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An Arm and a Leg: Know Your Healthcare Rights By Kaiser Healthcare News

Transcript published Jan 28, 2021
Note: Most of this transcript is machine-generated, so it’s NOT letter-perfect. We’re doing our best! Also, I’ve left off the
list of new donors at the conclusion. (I spell some of them phonetically in the script, so I can try to avoid screwing them up,
but you don’t need to see that. Also, not everybody wants their name on the Internet.) – dw
Hey there– sometimes we have more rights than we think. And more options. In fact, I am starting to think,
that’s true a LOT of the time. I mean, actually enforcing our rights, that can be tough. But just knowing that we
have them? That seems like a pretty good start.

I’ve done a bunch of stories recently with NPR and our pals at Kaiser Health News for their Bill of the Month
series. And honestly, a lot of them, I do not share on this podcast — because they’re basically dead-end
stories. Stories where a super-nice, reasonable, RESOURCEFUL person gets a bill that makes no sense, and
goes to work fighting it
… and hits a dead end. Usually these stories have a sort-of-happy ending: The hospital, or the insurance
company, or whoever, gets a call from a reporter, and suddenly they’re like, “TELL NPR WE’RE FIXING THIS,
OK?” And they fix this one thing, this one time.
I mean, pretty much every story in this series ends like that. Which, you know, is good for the individual person
— and maybe there’s a little bit of satisfaction in hearing, “SEE? THESE GUYS CAVE WHEN THEY GET
CAUGHT.”
But it doesn’t exactly do much to inspire confidence for the rest of us. It leaves kind of a rotten taste.
One of these stories I did last fall, I really wished it had gone another way: The woman in the story, Tiffany Qiu,
was such a fighter, and just a stand-up person. I liked her a LOT, I loved how determined she was, and how
thoughtful. But her story was a total dead end until a reporter showed up.
Actually, in the web version of the story, the reporter from Kaiser Health News quoted a professional patient
advocate– someone who helps people fight weird medical bills– SAYING that, yeah, Tiffany was getting a raw
deal, but legally speaking, she didn’t exactly have any rights she could enforce.
And then we published the story online, and something interesting happened on Twitter. A lawyer named Jeff
Bloom responded to that quote, writing: “Actually, that’s not true.” He said Tiffany totally had legal rights
here– specific, enforceable ones.
And when I asked, Jeff Bloom got on Zoom, explained the whole thing to me, and laid out a bunch more about
our legal rights and how to fight for them. AND a bunch more insight into a bigger question: Why do we run
into dead ends so often?
With more advice from people like Jeff, more of us might be able to find more openings.
[
This is An Arm and a Leg– a show about the cost of health care. I’m Dan Weissmann– I’m a reporter, and I
love a challenge. So my job on this show is to take one of the most enraging, terrifying, depressing parts of
An Arm and a Leg Two-Small-Doses-of-Good-News Transcript published Jan 28, 2021
p. 2
American life– and I know the last year or so has brought the competition on that front to a whole nother level,
but seriously, this one still completely bites– and produce a show that’s entertaining, empowering and useful.
And I think I’ve got a winner for you this time out. Let’s start with that NPR story.
Here’s the setup: Tiffany Qiu is a mom in Southern California who needed a pretty straightforward procedure,
and wanted to make sure she didn’t pay more than she needed to. She worked hard at it, but things didn’t go
her way.

And here’s how it sounded on the radio
Steve Inskeep: We have in hand another baffling medical bill. the story. comes from Dan Weisman,
host of the podcast and arm and a leg who talked with Tiffany to find out what happened.

Dan: Tiffany Qiu took every precaution before committing to a minor surgery at a local hospital. She
called for an estimate. And when the hospital said her share after insurance would be 20% of the bill.

Tiffany Qiu: I said, did you talk to my insurance company? You need to double check that

.
Dan: She knew her policy said she was supposed to pay 30%. They said they were sure. She called
back a couple of days later to ask again, said, I talked to my insurance. They said 30% hospital was
like, no, no, really 20%. It seemed too good to be true

Tiffany Qiu: But I asked them twice and this is a big hospital. I said, okay

Dan: Dave surgery, the hospital wants to be paid upfront, which is a surprise. She drills them

Tiffany Qiu: Is this all I have to pay? Because this is already a surprise. Is it, will there be any other
surprise for me?

Dan: And she makes sure to get a receipt. And then, uh, later she gets a bill $933 and 87 cents. Which
is the difference between the 20% she’s already paid. And the 30% her insurance would usually expect
her to pay. She’s like, wow, I got receipts, calls them and calls and calls. The best she gets from them
is, OK, we’ll send you a detailed statement. But she doesn’t get ANYTHING from them, until, six
months later… .

Tiffany Qiu: In may I suddenly received this collection letter? wow. Collection. My first time
Dan: She considered just paying it. She could have.

Tiffany Qiu: I said, no, no, no. I’m not paying it because this is not right.

Dan: Tiffany does not love this kind of thing. The calls, the emails, the confrontation, but she does it.
And she keeps her guard up. When she sends a written dispute letter to the collection agency. It’s
certified mail. And when they don’t respond, she calls, Hey, your letter says, I’m supposed to hear back
within 30 days.

They say, Nope, the law gives us 60 days.
Tiffany Qiu: I said, really, I’m not a lawyer. But your letter says, will get a response within 30 days.
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Dan: They say whatever, it’s 60 call back later. And when she does, they say, Oh, we’ve sent it to the
hospital. I guess they’re looking at it.

Tiffany Qiu: Nobody can give me a very clear answer. What’s going on? Who is in charge? where the
case is. Nobody knows.

Dan: And then Tiffany gets lucky. A reporter gets interested in her case, makes a call to the hospital.
Suddenly after that one phone call, Tiffany is hearing from a hospital executive with an apology.

Tiffany Qiu: That phone call, just magic, solve everything in one hour, not just one day, but one hour.

Dan: Taking this road was harder for her and it’s not something she would have done when she arrived
in the U S from China at age 26.

Tiffany Qiu: I have changed a lot: how to see the world, how to do things, how to fight. Including this.
I’ve learned from my kids about U. S. History and politics. And I agree there is something we can do
—everybody can do. We need to get pressure to the system to change a little bit over time so that it
can get better.

Dan: As a proud us citizen, she’s doing her bit for NPR news. I’m Dan Weissmann.

So, that’s what aired on the radio. The web version of the story had a patient advocate– somebody who
patients hire to help them negotiate lower medical bills– saying “The simple fact that a hospital staffer
misinformed a patient isn’t a legal reason to force a hospital to lower a bill”
Jeff Bloom saw that and chimed right in on Twitter: He said, a hospital staffer misinforming a patient, quote,
“literally is a legal reason to force them to lower the bill. It’s promissory estoppel slash detrimental reliance.”
I was like, WHEN CAN WE TALK?
Here’s Jeff’s deal. He’s in the DC area. Out of law school, he worked for a firm that did medical malpractice and
personal injury cases. Then he went out on his own. He liked trial work– which lots of lawyers don’t.
Jeff Bloom: Being in a courtroom is, uh, nerve wracking. Bad things happen. Clients get perp walked
out in handcuffs on occasion, depending on the nature of your practice. And a lot of attorneys don’t
like to do that.
He did, so he got other lawyers to hire him to go to court for them. And a couple of debt-collection agencies
became regular clients.
Jeff Bloom: so they would hire me to access trial counsel for these big medical providers.
So if ANYBODY knows how things really work when a medical bill goes to court? It’s Jeff. he’s the guy that
medical providers and debt collectors used to hire to go to court and fight these things out.
Jeff Bloom: yeah, I was the bad guy. That’s for sure.
Then, a few years ago, he switched sides.
Jeff Bloom: I now do the Lord’s work and I represent a lot of consumers in protecting them against,
you know, nefarious billing practices.
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So, OK! Jeff’s our guy for this. First thing, I get him to run down for me: What are these terms he threw out on
Twitter? Promissory estoppel and detrimental reliance?
Basically, it means: You offered me a deal– made a promise– and I took it. Now, you’re changing the terms of
the deal, you want more from me. I’m asking the court to stop you from collecting more.
Or, his way of putting it:
Jeff Bloom: well, then you would basically say, your honor, judge. I relied on what they told me. They
gave me a very clear and definite promise. So therefore they should be, and I’ll use the Latin words
stopped from executing on this collection.
Dan: Huh? It sounds so reasonable. It’s so simple when you put it that way.
Jeff Bloom: It’s like, we forget sometimes that all of these cases are just basic contract cases. And we
forget that the judges in these courts, they generally want to help the consumer. Right? They’re they’re
people, they generally feel bad about the positions you’re in. So you want to just give them an
opportunity to help you. That’s all you’re trying to do in defense of the case. Give the judge an out.
Dan: (Laughs) That’s nice. I like that. I like that a lot.
Yep. Give the judge an out. Jeff does have a caution, though.
Jeff Bloom: All of these collection related theories are our state law. Okay. So they vary depending on
what. The state you’re in
So, as always, the advice here is: DO YOUR HOMEWORK. But Jeff’s other advice is, whatever legal
argument you can make, you are really helping yourself if you can bring what he calls an affirmative claim
against the other side: In other words, you’re making a claim against them– something they did to you.
Something that creates potential liability for them.
Jeff Bloom: and you prosecute the case, uh, which I’ve always found to be like the most helpful thing
you can do
Because it’s a way to bust past these crazy-making dead-ends.
Jeff Bloom: consumers are always super surprised. Why won’t they negotiate? Why won’t they
negotiate with me? Well, it’s because you have no leverage, right? You’ve got to do something to
create some form of leverage. You did something else that is unfair to me. That gives me an actionable
claim under the wall.
You write that up in a savvy way… well, NOW an attorney from the other side is going to actually LOOK at it.
Jeff Bloom: they go back to the medical provider or the deck laughter and say, okay, we’ve got a case
that has some fleas on it. Let’s punt. This Let’s settle it for less than we normally would. Or if it’s really
bad, let’s drop it.
Jeff says a lot of the time, that attorney and the people they work for, they’re not JUST thinking about whether
they might lose your particular case.
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Jeff Bloom: The medical providers in particular– less so the debt collectors– they actually do care
about their reputation. So if you get them on something that they think is going to bother a judge,
who’s going to hear a lot of their cases. They are occasionally willing to punt because they don’t want
to completely destroy their credibility.
Dan: Ah, that’s very interesting that one of the considerations is like, we don’t want to bring this in
front of a judge cause we’re gonna be in front of that judge for other stuff. And we don’t want to show
up defending a case that’s a real dog.
Jeff Bloom: Why poison your whole collections practice by bringing one dog when you’re going to
have hundreds and hundreds of thousands of dollars worth of other cases next week, right? Uh, so
you would never want to screw anything up with like prosecuting in a $500 claim that isn’t quite clean,
And Jeff REALLY knows because– remember– that’s the side he used to be on. He especially got sent in on
cases that, as he says, had some fleas on them.
But this raises a new question. If these folks don’t want to go in front of a judge with a lousy case… why did
they ever hire him? Like, why did he have a job?
And the answer? It opens up a whole new level of insight. I That’s in just a minute.
This episode of an arm and a leg is a co-production with Kaiser health news. That’s a nonprofit news service
covering healthcare in America. Kaiser health news is not affiliated with the big healthcare outfit. Kaiser
Permanente will have a little more information about Kaiser health news. At the end of this episode.
OK, so we know: You threaten to sic the law on someone who’s after you for a bill that’s actually bogus, they
have good reason to cave.
But Jeff says he made his living for years going to court for medical providers and debt collectors to defend
pretty bogus claims. Why on earth would they bother to pay him to do that?
Jeff Bloom: so one of the problems is, is that there’s so many people with their hands in these
different cases,
Jeff says a big problem is that SO many people have their hands on any given case: There’s the provider and
their billing office. Then there’s a collection department– or often an outside collection agency. By the time a
lawyer like Jeff sees a case, he says a bunch of people have passed it around, BUT none of them are exactly
decision-makers.
Jeff Bloom: no one really ever got authority or the discretion.To make a judgment call. Okay. So I show
up to court 95% of the time, the person who sends me says, yeah, I couldn’t get ahold of the vice
president of whatever. I couldn’t get approval to, to drop the case. I couldn’t get approval. They let you
negotiate down the case. And so get in there and present the claim and see what happen.
Dan: Holy shit. That is wild to me. That is so revealing.
Jeff Bloom: Also a good reason to be really nice to the attorney that’s involved in the process, right. He
usually has no authority, but if he does be a good guy to him, because he might not care all that much.
And he might use that discretion to help you out if he does have it.
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Dan: All of that is wild—wild that you end up in a courtroom, cause like everybody’s too busy,
confused…
Jeff Bloom: The case isn’t worth enough to get anyone’s eyeballs on it.
Dan: What are we talking about? Like, is $10,000 enough to get somebody’s eyeballs on it.
Jeff Bloom: Not always, but, but I get from the consumer perspective, $1,000 can be life altering. Right?
That’s the difference from living paycheck to paycheck, to being a little comfortable.
Dan: Or being a giant hospital, right? Where people get more than a little comfortable. Holy wow.
Jeff Bloom: I feel like I’ve surprised you too much
Dan: Well, no, no, it’s so good. It’s so good. It’s so good. We just don’t get inside this enough as
consumers. And even as a reporter, it’s like: this is such an important conversation to me cause I’m
just like, “Oh– right. Yeah…”
Jeff Bloom: The reasons I said earlier that we want to bring an affirmative claim against, uh, on behalf
of the consumer, the reason why is one of those things that happens when you make an affirmative
claim, it gets people’s eyeballs on the file. Your file gets pulled out of the normal usual course of
things.
Hopefully, there’s an attorney who has better judgment than maybe a medical biller in a warehouse in
Michigan somewhere and says, okay, there’s something legitimate here. There’s something that we
want to take a second. Look at this file and see if we can get greater discretion.
Dan: This is just amazing to me. Like we kind of know. We know from talking to people on the phone,
right? Like as consumers, like you got a bill, it’s unreasonable, you talk to somebody and they don’t
have a lot of authority. They may not have a lot of understanding. They may not — all kinds of things
and they’re, and the conversation may not get documented or sent on to anybody.
But this degree of like, non-communication, of all of it, it’s completely in line with what I know. And it’s
just somehow, so —it’s flabbergasting in a way just to have the confirmation of like, right. This is just
how it happens.
Jeff Bloom: A big shift moving towards you. And you know, we, we actually, here’s the good news. We
think of them as very malicious a lot of times. Well, the reality is more of it is this. They have a volume
game. And it’s hard to get all the different cogs to move in the correct direction. So it just moves.
Dan: Holy crap. Uh, and that’s good news. Why? Okay. Hmm.
Jeff Bloom: I prefer it to malice. I prefer representing stupid clients to, to malicious clients personally.
Dan: Fair. Fair, fair, fair. And so what were some of the things that got traction I mean, you did this for
years. Like, what are some of the things that would be useful for us to know about,
Jeff Bloom: So look at your state’s consumer protection laws.
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Dan: Jeff says, every state has one: the idea is that businesses shouldn’t be able to get away with making
false or misleading claims. Sometimes medical providers are exempted, so you know: Do your homework. But
he says they can be very much worth checking out.
Jeff Bloom: The beauty of a consumer protection statute.
Is it often permits you to make a claim. That can pay for the attorney.
So, maybe you’re fighting a bill that’s a thousand bucks, and Jeff, for instance costs 400 bucks an hour. That
seems like a dead-end, unless you’ve got a consumer protection law that says the OTHER side is gonna pay
Jeff if you win. That’s how it works in DC, where Jeff does a lot of work.
Jeff Bloom: This is a super dangerous statute for them because they can be prosecuting a $1,000
claim against you. And if you really get them on the hook for something and you get a good attorney,
who’s billing at 300, 400, $500 an hour.
Dan: NOW you’re getting some eyeballs on that file. Now, maybe that particular road isn’t open to you: you
can’t find a law that’ll make it worth a lawyer’s while– or a lawyer willing to give it a go. So I asked Jeff, how
often do people represent THEMSELVES… effectively?
Jeff Bloom: Uh, I always recommend, if you can get an attorney, get an attorney, it there’s a reason
why I have a job. So maybe one out of every 25 cases, you’ll see a consumer who kind of tripped into
something and did it correctly in front of a judge. Usually again, it’s not quite doing it quite right.
It’s giving the judge and opportunity to lock onto something for you. Right.
Dan: So do your homework, AND…
Jeff Bloom: , be a good guy. Don’t be threatening. Don’t yell at people. Don’t ask, just cause of debt,
collectors being nasty to you.
Judges are your audience. And if you’re a good guy, they might help you out.
So, to bring this back to Tiffany Qiu’s story: there’s a reason why the patient advocates Kaiser Health News
talked to said Tiffany didn’t have a legal right to force the hospital to lower the bill. I ran some of what Jeff had
to say by some law professors and public-interest lawyers in California, where Tiffany lives. They agreed:
Tiffany case, and this promissory-estoppel principle, might not be a slam-dunk in a big courtroom– lawyers,
there’s always a wrinkle– but a judge in small-claims court, or an arbitrator: They’re likely to just ask, What
seems fair here?
They also reminded me about something Jeff touches on, something we’ve heard before: If you do it right, just
letting folks know you’re prepared to haul them into court with a solid claim– that can get their attention and
cooperation.
But as we’ve also heard before: Doing it right is … complicated. It takes knowledge and can take a lot of time–
and it helps to have training and practice. And all of this has me thinking: We’ve been focusing in this show on
self-defense against things like unfair bills. Could we go beyond just SELF-defense?Could we build up a kind
of legal guerilla army? I mean, it’s a BIG project, it would take a long time. And it wouldn’t solve everything.
BUT WOULDN’T IT BE FUN? I get notes from people, from time to time, saying: Hey, I’d like to put some of my
spare time into helping other people fight weird bills. And I never know quite what to say.
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I’m saying now: I’m personally kind of interested in this idea, of bringing people together– like, online– to start
figuring out: what are the laws in different states? What resources exist– what kind of information is out there,
and are there people who can… mentor us, to put it to work?
I mean– I REALLY don’t know exactly how to do that. I’m a reporter. I make a podcast. But I’m getting
interested in figuring it out. It just sounds fun.
Meanwhile, there are OTHER ways to fight– including just playing nice, keeping it cool. I got a note recently
from Nicole in Milwaukee, with the heading: “WORKS FOR OTHER THINGS TOO”
She had a new laptop, and it seemed like a lemon. She got in touch with the company, and was getting a hard
time about her warranty. Then, she writes…
I took a few deep breaths and started over. I asked where the person on the other end was from, learned they
were from India and told them I had traveled there in the past and to what cities, and asked how they were
doing during the pandemic. I learned they were able to work from home and that their family was all well. I then
explained that I had been working long hours during covid in healthcare, had a toddler home with me and lost
two family members during this time. I said that the issue started immediately when I got the laptop, but that
due to everything going on I just had not had time to call and then send in my laptop, all true. Long story short,
he accepted my reasoning and agreed to cover the fix under my warranty for free. 100% it was because I took
the advice on the podcast.
I AM TELLING YOU, YOU ARE MAKING MY DAY HERE. Every day.
Please keep these stories coming. They do NOT to have happy endings either. I mean, that’s not the world we
live in. If it was, I wouldn’t need to do this show.
Hit me up at arm and a leg show dot com, slash contact– OR leave a message on our hotline. Maybe we’ll
play it! That number is (724) 276-6534; that’s 724 ARM N LEG.
724 ARM N LEG.
I’ll be back in a couple weeks.
Till then, take care of yourself.
An arm and a leg is produced by me, Dan Weissmann, and edited by Marian Wang. Daisy Rosario is our
consulting managing producer. Adam Raymonda is our audio wizard. Our music is from Dave Winer and Blue
Dot Sessions.
This season of an arm and a leg is a co production with Kaiser Health News. That’s a nonprofit news service
about healthcare in america, an editorially independent program of the Kaiser Family Foundation. Kaiser
Health News is not affiliated with Kaiser Permanente, the big healthcare outfit. They share an ancestor. This
guy, Henry J Kaiser. He had his hands in a lot of different stuff.
Really different. Smelted aluminum. Owned TV stations. Built ships– and built one of the first big resorts in
Hawaii. When he died more than 50 years ago. He left half his money to the foundation that later created
Kaiser Health News. You can learn more about him and kaiser health news at arm and a leg show dot com
slash kaiser.
An Arm and a Leg Two-Small-Doses-of-Good-News Transcript published Jan 28, 2021
p. 9
Diane Webber is national editor for broadcast and Taunya English is senior editor for broadcast innovation at
Kaiser Health News. They are editorial liaisons to this show.
Thanks to Public Narrative — a chicago-based group that helps journalists and non-profits tell better stories–
for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about public
narrative at www dot public narrative dot org.
Finally, thank you to some of the folks who have pitched in at arm and a leg show, dot com slash support.
Thanks this time to…

Thank you!!

Baby Blues: First-Time Parents Blindsided by ‘the Birthday Rule’ and a $207,455 NICU Bill

In the nine months leading up to her due date, Kayla Kjelshus and her husband, Mikkel, meticulously planned for their daughter’s arrival.

This story also ran on NPR. It can be republished for free.

Their long to-do list included mapping out their family’s health insurance plan and registering for baby gear and supplies. They even nailed down child care ahead of her birth.

“We put a deposit down to hold a spot at a local day care following our first ultrasound,” said Kayla Kjelshus, of Olathe, Kansas.

The first-time parents felt ready for their daughter’s debut on Feb. 15, 2019. But one of the happiest days of their lives turned out to be one of the scariest. Their daughter, Charlie, had a complication during delivery that caused her oxygen levels to drop and put her at risk for brain damage.

“We had a waiting room filled with family and friends,” Mikkel recalled. “To come out and say things aren’t well … it was really hard.”

Charlie was transferred from St. Luke’s Community Hospital to HCA Overland Park Regional Medical Center, where she received treatment in the neonatal intensive care unit, known as the NICU, for the next seven days.

Doctors sent Charlie home with a positive prognosis. The couple had decided that Kayla, a nurse practitioner, would carry Charlie on her insurance plan through Blue Cross and Blue Shield of Kansas City. Her plan offered better rates than Mikkel’s, and his plan was based in another state and carried a higher deductible. So when the hospital asked for insurance information, Kayla provided her policy number; Mikkel did not.

They expected things to work out fine between the insurance company and the hospitals.

Then the bills came.

The Patient: Charlie Kjelshus, an infant covered by her mother’s plan through Blue Cross and Blue Shield of Kansas City and, eventually, her father’s plan, CommunityCare of Oklahoma

Medical Service: Whole body cooling and other treatment in the NICU to prevent brain injury that may result from oxygen deprivation during birth

Service Provider: HCA Overland Park Regional Medical Center in Overland Park, Kansas

Total Bill: Multiple charges totaling $270,951, according to Mikkel Kjelshus, including a charge of $207,455 for the NICU stay

What Gives: Kayla Kjelshus filed a claim with Blue KC, and the insurer started paying for baby Charlie’s care. But then it canceled payments to the HCA Overland Park hospital, St. Luke’s Community Hospital and Charlie’s neurologist, pediatrician and other physicians.

“We thought, ‘This is crazy,’” Mikkel said. “‘We have insurance.’”

What was going on?

The Kjelshus family had slammed into something well known among insurance experts but little understood by the general public. “Coordination of benefits” and “the birthday rule” are the jargon terms for the red tape that snared them.

When a child is born into a family in which both parents have insurance through their jobs, the parents are supposed to “coordinate benefits” — meaning they must tell both insurers that their child is eligible for coverage under two plans. The parents might be forgiven for thinking they have some say in how their child will be insured. In most cases, they don’t.

Instead, a child with double health insurance eligibility must take as primary coverage the plan of the parent whose birthday comes first in the calendar year; the other parent’s insurance is considered secondary. This model regulation was set by the National Association of Insurance Commissioners and adopted by most states, including Kansas, said Lee Modesitt, director of government affairs with the Kansas Insurance Department.

For Charlie Kjelshus, the birthday rule meant her dad’s plan — with a $12,000 deductible, a high coinsurance obligation and a network focused in a different state — was primary. Her mom’s more generous plan was secondary.

Mom Kayla said Blue KC dispatched an investigator to discover that dad Mikkel had insurance through his job. The family had not been trying to hide Mikkel’s coverage; they merely weren’t aware of the birthday rule and that they may be subject to state laws that ensure babies are covered for the first 31 days of life.

“If these are the rules of engagement, you need to tell people upfront that these are the rules,” said Dr. Linda Burke, an OB-GYN and author of “The Smart Mother’s Guide to a Better Pregnancy.” “It’s a communication problem.”

After Blue KC informed Mikkel that his insurance had to serve as primary coverage, CommunityCare of Oklahoma did pay Charlie’s bills from the hospitals and other providers. It paid HCA Overland Park $16,605 on the $207,455 NICU charge. The insurer said its negotiated rate on the bill was $35,721. With Mikkel’s deductible and coinsurance, that left the family on the hook for more than $19,116, it seemed.

“When an insurance company finds out that a baby is in the NICU, then it’s a red flag,” Burke said. “They are going to look for ways to cut their losses.”

Resolution: The couple turned to the Kansas Department of Insurance to file a complaint about the bill, but the department declined to help because Kayla’s policy is self-funded by her employer, which means the company is subject to federal rather than state regulations.

After close to a year and a half of going back and forth with their insurance companies and the hospitals, Blue KC paid $19,116 of the Kjelshuses’ bill as a secondary insurer and said the Kjelshuses should not be responsible for a remaining balance of $7,504.51 from HCA Overland Park. But the family kept getting bills.

And, beginning in summer 2020, collections calls from the hospital rolled in daily, leaving the couple frustrated and confused.

Eventually, after a human resources officer at Kayla’s job stepped in to help, they received a statement with a zero balance. Their own calls to HCA Overland Park hospital billing department didn’t get them anywhere.

“We always got a different answer,” Kayla said. “It was so frustrating.”

A spokesperson for the hospital apologized for the deluge of calls from collections.

“We made an administrative error and an automated billing call system for payment occurred, causing the family undue frustration during an already stressful time, and we apologize,” the hospital wrote in a statement. “Once the issue was identified and resolved, the insurance companies processed the claim and we informed the family that there is a zero balance on the account. Again, we are sorry for the stress and inconvenience, and wish them well.”

In a statement, Blue KC acknowledged that coordination of benefits can be confusing for members, and that the company follows rules of state and federal regulators, modeled on standards set by the NAIC. It said the Kjelshuses’ future claims would continue to be paid and that a “dedicated service consultant” would continue to work with Kayla Kjelshus.

In the end, the insurers and hospitals settled Charlie’s bill as they were supposed to: The primary insurer paid first, and the secondary paid what had not been covered by the first. But it took more than a year of phone calls, appeals and complaints before the Kjelshus family had the matter settled. Charlie turns 2 next month.

The Takeaway: In theory, “the birthday rule” would be a fair, if random, way to figure out which insurance should be primary and which secondary for families with insurance from two employers. The presumption is that the premiums, deductibles and networks are roughly similar in both parents’ insurance plans — but that’s simply not the case for many families.

The Kjelshuses found out the hard way they didn’t have a choice about which parents’ insurance was primary. They might have avoided their quagmire if Mikkel had dropped his own coverage and gotten onto Kayla’s plan before Charlie was born.

It’s not clear whose responsibility it is to help families navigate these rules before a baby is born. It’s even more complicated for parents who are divorced or never married. Insurance companies don’t always offer the critical information families need about the coordination of benefits.

“Expecting parents should try to get in touch with their health plan before the baby is born to find out about the coverage rules,” said Karen Pollitz, a senior fellow at KFF, the Kaiser Family Foundation. (KHN is an editorially independent program of KFF.)

“Also figure out if they want to switch the entire family onto one plan once the baby is born.”

It’s also a good idea to speak to human resources representatives at both parents’ jobs. The birth of a baby is considered “a qualifying event” for insurance coverage in all group health plans, so families can make decisions about changing coverage at that time. Otherwise, families might have to wait for open enrollment to make coverage changes.

“It is ridiculous to me my wife and I faced so many issues since both parents have health insurance,” Mikkel Kjelshus wrote. His daughter, Charlie, now is covered only by his wife’s plan.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Trump Rule Gives Small Companies a New Tool to Help Workers Buy Health Coverage

Until October, Andrea LaRew was paying $950 a month for health insurance through her job at the Northwest Douglas County Chamber & Economic Development Corp. in the metro Denver area.

Her company didn’t contribute anything toward the premium. Plus, LaRew and her husband had a steep $13,000 deductible for the plan. But the coverage and the premium cost were in line with other plans available to the company since options for such a small work group — just LaRew and another employee wanted to enroll — weren’t plentiful.

Now they’re trying a new approach. Instead of a traditional plan, the chamber established an “individual coverage health reimbursement arrangement” (sometimes referred to as ICHRA) to which it allocates $100 a month per employee that they must put toward comprehensive coverage on the individual insurance market. These employer contributions may be used to pay for expenses such as premiums or cost sharing.

The reimbursements don’t count as taxable income to workers.

Proponents of the plans say they’re a good option for companies that may not feel they can afford to offer a traditional plan to workers but want to give them something to help with health care expenses. But consumer advocates are concerned they may shortchange some workers.

These small businesses can’t afford to offer health care coverage as the premium prices rise, said Garry Manchulenko, a principal at GMBA Advisors Group in the Denver metro area, who suggested the arrangement to the chamber. “They want to help their employees, but they can’t sustain these increases, particularly at the small-group level.”

Manchulenko said he’s suggesting the new setup for some of his clients, noting that in certain places premiums on the individual market are lower than those for group plans.

LaRew, 48, bought a plan similar to the group plan, but with a monthly price tag of $730 after she factors in the company’s contribution, a savings of more than $2,600 a year.

“It’s still super expensive for two healthy people,” said LaRew, who oversees many of the chamber’s administrative functions. But she appreciates that her premiums are deducted from her pretax income, just as when she was on the group plan.

She also liked having her pick of several plans. “I could choose my own individual plan that suits my family best, and not be tied to a group plan that works great for a co-worker but not for me.”

The new coverage option was established through a rule issued by the Trump administration last year. It could be helpful for workers like LaRew whose income is too high to qualify for the Affordable Care Act’s tax credits that help pay for policies sold on the individual market. It may also be attractive to part-time or seasonal workers who don’t qualify for their employer’s coverage, according to insurance brokers and policy experts familiar with the new option.

But consumer advocates warned that it could encourage employers who had offered a traditional insurance plan to switch to the new arrangement because of the cost savings. That might leave their workers with a more cumbersome enrollment process and less generous coverage.

“I do think there are pitfalls for employees,” said Jason Levitis, a nonresident fellow at the USC-Brookings Schaeffer Initiative for Health Policy. “There’s confusion about the ICHRAs themselves.”

“And even if you know you need an ACA-compliant plan, how do you find one?” he asked, noting the prevalence of deceptive marketing of plans that don’t meet ACA standards.

In addition, because of a quirk in how the new rules work, lower-income workers who bought ACA marketplace plans because their employer didn’t offer coverage could lose the federal subsidies for their marketplace plans if their company puts an ICHRA in place.

Here’s how that could come into play. Only people earning 400% of the federal poverty level or less (about $51,000 for one person) are eligible for premium subsidies. In addition, in order to qualify the coverage offered by an employer must be considered unaffordable to the worker. If an employer offers an individual coverage health reimbursement arrangement, that means workers who would otherwise meet the poverty threshold would also have to contribute more than 9.78% of their income to buy the lowest-cost individual silver plan on the exchange. That amount would be based on the plan’s cost after factoring in the contribution from an employer.

If the worker’s contribution is lower than that standard, then the only assistance they are eligible for is through the ICHRA contribution. Federal rules don’t allow workers to accept both ICHRA contributions and premium tax credits.

“My concern is for people who are out there with a premium tax credit” who might lose that subsidy if they don’t meet the federal standard, said Peter Newell, director of the Health Insurance Project for the United Hospital Fund in New York, who authored an analysis of the new coverage option in October.

There are affordability caps in the ACA for regular employer-sponsored coverage, too, but those caps are generally lower than the caps for ICHRAs. As employers move to offer ICHRAs instead of traditional coverage, some workers will lose their premium tax credits because of the higher affordability threshold, Newell’s analysis found.

If this sounds complicated, it’s because it is, and brokers and advocates agree that many workers will need assistance figuring out what to do. In addition to running the numbers, people may need to work through where to buy a comprehensive plan that complies with the ACA. Such plans can be purchased on and off the exchange, but if workers want the company to deduct their premium costs from their salary, as LaRew did, they must purchase a plan outside of the exchange.

“There are so many paths to take and so many points of confusion, it’s super, super important that employees have some support going through this,” said Cat Perez, co-founder and chief product officer at Health Sherpa, whose technology platform helps people enroll in marketplace plans. It has incorporated information about ICHRAs.

Colorado is working with the broker community to drum up interest in the new product, said Kevin Patterson, chief executive officer of Connect for Health Colorado, the state’s insurance exchange.

“If we can get more people into the individual marketplace that makes it stronger,” Patterson said.

In theory that makes sense, but some analysts worry that the adoption of these new arrangements could drive up marketplace premiums by encouraging employers with sick workers to shift them into the individual market.

“This is a way to offer a lower premium option to some employers, but with the consequence of increasing premiums in the individual market and costs for the federal government via higher premium tax credits,” said Matthew Fiedler, a fellow in economic studies at USC-Brookings, who co-authored an analysis of the new offerings.

Still, larger employers aren’t currently very interested in embracing these new arrangements, said Jay Savan, a partner at human resources consultant Mercer.

The federal rules don’t allow employers to offer an employee both a traditional plan and an ICHRA simultaneously, and most large employers aren’t ready to replace their traditional plans.

“As long as it’s black-or-white, there are precious few employers of size that are willing to take that leap,” he said.

Top 82 U.S. Non-Profit Hospitals-Quantifying Government Payments and Financial Assets

OPEN THE BOOKS IS A GREAT WEBSITE THAT REVEALS GOVERMENT SPRNDING AND WASTE. THE LINK BELOW LOOKS AT 82 NON FOR PROFIT HOSPITALS AND REVEALS SOME EYE POPPING INFORMATION.

 

https://www.openthebooks.com/assets/1/6/Top_82_U.S._Non-Profit_Hospitals_Final_Report.pdf

 

In households across America, healthcare costs are crushing the American dream. The average family now pays nearly
$20,000 annually between insurance premiums, deductibles,
and out-of-pockets costs.
In 1970, healthcare amounted to seven-percent of gross
domestic product (GDP). Today, estimates suggest the soaring
cost of healthcare will consume 20-percent of our GDP.
Our OpenTheBooks Oversight Report – Top 82 U.S. Non-Prof-it
Hospitals, Quantifying Government Payments & Financial
Assets studied the largest charitable healthcare providers. Last
year, patients spent roughly 1 out of every 7 U.S. healthcare
dollars within these healthcare networks. Many are household
names: Mayo Clinic, Cleveland Clinic, Kaiser Foundation, Dignity Health, and Partners HealthCare.
These powerful institutions are organized as public charities –
not as for-profit corporations. Their mission is to deliver the
latest in medical technologies and affordable healthcare to
their communities. Any “profits” must be re-invested into their
charitable mission.
However, these 82 non-profit medical providers are making
big money. Last year, their combined net assets increased from
$164.2 billion to $203.1 billion – that’s 23.6-percent growth.*
Meanwhile, their executives are highly compensated. The Banner Health Chief Executive Officer and President earned $21.6
million and their Executive Vice President and CAO made $12
million last year. Top executives at Memorial Hermann Health
System, Kaiser Health, Ascension, Advocate Health Care, and
Northwestern Memorial made between $10 million and $18
million.

For comparison, our analysis also includes the five largest pubcly traded for-profit U.S. hospitals. These five corporations
had $96 billion in revenues last year with net asset growth of
$600 million: an increase in assets from $40.1 billion to $40.7
billion year-over-year (1.5% increase).
Taxpayers deserve to know whether our non-profit healthcare
providers, which use our laws to structure themselves as charities, are truly working for patients. After all, these non-profits
pay no income taxes, or property taxes, and raised over $5
billion last year in tax-deductible contributions from donors.

From Prisoner to Customer to Sophisticated Consumer (Continued)

Hopefully you’ve had time to get your medical house in order. You’ve done the research on your family’s medical history. You’ve found the appropriate internal medicine physicians that specialize in whatever chronic issues your family members face. You are now engaged in your medical care.

 

The topic on the table today continues to be pricing transparency. The debate continues to rage on by skeptics that argue patients have little incentive to “shop” for medical care because insurance insulates them from medical costs. They also point to studies showing few patients use current pricing transparency tools to shop for medical care.

 

We can be as skeptical as the next person but a recent event bolstered our belief that pricing transparency in a simple, well-constructed form has an important place in health care. Recently, a company we’ve mentioned before, GoodRx, had a public stock offering for over $1 billion and placed the value of the company at $12.6 billion. Simply stated, GoodRx is a pricing transparency company in the pharmaceutical area. The company provides a simple to use and effective way for consumers to obtain significant discounts on prescription drugs. So given Wall Street’s reaction, we believe there is a place for pricing transparency in health care.

 

Here’s the catch-twenty two. The health care industry doesn’t. There’s seemingly consensus from both providers and insurers that somehow pricing transparency will cause massive damage to their economic interests and not be helpful to patients. From our media scanning, employers can expect estimated increases for 2021 health insurance premiums to be around 5%. Health benefit consultants are continuing to provide solutions to mitigate these increases. Surprisingly, pricing transparency “tools” are now starting to emerge as consultant recommendations as a means of minimizing the impact of these increases.

 

We recently surveyed a metropolitan area with an aggressive pricing transparency provider that provides a sophisticated website pricing tool. Our thinking was that with a “bell cow” in the market others would be inclined to follow in some reasonable fashion. Our thinking was wrong. There was little to no discernible impact on others’ to provide some means of pricing transparency. What we weren’t able to determine was the “spillover” impact on other organizations’ pricing for similar services.

 

Our research is providing us with some undeniable facts. The external business environment is moving rapidly further and further away from the business practices of healthcare. Some of this gap is being created by outdated government legislation and some of it is being created by the industry’s resistance to ongoing technology developments. We accidentally stumbled on to an example of how over 20 year old legislation is having what now might be an unintended negative consequence on private contracting between a physician and patient. The Balanced Budget Act of 1997 prevents an Original Medicare Beneficiary from entering into a private contract with a physician. At the time, the thinking was this legislation was providing the patient with “protection”  from inflated prices. In today’s environment, the legislation prevents patients from gaining access to physicians and from negotiating prices. This finding reinforces our belief that neither the government nor significant industry leadership is going to result in a successful pricing transparency movement.

 

Unleashing market place competitive forces on health care will lower prices despite what skeptics say. Will there be unintended consequences? Sure. There are examples, like reference pricing that have proven successful in lowering prices. This practice has largely been utilized by large organizations with large workforces. So the benefits have been constrained without creating any type of “spillover” impact.

 

We are now entering a new era in health care. The “Pandemic” has created wide-spread changes in every day life practices. In health care, we’ve seen a tremdous surge in telemedicine which prior to Covid was being strongly resisted by the health care industry. We’ve seen significant changes in how hospitals protect both their employees and patients from infectious disease. We’re now going to see how the country deals with a significant number of people  having lost employment based health care insurance coverage. This is going to unleash huge numbers of people searching for better deals in health care.

 

We are now asking for your help in creating a health care marketplace where there is transparency in pricing, quality and access. We have relied upon market forces in almost every aspect of our lives. Health care has been “special” and exempted from these forces. We believe the implementation of pricing transparency legislation will be a first step to pulling back the curtain. As consumers we’re critical in this transformation. We need your insights and experiences to share with others. We’re creating a section on our website where patients and consumers can be a community of health care activists. Share your experiences!

After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion

Adam Woodrum was out for a bike ride with his wife and kids on July 19 when his then 9-year-old son, Robert, crashed.

“He cut himself pretty bad, and I could tell right away he needed stitches,” said Woodrum.

Because they were on bikes, he called the fire department in Carson City, Nevada.

“They were great,” said Woodrum. “They took him on a stretcher to the ER.”

Robert received stitches and anesthesia at Carson Tahoe Regional Medical Center. He’s since recovered nicely.

Then the denial letter came.

The Patient: Robert Woodrum, covered under his mother’s health insurance plan from the Nevada Public Employees’ Benefits Program

Total Bill: $18,933.44, billed by the hospital

Service Provider: Carson Tahoe Regional Medical Center, part of not-for-profit Carson Tahoe Health

Medical Service: Stitches and anesthesia during an emergency department visit

What Gives: The Aug. 4 explanation of benefits (EOB) document said the Woodrum’s claim had been rejected and their patient responsibility would be the entire sum of $18,933.44.

This case involves an all-too-frequent dance between different types of insurers about which one should pay a patient’s bill if an accident is involved. All sides do their best to avoid paying. And, no surprise to Bill of the Month followers: When insurers can’t agree, who gets a scary bill? The patient.

The legal name for the process of determining which type of insurance is primarily responsible is subrogation.

Could another policy — say, auto or home coverage or workers’ compensation — be obligated to pay if someone was at fault for the accident?

Subrogation is an area of law that allows an insurer to recoup expenses should a third party be found responsible for the injury or damage in question.

Health insurers say subrogation helps hold down premiums by reimbursing them for their medical costs.

About two weeks after the accident, Robert’s parents — both lawyers — got the EOB informing them of the insurer’s decision.

The note also directed questions to Luper Neidenthal & Logan, a law firm in Columbus, Ohio, that specializes in helping insurers recover medical costs from “third parties,” meaning people found at fault for causing injuries.

The firm’s website boasts that “we collect over 98% of recoverable dollars for the State of Nevada.”

Another letter also dated Aug. 4 soon arrived from HealthScope Benefits, a large administrative firm that processes claims for health plans.

The claim, it said, included billing codes for care “commonly used to treat injuries” related to vehicle crashes, slip-and-fall accidents or workplace hazards. Underlined for emphasis, one sentence warned that the denied claim would not be reconsidered until an enclosed accident questionnaire was filled out.

Adam Woodrum, who happens to be a personal injury attorney, runs into subrogation all the time representing his clients, many of whom have been in car accidents. But it still came as a shock, he said, to have his health insurer deny payment because there was no third party responsible for their son’s ordinary bike accident. And the denial came before the insurer got information about whether someone else was at fault.

“It’s like deny now and pay later,” he said. “You have insurance and pay for years, then they say, ‘This is denied across the board. Here’s your $18,000 bill.’”

When contacted, the Public Employees’ Benefits Program in Nevada would not comment specifically on Woodrum’s situation, but a spokesperson sent information from its health plan documents. She referred questions to HealthScope Benefits about whether the program’s policy is to deny claims first, then seek more information. The Little Rock, Arkansas-based firm did not return emails asking for comment.

The Nevada health plan’s documents say state legislation allows the program to recover “any and all payments made by the Plan” for the injury “from the other person or from any judgment, verdict or settlement obtained by the participant in relation to the injury.”

Attorney Matthew Anderson at the law firm that handles subrogation for the Nevada health plan said he could not speak on behalf of the state of Nevada, nor could he comment directly on Woodrum’s situation. However, he said his insurance industry clients use subrogation to recoup payments from other insurers “as a cost-saving measure,” because “they don’t want to pass on high premiums to members.”

Despite consumers’ unfamiliarity with the term, subrogation is common in the health insurance industry, said Leslie Wiernik, CEO of the National Association of Subrogation Professionals, the industry’s trade association.

“Let’s say a young person falls off a bike,” she said, “but the insurer was thinking, ‘Did someone run him off the road, or did he hit a pothole the city didn’t fill?’”

Statistics on how much money health insurers recover through passing the buck to other insurers are hard to find. A 2013 Deloitte consulting firm study, commissioned by the Department of Labor, estimated that subrogation helped private health plans recover between $1.7 billion and $2.5 billion in 2010 — a tiny slice of the $849 billion they spent that year.

Medical providers may have reason to hope that bills will be sent through auto or homeowner’s coverage, rather than health insurance, as they’re likely to get paid more.

That’s because auto insurers “are going to pay billed charges, which are highly inflated,” said attorney Ryan Woody, who specializes in subrogation. Health insurers, by contrast, have networks of doctors and hospitals with whom they negotiate lower payment rates.

Resolution: Because of his experience as an attorney, Woodrum felt confident it would eventually all work out. But the average patient wouldn’t understand the legal quagmire and might not know how to fight back.

“I hear the horror stories every day from people who don’t know what it is, are confused by it and don’t take appropriate action,” Woodrum said. “Then they’re a year out with no payment on their bills.” Or, fearing for their credit, they pay the bills.

After receiving the accident questionnaire, Woodrum filled it out and sent it back. There was no liable third party, he said. No driver was at fault.

His child just fell off his bicycle.

HealthScope Benefits reconsidered the claim. It was paid in September, two months after the accident. The hospital received less than half of what it originally billed, based on rates negotiated through his health plan.

The insurer paid $7,414.76 of the cost, and the Woodrums owed $1,853.45, which represented their share of the deductibles and copays.

The Takeaway: The mantra of Bill of the Month is don’t just write the check. But also don’t ignore scary bills from insurers or hospitals.

It’s not uncommon for insured patients to be questioned on whether their injury or medical condition might have been related to an accident. On some claim forms, there is even a box for the patient to check if it was an accident.

But in the Woodrums’ case, as in others, it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.

If an insurer denies all payment for all medical care related to an injury, suspect that some type of subrogation is at work.

Don’t panic.

If you get an accident questionnaire, “fill it out, be honest about what happened,” said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs lawyers. Inform your insurer and all other parties of the actual circumstances of the injury.

And do so promptly.

That’s because the clock starts ticking the day the medical care is provided and policyholders may face a statutory or contractual requirement that medical bills be submitted within a specific time frame, which can vary.

“Do not ignore it,” said Domnick. “Time and delay can be your enemy.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Medicare Open Enrollment Is Complicated. Here’s How to Get Good Advice As Kaiser Health News Explains.

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in Californiado not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”

Trump Administration’s Rule Ending Drug Rebates in Medicare Nears Final Approval

The Trump administration’s revived rule to end rebates that drugmakers give to middlemen in Medicare is awaiting approval from the Office of Management and Budget and a final rule could be imminent, according to a person familiar with the matter.

The administration has said the rule would drive down the prices consumers pay for prescription drugs. An earlier version of the rule, a signature part of President Trump’s plan to lower drug prices, was withdrawn in 2019 because some White House advisers raised concerns that it could increase Medicare premiums. Mr. Trump in July signed an executive order that revived the rule and added a requirement that it not raise premiums or increase federal spending.

Ending the annual rebates would spare drug companies from paying billions of dollars to middlemen in Medicare, the federal health-insurance program for seniors and the disabled. Health plans had fought against the proposal because they would then have to cover higher drug costs. The rule was revised because of the requirements on premiums imposed by the executive order, the person said.

The Department of Health and Human Services’ decision to submit the rule to the OMB shows the administration plans to continue making health-related rules and regulations before Jan. 20, when President-elect Joe Biden is scheduled to be inaugurated.

Trump officials preparing to move forward with major step to lower Medicare drug prices

The Trump administration is preparing to move forward with a major proposal to lower drug prices and rulemaking could come as soon as this week, according to people familiar with the effort.

The move, fiercely opposed by the pharmaceutical industry, would implement President Trump’s “most favored nation” proposal and lower certain Medicare drug prices to match prices in other wealthy countries.

Trump issued an executive order in September calling for steps to that effect, but it was unclear whether the administration would still go forward with implementing the proposal, especially given the election and a coming change in administration.

Sources said that while plans can always change at the last minute, the administration is preparing to take the regulatory steps to implement the idea as soon as this week and that it is likely to take the form of an interim final rule, meaning it will skip some of the steps in the regulatory process and go forward faster.

Asked about the plans, a spokesperson for the Department of Health and Human Services said “we don’t have any announcements at this time.” A White House spokesperson did not immediately respond to a request for comment.

Trump’s actions would be sure to set off a backlash from drug companies, possibly including lawsuits to try to stop the rule.

Many congressional Republicans also oppose the proposal, warning that it veers from traditional GOP free-market principles and instead constitutes “price controls.”

In a twist, though, the proposal is similar to ideas proposed by Democrats to lower drug prices, increasing the odds that the incoming Biden administration would choose to continue the program if it’s implemented.

Trump has long railed against high drug prices, but none of his major proposals have taken effect. This proposal would be his most sweeping move on drug prices.

“Just signed a new Executive Order to LOWER DRUG PRICES!” Trump tweeted in September. “My Most Favored Nation order will ensure that our Country gets the same low price Big Pharma gives to other countries. The days of global freeriding at America’s expense are over and prices are coming down FAST!”

While the details of the regulation remain to be seen, the executive order proposed lowering Medicare drug prices to more closely match the lower prices in other wealthy countries that make up the Organization for Economic Cooperation and Development. It is also unclear whether the rules will apply to drugs in just Medicare Part B or Medicare Part B and Part D.

On a separate drug pricing front, a rule to eliminate rebates that drugmakers pay to pharmacy benefit managers, in a bid to simplify the pricing system and lower out of pocket costs for patients, could also come before President-elect Joe Biden takes office. The rule went to the Office of Management and Budget for review on Friday, an online government dashboard shows.

That proposal is supported by the pharmaceutical industry but opposed by pharmacy benefit managers, the companies that negotiate prices with drugmakers and receive the rebates. The Pharmaceutical Care Management Association (PCMA), which represents those companies, pointed to projections that eliminating rebates could increase premiums and government spending, and threatened to sue.

“If this rule is finalized as originally proposed, PCMA will explore all possible litigation options to stop the rule from taking effect and destabilizing the Medicare Part D program that millions of beneficiaries and people living with disabilities rely on,” the organization said.

The combination of the two different possible drug pricing rules in the closing days of the Trump administration would mean that officials are going out with a burst of moves on a front where action was stalled for much of Trump’s presidency.

Trump first announced a version of the most favored nation proposal in 2018, shortly before the midterm elections, but the proposal went nowhere.

But the approach taken by the administration could open the proposed rule to legal challenges.

Fast-tracking the proposal through an interim final rule, rather than the normal process of first doing a proposed rule and gathering comments, could make it easier for drug companies to win their lawsuits seeking to stop the proposal.

“In the last weeks of the administration, [Health and Human Services] Secretary [Alex] Azar seems inclined to try to move this and other rules forward in a way that creates much more legal jeopardy for them than is necessary,” tweeted Rachel Sachs, a health law professor at Washington University in St. Louis.

Five Important Questions About Pfizer’s COVID-19 Vaccine As Reported By Kaiser Health News

Pfizer’s announcement on Monday that its COVID-19 shot appears to keep nine in 10 people from getting the disease sent its stock price rocketing. Many news reports described the vaccine as if it were our deliverance from the pandemic, even though few details were released.

There was certainly something to crow about: Pfizer’s vaccine consists of genetic material called mRNA encased in tiny particles that shuttle it into our cells. From there, it stimulates the immune system to make antibodies that protect against the virus. A similar strategy is employed in other leading COVID-19 vaccine candidates. If mRNA vaccines can protect against COVID-19 and, presumably, other infectious diseases, it will be a momentous piece of news.

“This is a truly historic first,” said Dr. Michael Watson, the former president of Valera, a subsidiary of Moderna, which is currently running advanced trials of its own mRNA vaccine against COVID-19. “We now have a whole new class of vaccines in our hands.”

But historically, important scientific announcements about vaccines are made through peer-reviewed medical research papers that have undergone extensive scrutiny about study design, results and assumptions, not through company press releases.

So did Pfizer’s stock deserve its double-digit percentage bump? The answers to the following five questions will help us know.

1. How long will the vaccine protect patients?

Pfizer says that, as of last week, 94 people out of about 40,000 in the trial had gotten ill with COVID-19. While it didn’t say exactly how many of the sick had been vaccinated, the 90% efficacy figure suggests it was a very small number. The Pfizer announcement covers people who got two shots between July and October. But it doesn’t indicate how long protection will last or how often people might need boosters.

“It’s a reasonable bet, but still a gamble that protection for two or three months is similar to six months or a year,” said Dr. Paul Offit, a member of the Food and Drug Administration panel that is likely to review the vaccine for approval in December. Normally, vaccines aren’t licensed until they show they can protect for a year or two.

The company did not release any safety information. To date, no serious side effects have been revealed, and most tend to occur within six weeks of vaccination. But scientists will have to keep an eye out for rare effects such as immune enhancement, a severe illness brought on by a virus’s interaction with immune particles in some vaccinated persons, said Dr. Walt Orenstein, a professor of medicine at Emory University and former director of the immunization program at the Centers for Disease Control and Prevention.

2. Will it protect the most vulnerable?

Pfizer did not disclose what percentage of its trial volunteers are in the groups most likely to be hospitalized or to die of COVID-19 — including people 65 and older and those with diabetes or obesity. This is a key point because many vaccines, particularly for influenza, may fail to protect the elderly though they protect younger people. “How representative are those 94 people of the overall population, especially those most at risk?” asked Orenstein.

Both the National Academy of Medicine and the CDC have urged that older people be among the first groups to receive vaccines. It’s possible that vaccines under development by Novavax and Sanofi, which are likely to begin late-phase clinical trials later this year, may be better for the elderly, Offit noted. Those vaccines contain immune-stimulating particles like the ones contained in the Shingrix vaccine, which is highly effective in protecting older people against shingles disease.

3. Can it be rolled out effectively?

The Pfizer vaccine, unlike others in late-stage testing, must be kept supercooled, on dry ice around 100 degrees below zero, from the time it is produced until a few days before it is injected. The mRNA quickly self-destructs at higher temperatures. Pfizer has devised an elaborate system to transport the vaccine by truck and specially designed cases to vaccination sites. Public health workers are being trained to handle the vaccine as we speak, but we don’t know for sure how well it will do if containers are left out in the Arizona sun too long. Mishandling the vaccine along the way from factory to patient would render it ineffective, so people who received it could think they were protected when they were not, Offit said.

4. Could a premature announcement hurt future vaccines?

There’s presently no way to know whether the Pfizer vaccine will be the best overall or for specific age groups. But if the FDA approves it quickly, that could make it harder for manufacturers of other vaccines to carry out their studies. If people are aware that an effective vaccine exists, they may decline to enter clinical trials, partly out of concern they could get a placebo and remain unprotected. Indeed, it may be unethical to use a placebo in such trials. Many vaccines will be needed in order to meet global demand for protection against COVID-19, so it’s crucial to continue additional studies

5. Could the Pfizer study expedite future vaccines?

Scientists are vitally interested in whether the small number who received the real vaccine but still got sick produced lower levels of antibodies than the vaccinated individuals who remained well. Blood studies of those people would help scientists learn whether there is a “correlate of protection” for COVID-19 — a level of antibodies that can predict whether someone is protected from the disease. If they had that knowledge, public health officials could determine whether other vaccines under production were effective without necessarily having to test them on tens of thousands of people.

But it’s difficult to build such road maps. Scientists have never established correlates of immunity for pertussis, for example, although vaccines have been used against those bacteria for nearly a century.

Still, this is good news, said Dr. Joshua Sharfstein, a vice dean at the Johns Hopkins Bloomberg School of Public Health and a former FDA deputy commissioner. He said: “I hope this makes people realize that we’re not stuck in this situation forever. There’s hope coming, whether it’s this vaccine or another.”


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