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Covid-19 and the Vaccines. Legal Protection for the Pharmaceuticals ; The Prep Act of 2005

God bless vaccines. They and their creators have done wonders for humanity. However, Washington may have ruined it for us all.  The Prep Act of 2005, The Public Readiness and Emergency Preparedness Act, may have removed proper incentives for pharmaceutical companies to do the right thing for patients.  The Prep Act, once invoked by the Secretary of HHS,  protects pharmaceutical companies and other stakeholders from legal liability. Now, if you want to sue a pharmaceutical company you will be taking on the HHS and the Department of Justice and all their respective resources. Consider that the very same source that provides you safety information on vaccines is now also protecting the pharmaceutical companies. These are perverse incentives and a situation that only good positive news will be released by the very same party that is supposed to keep all of us well and accurately informed, HHS.  Read more HERE:Prep Act Immunity and Covid19 NLR 08.05.2020

Covid-19 Diagnostic Test and your health insurance plan, Biden’s Administration Requirement

The Biden-Harris Administration is requiring insurance companies and group health plans to cover the cost of over-the-counter, at-home COVID-19 tests, so people with private health coverage can get them for free starting January 15th. The new coverage requirement means that consumers with private health coverage can go online or to a pharmacy or store, buy a test, and either get it paid for up front by their health plan, or get reimbursed for the cost by submitting a claim to their plan.

Beginning January 15, 2022, individuals with private health insurance coverage or covered by a group health plan who purchase an over-the-counter COVID-19 diagnostic test authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA) will be able to have those test costs covered by their plan or insurance. Insurance companies and health plans are required to cover 8 free over-the-counter at-home tests per covered individual per month. That means a family of four, all on the same plan, would be able to get up to 32 of these tests covered by their health plan per month. There is no limit on the number of tests, including at-home tests, that are covered if ordered or administered by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.

This coverage is for a limited period of time, please click here for Public Emergency Declarations.

White House press statement is here.

CMS is here.

United Health Care is here.

Anthem BCBS is here.

Aetna is here:

Cigna is here:

Any further questions or concerns please contact me.


MLR Rebate, What’s an employer to do?

Some employers will receive rebates from carriers that did not meet the medical loss ratio (MLR) requirements for the prior calendar year.

The MLR is the percentage of premium the carrier spent on medical expenses based on the experience of all of the carrier’s policies broken out by state and market (i.e., individual, small group, or large group). The MLR is not based on a group’s own claims experience. If the carrier spent less than 80% of premium dollars on medical expenses (or 85% for large groups with 51 or more employees), then the carrier must rebate to policyholders by August 1st after the end of the calendar year.

For employer, the carrier will generally pay the rebate to the employer who may then be responsible for sharing a portion with employees. If a portion of the rebate is considered an ERISA plan asset, employers are obligated to handle the rebate according to ERISA rules.

Note: The MLR rebate rules are slightly different for governmental and church plans that are exempt from ERISA, as well as for insured plans with a trust.

We have found a few documents throughout the years that we reference for guidance on this subject:

When Hospital Systems Lose Their Way

Many hospital systems are set up as not-for-profit systems or incorporate or charter themselves originally as a benefit to the community’s general good, later lose their way.  I remember living just outside of Winchester, Virginia many years ago coming home from work late one evening receiving a collection letter from Valley Health Systems regarding an unpaid medical bill. A health care episode I did not recall but would have been fine paying my bill and had the ability to pay, obviously some confusion that I would later straighten out. What I found most odd about that evening’s mail was while I had the hospital’s aggressive collection letter threatening to sue and use the full force of the law to collect on its self-interests  it was also accompanied within that same day’s mail delivery a letter from the same health care system asking me to donate to their hospital’s fund to help pay for things such as uncompensated care; most of us understand that to be accounts receivables.  All I could think about is how strange a system the nation’s health care had become.

I cannot help feel for individuals such as Heather Waldron and John Hawley who are losing their 4-bedroom home thanks to efforts by University of Virginia Health System.  Read: “UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes”

Balance Billing, a.k.a. “Surprise Billing”

Bipartisanship is in the air in Washington, D.C. Well, at least on one issue that has frequently made the news over the past several years: surprise, or balance, billing. Driven by devastating stories in the popular press, a slew of proposals have been introduced in Congress over the past year. While diverse in their approaches, all of the proposals seek to increase consumer protections and shield patients from unexpected and often outsized bills. President Donald Trump has expressed his support for these efforts. Without a doubt, federal action on the issue is long overdue.

Yet, ultimate success seems far from certain, as jousting among competing stakeholders has replaced the usual partisan quarrels in D.C. Moreover, while surprise billing has unquestionably caused great individual harm, the current debate has largely missed two other important problems related to provider networks: inaccurate provider directories and inadequate provider networks. These problems are inherently complex, harder to turn into news stories, and defy simple solutions. Yet, they also affect a much larger number of Americans’ financial and physical well-being than does surprise billing.

Learn more click here