Health Insurance Plans and Prices for Hawaii Women (Hawaii Health Care Book 1)
HCFA suggested additional waivers which might have helped. HCFA was also open to allowing us to adjust as we progressed. States need to understand that HCFA, as well as the States themselves, will need data to prove what works and what does not work. Do not scrimp on time to plan, yet recognize that there will never be enough time. Upfront involvement from all parties is critical to success. This includes providers, prepaid plans, advocacy groups, and other State agencies. Although this may take time and patience, it can reduce the anguish later.
Their involvement can result in better program planning. If they are on your side, they can help prevent, defuse, and solve problems. Greater concessions from prepaid plans may be negotiated during the design and implementation phases than would otherwise be anticipated. Spend time with your local media providing background information on your plan prior to implementation.
Problems with your old system were not especially newsworthy, yet any problem with the new system might be. If your local reporters have a fairly broad understanding of the basics of your program, they may approach their stories more fairly. As you implement your program, recognize that all issues have some level of importance to someone. Assess the critical nature of the problem, then show the interest groups the timetables and processes through which you will try to address them.
If the end result is that you make no change, explain why, and be sure others they may contact, such as legislators, also understand why. Be prepared to prioritize and turn down requests to evaluate or research various aspects of your program. Staff and systems resources needed to support outside researchers can be overwhelming.
Give yourself time before making another set of major changes. Staff, plans, and providers need time to recover and stabilize. Remember that this is a demonstration; not everything will be perfect. If you have your major interest groups in this with you, the ability to make mid-course corrections is greater. Above all else, hire highly competent, energized staff who have good negotiating skills and lots of patience! On August 1, , Hawaii took a giant step forward in health care with the implementation of the State's section waiver program: Hawaii QUEST Quality care, ensuring Universal access, encouraging Efficient utilization, Stabilizing costs, and Transforming the way health care is provided to public clients.
As of January , more than 15, new applications had been received. New procedures and systems were developed, various issues were addressed, and the resources of the participating health plans were scrutinized, all to help ensure QUEST'S stability and viability. Some of these processes were unique to Hawaii, specifically Hawaii's actions in systems adaptation and development, assurance of an adequate provider network, review of the health plans' financial solvency, development of a quality assurance system, and addressing the issue of loss of cost-based reimbursement by the Federally Qualified Health Centers FQHCs.
The major functional areas of the QIS include:. Administering the billing and collection of the recipients' share of their monthly premium. Monitoring the utilization and quality of services provided to QUEST clients by health and dental plans. This system has the basic function of the QIS and was developed using existing systems as well as systems developed specifically for the interim period. The interim system is comprised of five major processing components, which follow.
Understanding the Affordable Care Act
Enrollment information is provided to plans on a daily and monthly basis. It is updated monthly with information from HAWI. It is updated daily and monthly with information from HAWI. The interim encounter data system is being developed on a client-server system, using the processing power and storage capacity of a dedicated file server to process and store encounter, eligibility, and provider data. The primary function of this subsystem is to accept, edit, validate, and store encounter data submitted by QUEST health and dental plans.
Plans are required to submit service data in a standard format for:. The requirements of the following functional areas were factors in the development and design of the interim encounter system:. This system will be designed, developed, and operated by the QIS contractor. It will provide program management reports from data residing on all interim subsystems. Prior to QUEST'S implementation, the State required that the participating medical and dental plans establish and demonstrate adequate provider networks.
They were asked to provide to the State a listing of their provider networks in the various geographic areas they would be serving. As the program implementation date neared, plans were required to submit names of providers with whom they had executed signed contracts. They were required to submit provider lists at least twice before program initiation. Each time, the lists were reviewed by geographic area to ensure that there were reasonable numbers of primary-care providers in each area of service.
After implementation, assigned plan liaisons randomly reviewed plan contracts to determine whether or not the plans actually had signed contracts with those providers listed on their rosters. In addition, HCFA staff was provided with complete rosters of participating providers for each plan. HCFA then initiated random verification calls to again ensure that those providers claimed by the plans were in fact participating. Participating plans were also reviewed and are continually monitored to ensure their financial solvency.
In order to review the plan's financial viability, the State developed a number of procedural and functional guidelines and policies. The Guide details the reporting requirements, the timing of reports, and the sanctions for non-compliance. Although QUEST'S requests for proposal RFPs required quarterly financial reporting by the plans, they also provided the State the right to require monthly reporting if it deemed this necessary. During the negotiation process, it was agreed with two participating plans that they must submit monthly financial reports.
To date, both have submitted as required. The first-quarter financial reports for the rest of the plans were submitted on November 15, The State will use these monthly and quarterly financial submissions to evaluate the ongoing financial viability of the plans. Specifically, the State will identify baseline ratios which must be met and warning indicators which will be observed. The financial information will be used to compute ratios and identify any potential problems. If problems are noted, the Finance Office and the Health Coverage Management Branch shall determine the additional requirements which should be imposed on the plan, e.
Department of Health and Human Services, Each health plan's QAP was reviewed in the onsite review of bidders in the RFP process, and written policies and procedures were reviewed and rewritten, following specific guidelines American Public Welfare Association, Monitoring visits will be keyed to the quarterly and annual reports required of the health plan's QAP activities, as well as to the annual audit conducted by the contracted external reviewer. Any problems identified by the technical assistance review, the annual external independent review, or the analysis of reports will result in a review by the State.
The nature of the findings will determine the type of review to be conducted:. An uncomplicated problem involving a single element will require a review of the case and the key element only;. Multiple problems involving one or two elements will likely require a review of a sample of cases and a review of the QAP process; and.
Multiple problems involving multiple critical elements will require a full contractual review. Although all of the FQHCs have contracts with one or more health plans, the FQHCs feel that the negotiated capitation with each health plan does not provide them with the level of revenue which they enjoyed under the previous cost-based reimbursement.
They have lobbied the legislature, the Hawaii Congressional delegation, and the Governor to seek relief from their plight. This offer appears to appeal to the majority of the centers.
Understanding the Affordable Care Act
Clearly, there are some centers which are suffering a greater deficit than others, and the DHS is committed to an adjustment which is fair and equitable. The HSPCA has contracted with an independent accounting firm to calculate the budget for each center and will be working with the State staff on agreement of numbers. The development and implementation of the QIS, plans to eventually fold in the currently excluded aged, blind, and disabled ABD populations, the legislative session which began in January—all are certain to bring a continued scrutiny of QUEST.
However, as the areas detailed herein have been addressed and challenges met, so will future issues and concerns be resolved in pursuit of keeping Hawaii healthy. The waiver was granted in November , and implemented less than 2 months later. Under the waiver, all , of the State's Medicaid beneficiaries have been assigned to managed-care organizations. The waiver also authorized coverage of individuals who are uninsured or uninsurable, and by year's end, approximately , such individuals had enrolled.
Altogether, more than 1. As other States and Congress contemplate rapid expansion of mandatory managed care for Medicaid beneficiariesTennCare's experience may be instructive. Lessons from TennCare are especially relevant for States with little prior managed-care experience. Quantitative measures of TennCare's performance are not yet available, and it is premature to draw definitive lessons.
However, the TennCare experience already sheds light on those problems which similar Medicaid managed-care initiatives are likely to encounter, and suggests at least some possible approaches to addressing those problems. A central concern in any transition to managed care is the protection of enrollees and the quality of their care. Several TennCare features were designed to address that concern. The TennCare waiver did not exempt Tennessee from Medicaid's requirement that it afford beneficiaries access to care at least equivalent to that afforded the general population.
In fact, the waiver quantified the requirement by specifying that, throughout the State, there must be available at least one primary-care physician accessible to each 2, enrollees. Meeting the access requirement has been a difficult challenge for Tennessee's Medicaid program, as it is throughout the country. Crucial to the State's effort to meet the access requirement was a policy linking TennCare to the State employee insurance plan.
State and local government employees represented the largest subgroup of the Tennessee Preferred Network TPN , whose 1,, enrollees also included many other private and public employees. Without actually merging the State employee plan and its new Medicaid waiver program, Tennessee was thereby able to capitalize on TPN's large market share to pressure providers to serve TennCare enrollees.
Although resented by many physicians and highly controversial, this policy is regarded by many beneficiary advocates as the single most important consumer protection in TennCare.
Although access remains problematic, this policy has made available to TennCare enrollees the services of many providers who previously refused to see Medicaid patients. Despite provider criticism of the TPN-TennCare link, severing the link would have an immediate adverse impact on access to care for much of the TennCare population. Movement from traditional FFS coverage to a capitated system of managed care demands major adjustments from any population.
Success in making those adjustments depends, to a great extent, on the quality of education and information provided to the program's beneficiaries. This task is especially important—and challenging—for Medicaid programs. In addition to lacking sophistication regarding the use of health care systems, many Medicaid beneficiaries have limited reading skills, significant cognitive or communicative disabilities, or limited English language proficiency.
Shortly after submitting their waiver application, Tennessee Medicaid officials established a working group to develop educational materials, application forms, and enrollee communications. The group included representatives of the State Medicaid bureau, a public relations firm, and several legal aid and consumer advocacy organizations. At the urging of the consumer advocates, State officials established two protocols that were to govern all TennCare written materials.
First, all materials were to be written, if possible, at a sixth grade level of reading comprehension, and in no event were to exceed an eighth grade level of readability. Also, all materials were to be field-tested before final approval, by having them reviewed and critiqued by individuals who are representative of the target audience. Experience has taught that such field-testing is as simple as it is essential. People waiting for Medicaid appointments in the local office of the welfare department usually are quite willing to spend a little time reviewing and critiquing draft materials.
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For example, the design team spent hundreds of hours drafting multiple revisions of the one-page application form to be used in the enrollment of uninsured or uninsurable individuals. Nonetheless, when residents of a homeless clinic reviewed the form, they immediately identified several important problems that the professional designers had missed.
Whenever the working group, which operated under intense time pressures, put into use forms or publications that had been inadequately reviewed by members of the target population, they later had reason to regret the lapse, because of enrollee and staff confusion and corresponding inefficiency. The effort to inform affected Medicaid beneficiaries of the impending change was aided by extensive news media coverage of the TennCare proposal from the moment it was announced.
Media coverage meant that many individuals were at least aware that Medicaid changes were in the offing, even before the State began to inform beneficiaries of the new program. In October , the State sent all Medicaid households a ballot on which beneficiaries were to show their preference of MCOs. The ballot was accompanied by brochures from those MCOs that served the region of the State in which the household resided. The brochures were confusing and the amount of information provided about the new managed-care plan was sparse. Still, some 60 percent of all Medicaid households completed and returned their ballots.
This is an extraordinarily high number of returns for any mass mailing, and attests to the relative success of efforts to design TennCare written communications in an appealing and readable manner. TennCare officials recognized that, no matter how readable their written materials, any effort to communicate with the target audience would require substantial reliance on the electronic media.
They recognized, too, that such media could only deliver a short, simple message, far short of the volume and complexity of information that had to be disseminated regarding TennCare. A paid television and radio campaign urged Medicaid beneficiaries and prospective waiver-eligibles to contact a toll-free telephone hotline for further information about the program. The effectiveness of that message was evidenced by the huge volume of calls received by the hotline during its first weeks of operation.
The hotline was often overwhelmed by the volume of calls and was not always adequate. However, the use of a centralized telephone operation for this purpose enabled the State to monitor system problems highlighted by the type of calls received. The centralized operation also served to maintain a relatively high degree of consistency in the information disseminated by the program during its initial phases.
Although these aspects of the TennCare outreach effort were successful, others were not. Notably, the State failed to require the MCOs to meet the same standard of readability in their written communications with enrollees. The toll-free hotlines maintained by the MCOs for servicing their enrollee populations were grossly inadequate. There were not nearly enough telephone lines to meet the demand, and MCO staff were often untrained or otherwise ill-equipped to answer the questions or resolve the problems that had prompted the enrollee's calls.
Also, keep in mind that the cost of anything, including health insurance, goes beyond just monetary impact. For example, continuing to go to the doctor you've had for years might be worth paying more on your monthly premiums. Make sure you look carefully at the provider networks for each health insurance plan you're considering if choice of provider is important to you. Finding cheap health insurance isn't as difficult as finding a unicorn or the Holy Grail or both simultaneously. It can take a little time and effort, but it's an investment that should pay solid returns over time.
Keith began writing for the Fool in and focuses primarily on healthcare investing topics. His background includes serving in management and consulting for the healthcare technology, health insurance, medical device, and pharmacy benefits management industries. Follow keithspeights. Premium Services.
Stock Advisor Flagship service. Rule Breakers High-growth stocks. View all Motley Fool Services. Stock Market News. Popular Stocks. How to Invest. Learn How to Invest. Track Your Performance. Retirement Planning. Personal Finance. The Ascent is The Motley Fool's new personal finance brand devoted to helping you live a richer life. Let's conquer your financial goals together See you at the top! Search Search:. Keith Speights. Updated: Sep 28, at PM.
Image source: Getty Images. Source: Healthcare. Article Info. Read the full review here: Kaiser Permanente. UnitedHealthcare's online account system is easy to use because you can do everything in one place. Once you've logged into your account you can access a nurse hotline, order prescriptions and more. There are also online tools for tracking deductibles and expenses or finding a doctor in your area.
If you'd prefer to have on-the-go access, the Health4Me app is free and easy to navigate. While this is a really good option for digital-first users, UnitedHealthcare was more expensive than the other companies we tested. It's easy to see what your own costs might be if you take a few minutes to enter your information on the website.
The website is also very easy to use as you can filter plan options or compare them side-by-side with a couple clicks. There are also pop-up windows that explain certain terms if you hover your mouse over them. Read the full review here: UnitedHealthcare. Everyone's needs are different, but this insurance company has a lot of affordable options.
They might not apply to everyone, but most users will be able to find a low-cost plan that works for them. In our tests we found the plans available were far cheaper than the other companies we reviewed, with the exception of our year-old use case. Getting a quote isn't as simple as with other insurance companies, and when we used it, the side-by-side comparison tool sometimes failed, but that doesn't mean everyone will have the same experience.
There is a FAQ page, and Aetna is also very active on social media if you're trying to get a fast response to a question. Affordable Care Act-approved plans are available, and you can even get supplemental insurance if the insurance you get through your job doesn't cover the things you need. Read the full review here: Aetna.
Health Insurance Guides
Health insurance is now available to more Americans than ever before. Subsidized options are easily available to low-income individuals and families. In the past, many people took the risk of not being insured, but with the Affordable Care Act ACA you can be fined if you don't have qualified health care insurance. Instead of paying a fine, people who have not been able to afford insurance before are looking for affordable medical insurance options. While some may be asking themselves if it would it be cheaper to just pay the fine, statistics show that more Americans have health insurance now than before the ACA was enacted.
There are several reasons why more people have insurance now, but one is certainly the increase in affordable health plan options, including subsidized, or tax credits, health insurance purchased through one of the state exchanges. Compliant insurance can also be purchased privately. The options available to you depend primarily on your income level. In many cases this is not free health insurance but subsidized. Extremely low-income individuals and elderly persons often qualify for Medicare. If you paid the fine for you may still qualify for insurance via an exchange, even if it is not during the open-enrollment period, to avoid the fee in Those above the poverty rate can still shop for insurance via an exchange but will not benefit from subsidies.
However, income thresholds change depending on household size, so it is worth finding out if you qualify. Individuals can also shop for insurance through one of the major carriers, including those listed in this review, such as Humana, Kaiser Permanente or Blue Cross Blue Shield BCBS , depending on what is available in your area. If you don't know if your income qualifies for subsidies, you can use one of the exchange calculators to help you figure that out. Another option for healthy mid-income individuals is high-deductible health plans. Best Options for Mid-Income: Individual health insurance lowest-option or high-deductible health plans.
High Income: Those with a high income are facing a different problem. Many who have high incomes didn't purchase insurance in the past; they just paid health care expenses as needed. Paying two percent of a high income for the penalty can be a rather large sum for high-income persons. In this case, it might be cheaper to just buy qualifying health insurance. If you are in good health, you might want to choose the lowest qualifying plan. If you have ongoing health issues, you may as well bite the bullet and choose a more exhaustive plan and lower your out-of-pocket expenses.
Best Options for High-Income: A low-cost qualifying plan for healthy people or more comprehensive plan for those with larger health expenses.
Evaluating health insurance companies for every person's needs is impossible. Plan pricing can vary greatly depending on your exact circumstances. If your employer does not offer an affordable health insurance option and you do not qualify for subsidized insurance or Medicare, you can shop the open market for medical insurance. The health insurance companies we reviewed will allow you to request a quote online rather easily.
Premium rates vary significantly by multiple factors. You'll learn that the monthly rates increase quite a bit as you age. Smoking also increases the premium rate. In most cases you can select non-smoking if you have not smoked in over six months. Services such as eHealthInsurance are simple to use and provide a variety of quotes but may not always show every option available. You may find more plan options by requesting plan information directly from the insurance company's website. Before purchasing new insurance it is always a good idea to ensure that your preferred doctor accepts the insurance you are looking to purchase.
While your doctor may be listed on the insurance company's website, it is smart to call your doctor's office directly to verify. Even if the open-enrollment period has passed for signing up for insurance via one of the exchanges, you might still be able to purchase subsidized insurance if you've had a qualifying life event. Qualifying events include moving to a new state, change in income, change in family, loss of coverage and others. You may even be able to apply simply because you did not understand that open-enrollment ended or you did not understand the health care law.
If your income qualifies you for subsidized health care, you'll want to purchase through your state exchange. Plans vary greatly. But the general rule of thumb is that the less you pay per month, the higher your deductible is. Higher premiums are usually associated with lower deductibles. Generally it is beneficial for those with existing health issues to opt to pay more per month and less out-of-pocket for services. Those in good health often opt for a high deductible option in hopes that they never have to actually pay the deductible but would mostly be covered if something major happened.