seeks to submit a claim to the plan. The government, recognizing that providers and facilities must develop complex technical infrastructure to comply with this provision, has decided to defer enforcement of this portion of the final rules until it can issue further rules on implementing these requirements. For nearly identical reasons, the government also decided to defer enforcement of requirements that plans and health insurance issuers provide individuals an advanced explanation of benefits pending further rulemaking.

The government further stated its plan to streamline some of the overlapping requirements in the No Surprises Act and the Transparency in Coverage final rules. For example, the Transparency in Coverage rule requires certain group health plans and health insurance providers to publicly disclose specified information about their in-network provider rates, out-of-network allowed amounts and billed charges for covered items and services, and negotiated rates and historical net prices for prescription drugs in separate, machine-readable files for plan years beginning on or after January 1, 2022. (”Grandfathered” health plans and health insurance providers, however, are exempt from these rules if they were in place prior to the March 2010 enactment of the Affordable Care Act.)

The government has decided to defer enforcement of the Transparency in Coverage rules that require plans and health insurance issuers to publish machine-readable files related to prescription drug pricing pending further rulemaking, given overlap with similar requirements in the No Surprises Act. The government also indicated it will defer enforcement of all other machine-readable file publication requirements of the Transparency in Coverage final rule until July 1, 2022.

The requirements of the No Surprises and Transparency in Coverage final rules are complex and will require significant effort from health plans, healthcare facilities, and others to implement. Despite the government’s decision to defer enforcement of certain requirements, health care facilities and health insurance providers should begin preparing to meet as many of these requirements as possible – and should do so as soon as possible. This starts with understanding which of the myriad remaining No Surprises Act and Transparency in Coverage requirements still apply to which health plans or healthcare facilities.

Partnering with trusted legal counsel early on can help ensure health care providers and insurers are prepared when the full requirements of the No Surprises Act and Transparency in Coverage rules begin being enforced by the government.

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Health insurance: NBA, NHIS sign MoU for lawyers

September 3, 2021 by Staff Reporter

Published 3 September 2021

The National Health Insurance Scheme and Nigerian Bar Association has signed a Memorandum of Understanding to enroll lawyers in the country under the Group, Individual and Family Social Health Insurance Policy.

GIFSHIP is a health insurance that is taken up and paid for by groups, individuals and families not covered by other NHIS coverage platforms.

During the signing of the initial MoU engagement in Abuja on Thursday evening with NHIS, the NBA presented a cheque of N15 million to the Executive Secretary of the NHIS, Prof. Mohammed Sambo, to formally register 1000 members on the health insurance scheme.

The President of NBA, Olumide Akpata, said that the organisation was expecting to access quality health for lawyers through the NHIS GIFSHIP platform.

Akpata said, “This is very important for us at the NBA to be able to access quality healthcare and we see the NHIS as one channel to achieve this. So we have started with 1000 of our members. It is just the beginning, we have over 100,000 members across the country.”

According to him, the NBA was delighted with the partnership arrangement with the NHIS, adding that the MoU would ensure that the programme remained sustainable.

Sambo described the MoU with the NBA as a landmark achievement for the NHIS which has been campaigning for more Nigerians to register under the health scheme.

“The event of today is very significant in that our drive towards attaining universal health coverage is gaining momentum”, he said.

Sambo said that the development of the GIFSHIP insurance platform was meant to give everyone opportunity to join the health insurance scheme irrespective of where he or she works.

He said that Federal Executive Council has approved a proposal put forward by the NHIS management to embark on massive infrastructure development at all its offices nationwide and ensure the deployment of information and communication technology devices that will ensure its operations become automated in the next few months.

Sambo said that with the deployment of the ICT infrastructure, individuals would be able to sit in the comfort of their homes and register for the health scheme online.

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Covid-19 claim rejected? Here’s how to lodge complaint with insurer, Ombudsman and consumer court

September 2, 2021 by Staff Reporter

Against the rejection of a claim, the first recourse is to the grievance committee of the insurer.

Coronavirus is not out of the woods yet and the threat of the third wave is doing the rounds. While maintaining all Covid-19 protocols is the need of the hour, one also needs to ensure there is adequate health insurance coverage to fall back upon in times of hospitalization. But, of late, there have been apprehensions about the Covid-19 related insurance claims not being accepted by insurers or claims getting delayed or partially paid to the policyholders.

Health insurance companies have received a total of 23.06 lakh claims worth Rs 29,341 crore as on August 6, 2021, according to figures compiled by the General Insurance Council. However, insurance firms have settled Rs 17,813 crore involving 18.99 lakh claims so far.

In order to clear the air around insurance claims and the mechanism for the policyholders to raise a grievance, FE Online in an email interview sought the answers around settlement of claims from Abhishek Tripathi, Managing Partner, Sarthak Advocates & Solicitors. Excerpts:

What is the course of action if a claim is denied? What is the process and timeline before lodging a complaint with the insurer, Ombudsman and consumer court?

If the claim is denied, the policyholder must inquire about the reasons. Often rejection on the grounds such as inadequate bills or documents can be resolved by submitting the relevant documents.

Against the rejection of a claim, the first recourse is to the grievance committee of the insurer. Although no timeline has been specified for the same, it will be ideal to avail this remedy within 3 years of rejection of the claim to avoid the claim becoming time barred under laws of limitation.

Against the grievance committee’s decision, the Ombudsman can be approached. The communication from the insurer should specify the details of the Ombudsman to be approached. Ombudsman must be approached within one year from the date of rejection of the complaint by the insurer’s grievance committee.

If the consumer is dissatisfied with the Ombudsman’s determination, (s)he can approach the consumer courts within 2 (two) years.

It is pertinent to note that IRDAI has established an online complaints registering system called the Integrated Grievance Management System (IGMS) where the form with the complaint can be filled and submitted. Complaints submitted on IGMS are forwarded to the insurer as well as IRDAI. IRDAI monitors the disposal of the complaint submitted on IGMS portal.

In case a claim is partially settled, should one accept and later on approach court etc to settle full dues?

It is common for the insurance companies to seek a letter or undertaking from the insured releasing the insurer of any further claim. It is advisable to avoid giving such undertakings, and where such undertakings are forced, a protest is lodged immediately with the insurer. Partially settled claims can, thus, be accepted under protest, and the courts may be approached for the settlement of the remaining claim. Courts may have to be convinced, in such cases, that the release, if any, executed by the consumer was executed under duress and should be disregarded.

What is the general trend in terms of Covid-19 claims being settled by the insurance companies?

Claim settlement turnaround time has been reduced by most insurers following IRDAI’s directive, however, some concerns around settlement remain. According to the industry data, as on July 19, 2021, of the total reported claims of Rs 27,640 crore, claims worth Rs 16,396 crore were settled. Settlement amounts ranged between 55 per cent and 65 per cent of the claim.

In the first Covid wave (up to February 22, 2021), insurers reported claims worth Rs 13,736 crore, of which claims worth Rs 7,125 were settled.

In the second wave – from February 23 to July 19, 2021 – of total health insurance claims of Rs 13,905 crore, claims worth Rs 9,271 crore were settled.

As per IRDAI, within how many days should insurers make reimbursement to the policyholder?

According to the guidelines issued by the IRDAI, insurers are required to settle or reject the claim, as the case may be, within 30 days from the date of receipt of the last necessary document. Where investigation is warranted, the insurer is required to complete the investigation within 30 days and accept or reject the claim within 45 days of receipt of the last necessary document. If there’s a delay in the payment of the claim, the insurer is required to interest at a rate 2% above the bank rate, from the date the reimbursement is payable.

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ACA Round-Up: Navigator Grantees, GAO Investigation, Contraceptive Mandate, And More

September 1, 2021 by Staff Reporter

As we await potential new health care legislation from Capitol Hill and the release of several major new federal rules, the Biden administration continues to advance its priorities under the Affordable Care Act (ACA). This post summarizes navigator grantees for 2022, updates to HealthCare.gov operations for those receiving unemployment compensation, a new investigation of agents and brokers on HealthCare.gov, planned rulemaking for the contraceptive mandate, and additional guidance on direct enforcement (DE) entities, risk adjustment, and more.

CMS Announces New Navigator Grantees

On August 27, 2021 CMS announced $80 million in grants to 60 organizations to serve as navigator grantees beginning with the 2022 plan year. The 60 navigator grantee organizations will be able to train and certify more than 1,500 navigators to help uninsured consumers in the 30 states that use the federal marketplace. The history of the navigator program, funding, and implementing regulations are described in detail in prior posts.

This is the largest-ever funding allocation for navigators and a significant increase from the $10 million in annual funding in recent years. It also doubles the number of navigator entities from 30 organizations for 2021 to 60 organizations for 2022. These gains notwithstanding, this number remains below 2018 when more than 80 organizations served as navigators (and below CMS’s expectation of issuing 85 to 120 awards). Entities may not have had enough time to apply given a short application window.

Navigator grants are awarded from August 27, 2021 to August 26, 2024, with the expectation of $80 million in funding per year. However, funding for subsequent years (i.e., beyond the initial budget period that extends to August 26, 2022) is contingent on the availability of funds and compliance with the award. Funding varies by state and ranges from a minimum of about $245,000 in Hawaii to $14.4 million in Florida. Several states will have more than one navigator entity for the first time in several years, and all 30 states with the federal marketplace will have at least one navigator entity.

Consistent with the Biden administration’s navigator funding announcement, grantees will focus on outreach to underserved or vulnerable communities. This includes people of color, people in rural communities, LGBTQ people, American Indians and Alaska Natives, refugee and immigrant communities, low-income families, pregnant women and new mothers, people with transportation or language barriers, people who lack internet access, veterans, and small business owners.

HealthCare.gov Enrollment For Those With Unemployment Compensation

The American Rescue Plan Act (ARPA) extended marketplace subsidies to those who have received or been approved to receive unemployment compensation at any time during 2021. For those who qualify, their income will be treated as no higher than 133 percent of the federal poverty level, meaning they can receive the maximum amount of premium and cost-sharing subsidies; they can enroll in a $0 or very low-cost silver plan and receive platinum-equivalent marketplace coverage.

In new materials, CMS clarifies that these enhanced subsidies are available to all qualifying members of a household if the eligible taxpayer qualifies. Said another way, if a taxpayer currently or previously received or was approved to receive unemployment compensation during 2021, they and other members of their household who qualify can receive the maximal marketplace subsidies. There are some limits if only a tax dependent (rather than a taxpayer) received or was approved to receive unemployment compensation. CMS also confirms that those whose household income is below 100 percent of the federal poverty level—i.e., those in the Medicaid coverage gap or who are otherwise ineligible for Medicaid—who receive or are approved to receive unemployment compensation in 2021 can receive maximal ACA subsidies for their entire household. Additional details, including what counts as unemployment compensation, are included in these materials.

CMS also highlights some operational changes. The subsidy enhancement became available through HealthCare.gov on July 1. As a result, many people who qualified were able to enroll during the Biden administration’s broad COVID-19 special enrollment period, which extended through August 15. However, now that this broad enrollment opportunity has ended, CMS confirms that individuals who qualify for this ARPA subsidy can still enroll in marketplace coverage for 2021.

To help CMS identify those who qualify, the marketplace application includes a new question that asks whether the applicant has received or was approved to receive for unemployment compensation during 2021. Individuals who are uninsured but agree to the attestation can enroll in marketplace coverage via a separate special enrollment period. This is true even if the individual does not otherwise qualify for a special enrollment period (such as losing job-based coverage).

CMS will not, however, build this into an individual’s eligibility results, meaning a consumer may not be aware of this option to enroll when completing the marketplace application. Instead, CMS will review HealthCare.gov applications on a weekly basis and identify those who qualify. The marketplace will then email or call the applicant to inform them that they are eligible for this special enrollment period; this notification will also appear in their HealthCare.gov account. From there, eligible consumers can select a plan and enroll in coverage. CMS encourages consumers to contact an enrollment assister or the marketplace call center with any questions. Those who attest to currently receiving unemployment compensation will complete their application as normal and not be asked to attest to prior receipt of unemployment compensation.

New GAO Report On Agents And Brokers Listed On HealthCare.gov

On August 10, the U.S. Government Accountability Office (GAO) issued a new report summarizing its covert testing of sales representatives listed on HealthCare.gov from five states. The GAO was asked to conduct this covert testing to assess the degree to which sales representatives listed on HealthCare.gov provided accurate information to a consumer with a preexisting condition or tried to sell a consumer a non-ACA-compliant product (that may not cover preexisting conditions).

GAO investigators conducted 31 undercover phone calls to sales representatives listed on HealthCare.gov under the “Find Local Help” link. The investigator posed as an individual with diabetes or heart disease in need of health insurance and requested coverage for those conditions to see if the sales representative would refer them to an ACA-compliant plan or a different plan option. The calls were placed from November 5, 2020 to February 3, 2021 to sales representatives in Alabama, Florida, Kansas, Texas, and Wyoming. Half of the study was conducted during the 2021 open enrollment period; half was conducted outside of that period while making clear that the individual would qualify for a special enrollment period under the ACA. (Investigators called a total of 39 sales representatives, but eight sold only ACA-compliant plans and were thus excluded from the study results.)

Of the 31 calls with sales representatives, none engaged in deceptive marketing practices, and all referred the caller to an appropriate plan that covered preexisting conditions. Most sales representatives also explained that non-ACA plans would not cover preexisting conditions. And no sales representative engaged in potentially deceptive marketing practices that misrepresented or omitted information about the products they were selling. CMS has removed 362 of its 59,000 registered sales representatives from the HealthCare.gov website for invalid licenses or misconduct since 2016. Of those removed, 288 had a revoked or invalid license while 74 engaged in enrollment misconduct.

This GAO investigation follows a 2020 investigation that revealed far more troubling marketing practices by sales representatives selling non-ACA products such as short-term plans, limited benefit plans, health care sharing ministries, and association health plans. In that investigation, the GAO identified sales representatives through web searches (as opposed to contacting sales representatives listed on HealthCare.gov). In the prior study, 26 percent of calls included potentially deceptive practices and another 6 percent of calls were not deceptive but provided unclear or inconsistent information. The remaining 68 percent of calls were appropriate and accurate.

Both GAO investigations were conducted in response to requests from Sens. Robert P. Casey (D-PA) and Debbie Stabenow (D-MI). Sen. Casey previously issued an investigative report on misleading online ads for non-ACA plans and the challenges consumers face when shopping for health insurance.

New Rulemaking On The Contraceptive Mandate

There is a long history of rulemaking and litigation over the ACA’s contraceptive mandate, which stems from Section 2713 of the Public Health Service Act. To date, there have been three major Supreme Court decisions on the scope of the contraceptive mandate and whether it applies to entities that object to providing contraceptive coverage for religious or moral reasons: Hobby Lobby v. Burwell in 2014, Zubik v. Burwell in 2016, and Little Sisters of the Poor v. Pennsylvania in 2020.

(Litigation continued even after the most recent decision in Little Sisters. Lawsuits from California and Pennsylvania were remanded and separate litigation in Massachusetts continued, as did a class action lawsuit over the Obama-era rules on the contraceptive mandate and a lawsuit in Indiana over the Trump-era rules and a settlement agreement between the Trump administration and objecting organizations. Other litigation over Section 2713 itself is pending in Texas. These lawsuits are not described in detail here.)

The Biden administration issued new guidance documents on the contraceptive mandate and women’s preventive services. On August 6, CMS issued a new notice soliciting public comment on materials associated with the contraceptive mandate. These include a model notice that can be used as part of the accommodations process, a notice to enrollees, a revocation notice, and a self-certification form. These documents are unchanged from the currently approved information collection request, and any comments on these materials must be received by October 5.

These materials are related to the accommodation process adopted by the Obama administration. This process enabled employees and students of objecting entities to access contraceptives without cost-sharing directly from an insurer. However, the Trump-era rules made this process optional. In their accompanying analysis, federal officials estimate that nine entities will seek an accommodation from the contraceptive mandate for the first time while 100 entities will continue a voluntary accommodation.

On August 16, the tri-agencies—the Department of Health and Human Services (HHS), Labor, and the Treasury—released a new, one-page frequently asked questions document indicating their intent to “initiate rulemaking within six months to amend the 2018 final regulations” on the contraceptive mandate. Federal officials intend to solicit public input and are considering “how to best address” the prior rules’ religious and moral exemptions “in light of recent litigation.”

While not related to the contraceptive mandate, HHS and the Health Resources and Services Administration (HRSA) separately asked for public comment on recent draft preventive service recommendations that would update HRSA’s women’s preventive services guidelines. Under Section 2713, insurers and plans must cover these evidence-based recommended preventive services.

The draft recommendations update existing recommended preventive services related to well woman preventive visits; counseling for sexually transmitted infections (STIs); and breastfeeding services and supplies. The updated recommendation for well woman preventive visits, for instance, would newly include pre-pregnancy, prenatal, and interpregnancy visits, among other changes. The recommendation on STI counseling would be broadened to include a review of the person’s sexual history and to be more inclusive of other risk factors beyond age, condom use, and number of partners. And the recommendation on breastfeeding services and supplies would include consultation to optimize successful initiation and maintenance of breastfeeding. Comments are due on September 20.

Additional Guidance: DE Entities, Risk Adjustment, And More

CMS has issued additional guidance and information related to COVID-19 and ahead of the upcoming 2022 plan year.

Updates On DE Entities

CMS continues to approve new third-party entities to use the enhanced DE (EDE) pathway. The EDE pathway allows a consumer to complete the entire marketplace enrollment process on the website of a third party, such as a web-broker or insurer. Consumers can thus apply for coverage, be determined eligible for financial help, and enroll in a marketplace plan on a single third-party website without ever visiting or creating an account with HealthCare.gov.

As of August 30, CMS had approved 11 entities to host an EDE platform (meaning these entities can lease their approved EDE platform to other EDE entities) and 35 entities to use the EDE process. Of the host entities, all but one is a web-broker or DE technology provider. The EDE users are primarily insurers with two web-brokers. The number of entities in both categories has increased over time.

Separately, on August 3, CMS issued a new bulletin regarding its enforcement of certain qualified health plan display requirements for DE entities. For instance, web-brokers must disclose and display all qualified health plan information provided by the marketplace or directly by insurers. If not all plan information is displayed, these entities must prominently display a standardized disclaimer that identifies those qualified health plans and refers consumers to the marketplace. These requirements extend to the display of quality rating information; DE entities are expected to integrate quality rating information in a way that is consistent with the quality rating information bulletin for 2022.

Citing the COVID-19 public health emergency, CMS had relaxed enforcement of these requirements in August 2020. The new guidance informs DE entities that enforcement will resume in 90 days and compliance is expected by November 1.

Risk Adjustment And More

In mid-July, CMS issued updated 2022 final risk adjustment model coefficients. While final risk adjustment models were included in the final 2022 payment rule, CMS identified some errors that impacted the adult models and needed to be corrected. The overall impact of the update is, CMS notes, minimal. In early August, CMS issued revised risk adjustment software for 2021, including instructions, technical details, and the software itself.

In mid-August, CMS issued an updated toolkit on the COVID-19 vaccine for insurers and Medicare Advantage plans. The updates focused on operational considerations and discussed the availability of booster shots for immunocompromised individuals.

Finally, HHS released a list, updated as of early July 2021, of self-funded non-federal governmental plans that have opted out of certain federal health insurance requirements. The list includes more than 160 plans across 29 states and identifies the reforms that these plans waived. Every single plan sponsor and plan on the list opted to exempt those plans from (at least) federal mental health parity standards.

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Health Insurance Coverage Stable in 2020, Despite Pandemic

August 31, 2021 by Staff Reporter

Rates of health insurance coverage remained mostly stable during the pandemic, with an estimated 1.6 more Americans gaining coverage in 2020, according to an early release from the CDC’s National Health Interview Survey (NHIS).

From 2019 to 2020, the uninsured rate dropped from an estimated 10.3% (33.2 million) to 9.7% (31.6 million), a non-significant difference, reported Robin Cohen, PhD, of the National Center for Health Statistics, and colleagues.

Adults ages 18-64 were most likely to lack health coverage, at 13.9%, and the uninsured rate was twice as high in states that did not expand Medicaid compared to those that did (20.8% vs 10.2%, respectively).

“That’s pretty striking,” Cohen said, explaining that while some of that difference in these states could be accounted for by public coverage, the difference was also attributable to a greater percentage of people in expansion states having private insurance.

Public insurance coverage in expansion and non-expansion states accounted for 22.5% and 16.7% of coverage for adults ages 18-64, respectively, while private insurance coverage rates were 69.2% and 64.3%.

Joan Alker, executive director and co-founder of the Center for Children and Families and a research professor at Georgetown University McCourt School of Public Policy in Washington, D.C, said that while there is likely some “wiggle room” around the specific estimates, there’s “no question we’re seeing a growing gap in uninsured rates in states that have expanded and states that have not, and I fear that chasm will continue to grow.”

Data for the 2020 NHIS involved 31,568 adults and 5,790 children, and the interviewing process was modified due to the pandemic, noted Cohen, with in-person surveys switched to phone only beginning on March 19, 2020. This led to “an over-representation of more affluent households,” the researchers noted.

Overall, 38% of respondents had public coverage, and 61.8% had private coverage (some individuals were covered by both public and private plans). Among children sampled for the survey, 5.1% were uninsured, 42.2% had public coverage, and 54.9% had private insurance. Adults 65 and older were most likely to be enrolled in a public health plan, at 95.9%.

Alker cautioned that while the overall results are likely true, the low rates of response (50%) and changes in data collection give her pause: “I would not approach these numbers assuming there’s a great deal of precision here,” she told MedPage Today.

Race, Ethnicity, and Income

With regard to race and ethnicity, Hispanic adults ages 18-64 were the group most likely to be uninsured across all racial groups, at 29.3%, followed by non-Hispanic Black adults at 14.6%, non-Hispanic white adults at 9.2%, and non-Hispanic Asian adults at 8.8%, the report showed.

Black adults ages 18-64 were the racial group most likely to have public health insurance, at 33.1%, followed by Hispanic adults at 23.0%. White adults accounted for the largest share of private coverage enrollment at 76.0%, with Asian adults close behind at 75.4%.

Cohen’s group also broke down the coverage data by income level and found that 25.3% of adults below 100% of the federal poverty level (FPL) lacked insurance and 25.0% of adults between 100% and less than 200% FPL were uninsured. Among adults earning less than 100% FPL, 56.3% reported having public coverage compared with 38.8% of those between 100% and less than 200% of FPL.

Of the adults whose income was 200% FPL or greater, 82.5% had private insurance, the report noted.

With regard to enrollment in the federal and state-based exchanges established as part of the Affordable Care Act (ACA), 3.8% of adults below age 65 were enrolled in exchange-based plans, and coverage was higher in families earning between 100% to less than 200% FPL compared with families who earned less than 100% FPL — 4.8% and 1.9%, respectively.

Exchange-based coverage was also higher among Hispanic individuals compared with white and Black individuals, at 4.2%, 3.7%, and 2.6%, respectively.

Data Collection in a Pandemic

The changes to the process of data collection cited in the report may seem trivial, but to some experts they’re not.

Alker said it’s unlikely the public will ever really know how many people were uninsured in 2020 because of the challenges of conducting surveys during the pandemic. Due to unreliable data and low response rates, she said, the Census Bureau won’t be releasing its American Community Survey 1-year estimates this fall.

She added that the NHIS had a “pretty small” completion rate, but researchers made a judgment call and decided the data were “good enough” to be shared.

And the survey “is showing us something, which is that there probably wasn’t a precipitous growth in the number of uninsured,” Alker added.

The following are some reasons the uninsured rates may not have spiked, Alker explained.

First, many of the jobs lost during the pandemic were jobs that didn’t provide health insurance anyway. An analysis of what jobs uninsured people have in states that have not expanded Medicaid, conducted by Alker and colleagues, found that in nearly every state they researched, hospitality was “the number one industry” for employing uninsured workers. Hospitality was also “one of the hardest impacted industries” during the pandemic, she said.

Second, she noted, a Medicaid “disenrollment freeze” enacted in March 2020 as part of the Families First Coronavirus Response Act prohibited states from dropping participants for reasons related to small fluctuations in income or paperwork problems during the pandemic.

Lastly, the public now has a stronger safety net because of the passage of the ACA in 2010, Alker said. “People have more public coverage options for this recession than they did for the last big recession.”

She said that despite rationalizing the topline data, “I’m certainly taking these number with a little bit of a grain of salt.”

Shannon Firth has been reporting on health policy as MedPage Today’s Washington correspondent since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team. Follow

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