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5 reasons the health out-of-pocket cost fight is your headache, too

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A complicated battle over how health insurers treat enrollees’ out-of-pocket health care costs could make your day even longer.

The health insurers could be angrier, or your customers could be angrier, or they could both be angrier, and take up more of your time with phone calls and e-mails that take a huge effort to understand, let alone handle.

The question is how states will handle the cash insured patients pay out of their own pockets for out-of-network care. 

If the patients simply pay for out-of-network care, can they count the payments toward the new Patient Protection and Affordable Care Act (PPACA) limit on annual out-of-pocket spending? (This year, the limits are $6,350 for single coverage and $12,700 for family coverage. In 2015, the limits for plans not connected with health savings accounts will rise to $6,600 for individuals and $13,200 for family coverage.)

What if patients qualify for exceptions from the usual in-network rules, or they file appeals and win? Can they count out-of-pocket spending toward the annual maximums in those situations?

The Regulatory Framework Task Force, a part of the Health Insurance and Managed Care Committee at the National Association of Insurance Commissioners (NAIC) has ended up in the middle of that fight, because task force members are trying to update the NAIC’s basic individual and small group health insurance model regulations to reflect PPACA changes.

If you already have your cell phone set to alert you every time a font on a punctuation mark on a U.S. Department of Health and Human Services PPACA website changes, you know why this fight concerns you.

If you have not yet started to greet new entries on the NAIC exposure drafts page as if they were new episodes of “The Walking Dead,” you may want to know why ordinary insurance agents and brokers should care. Read on.

Crowd of consumers

1. For many ordinary consumers, the PPACA regulatory fight is the only insurance regulatory fight they will ever hear about.

Health finance policy is always controversial, at every time and in every country, whether the country handles health care with a pure government-run system, a mostly private system, or no effective system whatsoever.

PPACA has pushed obsession with the finer points of health insurance regulation to the point that ordinary agents and brokers greet new revisions of draft health insurance tax forms with butterflies in their stomachs.

Producers are also starting to get more familiar than they ever thought they would with the NAIC website.

Consumers have caught some of the PPACA regulatory obsession bug. They attend hearings. They read the draft tax form revisions. Some of them know who Marilyn Tavenner is.

Even if agents sell life insurance, or disability insurance, or homeowners’ insurance, and never get close to selling the kind of major medical policy affected by PPACA, the results of fights over PPACA implementation could affect how consumers and their elected representatives view all other insurance legislative and regulatory actions.

Image: A PPACA exchange hearing in Vermont. (AP Photo/Toby Talbot)

Children playing

2. Some of the people affected by the fight could be adorable.

Democrats have a reputation for attacking insurers and other financial services companies, but Republicans have also thrown them under the bus from time to time, as when some Republicans agreed on a need to prohibit annual and lifetime major medical benefits limits while PPACA was being crafted.

Backers of the idea of letting patients count at least some out-of-network spending — especially on care affected by exceptions to the in-network care use rules or by appeals — have mobilized support from groups such as the National Kidney Foundation and the Gist Cancer Awareness Foundation that may have long lists of appealing patients they can send to hearings or press conferences.


3. Some of the health care providers affected by the fight have a great deal of money at stake.

The list of groups asking the NAIC to take a generous approach to counting patient spending toward the out-of-pocket maximum includes the Pharmaceutical Research and Manufacturers of America (PhRMA).

Any group that has the lobbying clout to defend a manufacturing for setting a $84,000 retail price for a hepatitis C treatment is bound to be a formidable shaper of model regulations.

Beautiful lake

4. Regulators that fail to take insurers seriously could set unrealistic standards.

In the real world, some consumers may be able to keep careful tabs on exactly where they have sent their money, but major medical issuers may have no practical way to track the payments the consumers say they have made, or verify whether out-of-network providers have received the payments.

If a model regulation requires insurers to count at least some out-of-network payments toward the annual maximum, what kinds of mechanisms will help with administration of that requirement? How much running around will the patients’ agents, brokers and consumer advocacy services do when those mechanisms get stuck?

See also: Health IT exec hates silos

Image: A view of a lake in Sabine Parish, in Louisiana. (USDA photo)

Service questionnaire

5. Rules that don’t work could affect your own reputation.

Your reputation with customers depends partly on facts under your control, such as how quickly you respond to calls and e-mails, but it also depends to some extent on your ability to describe the products you’re selling accurately.

If regulators establish weak rules, they fail to implement the rules well, or insurer compliance is spotty, you may have trouble giving customers realistic ideas about what to expect from any major medical products you sell them.

See also: How to prevent Yelp from damaging your reputation


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