Bluegrass Family Health changes name to Baptist Health Plan

Bluegrass Family Health, the insurance arm of Baptist Health, is changing its name to Baptist Health Plan.

This change will make the Lexington-based health insurance carrier, which has offered insurance through area employers for more than 20 years, be more readily identified with its parent organization, which is based in Louisville, a news release said. It will take a few months for the name transition to be completed.

“As health care continues to evolve, it’s important to bring together the different parts of the Baptist Health system so everyone knows our entire organization is working toward the same goals of improving the health of our communities,” Baptist CEO Stephen C. Hanson said.

Bluegrass Family Health has nearly 80,000 members in Kentucky and parts of adjoining states.

“We look forward to continuing to expand our insurance business, bringing our products and services to both existing and new markets in Kentucky, Indiana, Ohio, Illinois, West Virginia and Tennessee,” James Fritz, president of the plan, said in the release.

As tax deadline nears, most uninsured appear likely to choose penalty; some with coverage are having to refund part of subsidy

Kentucky Health News

Most people facing a tax penalty for not having health insurance appear likely to pay it instead of taking advantage of a special opportunity to but coverage and minimize the penalty.

"Major tax-preparation firms say many customers are paying the penalty and not getting health insurance," reports Stephanie Armour of The Wall Street Journal. "Research also suggests that many people who lack health insurance will pay the penalty and not get covered this year."

Many polls have found that many if not most people without health insurance are unaware that they are subject to a tax penalty under the federal health-reform law. That percentage appears to be declining as they prepare their income-tax returns, but a poll taken in late February found that when told of the penalty, only 12 percent of the uninsured said they would get coverage.

For many people, the choice is simply financial, since coverage for them would be more expensive than the penalty -- 1 percent of their income, or $95 per adult or $47.50 per child, whichever is larger. Others say they don't need coverage, and some object to the penalty or the law altogether.

The penalty will increase to 2 percent of income and $325 per adult or $167.50 per child for the 2015 tax year, so if you are uninsured and don't qualify for Medicaid or one of the law's exemptions, the end of the special enrollment period, April 30, is the last chance to avoid that penalty.

"In late February, H & R Block reported that its uninsured clients had paid an average penalty of $172," reports Abby Goodnough of The New York Times. "The money comes out of refunds, while people who do not get refunds are required to pay the Internal Revenue Service by April 15."

Some people who have coverage "might find another unpleasant surprise: As many as half the nearly 7 million Americans who got subsidies to offset their premiums may have to refund money to the government, according to an estimate by H & R Block," the Journal reports. "The subsidies are based on consumers’ own projections of their 2014 income, but some estimated incorrectly and received overly generous credits. Those people will see smaller-than-expected refunds or could owe the government money."

"H & R Block also found that as of Feb. 24, just over half of its clients with subsidized marketplace coverage had to repay a portion of their subsidy because their 2014 income turned out to be higher than what they estimated when they applied for coverage," the Times reports. "The process includes "new forms that even seasoned preparers are finding confusing."

The Obama administration announced last month that 800,000 people with insurance bought under the reform law had received incorrect information needed for their tax returns. About 10 percent of them have still not received corrected forms, it announced Friday. "The administration said people who have not received the corrected forms do not have to wait to file their taxes and will not have to pay any additional tax due to the effort," The Hill reports.

The Wall Street Journal reports, "Consumers who already filed their tax returns using the incorrect forms provided though state or federal exchanges won’t be required to file amended forms, and the Internal Revenue Service won’t assess additional taxes, said Mark Mazur, the Treasury Department’s assistant secretary for tax policy."

Bill would require Medicaid managed-care firms to pay contracted fees for ER visits; Senate hearing targets two companies

This story has been updated with comments from Wellcare of Kentucky.

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- Managed care is touted as a way to achieve value-based care in the Medicaid program, but hospital emergency rooms in Kentucky aren't finding much value in not being paid the contracted price for their services by two of the managed care organizations.

Officials of two Kentucky hospitals told the Senate Health and Welfare Committee Feb. 25 that Wellcare of Kentucky and CoventryCares of Kentucky are denying payment for as many as half of their emergency-room patients who seek care in their facilities, reimbursing the hospital a flat $50 "triage fee," less the patient's $8 co-payment, regardless of diagnostic tests performed in the ER.

Cheri Sibley, CEO of Clark Regional Medical Center in Winchester, noted that emergency rooms are required by law to screen patients with appropriate diagnostic tests to rule out an emergency condition if they come to the emergency room and ask for care.

Wellcare and Coventry are two of the five Medicaid managed-care organizations that oversee care for the state.

Wellcare said in an e-mail that it is required by the Department of Medicaid Services to "have an affirmative program to address the high cost of emergency room treatment for conditions that do not require this level of care." The company said the triage fee is just one measure it has taken; it said an "emergency room prudent layperson program" has helped "identify and sometimes prevent payments as much as 500 percent to 1,300 percent more in an emergency room as compared to a physicians office for common ailments such as ear aches and sore throats."

Sen. Ralph Alvarado, a physician from Winchester, has sponsored a bill that would require MCOs to pay the previously negotiated rate for emergency-room examinations and allow the ER doctor to determine whether a patient's condition is an emergency or not,.

"This bill is an attempt to keep our Medicaid managed-care organizations accountable," Alvarado said at the meeting. "MCOs have been shortchanging our providers and our hospitals -- and, I would argue, purposefully -- for the past three years. . . . MCOs are basically managing health-care cost by non-payments to providers."

Since the advent of managed care in 2011, hospitals have complained about late and denied payments and difficulty dealing with MCOs. "The problem has reached critical mass, threatening the survival and financial viability of our hospitals, and almost every legislature has been contacted by their local hospital provider regarding these (issues)," Alvarado said.

Kentucky implemented managed care as a way to save money. Basically, insurance company subsidiaries get a certain sum per patient and increase their profits by controlling costs. The Cabinet for Health and Family Services maintains that managed care focuses on quality and provides better accountability for care as opposed to the traditional fee-for-service model, but provider complaints about slow payments and rejections of claims have persisted since its inception.

Hospitals bill insurance and Medicaid based on the level of complexity of emergency-room care provided based on the symptoms the patient presents, regardless of the final diagnosis. Payment has typically been based on a fee that was pre-negotiated between the hospital and the MCO.

Wellcare and Coventry have since implemented a non-negotiated "triage policy," which allows these organizations to determine, after the fact, whether a patient had an emergency. If they determine that a patient was a non-emergency, regardless of presenting symptoms and cost of diagnostic procedures (X-rays, CT scans, lab tests, and so on), they only pay $50 minus the $8 co-payment, or $42. Wellcare implemented this policy in September 2012 and Coventry in April 2013.

The legislaure's Administrative Regulation Review Subcommittee found last May that the triage policies did not follow federal standards, according to Sibley and Alvarado.

"One side seems to be meeting their contractual obligation, while the other side seems to be deficient in meeting their contractual obligations," said Sen. Julie Raque Adams, R-Louisville, chair of the committee.

Hospitals can appeal MCOs' decisions, but "hospitals report that only a small number of these are overturned with no explanation of decision given," Sibley said.

Sibley gave an example of a claim that had been determined a non-emergency by one of these companies at her hospital: An 18-month-old girl was brought to the ER because she was blue in color, wheezing and short of breath. She had an X-ray, other diagnostic tests and a breathing treatment, but the hospital was paid $42 by the MCO plus the $8 co-payment, if the patient paid it.

"The two MCOs in question should not be deciding which patients are non-emergencies," Sibley said. "They should be abiding by their negotiated contract and paying the contract rate," 95 percent of allowed cost.

Sibley presented Kentucky Hospital Association data from 64 hospitals affected by these triage policies. The report found that during calendar year 2014, the hospitals reported submitting nearly 380,000 emergency room claims to Wellcare and Coventry, of which 140,000 were denied except for the $50 fee. The overall denial rate was about 37 percent; Wellcare's was 48 percent.

The KHA report said the difference in the flat fee and the contracted rate totaled $37.4 million, and that the more complex visits (and this likely the more expensive) were the ones most often denied payment.

"With one in four Kentuckians now on Medicaid, this problem is only going to get worse, if this is not corrected by this Senate Bill 88," Alvarado's legislation, Sibley said.

Georgetown Community Hospital CEO William Haugh said almost 30 percent of its ER visits in 2014 were Coventry or Wellcare clients. Wellcare classified almost 60 percent as triage cases and paid only $50 each. The hospital appealed 92 percent of those cases, with a success rate of 16 percent, or 285 patient encounters. Haugh said that amounted to a $334,258 underpayment, plus an estimated $40,000 cost for preparing and prosecuting the appeals.

Haugh said Coventry classified 26.4 percent of its clients' Georgetown ER visits as triage and paid only $50 each. The hospital appealed 94 percent of those and had a success rate of 36 percent, or 366 patient encounters. He estimated an underpayment of $148,000 plus $22,000 in labor for appeals, and said the overall financial impact to the hospital was $543,894.

Wellcare said its appeals process allows three opportunities for review, with at least two independent medical directors.

The state Medicaid program's chief medical officer, Dr. John Langefeld, said the emergency-room problems are not a "straightforward, easy issue," He said many patients go to ERs for reasons beyond medical care. The cabinet has said that some hospitals have relied too much on ER revenues.

Sen. Reginald Thomas, D-Lexington, said rural hospitals need to change their business models and wondered if the bill was an attempt to mask that problem. Meanwhile, he added later, there is "documentation that hospitals have benefited from Medicaid expansion" under the federal Patient Protection and Affordable Care Act, in a recent report from Gov. Steve Beshear.

Adams replied that Beshear says, ""It is great, and it's putting all this money back in the system," but in fact we are not seeing it on the provider level."

Alvarado said, "There is a difference between what actually happens and what the governor's office wants to show you. So when you have KentuckyOne [Health] coming out publicly declaring a $218 million dollar loss in one year, that is hardly a profitability for them based on the ACA."

Alvarado said Citibank reported the companies have made $155 million in profits off of Kentucky Medicaid. "I'd get rich, too, if I didn't pay my bills," Alvarado said. "It is an outrage."

Poll illustrates how having insurance and access to a health care provider doesn't mean you can afford the care

Just because a person has appropriate access to a health care provider doesn't mean they can afford to pay for their services, according to the latest Kentucky Health Issues Poll.

The poll found that three out of every four Kentuckians with health insurance now have access to a health-care provider, defined as a usual or appropriate source of care. However, it found that lower-income Kentuckians are choosing to forgo or skip medical care because they still can't afford it. The poll found only about half of uninsured adults have a "typical and appropriate" health care provider.

The poll, taken Oct. 8-Nov. 6, found that 22 percent of Kentuckians said they or a family member needed health care in the past 12 months, but did not get care or delayed it because of cost. That was a decrease from 32 percent in 2009.

Not surprisingly, those with less money are more likely to forgo health care because they can't afford it. The poll found almost one-third, or 32 percent, of people with household incomes at or below 138 percent of the federal poverty level ($32,913 for a family of four) said they were likely to defer medical care due to cost. That figure was 14 percent among people with incomes more than 200 percent of the poverty line.

As for those who did seek medical care, 31 percent reported they or a family member had difficulty paying the bill in the previous 12 months. Among those without insurance, 47 percent said they had trouble paying a medical bill in the past 12 months.

“Being able to afford needed medical care and having access to appropriate usual sources of care are two important challenges that may prevent a person from receiving care,” said Susan Zepeda, President/CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll. “KHIP data indicate lower income Kentucky adults have to forgo treatment more often than their higher income neighbors and are more likely to have problems paying for their care.”

The poll is conducted by the Institute for Policy Research at the University of Cincinnati and is co -sponsored by Interact for Health, formerly the Health Foundation of Greater Cincinnati. It surveyed a random sample of 1,597 adults via landline and cell phone, and has a margin of error of plus or minus 2.5 percentage points.

Highly anticipated report on first year of Medicaid expansion says Kentucky can afford it even with higher-than-expected enrollment

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- Kentucky's decision to expand Medicaid under federal health reform is a better deal than previously projected and will more than pay for itself, Gov. Steve Beshear said as he unveiled a top consulting and accounting firm's study of the expansion's first year and projections for the next seven.

"For all the naysayers who claimed that expanding Medicaid was a budget-busting boondoggle, take a look at the facts. It's working, and it's literally paying off. The state is saving money, hospitals are earning more, and our people are getting healthier," Beshear said.

The report was conducted by Deloitte Consulting and the University of Louisville's Urban Studies Institute and cost $140,000, which was paid from Medicaid's administrative budget, half state funds and half federal.

Beshear said a study from Deloitte is "about as reliable as any study can be" and conclusively, with "an avalanche of facts," informs the critics that Kentucky can afford to pay for Medicaid expansion.

"Kentucky can indeed take care of its people, In fact, we can't afford not to do so," he said.

The report says that through 2021, Medicaid expansion will add 40,000 new jobs with an average annual salary of $41,000, putting $30 billion into the state's economy, and adding nearly $820 million to state and local budgets.

That, the report says, will cover the estimated cost of the matching funds that the state will have to pay for care of the newly eligible enrollees, those between 69 percent and 138 percent of the federal poverty level. The match will start at 5 percent of the cost in 2017 and rise to the law's cap of 10 percent in 2020.

For the next two budget years, from July 2016 to June 2018, the report estimates Kentucky will pay $74.4 million and $173.2 million, respectively. The report says this will be offset by $511.8 million of General Fund savings and tax revenues expected from the increased economic activity resulting from additional health care spending.

"These are conservative estimates," Beshear said, without any estimated savings from better health that he said will result from more people getting health care.

A Gallup poll released this summer said that Kentucky saw the second largest decrease of any state in its uninsured rate, dropping to 12 percent from 20 percent.

The study's projections were more favorable than those in a study by the PriceWaterhouseCoopers accounting and consulting firm, which Beshear cited when he announced in May 2013 that he would expand Medicaid. That study estimated the expansion would create 7,600 new jobs in 2014, but Beshear said the actual number was more than 12,000, including 5,400 in health care. Pricewaterhouse estimated 17,000 new jobs through 2021, well under Deloitte's forecast of more than 40,000.

Pricewaterhouse also underestimated the enrollment in Medicaid. In the first year, more than 375,000 people enrolled, about double the number that the firm estimated would enroll by 2020. That means the cost of the state's match will be higher than expected, but covered by jobs and taxes resulting from the higher enrollment.

“People can have whatever opinion they want, but they aren’t entitled to their own facts,” Beshear said. “It’s one thing just not to like [Medicaid expansion] because the president has his name on it, and if that’s the reason they want to take health care away from 500,000 Kentuckians, then that’s their opinion and people oughta know that. This report answers the questions, will it work, and yes it is working in Kentucky, and can we afford it, and yes we can."

The report is online at Governor.ky.gov. For county-by-county data, go to http://governor.ky.gov/healthierky/Documents/medicaid/Medicaid_Hospital_Report.pdf.

Second round of private insurance enrollment under Obamacare starts Nov. 15; rates estimated to rise an average of 4.6%

Enrollment reopens Saturday, Nov. 15, for health insurance under the federal health-reform law and the state insurance exchange, known as Kynect.

In the second year of what is typically called Obamacare, there will be new insurers, new rates, a shorter enrollment period and larger penalties for not having health insurance.

The changes in rates and subsidies will affect people who enrolled in the first round a year ago, because the factors used to calculate them, "such as age, income and the cost of a certain plan used as a benchmark," will change, report Laura Ungar and Chris Kenning of The Courier-Journal.

"PwC, an assurance, tax and consulting firm that collected individual insurance rate filings across the nation, estimated Kentucky's average premium increase on and off the exchange will be 4.6 percent," The C-J reports. (PwC was formerly known as PricewaterhouseCoopers.)

At a news conference Monday, Gov. Steve Beshear noted that premiums in the individual health-insurance market increased 8 percent or more a year before the reform law passed "and there were no subsidies or discounts to help defray costs," Jack Brammer writes for the Lexington Herald-Leader.

"Costs will vary widely," Ungar and Kenning write. "Officials said there are 70,000 premium rates between all the insurers offering various plans on the exchange, and they are still being certified so they cannot yet be made public."

Competition could be keeping rate hikes modest. Two new companies will offering policies on Kynect: CareSource and WellCare, joining five previous insurers.

Kynect provides premium subsidies based on applicants' incomes. "Officials estimate that, in total, around 290,000 Kentuckians are potentially eligible for subsidies with Obamacare plans," The C-J reports. The Kynect website has been changed so users can figure potential premiums and subsidies without actually starting applications.

State officials estimate that about 100,000 people have policies that don't comply with Obamacare rules but were allowed to keep them until 2016. "These could include more than 14,000 customers told in early October by their insurers that their plans are being discontinued," the newspaper reports. "Ronda Sloan, spokeswoman for the Kentucky Department of Insurance, said this is a business decision by insurers."

Kynect is more than doubling its call-center staff and expanding its hours to reduce wait times, which were as long as three hours last year, and is working with 2,800 insurance agents, twice as many as last year, exchange Director Carrie Banahan told the Louisville newspaper. It will also have a federally funded app for Android and Apple smartphones and a "pop-up" store in Lexington. The call center will be open from 8 a.m. to 7 p.m. Monday through Friday and 8 a.m. to 5 p.m. Saturdays.

This year's open enrollment is expected to be less hectic than last year's "because people signing up for Medicaid — who became eligible under the state's expansion of the program and made up the majority of Kynect's sign-ups last year — can enroll at any time," Ungar and Kenning write. They quote Prestonsburg insurance agent Darrell Patton: "There's not as much talk about it this time. It came and it passed, and the sun still came up the next morning."

Still, Patton said some confusion remains, and there is unhappiness with "narrow networks of doctors and hospitals or not being able to get needed services covered," the C-J reporters write.

The penalty for individuals without health coverage in 2015 will be $325 per adult or 2 percent of household income, whichever is higher, up from this year's $95 and 1 percent. The current penalty isn't very effective because taxpayers haven't been required to say on their tax forms whether they had insurance. They will on next year's forms. "Those who went without in some cases can claim an exemption on the form or provide additional documentation if one was previously granted," the writers report.

The second enrollment period will be shorter, closing Feb. 15. Beshear encouraged Kentuckians to shop around, and do it early. Those on Medicaid, form which enrollment is open year-round, do not have to re-enroll unless they want to change their managed-care organization.

Ky. neck-and-neck with Ark. for largest drop in percentage of uninsured; Kynect and Medicaid expansion make the difference

By Melissa Patrick
Kentucky Health News

Kentucky is finally near the top of a good list about health. It's neck-and-neck with Arkansas for the greatest drop in the percentage of uninsured adults since the federal health-care reform law's requirement to have insurance took effect in January, according to a recent Gallup-Healthways Well-Being Index poll.

Kentucky decreased its estimated share of uninsured by 8.5 percentage points between 2013 and midyear 2014, going from 20.4 percent in 2013 to 11.9 percent now. That was a 42 percent drop in the percentage of the state population that is uninsured. Arkansas' percentage-point drop was larger, but the results were within the polls' error margins.

Ky. error margins: 2013, plus/minus 1.8 percentage pts.; 2014, +/- 2.1 pts. Ark.: +/- 2.2 and +/- 2.4.

The poll found that states that expanded Medicaid and established a state-based marketplace or a state-federal partnerships showed the largest drop in the uninsured. Kentucky has participated in both of these measures with Kynect, its statewide health insurance marketplace, and its expansion of Medicaid to households with annual incomes up to 138 percent of the federal poverty level.

County-by-county estimates on Kynect Medicaid and private insurance through Kynect are at http://governor.ky.gov/healthierky/Documents/kynect/20140410_kynectEnrollmentData.pdf.

The gap between states that implemented these measures and those that did not nearly doubled between 2013 and midyear 2014, with the uninsured rate declining an average of 4 points in the 21 states that have implemented both measures, compared with a 2.2-point drop in the 29 states that have implemented one or neither.

The latest state figures show that 512,000 Kentuckians are newly enrolled in health coverage, with nearly three out of four of them under the Medicaid expansion.

Medicaid Commissioner Lawrence Kissner illustrated the dramatic impact of the expansion in Kentucky at a recent legislative committee meeting with county-by-county maps that show the estimated percentage of uninsured in each county in 2012 and this year.

The national poll results are based on both cellular and land-line telephone interviews of a random sample of 178,000 adults living in all 50 U.S. states during 2013, and 88,678 respondents between Jan. 2 and June 30, 2014.

Medicaid managed-care forums for health-care providers to be held around Kentucky in next six weeks

The Cabinet for Health and Family Services has scheduled a new round of forums for health-care providers in each of the eight Medicaid regions during August and September.

The forums will be attended by senior officials from CHFS, including cabinet Secretary Audrey Tayse Haynes, Medicaid Commissioner Lawrence Kissner, Public Health Commissioner Dr. Stephanie Mayfield and Behavioral Health Commissioner Mary Begley, among others.

 “Our first series of forums for health providers were so successful in opening the lines of communication and making connections that allow us to work better together,” Haynes said in a press release. “We decided to not only repeat but expand the scope of the forums this year, bringing new topics to the forefront like behavioral health, which is particularly timely due to improved access allowed by the Affordable Care Act. Once again, we will also allow time for private meetings with the managed-care organizations,” or MCOs.

Medical providers will be able to meet with MCO representatives, the Department of Insurance and the cabinet to discuss concerns about proper billing, appeals processes and any specific regional issues, in addition to a general conversation about how to improve the overall system of health care delivery in Kentucky. Sessions will also discuss behavioral-health opportunities, improving overall health and community workforce capacity, among other topics, according to the release.

The sessions will begin at 9 a.m. and concluding at 5 p.m., with an optional second day of workshops running from 9 a.m. to noon. The dates and locations are:
 · Aug. 5-6: Adron Doran University Center, Morehead State University
 · Aug. 11-12: Frankfort Convention Center
 · Aug. 20-21: Hazard Community College
 · Aug. 25-26: James E. Bruce Convention Center, Hopkinsville
 · Aug. 27-28: Owensboro Convention Center
 · Sept. 3-4: Northern Ky. University METS Center, Erlanger
 · Sept. 10-11: University of Louisville Shelby Campus
 · Sept. 15-16: Center for Rural Development, Somerset

Providers who would like to register or get additional information should visit the Department for Medicaid Services website.