Archive for February, 2013

Now, The Rest Of The Story……………..

Thursday, February 28th, 2013
Editor’s Note: This is extremely interesting article we received today in an email.   The  notation regarding Medicaid recipients age 55 or older under ObamaCare is interesting. (A recipient may qualify for, and get “free medical care”, but upon death this estate may be attached?)
Bill, did you catch this article posted by Paul Craig Roberts: “Obamacare: A Deception”?

And then there is this quote is from the Association of American Physicians and Surgeons (AAPS):

If a person is put into Medicaid, he has just gotten a mandated collateral loan if he uses Medicaid benefits at age 55 or older. Depending on state law, anything in the estate (the multi-generational family home and everything in it, annuities, bank accounts, etc.) may be subject to state recovery of funds expended by Medicaid for certain benefits, or possibly of all expenditures. This happens because the asset test was dropped as part of the Omnibus Budget Reconciliation Act of 1993 (OBRA 1993). While this provision does not come from the Affordable Care Act (ACA), ObamaCare’s Medicaid expansion means it can be applied much more widely. ‘Recovery provides revenue for cash-strapped states and it’s a big business,’ the article states. It is not clear how disclosure of this provision will be made if people are bumped into Medicaid or auto-enrolled.”

From Our Friend Rosie in Corpus Christi area:

This is just FYI——-
In Texas the State Assistance for NURSING FACILITY CARE, Home Health Providers (they clean your homes) and the CBA(community base-alternatives)--this handles like doing remodeling to your homes–building ramps, fixing bathrooms etc…. to accommodate the aged and or disabled needs) —–these 3 state assistance services might or will subject a CLAIM ON YOUR REAL ESTATE PROPERTY or ASSETS under the MERP (MEDICAID ESTATE RECOVERING PROGRAM) from March 2005.
See the Tx Dept of Aging and Disability Services——–the MERP Receipt Acknowledgement ——FORM 8001 (May 2011) that I faxed to your office. 
This is the form that anyone who applies for STATE ASSISTANCE will be asked to SIGN but YOU DO NOT HAVE TO SIGN THIS FORM. THERE IS A LOT OF RED TAPE and HARDSHIP CRITERIA applied BEFORE THE STATE files a CLAIM and takes over your REAL ESTATE PROPERTY.  THE STATE HONESTLY GOES AFTER PROPERTIES WITH HIGH VALUES or BIG ASSETS.  Some individuals who apply for these services ——–just give up and cancel their applications because they do not want their GROWN-UP children to lose their parents HOME SWEET HOME.
In my opinion—-their is a lot of mis-concepts about this Program.  What can protect their properties if they had transferred them over to their children —at least 5 years prior to applying for STATE ASSISTANCE.  The same applies for ASSETS if they were placed in a TRUST five years prior to applying for STATE ASSISTANCE.  The MERP has been here way before PRESIDENT OBAMA got into THE WHITE HOUSE office.
THE MERP was created to stop the STATE ASSISTANCE PROGRAMS from going bankrupt which they almost did back in 1993.  Sooner or later —smart lawyers alway find very good loop-holes to beat the systems —which again leads to finding TOUGHER laws or regulations.

Maxor Administrative Services LLC Announces New Plan

Thursday, February 28th, 2013

Maxor Administrative Services LLC, an Amarillo based third party administrator, has a unique plan for groups of 25-250 employee lives. With plan sponsors debating whether to continue offering group medical insurance but are frustrated with limited choices availble in the fully-insured market, this program may provide a viable option.


Unintended Consequences of PPACA – Say Farewell To Three Decades of Managed Care

Thursday, February 28th, 2013

Source: The Business of Medical Practice; Transformational Health 2.0 Skills For Doctors by David Marchiko & Hope Hetico

(1) Health care costs will be shifted to doctors in the form of lower reimbursments, (2) Hospital based physicians will demand and receive higher salaries, (3) Fewer physicians and more nurse practicioners, (4) Higher health insurance costs, (5) Medical care access impediments for most Americans but improvements for those previously uninsured, (6) Increased acceptance of MSA’s, HSA’s, concierge medicine, private pay, and other direct cash payment methods for medical care (7) widespread health data breach of epic proportions, (8) more community hospitals will close, (9) Fewer alternatives to commercial health insurance, other than Medicare and Medicaid, since the antitrust exemption for health insurers had not been repealed, (10) Medicare may become the de facto health insurance, much like public housing, food stamps, the USPS, and public transportation, (11) Physician compensation will gradually decline, (12) Private medical practices, often a doctor’s largest financial asset, will go down in value jeopardizing personal retirement plans, (13) Medicine’s lost professional status will become complete as health care becomes commoditized.

“… insurance reform is setting the stage for a new era of American health care. In launching this new period anchored by expanded access and insurance market reforms, we are expecting to say farewell to the three-decade era of Managed Care – a barren stretch of fiscal and social desert marked by spiraling costs, misaligned financial incentives, massive underfunding of Medicare and Medicaid obligations, fraud, overtreatment, public to private cost shifting, historic rates of chronic illness, and the slow erosion of employer sponsored health care, leading to an astounding number of Americans without insurance. …”

According to the author, whereas the old era was “a time characterized by consolidation of stakeholders, cost shifting, risk shifting, and scorched earth Darwinian battles on the supply and delivery side”, the new era will” begin a battle for the soul of medicine.”

Editor’s Note: This book is a must read for health insurance consultants

Aetna Publishes Commission Calculator For Agents/Brokers

Thursday, February 28th, 2013

Aetna Advantage Plans for Individuals, Families and the Self-Employed (under age 65)

Now you can see your earnings. Calculating your compensation is easy when you use our compensation calculator, give it a try!

1863 Civil War Statute Expanded To Address Fraudulent Health Care Claims

Thursday, February 28th, 2013

The statute, enacted in 1863 during the Civil War, protects against the submission of fraudulent claims by government contractors and enforces strict penalties for such violations. The 2010 health system reform law expanded the reach of the law and made it easier for federal investigators to launch FCA cases against alleged violators.

Editor’s Note: Physicians and hospitals who accept Medicare/Medicaid patients are “government contractors.”


HHS Rejects Insurers’ Pleas

Thursday, February 28th, 2013

            Despite strong pleas from insurance execs and industry lobbyists, the U.S. Department of Health & Human Services went ahead with its plans to implement strict age-rating requirements in a new rule published Friday.

Under the final rule, which largely resembles the proposed version published last November, insurers can only charge their older members up to three times as much as younger members, MedPage Today reported.

America’s Health Insurance Plans, though, pushed back on the new rules. “The new restrictions on age rating will result in an overnight increase in healthcare costs for people in their 20s, 30s and early 40s,” AHIP CEO Karen Ignani said in a statement. “This increases the likelihood that younger, healthier people forgo purchasing insurance until they are sick or injured. When this happens, costs go up for everyone, young and old.”

Ignani added that the age rating restrictions will simultaneously be implemented alongside requirements for essential health benefits and the new health tax, all of which will “further add to the cost of coverage.”

Conversely, AARP supported the new age rating rule. “Implementing a limited use of age rating immediately thwarts what would have been a negative and disproportionate effect on Americans aged 50 to 64 if they could not obtain affordable health insurance at a time when they need at most,” AARP Executive Vice President Nancy LeaMond said in a statement.

HCC Offers Turn-Key Captive Arrangement

Wednesday, February 27th, 2013

HCCRSC is an all-in-one, turnkey captive stop loss program designed specifically for stop loss producers who want to deliver innovative products to their clients seeking new alternatives.

UHC Broker Reform Guide Released

Wednesday, February 27th, 2013

Artex Vantage Medical Stop Loss Captive

Wednesday, February 27th, 2013

Vantage is a solution for controlling employee benefit health care costs. Vantage blends the advantages of self-funding medical costs with stop loss insurance, the stability of a group captive and successful risk management…

Simpkins & Associates Seeks Sales Associate

Wednesday, February 27th, 2013


Simpkins & Associates, with offices in Dallas and San Antonio, can trace it roots back to the 1940s. We are an independent consulting firm established to assist business owners, professionals, and their advisors in the design, installation, and administration of retirement and cafeteria plans.

“We know in order to prosper we must offer a service that is unique to the marketplace!”

That’s why S&A offers a wealth of sound options, including one of the most sophisticated websites, relationships with the leading financial organizations, true open architecture AND SOON a comprehensive program with significantly reduced fiduciary obligations and cost.

Let us know if you: 1. Have public speaking and presentation skills 2. Have a history of independent performance 3. The ability to travel within the confines of your region 4. Have a passion for helping plan participants prepare for retirement

Simpkins & Associates serves our clients well by collecting and disseminating data via our website: By visiting this site, you will also have a better feel for our firm and its people.

Submit your resume to

Visit our web site.

Companies Go Surgery Shopping

Tuesday, February 26th, 2013
Wal-Mart Stores Inc. will offer employees and dependents heart, spine and transplant surgeries at no cost at six major hospital systems across the nation, with free travel and lodging……………It’s all part of a growing movement by employers fed up with wildly different price tags for routine operations. In response, businesses are showering workers with generous incentives — including waiving deductibles or handing out $2,500 bonuses — to steer them to these top-performing providers offering bargain prices.

Why The Healthcare Industry Will Eliminate PPO Networks

Sunday, February 24th, 2013

“…..all elements within a market that do not add value to the overall market will eventually be eliminated……………….companies must work constantly to eliminate any cost factor that does not add value to a business process. ”


How To Make +$100,000 In Undisclosed Revenue On A 250 Life Case

Saturday, February 23rd, 2013

By William Rusteberg

Compensation earned selling self-funded group health insurance has never been better. Insurance brokers, in collaboration with their TPA partners, understand how to maximize revenue without clients knowing the true extent of their total compensation package.

Employers unknowingly fund the Scheme

Most employers trust their insurance broker. They rely on their broker to find the best and most cost effective program available in the market. They believe their broker is working in their best interests, and compensation is fully disclosed. In the case of a 250 life group, a broker fee of $5 per employee per month seems reasonable. That equates to about $15,000 per year in broker commissions.

So how is it possible for the insurance agent to make over $100,000 in undisclosed compensation, on top of what is disclosed? Certainly all costs associated with a self-funded health plan are known to the Plan Sponsor, right? Unfortunately, that is not always the case.

Revenue can be gained from stop loss insurance commissions (plus bonus & profit sharing with the carrier), pharmacy expenses (working the spread, share in rebates or just plain old commission add-on for every prescription dispensed), reinsurance fees (just a fancy word for “commissions”), and last but not least………. sharing of PPO discounts (hidden in claim costs).

Here is the formula: Rx (1.2) X 250 X 12 X $10 = $36,000; Stop Loss (45) X 250 X 12 X .15 = $20,250; Reinsurance Fee (7) X 250 X 12 = $ 21,000; PPO Discount Sharing (5%) X (3,666) X 250 = $45,825

Total undisclosed compensation in this case is $123,075.  With the PEPM disclosed broker fee of $5, the total annual compensation paid by the Plan Sponsor is $138,075, or a whopping $45 PEPM in agent compensation. Buying a new Cadallac every year has never been easier.

It is not uncommon for the broker’s TPA partner to earn additional hidden revenue too. In the TPA’s Administration Agreement you may find a statement such as “TPA may or may not share in compensation from some, or all of the subcontractors of the Plan.” Or, as we have seen in some of the BUCA’s Agreements, “If you want to know what your broker is making, ask him, not us.”

On groups that forego managed care networks, a TPA and their consultant/broker may earn additional revenue  as much as 35% of audit fees. And since audit fees are usually tied to a percentage applied to gross billed charges, or a percentage of savings, or applied to “allowed amounts”, a commission percentage on top of a percentage can add up fast. For example, a gross billed charge of $250,000 paid at $50,000 can generate an audit fee as much as $70,000 of which as much as $24,000 in commissions is paid to the TPA.  Not bad compensation to process a claim. (Forget the Cadallac, I want a company jet!)

Plan Sponsors are fiduciaries

Employers who self-fund an employee welfare plan take on certain requirements in the administration of the plan and managing its assets.  ERISA sets a standard for fiduciares which includes acting solely in the interest of plan participants by paying only reasonable plan expenses.

A plan participant may have recourse against a Plan Fiduciary for ERISA violations, a risk that should be addressed by plan sponsors. A careful review of expenses and contracts is of paramount importance.

Editor’s Note: Most  independent, fee based insurance consultants would charge $25,000 per year for advice and guidance. An employer may believe a consultant’s fee  of this magnitude is unreasonable. Afterall, they have a trusted insurance broker who is paid much less.



San Benito Independent School District Seeks Agent of Record

Friday, February 22nd, 2013

SBISD Agent of Record RFP

Editor’s Note: Type “San Benito ISD” in search button for previous postings

From an insurance consultant: Bill, is San Benito aware of this? – Commissioner’s Bulletin #B-0041-07

Employer Strategies Emerge To Control PPACA Costs

Friday, February 22nd, 2013

Editor’s Note: has developed the SCREW YOU Plan for those employers who want to avoid punishing government sanctions. Write for details.

Patients Opt For Expensive Care – OPM Syndrome

Friday, February 22nd, 2013

Some of those interviewed even said they would “go out of their way to choose the more expensive options, viewing such decisions as acts of defiance and a kind of well-deserved ‘payback’ after years of paying insurance premiums,” writes Dr. Pauline Chen in her New York Times blog post.


Why Your Boss Is Dumping Your Wife

Friday, February 22nd, 2013

Companies have a new solution to rising health-insurance costs: Break up their employees’ marriages.

Hospitals Win Battle Against Cost Plus Health Plan – Plan Sponsor Lacks Testosterone

Thursday, February 21st, 2013

Mason City Schools will abandon the controversial TrueCost health plan after several grievances by teachers.


Bitter Pill: Why Medical Bills Are Killing Us

Thursday, February 21st, 2013

      Where’s all that money coming from? And where is it going? I have spent the past seven months trying to find out by analyzing a variety of bills from hospitals like MD Anderson, doctors, drug companies and every other player in the American health care ecosystem.

Editor’s Note: AMPS sent this Time Magazine article to us this morning. Audit firms like AMPS (Advanced Medical Pricing Solutions) assist self-funded plans in hospital audits. For more information go to;



PPACA Out-Of-Pocket Expense Limit Finally Defined By Govt.

Thursday, February 21st, 2013

The regulation, issued Wednesday by the U.S. Department of Health and Human Services, says the maximum annual out-of-pocket expenses — which include deductibles, coinsurance and copayments for services received through in-network providers — cannot exceed the maximum limit allowed that year, starting in 2014, for contributions to health savings accounts


Universal To Drop Health Insurance For Part Time Workers

Thursday, February 21st, 2013

Universal Orlando plans to stop offering medical insurance to part-time employees beginning next year, a move the resort says has been forced by the federal government’s health-care overhaul.


Hospitals Boycott Cost Plus Group – A Classic Case of No Cajones?

Wednesday, February 20th, 2013
“After several teachers in the Mason City Schools had trouble getting medical care, the district waffled Tuesday on whether it would abandon the controversial TrueCost health care plan.”

PPACA – Employers Stunned, In Shock Mode

Wednesday, February 20th, 2013
“Employers are still coming to terms with the impact of health care reform, and many employers still seem to function in a ‘shock mode”

Self-Service Health Care Revolution?

Wednesday, February 20th, 2013

As Americans gain coverage under the federal health law, putting increased demand on primary care doctors and spurring interest in cheaper, more convenient care, unmanned kiosks like these may be part of what their manufacturer bills as a “self-service healthcare revolution.”


Self-Funded Medical Plans Gain Traction Under ObamaCare

Wednesday, February 20th, 2013

“Companies can avoid many standards in the new law by insuring their own employees, rather than signing up with commercial insurers, because Congress did not want to disrupt self-insurance arrangements that were seen as working well for many large employers.”


Recommended Reading

Sunday, February 17th, 2013

The Business Of Medical Practice: Transformational Health 2.0 Skills For Doctors by David E. Marcinko & Hope Hetico.

Page 33:  “Similarly, is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and faiirness in direct reimbursment compensation methods – William Rusteberg, 2010, Personal Communication –


ObamaCare Survey: Firms Will Drop Group Health Plans

Sunday, February 17th, 2013

One in five companies with fewer than 500 employees say they are “likely” or “very likely” to discontinue company-provided healthcare coverage within five years, a survey reveals. (NewsMax)


Amazing Yield On Six (6) Month Certificate of Deposit

Sunday, February 17th, 2013

In today’s Houston Chronicle there appears an advertisement for “The Presidential CD” paying 3.85% for a six month term. Sun Cities Financial Group advertises “FDIC – Insured 6 month CD, Working Hard So You Earn More Since 1998.” For more information call 713-267-2320

Also in the same paper is an advertisement from BBVA Compass for a 24 month CD paying 1%. The advertisement says “In today’s environment, a competitive rate is hard to find. Until Now.” For more information call 1-800-COMPASS

Why is there such a big difference in yields? See


ObamaCare Pre-Existing Condition Plan Going Broke

Saturday, February 16th, 2013

“What we’ve learned through the course of this program is that this is really not a sensible way for the health-care system to be run,” Cohen said.

$5,000,000,000 (billion) to be used up by only 135,000 participants – Seems high even if it is a pre-existing condition plan.  How much is going to administrationof the plan?


More Than 30 States Rebuke ObamaCare Exchanges

Friday, February 15th, 2013

There are less than two days to go before states have to decide whether they will go it alone or partner with the White House to set up Obamacare health insurance exchanges.


Walmart Rolling Back In-Store Clinics

Thursday, February 14th, 2013
Today Walmart has fewer than 130 clinics and is closing locations faster than it’s opening them. Meanwhile, CVS Caremark Corp., which already has about 630 MinuteClinics, is opening about three a week, and aims to have 1,500 within four years. It’s promoting the clinics heavily on TV and the web. While industry figures are hard to come by, CVS says its clinic business has grown at a compound annual rate of 39% in the last six years.

Buyer Looking For Texas TPA

Thursday, February 14th, 2013

Buyer looking for Texas TPA to purchase. Existing block to include medical, dental and vision. Minimum 10,000 employee lives. Contact

Wellpoint To Collaborate With Providers? Fox Guarding The Hen House?

Thursday, February 14th, 2013

In a surprise move, WellPoint announcedTuesday it has named Joseph Swedish, a former hospital official who has never managed a public company, as its new chief executive officer.

Swedish, who will assume WellPoint’s helm on March 25, has spent his entire career on the provider side of healthcare, most recently as the president and CEO of Trinity Health, which operates 47 hospitals across the country. He also led Colorado-based health system Centura Health and was an executive at hospital company HCA, WellPoint noted.

Naming Swedish as CEO signals WellPoint’s focus on collaboration and integrated healthcare delivery. His experience on the provider side will help WellPoint partner with healthcare providers to continue improving efficiency and lowering costs.

“My arrival is representative of the landscape transforming in healthcare,” Swedish told the Indianapolis Business Journal.

WellPoint already has begun collaborating with providers, including acquiring Medicare specialist CareMore and launching a new initiative that pays more money to primary care doctors that better manage patient care, and Swedish told The Wall Street Journal he hopes to “accelerate that at a very rapid pace.”

Swedish wasn’t included within WellPoint’s rumored list of CEO candidates, including retired Aetna CEO Ronald Williams and Amerigroup CEO James Carlson, to replace its former chief exec Angela Braly, who resigned amid shareholder scrutiny.

He will be paid $1.25 million in salary and as much as $3.75 billion in bonuses. He’ll also receive stock options valued at as much as $8 million, plus $3.56 million for leaving Trinity, Bloomberg reported.

ObamaCare Application – You May Qualify For Free Health Insurance!

Wednesday, February 13th, 2013

“Use this application to see what insurance coverage you qualify for. You may qualify for a  free or low cost program even if you earn as much as $92,000 per year (for a family of four).”

PPACA Application

Employers – see Employer Coverage Form (last page).

TPA’s To Pay For Birth Control

Monday, February 11th, 2013

Apparently I am going to be spending a fortune on birth control, sadly I don’t expect I will have time to use any of it.

“The preamble to the proposed rule suggests several ways in which this could be done, but the basic idea is that the TPA would take responsibility for providing coverage, and in turn contract with an insurer in the individual market to provide the coverage.  The insurer would in turn pass the cost of the coverage (which now will be a real cost since the insurer has no responsibility for covering maternity or any other health care costs) on to a federally facilitated exchange (FFE), which would offset the cost through a reduction in user fees — in other words, the insurer would receive a reduction in the user fee it otherwise owes to the FFE to cover both its costs and any administrative costs incurred by the TPA.”

That’s just the summary. Where to begin….
I have never seen a contraception-only policy before; are they even legal to sell?
I need to find a carrier, send them eligibility on a regular basis, and not got paid for any of it?
I am going to be really pissed if some carrier has a data breach and exposes PHI or Red Flag Data and I have to deal with the cost for services I didn’t get paid for; I haven’t seen any mention of immunity.
Will MLR apply to these policies? I foresee a lot of work to provide a small dollar benefit. In fact, I could see the administrative cost being higher then the cost of the drugs.
And who gets the rebates?

“Insurers providing contraceptive coverage would be responsible for notifying plan participants and beneficiaries of the availability of the coverage using language found in the proposed regulation.  The notice would be provided separately from any other plan information, generally on an annual basis.”

There starts the excessive administrative fee.  Apparently single males would also need to be offered this policy and notice?
Fraud potential in this is huge: I don’t see where anyone is asking the TPA to verify who these policies are being purchased for.

Source: Insureblog

Draft Dodging

Monday, February 11th, 2013

As Bob noted last week, some of the 58 states have begun to take a serious look at how their Exchanges (if any) will be run. A key issue is the role of agents/advisors, and how they’re to be qualified and compensated.
Now comes word that HHS Secretary Shecantbeserious is planning to “start registering agents and brokers around July 1.”
Okay, when you’re through laughing, we can continue.
Have you noticed the little countdown timer in our sidebar? That’s the countdown to the day the Exchanges are to go “live.” The date? October 1st. Now, keeping this in mind, wrap your head around this:
The federal exchange managers want to promote the agents by publishing lists of individual exchange producers starting in August and lists of the producers registered to sell Small Business Health Options Program (SHOP) exchange coverage starting in September.” [emphasis added]
Now, given the institutional efficiency for which the HHS is so widely admired, what are the odds of this actually working out?
Yeah, that’s what I think, too.
Anther question we might be asking ourselves is whether or not any sane insurance agent wants to participate. After all, under a state-regulated system, worst case scenario is generally a fine and/or loss of license. But these are (presumably) going to be subject to Federal laws, so the down-side must surely be more serious, no?
Which is not to say that it won’t happen (I’m still on the fence, for example), but it does give one pause. And since that clock is clicking down at a pretty good clip, this may end up being a rather high-stakes game of chicken with Ms Kathy.
Editor’s Note: Source: Insureblog – great blog!

What Does A Hip Replacement Cost?

Monday, February 11th, 2013

“If one hospital can put in a hip for $12,000, then every hospital should be able to do it. When there’s 100 percent variation in sticker price, then there is no real price. It’s about profit.”


Why Stop At 2.3% – Will Lawmakers Continue To Increase The Cost Of Health Care To Pay For The Increased Cost Of Healthcare?

Sunday, February 10th, 2013

To uninformed Americans, the 2.3%  medical device excise tax must seem like a painless way to fund the increasingly expensive Affordable Care Act. And since patients are more likely to blame providers rather than politicians for the increased treatment costs, where is the incentive to stop at 2.3%?

Will common sense cause repeal of the excise tax? Or will lawmakers continue to increase the cost of healthcare to pay for the increased cost of healthcare? I still like to think that as long as there is transparency in healthcare, common sense stands a fighting chance.

Dr. Pruitt –

Valley Baptist Health Plans Switches TPA

Sunday, February 10th, 2013

Effective April 1, 2013 Valley Baptist Health Plans will change TPA’s from FirstCare Health Plans ( ) to Advantage Health Care Management of Phoenix, Arizona.

Dr. Benjamin Carson

Sunday, February 10th, 2013


Saturday, February 9th, 2013

Chang W. Lee/The New York Times

Ken Sturm, who owns several restaurants and nightclubs, said he became interested in having a captive insurance company when his traditional insurance policy did not cover a claim.


Money Affects Behavior

Friday, February 8th, 2013

DES MOINES, Iowa (AP) — Once largely united in resisting the Obama administration’s new health care overhaul, a growing number of Republican governors are now buying into parts of the system as the financial realities of their states’ medical costs begin to counterbalance the fierce election politics of the issue.


National Health Service Corps Expands Primary Care Workforce

Friday, February 8th, 2013

The Health Resources and Services Administration’s (HRSA) Students to Service pilot program provides loan repayment assistance of up to $120,000 to medical students in MD and DO programs in their last year of education in return for their commitment to practice in the communities that need them most  upon completion of their primary care residency.


PPACA & ERISA: Regulation Of Self-Funded Plans

Friday, February 8th, 2013


erisa self-funded lawSelf-funded plans are able to realize significant cost savings and develop more flexible health plan designs due to the exemptions they receive from state and federal regulation. However, both PPACA and ERISA both impose a number of key regulations that govern health plan requirements and management.


Congress Passes Sweeping Insurance Legislation

Monday, February 4th, 2013

Washington – By Homer G. Farnsworth & Molly Mulebriar.

Today the Senate, with unusual bi-partisan support, passed SB 2431 which critics say will fundamentally change the insurance industry in the United States. By a vote of 97 to 3, the Senate passed the Affordable Insurance Protection Act (AIPA).


Insurers Must Offer “Free” Stand-Alone Contraceptive Insurance Policies

Monday, February 4th, 2013

Insurers will be required to offer stand-alone insurance policies that cover contraceptive costs to religious nonprofit companies that object to the reform law’s contraceptive coverage mandate.


HCAA Meeting

Monday, February 4th, 2013

The Health Care Administrators Association (HCAA) will be meeting tomorrow for their annual  three day event in Las Vegas. Participants  will include third party administrators, consultants, carriers, managed care networks, reinsurance brokers, pharmacy benefit managers and soon to become extinct health insurance brokers looking for nirvana (The Buddhist state of absolute blessedness, characterized by release from the cycle of reincarnations and attained through the extinction of the self. Oblivion, Bliss).

Most of the networking will take place at the bar in the Wynn Encore Hotel by the elevators. The three hot topics will be Medicare Plus Pricing, Captives and Aggregate Only Stop Loss insurance. Molly Mulebriar will be in attendance, working undercover disguised as a call girl.

Two Charts That Need To Be In Every Health Care Discussion

Monday, February 4th, 2013

Posted by Ezra Klein on January 25, 2013 at 9:00 am

“This is the chart that I think ought to dominate the conversation about public-sector health-care spending in the United States,” writes Matt Yglesias, “and yet it is curiously ignored.”

yglesias canada america health spendingThe data show government health-care spending per capita in the United States and Canada. The United States spends more. And that’s not more per person who gets government health insurance, it’s more per resident. And yet Canada covers all its citizens, and we don’t. That should be considered shocking stuff, and yet I rarely hear it mentioned.”

It should be considered shocking stuff. But I actually don’t think that’s the chart that should dominate the discussion over government health-care spending. This is:

government health spending per person

We spend more on government-provided health care than they do in Canada, France, Germany, Israel, Italy, Japan, Sweden or the United Kingdom. And all those countries have government-based systems that cover everybody. We don’t.

What this graph is missing, though, is how much more our private-sector health care costs us. So here’s that chart:


And this is, if anything, an understatement, as it doesn’t count the large tax subsidies we sink into the private health-care system.

The American health-care system is simply uniquely inefficient. Typically, it’s liberals railing at this fact, but the result is, to a degree that’s almost universally unappreciated, a disaster for conservatives. The U.S government spends more than any other government on health care and is thus much larger than it might otherwise be. That spending also increases our deficits and requires higher taxes. So we’re getting the downsides of government-run health care without the upsides of universal coverage, lower cost  and clear lines of accountability.

Obamacare will mostly fix the universal coverage problem, but it won’t fix the cost problem. The reason other countries spend less is that their governments set the prices, and they set them low. The reason we spend so much more is largely because our prices are higher, and by leaving private insurers and medical providers in charge of deciding prices, we’re not doing anything about that in Obamacare.

The argument you’d get for leaving prices in the hands of the private sector is that you get a much better product with much more innovation, much of it cost-saving. That’s clearly not happening in American health care, as America’s care is not, in general, measurably better than that of other nations. The more sophisticated argument you hear for why we need to spend so much more on health care is that by spending more, we’re subsidizing the medical innovation that makes other countries’ systems so good. That’s a more interesting (though unproven) argument, but I doubt that Americans would be happy to hear that the reason our health care costs so much, and needs to continue costing so much, is that we have a duty to subsidize the French.

Custom Design Benefits Develops TrueCost (Cost Plus) Health Plan

Sunday, February 3rd, 2013

“For businesses, the cost of health care has evolved from a difficult, oft-misunderstood, unavoidable issue, to an uncontrollable cost of doing business,” said Julie Mueller, president of Custom Design Benefits, a Cincinnati-based third-party administrator. “We launched this product, TrueCost, with no networks, no deductibles, and no co-insurance (employees pay flat dollar co-pays), based on tangible, certified Medicare pricing.”

“In the development of TrueCost, Custom Design Benefits worked with National Underwriting Services, Inc., The Phia Group (for PD and consultation), CPR Risk Solutions (for medical management and patient advocacy), and Chart-Tech (for re-pricing of claims.”


Survey Of Out-Of-Network Billed Charges Brings Health Care Pricing Into Focus

Friday, February 1st, 2013


Ah Ha! The Root Cause Of High Cost Health Care Finally Exposed! – Greedy Insurance Companies!

Friday, February 1st, 2013

A story in today’s LA Times describes in rare detail why US healthcare is insanely expensive.  It’s not due to malpractice lawsuits, patients who expect too much, high-tech medicine or burdensome regulations. No, it’s the result of insurance industry bureaucracy and greed. While many consumers have long suspected that, hard evidence has been elusive.  Now, an investigation by the Los Angeles Times has turned up that hard evidence.


IRS: Cheapest ObamaCare Family Plan Will Cost $20,000

Friday, February 1st, 2013

( – In a final regulation issued Wednesday, the Internal Revenue Service (IRS) assumed that under Obamacare the cheapest health insurance plan available in 2016 for a family will cost $20,000 for the year.

Under Obamacare, Americans will be required to buy health insurance or pay a penalty to the IRS.

The IRS’s assumption that the cheapest plan for a family will cost $20,000 per year is found in examples the IRS gives to help people understand how to calculate the penalty they will need to pay the government if they do not buy a mandated health plan.

The examples point to families of four and families of five, both of which the IRS expects in its assumptions to pay a minimum of $20,000 per year for a bronze plan.

“The annual national average bronze plan premium for a family of 5 (2 adults, 3 children) is $20,000,” the regulation says.

Bronze will be the lowest tier health-insurance plan available under Obamacare–after Silver, Gold, and Platinum. Under the law, the penalty for not buying health insurance is supposed to be capped at either the annual average Bronze premium, 2.5 percent of taxable income, or $2,085.00 per family in 2016.

In the new final rules published Wednesday, IRS set in law the rules for implementing the penalty Americans must pay if they fail to obey Obamacare’s mandate to buy insurance.

To help illustrate these rules, the IRS presented examples of different situations families might find themselves in.

In the examples, the IRS assumes that families of five who are uninsured would need to pay an average of $20,000 per year to purchase a Bronze plan in 2016.

Using the conditions laid out in the regulations, the IRS calculates that a family earning $120,000 per year that did not buy insurance would need to pay a “penalty” (a word the IRS still uses despite the Supreme Court ruling that it is in fact a “tax”) of $2,400 in 2016.

For those wondering how clear the IRS’s clarifications of this new “penalty” rule are, here is one of the actual examples the IRS gives:

“Example 3. Family without minimum essential coverage.

“(i) In 2016, Taxpayers H and J are married and file a joint return. H and J have three children: K, age 21, L, age 15, and M, age 10. No member of the family has minimum essential coverage for any month in 2016. H and J’s household income is $120,000. H and J’s applicable filing threshold is $24,000. The annual national average bronze plan premium for a family of 5 (2 adults, 3 children) is $20,000.

“(ii) For each month in 2016, under paragraphs (b)(2)(ii) and (b)(2)(iii) of this section, the applicable dollar amount is $2,780 (($695 x 3 adults) + (($695/2) x 2 children)). Under paragraph (b)(2)(i) of this section, the flat dollar amount is $2,085 (the lesser of $2,780 and $2,085 ($695 x 3)). Under paragraph (b)(3) of this section, the excess income amount is $2,400 (($120,000 – $24,000) x 0.025). Therefore, under paragraph (b)(1) of this section, the monthly penalty amount is $200 (the greater of $173.75 ($2,085/12) or $200 ($2,400/12)).

“(iii) The sum of the monthly penalty amounts is $2,400 ($200 x 12). The sum of the monthly national average bronze plan premiums is $20,000 ($20,000/12 x 12). Therefore, under paragraph (a) of this section, the shared responsibility payment imposed on H and J for 2016 is $2,400 (the lesser of $2,400 or $20,000).”

Who Are We To Believe? DOL or The IRS?

Friday, February 1st, 2013

Department of Labor (DOL) has issued certain rules regarding     “affordability”. Wednesday this week the Internal Revenue Service     (IRS) issued their own rules on the same subject. Both are at odds with each other. So who are we going to believe?

DOL definition of affordable mandates the cost must be 9.5% or less  of the employee’s gross income (Safe Harbor).

The IRS now says, in a memorandum issued Wednesday, that a plan is affordable only if the cost is 8% or less of a household’s adjusted gross income.
Is this a case of one hand not knowing what the other hand is doing?

Editor’s Note: This is great! Pick and choose your decision based on the “source” you like the best. Very old strategy employed before with dealing with the Texas Department of Insurance – keep calling the department and talk to as many as you can until you get the answer you are looking for and then say “Would you please put that in writing and send me an email confirming our conversation!”