Patient Bill Of Rights & Self Funding

[Guest Kary]

Can anyone direct me to clear information as to whether the patient bill of rights applies to self-funded insurance? We are a TPA and have conflicting information that it does/does not apply to us.

Thanks, Kary

[jeanine]

I say yes. (unfortunately). Earlier versions of a patients' bill of rights didn't, but I believe the Senate version and House version include self-funded plans. I would guess that whatever is hammered out to reconcile the House with the Senate would apply to SF's also. The thing that really bothers me about the press coverage of this bill is that all anyone ever hears about is that we are going to hold HMO's responsible. First, not all HMO's are villians. We have a non-profit HMO...we are not monsters. Secondly, this applies to all health plans, not just HMO's and really attempts to gut the entire basis of managed care. Everything that an enrollee thinks they should have covered , should be covered, makes no economic sense. If I buy car insurance it only covers what I've bought, not what I think it should cover. I can't wait to see the fallout from this one.

[Larry M]

Jeanine,

Why are you so upset?

Just because an employer did not pay your company for a health plan which would cover every conceivable medical service, does this mean your hmo should not provide all services, even those not purchased?

After all, if my employer buys a limited plan from you, why should I get less benefits than my neighbor whose employer bought a fatter plan?

...as an aside, whether your hmo is non profit or for profit should not be the basis for determining whether you are "good" or "bad". Just as whether the plan is self-funded or insured or pre-paid (old timers hmo term) is not, by itself a determining factor.

The administration of claims according to a plan document should be the determining factor.

Unfotunately, Congress will pass, and the President will sign, some law which will have a good sounding name ("patients' bill of rights" - or some such) and which will have the effect of reducing the number of persons covered by health plans.

Eventually, the uninsured, whose medical care is provided by local government agencies, will become so large in number, we will have, de facto, government provided medical coverage for 90+% of our population....and the "socialized medicine" we all decry will be upon us.

[jeanine]

If your employer buys a more limited plan, then they are paying less in premiums. If you want to have the same benefits as your neighbor, then you have to pay higher premiums. No insurance company, or HMO, can continue to operate with losing margins. I am upset by the entitlement mentality that Congress seems to think all Americans share. I have very good coverage--I actually get coverage through my husband's employer. This was a deliberate choice. I could have gotten a less restricted PPO instead of an HMO but chose the lesser hassle of an HMO. (don't laugh, it has to do with COB'). The point is we receive the services we are entitled to because we (and his employer) pay higher premiums. He deserves these benefits because of the stress he puts up with at work and in partial lieu of better pay.

If you look at some of the versions of the Patients Bill of Rights, there are some people who think you should have medical services that "should be covered" not just those that are actually covered. In effect, this negates the purcase contract between the plan and the employer. Don't like what your employer gives you?? Get another job or buy your own benefits. There's no law that requires employer sponsored health care. I'm afraid that this will just ruin it for a lot of people and there will be more uninsured than there are now.

[Guest Cathie]

I agree, Jeanine. I am a former employee of a national group health carrier, and my job was, in part, servicing unhappy customers. If I had to estimate a percentage, I would say fully half of the claims questions I answered had to do with people who thought we should make an exception and pay for something that was clearly not covered by the plan. The exact same people would then come back to me and tell me that we should lower their premiums. We seem to have decided as a nation that we are entitled to 100% of everything but we don't want to pay anything for it.

[KIP KRAUS]

Let us not forget that the HMO Act of 1973 was the brainchild of our federal government and the answer to the high cost of medical care. Let us also not forget that the Act required employers to offer an HMO if “Activated” by a “Federally Qualified” HMO. As someone who has seen this process go full circle I believe that HMOs are the ruination of the health care system and the perpetuator of health care inflation. After all, when mommy’s or daddy’s little baby has a sniffle why not take him to see a doctor, it only cost $5 or $10. What is the real cost? Does anyone know or care? Doctors and hospitals are seeing more patients than bargained for and now want more money, and they’ll get. Get rid of the $5 and $10 copayments and get back to the person having some responsibility for a portion of his/her health care expenses, and competition will return. I realize it’s not as simple as that, but HMOs have not demonstrated that they are the answer. On the other hand, as you may or may not know, premiums are a function of how high claims costs are, be it a fully-insured premium, self-insured premium or community/pooled premium.

Keep in mind that as Jeanine says an employer is not obligated to provide group medical coverage for employees, but then subsequently to that statement she says she and her husband deserve the medical plan they are in. No one deserves any particular type of medical plan. It is a fringe benefit and that’s all, take it or leave it, which a lot of people in this country choose to do. Jeanine and her husband are just fortunate that they have a choice. I hear what you are saying Jeanine, but most people don’t shop employers by the health care plan they provide unless they have special medical needs for themselves or dependents.

As to your comments Larry, I agree that eventually all of the federal and state legislation will force the cost of health care so high that employers will stop offering it, because even if they do it will be so expensive that employees will not want to pay for it. Could this be the subtle agenda of congress to force use into socialized medicine? It certainly has been the agenda of Ted Kennedy’s for years, and more recently Hillary’s. Yes, eventually Uncle Sugar Daddy will take care of your health care needs and maybe as good as they have through Medicare and Medicare, but keep one thing in mind it won’t be free, you will be taxed for it.

I thought I might as well get on the soap box.

[Guest mmarin]

From a review of both the House and Senate versions of the legislation, which can be downloaded from various websites, the definition of group health plan includes "self-funded", so yes you will be affected.