Category Archives: Insights

5 Ways You Could Benefit from the Health Insurance Exchanges

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The news is everywhere about the insurance exchanges! With all the hype, what should you know? And should you care?

With over 10 million people expected to be eligible for the exchanges, there’s actually a good chance that you should care… The exchanges will be online marketplace where individuals or employees of small businesses can go to compare and buy health insurance. Enrollment starts October 2013 and the plans go live January 2014.

And you’ll most likely benefit the most from them if…

1. You’re uninsured

If you’re shopping for insurance on a federal or state exchange, you can’t be denied health insurance because of your medical history. The plans are guaranteed issue for anyone (as long as you’re a US citizen or legal US resident). You’ll also be protected from the plan suddenly canceling the plan on you if they discover anything about your health history later on.

2. You’re currently paying a ton for your health care

If you’re insured but sinking half your paycheck into your health insurance, the good news is that pricing rules on the exchanges will keep premiums in check. There are only a few ways premiums will be allowed to vary:

  • Overall: the most expensive plan can only be 4.5 times the cost of the least pricey plan
  • By age: the price for older members can only be three times that of younger members
  • By geography
  • By family size

Sliding scale subsidies will also be available depending on your income. And they’re pretty generous: You’ll qualify if your income is up to four times the poverty line (about $45,000 for an individual). And the average annual subsidy is expected to be $4,600 in 2014.

3. You’re older but not old enough for Medicare

Both guaranteed issue and the premium pricing rules work out really well for you if you are older but haven’t quite reached 65. This is typically the most difficult age group to be in for finding affordable insurance. Health plans on the exchanges will have to sell you coverage and it can only be three times the price for younger members (today, that ratio is much more extreme).

4. You have really high medical costs

Starting in 2014, annual and lifetime limits on coverage will no longer be allowed by any health plan. Right now, it’s easy to reach one of these limits if you have ongoing health issues, which leaves you without coverage exactly when you need it. But plans will soon be banned from setting any of these limits.

5. You get confused comparing health plans

All plans sold on the exchanges will be standardized, with the goal of making them easy to compare. There will be four tiers of plans, with Bronze plans being the most basic, and Platinum the most comprehensive (and Silver and Gold in between). And all plans will have to cover a list of Essential Health Benefits so there should be no big surprises about what’s covered and what’s not.

Why Did my Health Insurance Deny My Claim!?

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No! You expected your health insurance to cover a service, and then you get the dreaded letter that it’s been denied. Why do claims get denied and when does it actually matter (that’s right, sometimes it doesn’t matter)?

Your health plan might refuse to pay for a service or treatment you received for many reasons. It’s good to know whether it was denied because of the services themselves OR because of how your provider submitted it. Why is this important? Because in the first case, you’ll probably be responsible for paying the claim. In the second, you won’t be.

Here are some common reasons claims get denied where you could be responsible:

  • You didn’t get a referral or prior authorization when it was required
  • The service isn’t covered by your plan
  • You already used up your benefits for the service (like a cap on the number of physical therapy visits per year)
  • You went out of network when you have an HMO
  • Your insurance wasn’t effective at the time of the service

Don’t confuse these situations with those where a claim (or a portion of a claim) was denied because of how your provider submitted it to your insurance. This happens surprisingly frequently.  It might be that:

  • Your doctor didn’t submit the right billing code to your insurance plan
  • Your doctor didn’t submit the claim in the timeframe your insurance required
  • The service was actually covered as part of another claim or set of services
  • The claim is a duplicate that was already paid

You might see these things show up on your EoBs, or Explanation of Benefits–the statements you get from your health plan just informing you about your coverage (the ones that say “This is Not a Bill”). Just know that if your provider made a mistake submitting a claim, or your insurer found that it had already been paid for, you’re not responsible!

So before you panic, look into the reason for the denial. And if you believe you were billed unfairly for the cost, you can always appeal the decision. All health plans have to honor a process of reviewing claim appeals from their members. 

 

 

Before 2013: Squeeze Extra Dollars Out of Your Health Benefits

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Before the new year rolls around, putting some attention towards your health benefits can save you a lot of money. Quick! You have limited time to make the most out of your health plan for 2012, and then to get ready for 2013.

Spend down your FSA or HRA 

If you have a Flexible Spending Account or Health Reimbursement Account, check on the date it rolls over (for most of them, it’s January). You’ll lose the funds if you don’t spend them in time. Some employers offer a grace period until March 15th, but after that date, the money disappears. See what expenses can be counted.

Don’t confuse your HSA. These funds stay with you year after year!

Take advantage of your deductible

Most plan deductibles also roll over at the end of the year. If you have already met your deductible, think about whether there are any other services or procedures you need to do soon. Scheduling them before the year ends might save you from having to pay completely out of pocket in the new year.

Fund your HSA

If you have an HSA, you already know that the money that goes into it is free from taxes. Did you also know that you can keep depositing up until April 15th and your contributions will count towards your 2012 income? That means you can add more funds if you didn’t deposit enough this year or aim for the maximum contribution to get the most tax savings.

Review next year’s plan

It’s time to look at what’s new for your health plan (or all the important details if you switched plans!). The top benefits to focus on? The deductibles (individual and family, as well as in-network and out-of-network), any changes to the drug formulary, and any changes to the provider networks. These last two rule changes often surprise consumers who think their plan will be the same as it was last year.

 

Why Understanding Your Health Plan Just Got a Bit Easier

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Wouldn’t it be great if overnight, understanding health insurance magically became easier?

That was the aim September 23, 2012, but whether it actually happened is still in question.

On the 23rd, a new benefit from Health Reform kicked in, aimed at making it easier for consumers to understand insurance and compare plans.

It’s called the Uniform Summary of Benefits and Coverage (SBC). Right now, health plans already send you long, complicated SBCs. But the problem is, every one is different (ever tried to compare two of these?).

But now, every plan will be required to present their information in a standardized way, using the same definitions, so you can compare apples to apples.

Think of nutrition labeling—we can see instantly exactly how much more sodium is in one bag of chips versus another. That’s the goal behind the Uniform SBCs. And the “labels” actually don’t look that different from what’s on your food…

Even better, the new document also include “coverage examples,” or a theoretical breakdown of costs for some common medical conditions. See example SBCs here.

It’s a step forward, but here at Simplee, we know it’s not enough to make shopping for health insurance as easy as shopping for sweet potato chips. For example, it’s still difficult to compare 70% and 80% co-insurance when you don’t know the full cost of a service.

Basically, the new SBC will make is easier for consumers to choose between health plans, but after that, it’s still a challenge to understand claims and bills once you start using the plan.

Everyone with a private health plan will see this benefit. Look for it when you receive your plan documents each year or on your health plan’s website.

 

How Does Your HSA Compare?

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Wondering how your HSA stacks up compared to others?

Are you saving enough or spending too much?

We decided to look at Simplee users as a group to see. As of the end of June 2012, the average Simplee member had $1654 in their HSA. This was up from $1385 at the beginning of the year, but not quite as high as the average of $2235 the previous fall. That seems to suggest many people are saving up as the year goes on and then paying out their deductible by the end of the year.

The good news? Most consumers seem to be saving more than they’re spending. For the first half of 2012, Simplee users contributed an average of $2289 each quarter to their HSA and only distributed $1903 per quarter.

So how much should you have in your HSA? Well, just like any savings account, the more the better—but of course, within reason. You obviously don’t want to tuck away so much money that you can’t afford your other bills. But at the very least, you want to have enough to cover your deductible.

The average American has $1490 in their HSA (as of 2011, according to the Employee Benefits Research Institute), so it looks like Simplee users are doing a bit better than average. Way to go!

To track your HSA transactions and manage your expenses easily, log in to Simplee.

Insurance Companies Are Courting You

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Have you noticed your health insurance company getting a little warmer and friendlier lately?

A trend of insurers “putting customers first” has definitely begun. Whether it will translate to real savings for consumers is the question.

In a great, recent blog in the New York Times, author Tanzina Vega talks about how insurers have been ramping up their PR campaigns, trying to combat the reputation the industry has picked up for bad service over the years. Now, many of the largest companies are trying to put more of a focus on their customers, in a variety of forms: discounts and rewards for losing weight or quitting smoking, consumer-friendly cost comparison tools, or just slick campaigns branding themselves as not just insurance, but family friendly health care solutions.

So this got us thinking. How do health insurers rank when it comes to customer satisfaction? Are they really that bad? Are they getting better?

We looked up ratings from the American Customer Satisfaction Index—a national scoring of major service sectors (ranging from 0 to 100). Turns out Americans’ opinion of health insurance companies has generally been getting better over the last 10 years. Though they are still near the bottom of the pack with an average score of 71: just a bit worse than the US Postal Service, which averaged 73, but still lagging far behind internet retail, at 81. However, most of us think calling our health plan is better than calling the airline we’re flying.

ACSI Health Insurance 2012
To compare other industries, visit http://www.theacsi.org/

 

Why the big push to please consumers now?

Much of it relates to the health reform bill, which is expected to make almost 20 million Americans newly eligible for private insurance coverage. So what better way to start competing for new customers?

So we might expect the score for health insurance companies to continue to rise, but is customer satisfaction the same as good health care coverage? Or could it be a distraction from increasing out-of-pocket costs? Reward programs are nice but when it comes down to needing a surgery covered, they’re no substitute.

We have yet to see, but one thing seems promising: insurance companies are paying more attention to you than ever before.

Tell us what your health plan has done for you that you love, and how you’d rank them on the Customer Satisfaction Survey.

 

 

 

The Best of the Health Care Reform Supreme Court Ruling

Posted on by Simplee
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Today’s big news was that the Supreme Court finally released their long-awaited ruling on the health reform bill, or Affordable Care Act (ACA). With the exception of a few pieces, mostly related to Medicaid, the Act is going forward.

Everybody’s writing about the ruling. So where are the best no-nonsense places to go to read about it? You know we like to simplify stuff, so here are our recommendations:

The shortest, simplest, plain-language summary of the ruling:

          Wall Street Journal Blog

The most straight-forward facts on how it will affect consumers:

          WebMD

The best way to follow the details:

          SCOTUS Blog

 The easiest way to read and navigate the official documents:

          NPR Interactive

 And of course, the Simplee explanation:

          Simlpee blog: What the ACA means for Consumers

 

Got specific questions about how the bill affects you? Let us know and we’ll get them answered.

 

 

 

Last Minute Tax Tips

Posted on by Simplee
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It’s almost April 17th. Yes, the IRS gave us all an extra two days for the 2012 tax filing deadline. Don’t forget that Simplee’s here to help you with your taxes!

If you still haven’t filed, and need some help figuring out your medical deductions, Simplee has you covered. Here’s what you can do in:

Less than 30 seconds – Log in to your Simplee account for a quick look at your medical expenses for 2011. The dashboard makes it easy to bring up claims only for the last year.  If you have dependents, you can also add in their medical expenses. Keep this figure on hand—you’ll need it soon.

Less than 1 minute – Pull out your 1099-SA. If you have an HSA, this will have been mailed to you by the HSA administrator. Use it to complete Form 8889.

Less than 2 minutes – Once you have your Adjusted Gross Income figured out, take 7.5% of it and compare this to the medical expenses from your Simplee account. If your expenses exceed 7.5% of your income, congrats! You can itemize your expenses for a bigger deduction. If not, you’re done—there’s nothing more you need to do with your medical expenditures for this tax year.

If the numbers are close, keep reading—you still might qualify for a deduction:

Less than 10 minutes (if you’re organized) – Gather up any other Qualified Medical Expenses which might not be in your Simplee account. This could include anything from premiums to travel expenses for medical appointments, or from acupuncture to improvements to your home for medical reasons. The IRS has a complete list. Make sure you have receipts or some other kind of record for each.

??? minutes – File those taxes! If you are itemizing, you need to use Form 1040 (not 1040A or 1040EZ).  If your expenses are not high enough to itemize, then the form doesn’t matter, unless of course, you’re itemizing for other reasons. You can deduct the amount of medical expenses that exceeds 7.5% of your Adjusted Gross Income. For example, if your income was $60,000, then 7.5% is $4,500. If you spent $5,000 on medical expenses, you can only deduct $500, the amount that exceeds $4,500.

For more details, see Taxes & Medical Expenses: What You Need to Know Before You Begin.

 

Health Reform Simplified – Why the Individual Mandate Matters

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It’s March 23rd, and exactly two years ago, the Patient Protection & Affordable Care Act, the health reform bill, was passed. And ironically, in a few days the Supreme Court will hear arguments over a few parts of the bill that some believe are unconstitutional. The biggest issue is the requirement that everyone must have insurance (the individual mandate), and what happens to the rest of the bill if the individual mandate is found to be unconstitutional.

Simplee isn’t taking a side, but we’re keeping an eye on how the Court’s decisions might affect insurance benefits and costs to consumers.

So we’re going to do a little crash course now on what’s really at heart of the debate.

 

First, remember that the Affordable Care Act (ACA) is already happening.

Several benefits have already gone into effect, while others will start in 2014. So far, the bill has:

  • Allowed children to stay on their parent’s health plan until age 27.
  • Prohibited insurance companies from denying coverage to children with pre-existing conditions
  • Set annual and lifetime limits so health plans can only ask you to pay so much out-of-pocket
  • Provided discounts to people with Medicare who hit the donut hole and would have had to pay all prescription drug costs out-of-pocket.
  • Made free preventive care available to people with Medicare

And in 2014:

  • Plans would be prohibited from denying coverage or charging higher premiums to people with pre-existing conditions
  • Health Insurance Exchanges will be set up so people can shop for plans
  • Subsidies will be available to help people purchase coverage

 

This means it could be a big mess to untangle…

If the Court decides the Individual Mandate should be repealed, that raises the next question: Can the Individual Mandate be separated from the rest of the ACA, or does that mean the entire Act should be repealed?

The answer is not simple. Because the parts of the ACA are not just a handful of changes related to health care. They are actually a set of interrelated policies, all intentionally created to work together and balance each other out. Let’s think back to Economics 101: Supply and Demand…

 

Why the Individual Mandate is actually kind of important

The ACA was intended to increase insurance coverage to as much of the population as possible. Think about all the benefits listed above—these things were all meant to increase the supply of health care. They prevent plans from being selective about who they sell coverage to. But imagine what might happen when everyone who is sick suddenly buys insurance: Costs to health plans would go up, premiums will probably rise, and a lot of insurance companies will struggle to stay afloat.

OK. That’s where the individual mandate comes in. It’s the piece that increases demand for health care. Health plans need people to buy coverage before they get sick. It’s the way to keep costs down for everyone.

 

Can the rest of the ACA survive alone?

This little balance of supply and demand is what’s making the debate tricky. If we get rid of the Individual Mandate, but keep the other benefits that increase access to insurance and health care, could costs for consumers go up? Would that just defeat the purpose of the Act?

Or will it be worse for consumers to keep the benefits that have already kicked in, and cross their fingers that costs will stay under control?

If the Individual Mandate is found to be constitutional, then none of this matters. But if not, then it could be a rocky road for consumers.

The Supreme Court’s decisions are expected in June or July.