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Because the State of Pennsylvania does not have a mini-COBRA plan in force for groups of 19 or less, COBRA benefits are only available to employees of a company with 20 or more employees. Federal COBRA guidelines provide for the continuation of health care coverage upon the happening of a qualifying event which causes an individual to lose their health insurance benefits under the employer-sponsored group health plan. COBRA coverage allows the individual to remain on the employer’s group health plan and receive the same level of coverage for a period of 18 months. In addition to a 2 percent administration fee, monthly premiums for this continuation coverage will be at the sole expense of the COBRA recipient. If COBRA coverage is not available, not elected, or exhausted, conversion products are available. Blue Cross Blue Shield of Pennsylvania offers guaranteed issue individual health plans to persons that are uninsurable and have no other options for coverage.

Pennsylvania allows the practice of medical underwriting to be applied during the application process of individual health insurance polices. Under this process, the health insurance carrier is allowed an opportunity to examine the applicant’s past and present medical conditions and, based upon their findings, do one of the following: (1) Approve the application and offer health insurance coverage under the terms of the health plan, (2) Approve the application offering modified coverage under the terms of the health plan, or (3) deny coverage to the applicant. Pennsylvania law permits health insurance carriers a 60 month look back, 36 month exclusionary period on pre-existing conditions and does not require that credit for prior coverage be given. Elimination riders permitting the exclusion of coverage on specific pre-existing conditions are permitted. In Pennsylvania, Blue Cross/Blue Shield does offer a variance of guarantee issue products. These products would allow the applicant to obtain health insurance coverage, despite his/her medical history and without the need of the medical underwriting process. These plans vary by region and may be limiting in the benefits that are offered.

Even as the financial markets were in complete turmoil, the presidential debate last week included some sparring over who has the best health care reform plan, prompting a new wave of coverage of the two candidates’ proposals. At the same time, The Lewin Group released a new analysis of the two plans and predicted that John McCain’s proposal would reduce the number of uninsured by 21.1 million if operational by 2010 while Barack Obama’s proposal would result in 26.6 million fewer uninsured Americans. The analysis also projects that McCain’s plan would cost $2 trillion from 2010 to 2019, while Obama’s would cost $1.17 trillion. To do your own analysis, use one of the side-by-side comparison tools that are currently available.

Source: Aetna

The U.S. Census Bureau announced last week that the number of uninsured in America had dropped for the first time in years, from 47 million in 2006 to 45.7 million in 2007. Nonetheless, Aetna believes the need for meaningful health care reform is no less urgent and that the momentum should continue until all Americans have access to quality health care coverage. One of the most closely watched bellwethers in the industry, the Census Bureau estimates showed improvement in the number of uninsured largely because government programs provided coverage to an additional 2.7 million people in 2007. However, many of the underlying problems causing a drop in private coverage remain, and the struggling economy this year has some states trying to reduce their Medicaid spending.

Federal
The Democrats have expanded the Party’s official health care platform to include a provision calling for widespread adoption of health IT. Although it does not represent a binding commitment for candidates, the platform helped draw attention to health IT in time for last week’s Democratic convention in Denver. According to the Democratic National Platform Committee, health IT has the potential to save the average family up to $2,500 in annual health care costs through increased efficiencies. The elevation of health IT to the Democratic health platform increases the likelihood it will be addressed during the presidential debates.

States
COLORADO: An employer “play or pay” mandate has qualified for the November ballot in Colorado. Sponsored by labor organizations, Constitutional Amendment 56 would require every employer in the state that employs 20 or more workers to provide major medical health care coverage for both employees and their dependents. The legislature is charged with determining what constitutes “major health care coverage.” The employer would be required to contribute at least 80 percent of the premium cost for employees and at least 70 percent of premium cost for their dependents. However, similar state “play or pay” coverage mandates have been litigated by the business community and subsequently struck down by federal courts as being preempted by ERISA. The rift between labor unions and business that spawned the ballot initiative continues to grow. Amendment 56 is among four union-sponsored ballot ideas intended to counter Amendment 47, an initiative that would bar unions from collecting mandatory dues. Representatives of union-sponsored ballot measures say they will consider withdrawing the measures if Amendment 47 is withdrawn.

KANSAS: Assisting small businesses with the purchase of affordable health insurance is among Kansas Health Policy Authority (KHPA) Executive Director Dr. Marcia Nielsen’s recommendations to the full KHPA board for legislation in 2009. The proposal also includes increased tobacco products assessments, expanded Medicaid coverage for parents/caretakers, tobacco cessation coverage for all Medicaid recipients, implementation of a statewide community health record program, and cancer screening initiatives. Also, the Kansas Legislative Coordinating Council (KLCC) has approved interim studies on medical malpractice cost data, small employer health insurance, and colon cancer. Reports will be issued beginning in November and continuing through January 2009. Further rulemaking and committee deliberations will occur throughout 2008. Aetna will participate in the hearings and meetings over that time and work with the stakeholders on solutions that Aetna can support.

NEW JERSEY: The Department of Banking and Insurance has issued a record $13 million fine against Health Net of New Jersey for having under-reimbursed subscribers for out-of-network services. The $13 million fine is on top of another $28 million Health Net has paid in claims, interest, and fees, bringing total restitution in the matter to a record $41 million. The fine covers Health Net practices occurring over the last 10 years.

NEW YORK: The Departments of Health and Insurance plan to hold a joint hearing on October 7 regarding balance billing practices by out-of-network providers. The hearing was prompted by concerns raised by consumers and insurers regarding specialty services provided by out-of-network providers. In many such cases, non-network providers billed patients for additional expenses after receiving reimbursement from insurers. The two departments are considering statutory and regulatory changes to address the issue and are seeking input from consumers, health plans, providers and other interested parties.

OKLAHOMA: The House Health Care Reform Task Force charged with identifying and reducing barriers to affordable health care coverage in the state recently announced principles that will “serve as a blueprint for possible reforms.” The guiding principles include: Consumer empowerment and consumer choice; encourage personal responsibility; incentives to carefully utilize health care resources; fair compensation for providers; efficient, effective administration; effective use of technology; improved health outcomes; effective communication; efficient use of resources; and increased access to quality, affordable private health insurance. A 30-member advisory committee charged with assisting in the development of task force recommendations has significant industry representation, including Aetna. Aetna will continue to monitor the efforts of the task force, which will continue until the next legislative session begins in January 2009.

PENNSYLVANIA: It appears that Insurance Commissioner Joel Ario intends to close the record at the end of September on the proposed Highmark/IBC consolidation. If so, the comment period for the Senate and House Insurance Committees would run into mid-November, and a decision could be reached by early next year. Aetna will provide testimony at the Senate Banking and Insurance Committee public hearing scheduled for September 23. Aetna’s comments will continue to challenge the economic benefits Highmark and IBC claim would result from the consolidation.

Resources
America’s Health Insurance Plans
Coalition to Advance Healthcare Reform
Transforming Health Care in America

Before wrapping up its work in Minnesota last week, the Republican National Convention adopted a platform that, on health care, syncs up closely with Republican Presidential candidate Sen. John McCain’s proposal. The platform specifically rejects a single-payer, government-run health care system and instead calls for universal coverage enabled by more affordable health care. The platform calls for changing the tax code so that those who buy health insurance in the individual market get the same tax benefits as those with employer-sponsored coverage. This is a linchpin of McCain’s health care proposal. The Wall Street Journal recently characterized McCain’s plan as “the most fundamental health-care reform” with the “better chance of of insuring the uninsured and controlling health care costs.” The platform also calls for greater insurance portability, a “culture of wellness,” allowing the purchase of health insurance across state lines, greater use of information technology and pay-for-performance medicine.

Federal
Congress has been on recess while the Republicans and Democrats held their national conventions during the past two weeks. There are no important health care-related developments to report from Washington, D.C.

States
CALIFORNIA: The legislature adjourned the 2007-2008 regular session after dispensing with nearly 900 remaining bills, except the most important one, the state budget. The state has been operating for 67 days without a budget. The legislature will continue to meet but only on budget-related bills or bills that require a 2/3 vote. A few of the more problematic bills that the legislature passed in the waning hours of the legislative session include an 85 percent medical cost ratio requirement, an insurer assessment to fund the state’s high-risk pool, and new rules for the individual market that include standardized applications and the creation of an independent third-party review process that must be employed prior to rescinding a policy. Governor Arnold Schwarzenegger has not taken a position on any of these bills and has vowed not to sign any legislation until the legislature passes a budget. The State Constitution requires the Governor to either sign or veto all legislation that reaches his desk on or before September 30. Therefore, any bill not acted on by October 1 would become law without his signature.

GEORGIA: The board of the Department of Community Health approved a fiscal year 2009 budget proposal that includes a new assessment on commercial HMOs. If the proposal is included in the final budget, commercial HMOs would have to pay a fee that is now charged only to managed-care companies that operate the state’s Medicaid program. The Department is seeking to reconcile a 5 percent reduction in state Medicaid funds ordered by Governor Sonny Perdue, in response to a deep slump in state revenue.

Resources
America’s Health Insurance Plans
Coalition to Advance Healthcare Reform
Transforming Health Care in America

The number uninsured declined from 47 million in 2006 to 45.7 million in 2007, according to a report called Income, Poverty, and Health Insurance Coverage in the United States: 2007, compiled from information collected in the 2008 Current Population Survey Annual Social and Economic Supplement.

Those without access to insurance fell among all socioeconomic classes, according to the report.

The number of uninsured children declined from 8.7 million (11.7%) in 2006 to 8.1 million (11%) in 2007.

Both the number and percentage of uninsured for non-Hispanic whites decreased in 2007, to 10.4% and 20.5 million, respectively.

For blacks, the number of uninsured remained statistically unchanged from 2006, at 7.4 million, while the percentage declined from 20.5% in 2006 to 19.5% in 2007. The uninsured rate for Asians rose from 15.5% in 2006 to 16.8% in 2007.

The number and percentage of uninsured Hispanics decreased from 15.3 million and 34.1% in 2006 to 14.8 million and 32.1% in 2007.

Based on a three-year average (2005-2007), 32.1% of people who reported American Indian and Alaska Native as their race were without coverage. The three-year average uninsured rate for Native Hawaiians and Other Pacific Islanders was 20.5%.

The report also ranked individual states.

Rates for 2005-2007 using a three-year average show that Texas (24.4%) had the highest percentage of uninsured. No one state had the “lowest” uninsured rate.

At 8.3%, Massachusetts and Hawaii had the lowest point estimates for uninsured rates, but they were not statistically different from Minnesota (8.5%), Wisconsin (8.8 %) and Iowa (9.4%). In addition, Hawaii was not statistically different from Maine (9.5%).

Comparing a pair of two-year average uninsured rates (2004-2005 versus 2006-2007), five states and Washington, D.C., saw a decline, while 10 states experienced an increase.
SOURCE: Ifawebnews

In the recently released 2008 PayerViewSM Rankings by athenahealth, Aetna has been ranked #1 of eight national health plans. The independent organization’s survey ranks health insurers on financial measures, administrative performance, and medical policy complexity. The rankings use athenahealth’s claims data from more than 12,000 medical providers representing over 30 million medical procedure charges for 2007.

Some highlights of the PayerView Rankings:

Aetna pays physicians faster and denies claims less often than other health plans that were measured
Aetna earned high scores for the percent of claims that were resolved the first time they were submitted
When a claim is denied for insufficient information, Aetna is one of the best at clearly communicating with physicians to ensure the claim will close with only one resubmission
This is the third annual PayerView Rankings by athenahealth, a provider of practice management and electronic medical record services to medical groups. Aetna progressed to the top from its previous rankings of second in 2007 and fourth in 2006.

For more information about the PayerView Rankings results, please use these links:

Aetna news release
athenahealth news release
May 29 Wall Street Journal article about the rankings
The complete 2008 PayerView Rankings, evaluating 137 national, regional and government payers

As of April 1, when members call 1-800-ASK-BLUE, they’ll be greeted by a new interactive voice response system that detects voice and touch tones to complete transactions. Even better, members can get answers to their benefits questions when it is most convenient for them.

The new system is safe and secure. When members call, they’ll need to provide their member ID number and birth date to ensure the highest level of security. Please note, policyholders can receive information on their self and dependents under 18. Spouses and dependents can only receive information on themselves.

Through the four self-service options, members can:

Get eligibility data including effective date or termination date, primary care physician, and cost-sharing information.

Obtain detailed claim information such as claim number, billed amount, and coordination of benefits.

Order ID cards quickly and easily.

Find billing information like payment due dates, account balances, and date of last bill.

The new automated customer service system is easy to use. All transactions offer the option to return to the main menu, repeat information, or to speak to a customer service representative during normal business hours. As always, our customer service representatives are available Monday through Friday, from 8 a.m. to 6 p.m., to answer members’ questions.

For more information, contact your Independence Blue Cross Account Executive.

Four area hospitals have been selected as Blue Distinction® Centers for Complex and Rare CancersSM, Independence Blue Cross (IBC) is pleased to announce. These are the first in a line of Blue Distinction Centers focused on cancer treatment.
This program offers comprehensive inpatient cancer care programs for adults, programs that are delivered by multidisciplinary teams with subspecialty training and distinguished clinical expertise in treating complex and rare subtypes of cancer.

Blue Distinction is a nationwide program created to give consumers more information with which they can make wise health care decisions and work with their health care providers to improve the quality and affordability of medical care. Blue Distinction identifies specialty centers that offer the best practices and highest standards in cardiac care, bariatric surgery, transplants, and, now, complex and rare cancers. IBC participates in the Blue Distinction program as a member of the Blue Cross and Blue Shield Association.

Those recognized as Blue Distinction Centers for Rare and Complex CancersSM are:

Abington Memorial Hospital

Fox Chase Cancer Center

Hospital of the University of Pennsylvania

Thomas Jefferson University Hospital

Complex and rare cancers comprise approximately 15 percent of new cancer cases each year. Patients may find it difficult to locate or research facilities with oncological or surgical teams that are experienced in this specialty. The Blue Distinction designation helps identify these institutions.

“We are committed to working collaboratively with physicians and hospitals so that together we continually raise the quality of health care in our region – whether through Blue Distinction, our incentive-based reimbursement program for physicians and hospitals, or other joint efforts, like the Partnership for Patient Care,” said Joseph A. Frick , IBC’s president and chief executive officer. “We are proud that we partner with the four cancer-care facilities in our region that are Blue Distinction Centers and very pleased to offer our members access to the sophisticated, specialized treatment they offer to properly manage complex and rare types of cancers.”

Collaborating with area hospitals that specialize in the treatment of cancer is one more way IBC is optimizing its members’ health. You can find out more information about Blue Distinction Centers at www.bcbs.com.

The first step in understanding how prevention affects health care costs is to define exactly what is meant by “prevention.” Its broadest definition includes anything that prevents disease, including healthy lifestyle habits and programs that usually fall under the “wellness” umbrella. Its narrowest definition is preventive care such as screenings for various types of cancer and other health risks.

Ideally, a health benefits program should include both clinical screenings and healthy lifestyle programs. Over the past several decades, the focus has shifted toward providing more preventive care benefits, but a stronger focus on preventing disease is still needed.

Preventive care in the United States

Prevention takes many forms: vaccines that prevent disease completely; medications that reduce the risk of developing disease; screening tests that detect disease at an early stage when treatment is more effective; and lifestyle changes - smoking cessation, exercise, diet - that keep people healthy longer.1

Through a combination of public education and the growth of managed care, the use and coverage of many preventive care strategies has become more common. But preventive health care statistics in the United States still fall short of expectations. For example:

An estimated 30 percent of the more than 20 million Americans with diabetes remain undiagnosed.2
The lifetime risk of developing hypertension is approximately 90 percent for adults between the ages of 55 and 65, but one-third of those affected don’t know they have it.2
Americans receive appropriate preventive, short-term and long-term health care as recommended by professional guidelines only about 55 percent of the time.3
Approximately 45 percent of the U.S. population has a chronic medical condition, and about half (60 million people) have multiple chronic conditions.3
Preventable causes of death, such as tobacco smoking, poor diet and physical inactivity, and misuse of alcohol have been estimated to be responsible for 900,000 deaths annually - nearly 40 percent of total yearly mortality in the United States.4
One reason why the use of preventive care is not as high as it should be is the large number of uninsured.
People without health insurance are much less likely to receive recommended preventive services and medications or have access to regular care by a doctor than those who are insured.3 But simply having health insurance isn’t the solution - it’s important to have a plan that encourages the use of preventive care. In one study, screening rates dropped 5.5 percent in insurance plans that introduced cost sharing during the study period, yet increased by 3.4 percent in plans that maintained full coverage.5 By reducing or eliminating cost-sharing in health plans, plan sponsors can increase the use of key preventive services such as adult immunizations and tobacco cessation programs.6

Another is lack of education. People often don’t consider themselves to be at risk, don’t know what preventive services they should receive based on their age, gender and risk factors, or are unsure about their effectiveness.7 It took a concerted effort by doctors, parents, government agencies, health insurers, employers and advocacy groups to achieve higher vaccination rates for children.7

Saving lives and money with preventive care

While immediate costs may be higher in some cases, preventive care can provide significant savings in both short- and long-term health-related costs.

Preventable illness and chronic disease are major causes of employee absenteeism and presenteeism (decreased on-the-job effectiveness), causing a financial drain on businesses.6
A recent study found that increasing the use of just 5 clinical services to 90 percent of the target population would prevent 113,000 premature deaths each year.8
At least half of the deaths from cancers could be prevented by greater use of established screening tests and existing knowledge.2
Chronic conditions account for 70 percent of all deaths in the United States and the costs associated with them account for more than 60 percent of national medical care costs.2
Studies indicate that prevention, early detection and chronic disease management would reduce the economic impact of disease by 27 percent, or $1.1 trillion annually by 2023 and the number of cases of chronic disease by 40 million.9
Flu vaccination reduced absenteeism by as much as 45 percent.6
Based on these numbers, you would expect that most plan sponsors would include coverage for preventive care in their health benefits plans. Unfortunately, that’s not the case. One study found that:

Only 57 percent of employers covered the flu vaccine.10
Less than 25 percent offered any kind of smoking cessation program.10
Colorectal cancer screening is offered by just over 70 percent of employers.10
Cost is the primary reason cited by plan sponsors for not providing more comprehensive health benefits that include preventive care.10 But some employers are beginning to realize that they can reduce absenteeism and presenteeism by investing in a healthy, productive workforce.2 In your role as a consultant, you can help your clients decide which preventive care services and programs will be most beneficial to their employee population.

Consumerism is also helping to increase the use of preventive care services. As consumers assume greater financial responsibility for their health care and become more informed about their risks, they’re more likely to demand additional tests and procedures to protect their health.

Aetna’s approach to preventive care*

We realize how important all aspects of preventive care are, both to our members’ health and our customers’ bottom lines. That’s why we provide coverage for recommended clinical screenings, vaccinations and preventive care doctor visits. In fact, many of our plans cover most preventive care services at 100 percent, with no copays or deductibles.

We also provide an extensive array of wellness programs designed to promote healthy lifestyles and improve members’ overall health. For those members who already have chronic conditions, our disease management programs help them manage their conditions and minimize complications.

But making the benefits available isn’t enough - we also actively encourage members to take advantage of their preventive care benefits through targeted mailings and programs. For example, our ActiveHealth® Management CareEngine® system compares member health data with over 1,000 current evidence-based guidelines of care to identify opportunities for better care, including preventive care and increased patient safety. Information gained through some wellness programs, such as the health risk assessment filled out in the Simple Steps To A Healthier Life® program, can be incorporated into the CareEngine.

The Aetna Healthy ActionsSM Program allows plan sponsors to reward members for adopting a healthier way of life, including preventive care such as screenings, vaccinations and exams.

Aetna also offers a wide variety of tools to help plan sponsors and members get the most of their health benefits, including communications programs and online health information, such as:

Programs for Women - including our Beginning RightSM maternity program and an extensive women’s health website
Health Education Reminders - encouraging members to get the care today that will help prevent, detect or monitor conditions early on, when they are most treatable
Interactive health and wellness programs - with health assessments, tailored health reports, and personalized action plans available through Simple Steps To A Healthier Life®
24-Hour Nurse Line - members can have their health questions answered by a registered nurse anytime, night or day
Personalized support - experienced wellness counselors available to help members understand health issues, reduce risk and set meaningful goals
The Member Wellness Message Program - a series of single-topic educational pieces addressing general wellness topics and Aetna’s information tools for members that plan sponsors can distribute to Aetna members by e-mail, in their company newsletters or on their intranet sites
Contact your Aetna representative for more information on all the preventive care and wellness benefits and programs available to your clients.
Source: www.aetna.com