Pharmacy benefit managers' group ranked No. 7 in spending for lobbying the General Assembly, after laying out $53,634 for ads

Commonwealth Fund flow chart, amended by Kentucky Health News to include patients and employers

By Al Cross
Kentucky Health News

The lobbying organization for pharmacy benefit managers, the middlemen between insurance companies and drug manufacturers, spent $86,168 in its successful effort to defeat a bill in the recent legislative session that would have reined them in. They prevailed over pharmacists with the help of insurers, who argued that the bill would raise costs.

The Pharmaceutical Care Management Association ranked seventh in spending by lobbying interests in the session that ended in mid-April, mainly because it spent tens of thousands of dollars in television commercials attacking the bill. The ads started the day the bill overwhelmingly passed the House, where a pharmacist-legislator was the sponsor. PCMA said it spent a total of $53,634 on TV, internet and newspaper ads.

The bill got nowhere in the Senate, where President Robert Stivers said "When it got here, we started getting, from business sector and provider sector, various questions and comments about what the overall cost would be to various plans."

Tom Stephens, executive director of the Kentucky Association of Health Plans, cited a state Department of Insurance statement that a family of four would have paid up to $167 more a year for coverage if the bill had passed.

House Bill 457 would have ensured that patients could pick their pharmacy, instead of being required to use one affiliated with a pharmacy benefit manager; increase transparency between insurers and PBMs; and ban PBMs from retroactively denying a pharmacy claim after adjudication, commonly referred to as "clawing back." It passed the House 88-3.

The Federal Trade Commission voted Tuesday to investigate how pharmacy benefit managers affect the cost of prescription drugs and consumers' access to the drugs.

Several other health-care interests, or lobbying groups with interests in health care, were big spenders on lobbying the session, according to their post-session reports. The Kentucky Chamber of Commerce was again No. 1, spending $183,949; the Kentucky Hospital Association was second with $149,046. Third and fourth were the American Civil Liberties Union of Kentucky, whose issues include abortion rights, $128,258, and Altria Client Services (Philip Morris Cos.), $126,793. Insurer Anthem Inc. ranked 10th by spending $70,597.

Other big health spenders were the Kentucky Medical Association, 16th, at $54,044, and HCA Healthcare, 22nd at $48,832. The state Legislative Ethics Commission’s searchable register of lobbyists, employers and lobbying expenses is online at http://apps.klec.ky.gov/searchregister.asp.

Special enrollment period for health insurance on healthcare.gov ends Aug. 15; subsidies are bigger, and more people qualify

By Melissa Patrick
Kentucky Health News

Time is running out to sign up for low- or no-cost health insurance through the federal marketplace under the special enrollment created by Congress and President Biden. The deadline to sign up on healthcare.gov is Aug. 15. 

AARP illustration

The president reopened the marketplace in mid-February under the American Rescue Plan Act, for people who needed coverage during the pandemic, and later extended the deadline to Aug. 15. 

The special enrollment is open to both new and existing customers, including the thousands of Kentuckians who got temporary Medicaid coverage during the pandemic through the state's "presumptive eligibility" program. 

About 120,000 Kentuckians lost that temporary Medicaid coverage in July, according to Brice Mitchell, a spokesman for the state Cabinet for Health and Family Services.  

Mitchell said the state has told some of those people they would be losing their coverage and encouraged them to check kynect.ky.gov to see if they qualify for traditional Medicaid, or go healthcare.gov to apply for a federally subsidized plan. He said state Kynectors, who help people enroll, will continue the outreach through August. 

Dustin Pugel, senior policy analyst at the Kentucky Center for Economic Policy, encouraged Kentuckians who recently lost their temporary Medicaid coverage and are not covered by work or traditional Medicaid to "Run, not walk, to the marketplace to find an affordable option." 

Priscilla Easterling, the outreach coordinator for Kentucky Voices for Health and a Kynector, also encouraged Kentuckians without health coverage to explore their options on healthcare.gov, especially those who looked at plans in the past and found them unaffordable at that time.

"With the increased subsidies that the American Rescue Plan included . . . we have seen so many people save a surprising amount of money," Easterling said. "It is 100-percent worth just checking it out. . . . It's a totally different ballgame."

A federal report says 34% of those who got a subsidized plan since April 1 paid $10 or less a month for their coverage, thanks to the American Rescue Plan's premium reductions. In Kentucky, 32% of new customers and 19% of returning customers were able to find a plan for $10 or less per month. 

In the special enrollment period, plans are more affordable due to bigger premium subsidies through tax credits, and no repayments are required if a tax return shows they didn't qualify for the tax credit. Also, more people eligible for the subsidies, and costs are limited to no more than 8.5% of income, down from nearly 10%.

For the first time, the new rules allow those earning more than 400% of the federal poverty level -- about $51,000 for an individual and $104,800 for a family of four in 2021 -- to get a subsidized plan. 

This change is especially helpful to older adults with incomes above 400% of the poverty level, because unlike traditional health plans, which are allowed to charge more based on age, special-enrollment premiums are capped at 8.5% of income.

"Compared to current premium payments, a 60-year-old with a $55,000 income would pay 77% less for a bronze plan ($146 vs. $634 per month), 56% less for a benchmark silver plan ($390 vs. $887 per month), and 52% less for a gold plan ($453 vs. $951 per month), on average," says the Kaiser Family Foundation.

Also benefiting from this expansion to 400% of the poverty line are self-employed people who have not had access to affordable health insurance. "As wonderful as the Affordable Care Act was to open up affordable coverage for so many people," Pugel said. "It really did leave that group of folks out." 

Through the end of June, 13,773 Kentuckians had signed up for health insurance during the special enrollment period, according to a federal report. That's an increase from the special enrollment periods in 2020 and 2019, when 6,747 and 7,041 signed up, respectively. 

But fewer than 10% of eligible Kentuckians have taken advantage of the opportunity. Easterling said about 115,000 Kentuckians who qualify for a subsidy under the special enrollment period have not yet signed up.

Nationwide, more than 2 million have signed up.

Open enrollment is usually in effect only six weeks at the end of a year, except for those who experience a "qualifying life event," like getting married or losing a job. After the special enrollment period closes on Aug. 15, open enrollment will re-open Nov. 1.

Biden's American Families Plan would make some of these measures permanent, including the bigger tax credits, coverage to those who earn 400% and above the federal poverty level, and the premium cap of 8.5% of household income. Those measures will stop at the end of 2022 unless Congress makes them permanent.

General Assembly has passed more than 35 health bills; several more could get passed, and a few are dead until next year

By Melissa Patrick

Kentucky Health News

Kentucky legislators have passed more than 35 health-related bills, addressing a range of topics such as health departments and pensions, substance-use disorder, immunizations, insurance co-payments and Alzheimer's disease. 

The bills now await Gov. Andy Beshear's signature or veto, he has already signed a few into law. Legislators can pass more bills when they wrap up the 2021 legislative session March 29 and 30, but they will be subject to a veto without the opportunity for an legislative override.

Here's a roundup of some of the health bills that have passed: 

Substance-use disorder: HB 219, sponsored by Rep. Danny Bentley, R-Russell, allows pharmacies to sell hypodermic syringes and needles without a prescription. This change was made to increase access to clean supplies for people who inject drugs, which will help to decrease the risk of blood-born diseases like hepatitis C and  HIV/AIDS. 

HB 219 would repeal requirements for pharmacies to keep records of sales of syringes and needles and allow their sale without a prescription, with a limit of 30 of each and proof that the purchaser is 16 or older. It would require pharmacies offering syringes and needles to provide educational materials on their safe and proper disposal, and referral information for syringe exchange programs and treatment of substance-use-disorder; and to offer naloxone, which is used to reverse opioid overdoses. 

The bill also allows for a specific-type of off-site pharmacy-related work that does not involve any dispensing.

Diabetes: HB 95, sponsored by Bentley, would cap the monthly out-of-pocket cost for a 30-day supply of insulin at $30 for Kentuckians covered by state-regulated health plans. The price cap would apply regardless of the amount or type of insulin the person with diabetes needs.

Health departments: HB 8, sponsored by Rep. Jim DuPlessis, R- Elizabethtown, would have quasi-governmental entities, including health departments, pay only what the Kentucky Retirement Systems needs to cover their employees' pensions instead of using the current "percentage of pay" formula. The effect on individual health departments varies widely.

Immunizations: Senate Bill 8, sponsored by Sen. Mike Wilson, R-Bowling Green, would allow several exemptions for "any child or adult" who doesn't want to receive a vaccine that the state mandates during an epidemic, including religious grounds, medical reasons or a "conscientiously held belief."

Drivers' sight: HB 439, by Rep. Kim Moser, R-Taylor Mill, would require a vision screening test be taken for renewal of a driver's license. Drivers could be screened at the renewal office or a medical office. 

Insurance: SB 55, sponsored by Sen. Stephen Meredith, R-Leitchfield, would get rid of all co-payments required by Medicaid.

SB 45, sponsored by Sen. Ralph Alvarado, R-Winchester, would limit the use of copay-accumulator programs by health plans, which prevent cost-sharing amounts paid on behalf of enrollees from counting towards their maximum out-of-pocket limits. 

SB 44, sponsored by Alvarado, ensures that any insurance payments made on behalf of an individual by a nonprofit organization are counted just as if the patient made it themselves. 

The Senate agreed to House changes in SB 44 that give providers until 2025 to tell women whose X-ray mammograms show dense breast tissue that such tissue is not abnormal, but slightly increases the risk for developing breast cancer. Providers are also asked to encourage "digital mammography" which provides a three-dimensional image of the breast. It also agreed to House changes that make sure the insured is responsible for payment, even if it is made by someone else, and prevent providers from paying premiums for their patients.

HB 48, sponsored by Bentley, a retired pharmacist, would allow pharmacists to be reimbursed by commercial insurance for providing medical care that other providers typically bill for, such as rapid flu tests, smoking cessation counseling or immunizations. Beshear signed the bill March 18. 

Telehealth: HB140, sponsored by Rep. Deanna Frazier, R-Richmond, would permit telehealth services that were allowed to expand due to the pandemic to remain in place after it ends. A key part of the bill would continue to allow audio-only visits, which is important because the state has many places without high-speed internet and many patients who are not adept at using technology.

Organ donation: HB 75, sponsored by Rep. Shawn McPherson, R-Scottsville, would keep insurance companies from increasing rates on organ donors or dropping their coverage. It would also encourage the cabinet to develop educational materials relating to organ donation. 

SB 12, sponsored by Alvarado, would prohibit a person from selling or purchasing human organs or tissue and ban for-profit entities from procuring any eye, cornea, eye tissue, or corneal tissue.

Alzheimer's disease: SB 61, by Meredith, would require six hours of dementia-specific training and three hours of annual continuing education for home-health aides and personal-service aides who provide care for Alzheimer’s or dementia, an often frustrating line of work with a very heavy turnover.

SB 74, by Alvarado, would establish but not fund a dementia services coordinator in the Cabinet for Health and Family Services to manage the Alzheimer’s Disease and Related Disorders Council, be in charge of the state plan to address Alzheimer’s in Kentucky and apply for federal funding opportunities.

Colon cancer: SB 16, by Alvarado, addresses several issues related to the screening program, including adding "prevention" to its name and requiring the Department of Medicaid Services to compile and present annual statistics on services related to colorectal cancer. 

Beshear had already signed HB 108, sponsored by Melinda Gibbons Prunty, R-Belton (Muhlenberg County) into law. It codifies existing Medicaid coverage of colorectal cancer, which includes screenings starting at age 45 for most people and genetic cancer-risk testing for the disease, to ensure uniform coverage for Medicaid patients that lines up with commercial-plan requirements. 

Infants and new mothers: HB 155, sponsored by Rep. Nancy Tate, R-Brandenburg, would allow the use of a “newborn safety device” to aid the anonymous surrendering of a newborn infant at a participating hospital, police station or staffed fire station. 

HB 212, sponsored by Samara Heavrin, R-Leitchfield, would require data in an annual state report on fatalities among children and new mothers to include information on demographics, race, income and geography associated with the fatalities. 

Mental health: HB 50, by Moser, would make health-insurance plans comply with a 2008 federal law that requires them to treat mental-health conditions and substance-use disorders just like physical conditions and file annual reports to show how they are complying. Beshear signed this bill March 12. 

Several health bills could still pass

HB 556, sponsored by Bentley, would allocate $20 million to a rural hospital operations and facilities loan fund created but not funded in the 2020 session. The bill has received two of the required three readings in the Senate and is in the Appropriations and Revenue Committee.

SB 51, by Alvarado, would ban the requirement of prior authorization for any prescription drug that is used in the treatment of alcoholism or opioid-use disorder and that contains methadone, buprenorphine or Naltrexone, or that is approved by the U.S. Food and Drug Administration for the mitigation of opioid withdrawal symptoms. It awaits a House floor vote. 

HB 91, sponsored by Rep. Joseph Fischer, R-Fort Thomas, would add to the state constitution a statement that it does not secure or protect a right to abortion or funding of abortion. The bill has had two readings and is in the Senate Rules Committee awaiting a floor vote. If passed, it would go on the ballot for voters to consider in November 2022. Governors don't act on constitutional amendments.

Health bills that are dead

SB 81, sponsored by Republican Caucus Chair Julie Raque Adams of Louisville, and HB  147, by Moser, would have restored local government control over use, display, sale and distribution of tobacco or vapor products. Neither was assigned to a committee, though Moser is chair of the House Health and Family Services Committee. Advocates of the bill said it had the votes to pass. 

SB 78, sponsored by Adams and Sen. Paul Hornback, R-Shelbyville, would have permanently removed the required collaborative agreements for prescriptive authority of controlled substances between a physician and an advanced practice registered nurse, and upon approval of the Kentucky Board of Nursing. The bill got out of committee, but wasn't called for a floor vote. 

Rep. Jerry Miller, R-Eastwood, tried to add SB 78's language as a floor amendment to SB 166. He ended up withdrawing it because it was deemed to not be germane, but made a floor speech about the importance of getting this legislation passed in the next legislative session.

After noting that this is the fourth year the legislation has been filed, and that he knew 70 of the 100 House members would have voted for it, Miller said, "This is a bill that's time has come. . . . APRNs are the general practitioners of the 21st century and we need to give them greater authority." 

SB 83, sponsored by Meredith, would have let medical professionals refuse to perform procedures that violate their religious or moral beliefs. It got out of committee, but was never called up for a floor vote. Meredith filed a similar bill in the 2020 legislative session that did not pass.

Medicaid contracts rejected by legislative committee; members of another panel see secrecy and a rush to award $8 billion in deals

On Gov. Matt Bevin's last day in office, a legislative committee voted unanimously to reject his administration's recent approval of $8 billion in Medicaid managed-care contracts covering 1 million Kentuckians. Later in the day, legislators on another committee asked the outgoing health secretary why the contracts were approved so quickly, and without legislative oversight.

On Dec. 9, the Government Contract Review Committee voted unanimously to reject the contract, saying the Bevin administration failed to give them the contracts in advance for review, Deborah Yetter reports for the Louisville Courier Journal.

The committee has only advisory power, but its vote could add weight to the promised appeals of major health insurer Anthem Inc. and Louisville-based Passport Health Plan, which the Bevin administration dropped as managed-care organizations (MCOs) for Medicaid.

Sen. Stephen Meredith

Sen. Stephen Meredith, a member of the committee, told Yetter that the Bevin administration claimed the contracts were exempt from review by the committee, but the committee determined that they were not. The administration ended up sending the contracts to the committee for approval, but only after it had already awarded them to five MCOs.

"It's like we're being strong-armed into doing something," said Meredith, a Republican from Leitchfield, later adding, "We should have seen these contracts before they were awarded. If we're not seeing these contracts, I'm truly wondering about what else we're not seeing."

At a meeting of the Medicaid Oversight and Advisory Committee, which Meredith co-chairs, "Lawmakers demanded to know why the contracts were awarded in apparent haste and why lawmakers were not consulted about details that affect their communities," Yetter reports.

"This looks like, from my perspective, this was a very rushed procedure with the intention of trying to limit any legislative input," Meredith told Adam Meier, secretary of the Cabinet for Health and Family Services, which runs Medicaid.

"I've got some great concerns with the process," said Senate Minority Leader Morgan McGarvey, D-Louisville. He asked Meier, "Why has there been such secrecy around this process, and why was there an $8 billion contract award issued after the election?"

Health Secretary Adam Meier at the Medicaid
Oversight and Advisory Committee meeting

Meier defended the contract process, saying, "They're not secret, they're confidential."

He said the contract bids were independently evaluated by a five-member committee that scored them for how well it met state specifications, adding that they have been working for months on the awards. "The idea that this was rushed is absurd," Meier said.

The lawmakers also wanted to know why the administration chose contract with five companies (including two new ones) when federal regulations only require two.

Legislators have repeatedly said five companies are too many because they create administrative burdens for health-care providers that are not necessary or sustainable. They have suggested no more than three companies, and Meredith has filed bills calling for this change.

"This body has made it clear, abundantly clear, that we expect three," said Sen. Danny Carroll, R-Paducah. "Why do we have five? Is there something I'm missing?"

Meier said the state chose five MCOs to create more competition. "I don't see us trying to limit competition," he said.

The administration announced the contract awards Nov. 27 to Aetna Better Health of Kentucky, Humana Health Plan and Wellcare Health Insurance of Kentucky, all of which hold existing contracts with the state, and two newcomers, United Healthcare and Molina Health Care. The contracts take effect on July 1.

The contracts were re-approved over the committee's objection by Finance Secretary William Landrum on his last day in office, Yetter reports. Gov. Andy Beshear, who took office the next day, has promised to review them. Meredith said he wouldn't be surprised if the dispute ends up in court. 

Employer-sponsored insurance health plans in Ky. more costly in 2018; high premiums and deductibles leave many underinsured

By Melissa Patrick
Kentucky Health News

A recent analysis by The Commonwealth Fund, a foundation interested in the health-care system, shows that the overall cost of employer-sponsored insurance plans keeps going up, and families are spending more of their income on health care.

“The majority of people under age 65 in the U.S., 164 million, get their health insurance through an employer, and that insurance is less and less affordable for many of them,” Dr. David Blumenthal, president of The Commonwealth Fund, said in a news release. “Ensuring that everyone can afford health insurance and health care will require policy fixes and systemwide efforts to get to the heart of the health care cost problem: the exorbitant prices we often pay for health care in the United States.”

The analysis found that Kentucky families covered through employer plans spent on average, 13 percent of their yearly income for health coverage in 2018 -- or $7,471 in out-of-pocket spending. That was slightly above the national average of 11.5%.

That was a 3.1% increase from 2016, compared to a 4.4% jump in the national rate. But when you compare the state's average potential out-of-pocket spending in 2018 to what Kentuckians were paying a decade ago ($3,886), it's up 92%.

And because Kentuckians make less money on average than people in other states, they spend a larger share of their incomes on their premiums and deductibles. For example, in Kentucky, the median household income in 2018 was $50,247, compared to $61,937 nationally.

“Over the last decade, employer health-insurance premiums and deductibles have grown faster than workers’ wages. This is concerning, because it may put both coverage and health care out of reach for millions of people," Sara Collins, lead author of the study, said in the release.

The analysis of Kentucky empoloyer-based insurance shows that the premium cost for single-coverage plans saw the biggest jump between 2016 and 2018, from $1,290 to $1,633, or 12.5%. The rest of the nation saw a 3.8% increase for this measure.

Deductible costs for single coverage dropped 1.9%, to $1,833; deductibles for the combined average of single and family coverage dropped 3.2%, to $2,930; and premiums for family coverage increased 6.6%, to $5,382. Changes nationally were higher for the deductible costs, but lower for the premium cost.

Offering a bit of perspective, the Commonwealth Fund points out that high-deductible plans leave many people at risk of being underinsured, which is defined as having a deductible equivalent to 5% or more of their income. That said, a $2,930 deductible would leave many middle-class families in Kentucky underinsured, making it difficult for them to pay their medical bills and more likely resulting in skipping care because of the cost.

In general, the report says, employees pay about one-fourth of U.S. employers’ portion of the premium costs -- and that holds true in Kentucky. Employer-sponsored insurance premiums, which includes contributions from both the employer and employee, for single coverage in Kentucky in 2018 was $6,690 (up 7.8% from 2016) and $19,277 for family coverage (up 7.5% from 2016).

The researchers note that recent proposals to address the rising cost of health insurance include enhancing the affordability and cost protection of Affordable Care Act marketplace plans, allowing people with employer plans to buy coverage on the marketplace, or replacing private insurance with a public plan like Medicare.

The study used data from the federal Medical Expenditure Panel Survey. Researchers surveyed more than 40,000 business establishments in 2018, with an overall response rate of 67.8%. It looked at both premiums, the amount a person has to pay each month for their plan, and deductibles, the amount a person has to pay before an insurance company's payments kick in; and the size of the costs relative to the median income in each state.

Medicaid program that pays employer-sponsored insurance premiums for employees has a new application process

By Melissa Patrick
Kentucky Health News

A program that will pay the premiums of working Medicaid members who have access to insurance through their employers has a "new and improved" application process, the state says.

The voluntary program, called the Kentucky Integrated Health Insurance Premium Payment program or KI-HIPP, allows Medicaid members to sign up for their employer-sponsored health insurance plan and have Medicaid pay their part of the premium.

Starting Nov. 4, KI-HIPP allows primary policyholders who are not on Medicaid to apply for the program if they have at least one Medicaid-eligible person on their policy. In addition, it allows families with anyone enrolled in a 1915(c) Medicaid Home and Community Based Services waiver.

“KI-HIPP is an excellent example of a government partnership that works with the employer-sponsored insurance market to expand insurance coverage options, particularly for families,” Medicaid Commissioner Carol Steckel said in a news release. “It allows Medicaid beneficiaries to choose a plan that meets their needs and empowers them to take control of their health. The added benefit is that this partnership saves the Medicaid program money.”

As of Oct. 30, the program had 220 members enrolled which would translate to a projected annual savings of nearly $800,000 for the Medicaid program, says the release.

Jason Dunn, a policy analyst for Kentucky Voices for Health, told Kentucky Health News that while KI-HIPP could be a great plan for some people and their families, he cautioned that it is important for consumers to carefully examine what he called the "risk" before making a switch, especially those with very low incomes.

For example, he pointed out that those who choose KI-HIPP will have more paperwork to manage, since participants are required to submit a copy of their paystub each pay period as proof of premium payment. It also requires the participant to submit annual re-certifications for both plans.

Dunn also noted that there is a risk that KI-HIPP participants could end up paying more out-of-pocket costs for their health care if they don't see providers who accept both the employer-sponsored insurance and fee-for-service Medicaid. If the provider only takes the employer's insurance, the KI-HIPP participant must pay all out-of-pocket costs, including co-pays, deductibles and co-insurance. "And that can be pretty pretty expensive," he said. "All that can be thousands of dollars a year."

Dunn added that individuals also need to explore what would happen if they were part of the KI-HIPP program, but then became no longer eligible for Medicaid, or were no longer able to meet the KI-HIPP requirements. In either case, the premium would no longer be reimbursed by Medicaid, and the employer could have to pick up the cost until the next open enrollment if they were not permitted to dis-enroll from the employer's plan.

Tens of thousands of Kentuckians go on and off Medicaid each month, for various reasons. As an example of that, the health cabinet confirmed that as of Nov. 4, 25 people had left the KI-HIPP program because their incomes rose above the Medicaid eligibility limit; by Nov. 6, the number of KI-HIPP participants had risen from 195 to 199.

To improve the application process, the system now includes a stand-alone application which is designed to make it easier for newly eligible Kentuckians to apply for KI-HIPP or to add it to an existing Medicaid case. "It's great to make it easier to apply, but we just want to make sure people know what they're applying for and what the risks are," Dunn said.

The release notes that Kentuckians enrolled in the existing Health Insurance Premium Payment (HIPP) program will move to KI-HIPP in December, and HIPP program members will get a letter in the mail with guidance on how to make this transition.

Sign up for KI-HIPP at benefind.ky.gov or call 855-459-6328. For more information see https://chfs.ky.gov/agencies/dms/member/pages/kihipp.aspx. Click here for a link to a Kentucky Voices for Health explainer about the program.

Be wary of the complex pros and cons of Medicare Advantage plans during open enrollment through Dec. 1, columnist advises

By Trudy Lieberman

Community Health News Service

Along with crunchy leaves and pumpkins, fall brings a slew of advertising for insurance plans that fill the gaps in Medicare coverage.

Misleading and confusing messages continue to reach beneficiaries and those nearing Medicare age. To take myself as an example, I’ve received an invitation to a Medicare Advantage plan informational meeting. I’ve gotten a solicitation from my physician’s medical group offering a “zero-cost, no obligation way to review coverage” online or over the phone. The “review” is likely to bring a sales pitch for a plan.

A mailer from another plan offered “a friendly, money-saving Medicare Advantage Plan” that seemed to promise the moon: savings of up to $2,380 a year, maximum dental coverage of $1,500, and a $750 hearing aid allowance, a drop in the proverbial bucket considering the average cost of two hearing aids is about $4,500. One seller seemed to think I was on both Medicare and Medicaid and pitched a “special needs plan.” Since I wasn’t a candidate for such an arrangement, was the insurer trying to get in the door to sell a regular Medicare Advantage plan?

Too many people fall for those kinds of pitches during Medicare's open enrollment period, which runs through Dec. 1. Shopping to cover the gaps in Medicare is a task no one should take lightly. The stakes are too high.

Medicare is a fine program, but it was never meant to cover everything. It’s based on the old Blue Cross model of insurance common in the 1960s, where the company paid 80 percent of the medical bill and the patient paid 20 percent. An industry selling "Medigap" policies sprang up to cover the 20 percent, and deceptive sales practices plagued the business for years.

Congress ended that and standardized the coverage into 10 plans (now 11, including a high-deductible option) that give people a broad choice for covering what Medicare does not pay. If people bought Plan F or Plan C as their supplemental insurance, they were pretty much covered for most illnesses.

Beginning next year, however, new Medicare beneficiaries – those who turn 65 on or after Jan. 1, 2020 – won’t be allowed to buy Plan F or C. Congress wants more beneficiaries in Medicare Advantage plans, so it eliminated the option to buy the most comprehensive plans. Lawmakers wanted seniors to pay more for their care.

They can still buy Plan G, which offers the same protection as F except that it doesn’t cover the Medicare Part B deductible, which is $183 next year. People already on Medicare can still buy Plans F or C.

The goal is to push more people into Medicare Advantage plans, a private alternative that is a step toward privatizing the entire program. To move the process along, the government has overpaid insurers to provide the care, which enables them to offer inducements to join. About one-third of Medicare beneficiaries have moved to MA plans, so that strategy seems to be successful.

But does it come at a cost?

Serious questions have arisen about the overpayments the government has made using taxpayer dollars– overpayments that allow plans to offer gym memberships and even Apple watches, as monitoring devices, to new enrollees as one plan is doing. In September six Democratic senators wrote to the Centers for Medicare and Medicaid Services, noting that taxpayers have overpaid Medicare Advantage plans more than $30 billion over the last three years and that CMS has “taken little to no action to correct” the overbilling and overpayments.

Even more troubling, the letter also says that several other government agencies such as the Office of the Inspector General in the Department for Health and Human Services have raised “serious concerns” about Advantage plans that fail to meet needs of older adults and those with disabilities.

The letter raises questions about the kind of care beneficiaries are actually receiving, and notes that Medicare’s own audits have found “widespread and persistent Medicare Advantage performance problems related to denials of care and payment” that “threaten the health and safety of their members.”

Those are government watchdogs raising a red flag about problems getting care when you’re really sick and need good insurance.

Medicare Advantage plan advisers note that traditional Medicare does not put a limit on the amount a beneficiary must pay out of pocket each year, while Advantage plans do – $6,700 for in-network providers and $10,000 for those out of network. They usually don’t mention that a good Medigap policy will cover those amounts, but the premiums may be higher than for an MA plan heavily subsidized by the government.

The trade-off becomes what it does with all insurance: Pay now in the form of higher premiums, or pay later in the form of higher expenses if the worst happens. Insurers seldom mention that tough trade-off when they host those informational meetings for Medicare shoppers.

McConnell, other senators targeted by misleading ads about legislation written to protect patients from surprise medical bills

The ad's spokeswoman criticizes a bill that she claims will help insurance companies hurt patients.

Kentuckians have been seeing lots of TV ads from a group that calls itself Doctor Patient Unity and says insurance companies are out to hurt patients by setting rates for health care. But that's a misleading description of what's going on, and the group "doesn’t list its members or disclose its funding," reports the Center for Responsive Politics, which tracks political spending.

The group, which was incorporated in Virginia on July 23, has bought at least $2.3 million in air time from late July through mid-August. Its ads are aimed at killing legislation written to reduce the amount and instances of surprise medical bills, that hit out-of-network patients "with exorbitant costs because the physician or hospital does not have a contract with the patient’s insurer," the center reports. "These unexpected bills, which can be hefty enough to bankrupt some Americans, often result from emergency room visits or ambulance rides," including expensive air ambulances.

Sen. Mitch McConnell at the Fancy Farm
Picnic (Photo by The Associated Press)

The bill "appears primed to pass the Senate," and the ads are aimed at mainly senators on the ballot in 2020, the center reports. In Kentucky, they mention Senate Majority Leader Mitch McConnell, who favors the bill, but also Sen. Rand Paul, an ophthalmologist who is up for re-election in 2022.

"Hospital and physician trade groups are opposed to the same kind of 'rate setting' mentioned in the ad as a giveaway to insurers, while insurers are eager to accuse providers of charging too much for emergency-room visits," the center notes. "Members of Congress had hoped to address surprise medical bills before the August recess but were unable to finish the job."

At issue is the proposed Lower Health Care Costs Act, a bipartisan bill that would establish the rates for reimbursement of providers for out-of-network emergency care. McConnell has said that the bill is a top priority for him.

"Doctor Patient Unity is effectively a counterbalance to the Coalition Against Surprise Medical Billing, a group publicly supported by some of the biggest insurance companies and groups, including the Blue Cross Blue Shield Association and America’s Health Insurance Plans" insurers' main lobbying group, the center reports.

"In addition to a multi-million dollar TV ad campaign, Doctor Patient Unity has also spent tens of thousands on radio ads and Facebook ads. Their Facebook ads mention numerous House members from both parties in addition to senators, urging users to contact their congressperson to “side with patients, not insurance companies.”

One Affordable Care Act insurer in Kentucky wants a 12% rate hike next year; the other one has asked for a decrease of 4.5%

By Melissa Patrick
Kentucky Health News

One of the two insurers offering government-subsidized individual health plans in Kentucky for 2020 is asking for a 12 percent increase, while the other is asking for a 4.5% decrease.

Insurers offering plans for small groups under the Patient Protection and Affordable Care Act are asking for average hikes of 10.5%. These overall percentages reflect an average that will vary, depending on whether individuals smoke, how old they are and where they live.

Anthem Health Plans of Kentucky requested an average 12% increase for the 13 plans to be offered.

CareSource Kentucky requested an average rate decrease of 4.5% for its 12 individual plans.

The requests are preliminary and subject to change. The Kentucky Department of Insurance can approve, lower or raise the rates. The department said in a press release that it expects to finalize the rates by August, which is also when it will finalize any expansion of the plans' service areas.

This year, Anthem offered plans in 93 of the 120 counties, and CareSource offered plans in 61. In 34 counties, both insurers offered plans, but in 16 of those the Anthem plans have a narrow network of providers.

“From our initial review, it appears that the popular silver and bronze plans offered by both insurers receive either a much smaller average increase or comprise the majority of the decreases when compared to other plans,” Insurance Commissioner Nancy G. Atkins said in the release. “Over 90% of the participants select one of these plans, and we anticipate this trend to continue.”

Last year, Anthem asked for an average 3.5% increase and CareSource asked for a 19.4 % hike. The Insurance Department gave Anthem a higher increase than it asked for at 4.3% and CareSource got the 19.4% it requested.

Kentucky saw 84,620 residents enroll in subsidized coverage via Healthcare.gov during the open enrollment period for 2019. That was a 5.5% decrease from 2018, when 89,569 Kentuckians enrolled, but up 4.3% from 2017, when 81,155 enrolled. Kentucky has yet to reach the same number of enrollees as it did in 2015, when 106,330 enrolled. The state shifted enrollment to the federal exchange in 2016, away from the state-based exchange called Kynect. Open enrollment for 2020 begins Nov. 1.

Bevin joins appeal of court ruling that blocked new association health plans; AG Beshear says they threaten health coverage

By Melissa Patrick
Kentucky Health News

Would association health plans, a type of insurance that makes it easier for small employers to band together, free of many of the requirements of the Patient Protection and Affordable Care Act, provide enough protections to consumers?

Business Management Daily graphic

Gov. Matt Bevin's health secretary says they would. Attorney General Andy Beshear, who is running against Bevin, says they wouldn't.

Bevin and officials from 15 other states, filed a court brief June 7 urging the U.S. Court of Appeals for the District of Columbia to reverse a lower court's decision against expanded access to association health plans.

The brief prompted a verbal tussle between Beshear, one of the original plaintiffs in the lawsuit, and Health Secretary Adam Meier, who released his statement from the governor's office, where he was deputy chief of staff, instead of the Cabinet for Health and Family Services, which he leads.

Beshear issued a statement saying, “I disagree with the governor’s new action because it threatens health care coverage for Kentuckians, including people with pre-existing health conditions. While Matt Bevin continues his work to strip vital coverage away from our families, I am fighting to make sure all Kentuckians get the health care they need and can afford it.”

In response, Meier called on Beshear to retract his "false and outrageous claim" and linked to official guidance from the U.S. Department of Labor that says association health plans "may not charge higher premiums or deny coverage to people because of pre-existing conditions."

“The Department of Labor has been very clear that association health plans cannot deny coverage to individuals based on pre-existing conditions,” Meier said. “To state otherwise is false and shows a complete lack of understanding of the intent of the Department of Labor rule, which is to provide workers and small businesses with greater access to affordable health insurance options. AHPs are a great way for sole proprietors and small businesses to have the same kind of health coverage that big corporations offer their employees.”

Technically, Meier is correct. But critics of the AHP rule say that while they recognize that the guidance says AHPs can't deny coverage based on pre-existing conditions, the rest of the policy is set up to allow them to easily do so by simply denying coverage for conditions they don't want to cover, such as not covering insulin for diabetics or not covering mental-health care.

The American Medical Association sides with Beshear on this issue. In a 2018 friend-of-the-court brief, the AMA laid out a list of concerns.

 "There is a significant risk that AHPs could disproportionately impact individuals with pre-existing conditions," the AMA said. "To be sure, on its face, the regulation states that it protects coverage of pre-existing conditions. But in reality, AHPs can easily evade that crucial legal requirement by using proxies for health status."

For example, AMA wrote that AHPs "can charge premiums based on factors that are not explicitly defined in terms of health or medical conditions, but that closely track those forbidden factors."

Further, it notes that the AHP rule allows them to charge different premiums based on age, gender, industry or geography. "But each of those seemingly neutral characteristics can be used to disguise differential treatment based on health status or one's likelihood of suffering from particular pre-existing conditions."

The AMA argued, "Denying patients coverage based on seemingly neutral characteristics that the insurance industry knows, in reality, are associated with higher medical costs or pre-existing conditions would leave patients with lower quality care, greater out-of-pocket expenses, and overall poorer health outcomes. Those consequences subvert the object and design of the ACA."

In addition to its concerns that AHPs will undermine the consumer protections in the ACA, the AMA said they would destabilize ACA exchanges by pulling healthy individuals out of ACA plans.

Citing examples, the AMA also noted that AHPs  have a "long history of fraud and abuse" and adds  that the AHP rule itself recognizes this when it says, "The Department anticipates that the increased flexibility afforded AHPs under this rule will introduce increased opportunities for mismanagement or abuse, in turn increasing oversight demands on the Department and state regulators."

What's it all about? 

President Donald Trump signed an executive order in 2017 to expand access to association health plans, stating that expanding access to such plans would "allow more small businesses to avoid many of the [Patient Protection and Affordable Care Act's] costly requirements."

In June of last year, the Department of Labor did just that, by expanding the types of groups that could ban together to offer coverage under an AHP.

The department also loosened association requirements so that more of them could be classified as large-employer coverage, which would exempt them from having to cover the 10 essential health benefits required by the ACA, like covering mental health or prescriptions. Nor, under the new rule, would they be required to pay the tax that large -group market insurers have to pay when they choose to not cover them. As previously noted,  association insurers can set premium rates based on age, gender, industry or geography.

In March 2019, the policy was struck down in federal court following a lawsuit filed by 11 attorneys general, including Kentucky's Beshear.

In his ruling, Judge John D. Bates, of the U.S. District Court for the District of Columbia, who was appointed by President George W. Bush, concluded that the labor department "unreasonably expands the definition of "employers" to include groups without any real commonality of interest" and that it had  misinterpreted the Employee Retirement Income Security Act's definition of an employer when it allowed working owners without employees to be covered by the AHPs. Bates added that the policy "was intended and designed to end run the requirements for the ACA."

This month, Bevin, along with 15 other states, filed a court brief urging the federal appeals court to reverse the district court's ruling. Bevin's involvement put Kentucky on both sides of the issue.

"By broadening the definition of a qualifying employer, more small businesses can take advantage of that purchasing leverage," says the brief. "Thus "a substantial number of uninsured people will enroll in AHPs because the Department [of Labor] expects the coverage will be more affordable than what would otherwise be available to them.""

AHPs in Kentucky?

The 2019 Kentucky General Assembly overwhelmingly passed House Bill 396 to update the Kentucky insurance code to adopt the Department of Labor's final rule and expansion of AHPs. Bevin signed it into law March 26.

Kentucky already has some association health plans that are fully insured and industry specific for employer groups, but has not approved any under the new policy, said Susan West, spokeswoman for the Public Protection Cabinet, which includes the Kentucky Department of Insurance.

West said in an email that the state was "on the cusp" of approving a fully insured AHP under the new rules that would have gone into effect June 27, but it has since been put on hold because of the federal court ruling and subsequent appeal. 

"Given the recent federal ruling and discussion among regulators at the recent [National Association of Insurance Commissioners] meeting, in which Kentucky participated, the DOI is waiting on the federal [Department of Labor] to determine their course of action and appellate options before moving forward with approving specific plans and registering associations," West said.

Study: Private insurance pays hospitals 241% more than Medicare (186% in Kentucky); suggests shift to a Medicare model

By Melissa Patrick
Kentucky Health News

As health-care costs continue to rise for both employers and employees, one group of researchers says private insurers should move away from how they pay for hospital services, which requires them to pay a percentage of billed charges, and start paying the way Medicare does, based on a fixed-price agreements that are transparent to all. The American Hospital Association says that would not be sustainable, because Medicare doesn't pay hospitals enough.

The Rand Corp., a global research firm, made this recommendation based on its a study that found private health plans in the U.S. paid hospitals 241 percent more than what Medicare would have paid them in 2017, up from 236% in 2015.

Kentucky's private plans paid 186% more than Medicare in 2017, the fourth smallest difference among those in the 25 states surveyed. For inpatient treatment, the state's costs were second lowest of the 25, but its outpatient costs were above average.

All but five Kentucky hospitals in the study had a rate greater than 200% of what Medicare pays for outpatient services, with nearly 19 greater than 300% for that same measure. There was a bigger difference in prices for outpatient care than for inpatient care. In Kentucky those rates were 245% and 142%, respectively; nationally, they were 293% and 204%.

“The widely varying prices among hospitals suggests that employers have opportunities to redesign their health plans to better align hospital prices with the value of care provided,” Chapin White, the study's lead author and a policy researcher at Rand, said in a news release. “Employers can exert pressure on their health plans and hospitals to shift from current pricing system to one that is based on a multiple of Medicare or another similar benchmark.”

The report says the data is also important because it allows employers to create networks that move their employees away from the higher-priced hospitals to the lower-priced ones.

The study reported on the relative price of private insurance to Medicare by dividing the amount allowed for private insurance by the amount allowed for Medicare for the same service, in the same facility. The researchers used data from about 4 million patients in 1,589 hospitals in 25 states.

The researchers used claims data from self-insured employers, two state all payer claims databases and records from health insurance plans that chose to participate. For each private claim, they re-priced the service using Medicare's grouping and pricing formulas.

Prices varied greatly by state and hospital. Of the 36 Kentucky hospitals in the study, private health-plan prices for outpatient services ranged from 85% of Medicare at Jane Todd Crawford Hospital in Greensburg to 526% at TJ Samson Community Hospital in Glasgow.

The study looked at three Kentucky hospital systems, including Baptist Health, Catholic Health Initiatives and Norton Healthcare. It found a decrease in relative pricing in each of the systems since 2015, with Baptist Health billing private insurers 168% more than Medicare in 2017, down from 203% in 2015; CHI billing 187% more in 2017, compared to 236% in 2015; and Norton Healthcare billing 185% more in 2017, compared to 205% in 2015.

Overall, the study found a wide variance among hospital systems, ranging from 150% of Medicare rates at the low end and more than 400% at the high end. "In general," the report says, "prices paid by private health plans are much higher than Medicare, and there is a wide variation."

The researchers found that if employers and health plans participating in the study reduced their hospital payments to Medicare rates, it would have resulted in $7.7 billion in savings for employers in 2015-17. It said reducing prices from the 75th to the 25th percentile would have reduced employer spending by $1.4 billion, about 40% of the employers' and plans' spending on hospitals in 2017.

The analysts offered two different interpretations for this variation. One is the "cost shifting story," which argues that Medicare severely underpays hospitals, compelling them to charge privately insured patients more. The other is "the leverage story," which says hospitals have used their leveraging power to extract unreasonable price deals from health plans, which in turn makes Medicare prices "look woefully inadequate by comparison."

The challenge is that while employers are looking for ways to decrease health-care costs, hospitals depend on cash flow generated by private insurance plans to upgrade and expand their services. "Lower private prices would require hospital managers to find ways to increase revenues to reduce costs to maintain current margins," says the report.

The American Hospital Association released a statement that took issue with the small sample size, which it described as less than 5% of all covered persons in about half of all states, and just 2% of the 181 million Americans with employer-sponsored insurance nationally.

It also took issue with the usage of Medicare payment rates as the benchmark for hospital prices, stating that in 2017, hospitals received payment for only 87 cents for every dollar they spent caring for Medicare patients.

"Simply shifting to prices based on artificially low Medicare payment rates would strip vital resources from already strapped communities, seriously impeding access to care," AHA General Counsel Melinda Hatton said. "Hospitals would not have the resources needed to keep our doors open, innovate to adapt to a rapidly changing field and maintain the services communities need and expect."

All that said, many think something has to give. Employers have increasingly shifted to high-deductible plans to help offset some of their costs, but this has created a situation where employees have become "under-insured" because they can't afford the cost burden that comes with such plans.

Further, according to an analysis by The Commonwealth Fund, the cost of employer health-insurance premiums and deductibles continues to outpace wages. The analysis found that Kentucky families covered through work spent, on average, 13% of their income for health coverage in 2017.

The study recognizes that it only used data for about one-third of U.S. hospitals, and that for many of those hospitals, only outpatient prices could be reported; and that it only includes facility claims and not claims for treatment by physicians or claims for prescription drugs.

The report offers detailed suggestions on how employers can use this data to seek lower prices for their health plans. It also includes suggestions for policymakers, including placing limits on payments for out-of-network hospital care or allowing employers to buy into Medicare or another public option that pays providers based on a multiple of Medicare rates.

The research was funded by the Robert Wood Johnson Foundation, the National Institute for Health Care Reform, and the Health Foundation of Greater Indianapolis and participating self-insured employers.

Most on Medicaid will have co-payments starting Jan. 1; foes say it's a barrier to care, proponents say it improves engagement

By Melissa Patrick
Kentucky Health News

Starting Jan. 1, most adult Medicaid beneficiaries in Kentucky will be required to make co-payments for many of their health-care services, a rule change that prompted 26 organizations to sign a letter asking state officials to reconsider this decision because they say it will create a barrier to care.

"Requiring co-payments from Medicaid beneficiaries is a choice each state must make. Any budgetary benefits are limited at best, as the unintended consequences of creating barriers to care are often offset by increased costs down the road," says the Dec. 11 letter to the state's new Medicaid commissioner, Carol Steckel.

Co-payments have long been required from Medicaid members who are aged, blind or disabled. They are not part of the "managed care" system in which insurance-company subsidiaries or other organizations oversee care funded by Medicaid. The managed-care organizations, or MCOs, have been able to waive co-pays, "and all of them have waived some or all of those," said Doug Hogan, spokesman for the state Cabinet for Health and Family Services. "The new regulation will remove that ability to waive the co-pays and create more uniform application across all populations."

These new co-pay rules are separate from the state's new Medicaid plan, which is set to roll out on April 1. And as soon as that plan is implemented, monthly premiums ranging from $1 to $15 per month will replace the co-pays for most beneficiaries. Implementation could be delayed by courts.

The rule that takes effect Jan. 1 requires MCOs to charge co-pays that range from $1 for some prescriptions to $50 for any type of inpatient service, including mental-health and substance-abuse admissions.

The rule exempts children, pregnant women, hospice patients and beneficiaries who have reached their "cost sharing limit" for the quarter, which amounts to 5 percent of a person's household income during three-month quarters of the year.

The  rule also exempts a few services, including emergency care, some family planning and preventive care, such as screenings, check-ups and patient counseling to prevent illnesses, like diabetes or heart disease.

Providers cannot refuse to see Medicaid beneficiaries who are below the federal poverty level if they cannot afford their co-payment, but can refuse services to those above the level -- though this has to be their current business practice for all patients, not just those on Medicaid.

The cabinet has provided a PowerPoint presentation to help providers navigate the changes.

The 26 organizations that signed the letter included links to two bodies of research that support their concerns that even small co-pays will cause many to go without care. One, published by the National Institutes of Health, cites several examples of state co-pay requirements that reduced faithfulness to prescriptions, and another that reviewed 65 studies from the Kaiser Family Foundation, which found that even modest co-payments create barriers to care for low-income populations.

"Having worked hand-in-hand with state agencies, providers, application assisters, legal aid programs, and others across the commonwealth to get Kentucky covered, we have found that even modest financial barriers can mean the difference between having access to healthcare or going without," says the letter.

Hogan said state health officials hope that mandatory co-payments and the new Medicaid plan will "empower individuals to improve their health and their lives," as well as help them to transition from Medicaid into commercial health insurance.

"We see from other states that premiums have an even more profound effect at increasing engagement and improving utilization," he said. "For example, in Indiana, people who chose the premium plan over the co-pay plan had nearly double the rate of primary-care utilization.  We think that may be because premiums are easier to plan and budget for, and serve as a monthly reminder that they have health coverage that they associate value with—which makes them more likely to use it in a preventable manner."

Op-ed: Pharmacy benefit managers exclude diabetes medications and supplies from coverage more than any other category

As insurers continue to exclude many diabetes-related medications and supplies from coverage, children with diabetes could be "saddled with lifetimes of exorbitant out-of-pocket costs," Stewart Perry and Jeff Hitchcock write in an op-ed for the Lexington Herald-Leader.

Perry, of Lexington, is the parent of a child with diabetes and the past national chairman of the board of the American Diabetes Association. Hitchcock is founder and president of Children with Diabetes and a member of the Doctor-Patient Rights Project.

Kentucky ranks fifth among all states in the rate of diabetes, with over 13 percent of the state's adults diagnosed with the disease.

The authors say that the growing number of Kentuckians with diabetes could be one of the reasons pharmacy benefit managers -- who act as middlemen between patients and drug companies -- are excluding so many diabetes-related medications and supplies from being covered. They note that these exclusions are "more than any other treatment category."

Perry and Hitchcock write that a Doctor-Patient Rights Project study found that in the last four years, "the number of diabetes-related medications or supplies excluded from coverage by the nation’s two largest PBMs (CVS and Express Scripts) has increased by almost 80 percent, the only treatment category where the PBMs consistently increased the number of excluded medicines every year."

"Diabetes-related treatments now account for one out of every five medicines excluded from coverage by these PBMs," they write.

The idea behind these exclusion lists is to compel patients to use less expensive treatment choices, "falsely assuming that every patient with diabetes will respond the same way to every treatment choice," the authors write. The study found that many patients who are asked to switch to a new medication choose to pay out-of-pocket for the treatment their doctor originally prescribed, rather than switch to the insurer’s preferred drug.

The authors of the op-ed add that other studies show that when patients have to pay more for their medications, they are more likely take the drug incorrectly by splitting pills or skipping doses to make it last longer. They add, "forced non-medical switching may even backfire as a cost-saving strategy for insurers" because failure to use medication as prescribed makes treatment less effective.

Such failure "accounts for up to 10 percent of hospitalizations, 25 percent of nursing home admissions and as many as 125,000 premature deaths annually, according to a study in the Journal of Managed Care & Specialty Pharmacy," they write. "As a result, it contributes an extra $100 billion to $289 billion in medical expenses each year, at least some of which fall to insurers to pay."

Perry and Hitchcock say fully covering prescribed treatments would allow parents to use the most effective medications for their children, and allow the medications to be used appropriately. They conclude: "The cost savings generated by letting doctors drive treatment decisions more than compensates for the higher pharmaceutical costs."

Senate bill to create tele-heath payment model, with anti-abortion measure attached, advances to full House

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A Senate tele-health bill aimed at increasing access to care and saving the state money is awaiting a vote in the House, amid an objection from the state's largest health insurer and opposition to an amendment that would keep tele-health form being used in abortions.

Sen. Ralph Alvarado

Senate Bill 112, sponsored by Republican Sen. Ralph Alvarado, passed the Senate without dissent and has been placed in the regular orders of the day in the House. It includes a Senate amendment to prohibit tele-health from being used for abortions.

Alvarado, a Winchester physician, told the House committee that telemedicine has been proven to save money through such measures as "video conference follow-ups and remote patient monitoring that decrease hospitalizations and increase the quality of care."

He added that it allows physicians the ability to remotely monitor chronic diseases more efficiently, increases access to specialty care, increases access to mental-health care, decreases use of emergency rooms, and increases provider access to those with transportation issues.

Alvarado cited a study in the journal Health Affairs which he said found savings of 7.7 percent to 13.3 percent per patient, per quarter, for chronically ill Medicare recipients. In addition, he said the state-employee tele-health program had saved the state $2.5 million.

The bill would require the Cabinet for Health and Family Services to develop telemedicine policies, including a reimbursement model, with similar expectations for the public insurance market. It also requires health-care providers to be licensed in Kentucky in order to receive reimbursements, though they would be able to live anywhere in the world.

Committee Chair Addia Wuchner realized after the panel approved the bill without dissent that there were lobbying interests that wanted to speak against the bill, and she gave them a chance to speak.

Lawrence Ford of Anthem Blue Cross and Blue Shield, said that the insurance firm supports tele-health and its expansion, but has concerns about the bill's requirement that providers be paid the same amount for a tele-health visit as an in-patient visit, unless a lesser rate had been negotiated. He said a tele-health visit through Anthem now costs $49, while an average in-person visit cost $83.

He added that while there was no fiscal note attached to the bill, "There was a statement that was prepared by the Department of Insurance that stated that this legislation could increase health care costs for insurance plans by as much as $7.7 million."

"We have issues and oppose any efforts by the General Assembly to venture into rate-setting services between two parties," Ford said. Later, Rep. Jim Gooch, R-Providence, filed a floor amendment to remove the equal-payment provision.

Tamarra Wieder of Planned Parenthood Advocates of Indiana and Kentucky told the panel that while the organization supports tele-health, it opposes the restrictions that the amended bill placed on abortions, which she referred to as a "constitutionally protected medical service."

"Telehealth delivery of medication abortion has been demonstrated to be just as safe and effective as in-person protocols and to improve patient safety by enabling abortion earlier in the pregnancy when it is the safest," Wieder said.

Kate Miller of the American Civil Liberties Union - Kentucky said the amended bill would decrease rural Kentucky women's access to legal abortions, since the only abortion provider in Kentucky is in Louisville.

After the opponents spoke, Wuchner asked if any committee members wanted to change their vote. None did.

Fewer Kentuckians are worried about losing health insurance, though fewer say they are on employer-sponsored plans

By Melissa Patrick
Kentucky Health News

Nearly one in four Kentucky adults with health insurance worry that they could lose their health coverage -- less than last year, when almost one in five said they were concerned, according to the latest Kentucky Health Issues Poll.

The survey, taken by telephone Oct. 24 to Dec. 2, found that the share of Kentuckians with public insurance (such as Medicaid, Medicare or veterans' benefits) in 2017 moved back up to its 2015 rate of 35 percent. It had dropped to 29 percent in 2016.

The share of Kentuckians with employer-provided insurance dropped to 39 percent, continuing a bumpy decline that began in 2014, when the rate was 50 percent. About 11 percent of Kentucky adults reported they bought health insurance on their own or through a parental plan.

The decline in employer-sponsored insurance could be significant, because part of Gov. Matt Bevin's strategy in adding work rules to Medicaid is to encourage those on the program to find jobs that offer insurance. Most of those who will be affected by the work rules already work, but many at low-paying jobs that don't offer insurance.

In 2014, when then-Gov. Steve Beshear expanded Medicaid to those who earn up to 138 percent of the federal poverty level, the share of Kentuckians without health insurance dropped from 25 percent to 12 percent. The rate rose to 15 percent in the latest poll, after two years at 13 percent, but those numbers were within the poll's error margin of plus or minus 2.4 percentage points.

The survey also found that an additional 6 percent of Kentucky adults who had health insurance at the time they were polled were without it at some time during the prior 12 months.

"Health insurance and good health go hand in hand," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll with Interact for Health, a Cincinnati foundation. "Preventive care and wellness checks are as necessary as treatment for chronic illness, and too many Kentucky adults are still going without the care they need due to lack of insurance."

Kentucky's new Medicaid program will have administrative hurdles that are likely to cost some their health coverage

Critics of the Trump administration's decision to add work requirements to Kentucky's Medicaid program cite research to support their concerns that this requirement will cause fewer people to enroll in the program.

Margot Sanger-Katz of The New York Times compiled a list of examples, writing that there is "a lot of research available about the Medicaid program, specifically, that shows that sign-ups fall when states make their program more complicated."

One of several examples that she shares is from 2003, when the state of Washington tried to reduce Medicaid spending by requiring beneficiaries to prove eligibility twice a year, instead of just once, and added some paperwork. One result: 40,000 fewer children in the health insurance program in just one year. The policy was reversed two years later.

Conversely, Sanger-Katz writes that in the early 2000s, Louisiana wanted to increase the number of children in the state health insurance program, so it simplified the sign-up process, resulting in a "surge of enrollment" and "the number of administrative cancellations fell by 20 percentage points."

Another example, which Sanger-Katz doesn't mention, comes form Indiana, the model for Kentucky's program. There, when small, income-based premiums were required, 55 percent of the affected enrollees either never made a first payment or missed a payment while enrolled.

Donald Moynihan, a public-affairs professor at the University of Wisconsin, who is writing a book on the effects of administrative burdens, told Sanger-Katz that it is well documented that complex programs make non-compliance more likely, especially for those who aren't well organized.

"Anyone who has ever forgotten to pay a bill on time, or struggled to assemble all the necessary forms of identification before heading to the DMV, is likely to sympathize with how administrative hurdles can stymie someone," Sanger-Katz writes. "But these may be especially daunting for the poor, who tend to have less stable work schedules and less access to resources that can simplify compliance: reliable transportation, a bank account, internet access."

Kentucky's new Medicaid program creates several "administrative hurdles," and nine other states have asked to make similar program changes, Sanger-Katz reports.

The Kentucky plan requires "able-bodied" Kentuckians on the program to work at a job or participate in an approved list of "community engagement" activities at least 80 hours a month, and to document their participation.

It requires enrollees to pay small, income-based premiums monthly; to report any changes in their income within 10 days of the change; and to renew their coverage promptly at the end of the year.
Failure to meet these requirements very quickly results in a six-month lock-out, invoking more rules.

For example, those below the federal poverty level who don't pay premiums will be required to make co-payments. Those above the poverty level will be allowed to re-enroll if they pay their past-due premiums and take a financial- or health- literacy course.

Gov. Matt Bevin and his lieutenants argue that the changes will give beneficiaries more "dignity and respect" and promote personal responsibility. But they also estimate that the changes will leave the program with almost 100,000 fewer enrollees after five years than without the changes, partly because of "non-compliance."

Analysts think Medicaid work requirements pose little political risk

Bevin and President Trump (AP photo)

"Kentucky is one of the poorest states in America, and its residents are among the sickest. Yet the governor's decision to force Medicaid recipients to meet a work requirement — something that could take health coverage away from 100,000 people — is unlikely to carry any political repercussions for the GOP in this deeply red state." Tony Pugh reports for McClatchy Newspapers' Washington bureau.

Pugh notes that 2017 Kaiser Family Foundation poll found that 70 percent of Americans support work requirements for Medicaid recipients, and that Republican Gov. Matt Bevin is betting Kentucky feels the same way.

Kaiser Family Foundation graphic.
Click on it to enlarge. Click here for more information.  

Read more here: http://www.mcclatchydc.com/news/politics-government/article194990909.html#storylink=cpy

In Kentucky and other states with many low-income residents, people who work but often struggle to pay for health care tend to resent those who get government-subsidized health care, according to Al Cross, director of the University of Kentucky's Institute for Rural Journalism and Community Issues, which publishes Kentucky Health News. "If you can say, 'All we’re doing is requiring people to be more active participants in their health care and require some work-related activities,' I think the general population looks at that and says, 'What’s the matter with that?'" Cross told Pugh.

"Supporters say the Medicaid work policy will cut government dependency, weed out people who don’t really need the assistance and build work ethic among low-income enrollees," Pugh reports. "Critics say the requirement will be expensive to administer, provide an unnecessary barrier to coverage and penalize people who can’t work due to undiagnosed medical problems." Kentucky's new policy estimates nearly 100,000 fewer Kentuckians will have health coverage in five years, than if the policy were not implemented.

Eight other states with Republican governors (Arkansas, Arizona, Indiana, Kansas, Maine, New Hampshire, Utah and Wisconsin) and one state with a Democratic governor (North Carolina) have asked the Trump administration for the green light to enact similar requirements. Several of those states could be battlegrounds in statewide and congressional elections in November. But the Medicaid work requirements aren't likely to be a problem for most Kentucky Republicans, since there are no statewide races this year.

The traditionally lower turnout among low-income voters who would be affected by the measure could also help protect Republicans, Cross said. And it's worth noting that the Kentucky counties with the highest Medicaid rates backed Bevin in 2014, mostly because of social issues such as religion, abortion and anti-Obama sentiment.

But the political dynamics at play in Kentucky may not apply in other states. "It may depend on rival Democrats making a linkage between Medicaid and overall concerns about health care and insurance," Pugh writes. Democrats are likely to emphasize health coverage in elections this year, since 3.2 million Americans lost health coverage in 2017 and it's an issue that most people care about. A poll by Hart Research Associates last week showed that voters cared about health care more than the economy, taxes, immigration, or terrorism in the 2018 congressional elections.