Fax Sent to Wrong Number Results in HIPAA Violation

Fax Sent to Wrong Number Results in HIPAA Violation

Dr. G, 58, was a urologist with a solo practice. His business was thriving, and he employed both a nurse and an office manager to help him.

One morning, the office manager got a call from one of the practice's patients, Mr. M, a 52-year-old, HIV-positive man who had been seeing Dr. G for a decade. Although he was happy with the treatment he had been receiving, Mr. M's company was promoting him and he was relocating to another town. He called to ask Dr. G to fax his medical records to his new urologist.

The office manager was juggling numerous tasks, but managed to send the fax out later that day. The office did not have personalized fax cover sheets, just sheets that the office manager printed off once a week which had spaces to fill in the “to” and “from” sections. She hurriedly filled them in and shot off the fax, one of several she had to do before checking in the next patient.

At the end of the day she told Dr. G that it had been done. He thought nothing of it until the following Monday when the office manager came into the back office to speak to him. She was pale and looked shaken, and the physician immediately asked if she was okay.

“It's Mr. M,” the office manager said. “He just called – absolutely furious. He says that we faxed his medical records to his employer rather than his new doctor, and that now his company is aware of his HIV status. He is extremely upset.”

“I'm so sorry,” the office manager said tearfully. “I was the one who sent that fax out. I must have accidentally grabbed the wrong number from his file. What should we do?” She looked at Dr. G for guidance.

Dr. G was holding his forehead, and trying to figure out how to remedy the situation. “The first thing we're going to do is to call Mr. M and apologize. Then we'll take it from there.”

The office manager and Dr. G called Mr. M and apologized profusely for the mix-up. Mr. M understood that it had not been done maliciously, but he was still not satisfied and reported the incident to the U.S. Department of Health and Human Services' (HHS) Office for Civil Rights (OCR). 

An initial investigation indicated that the incident was not criminal and so it was not referred to the Department of Justice. Rather, it was handled by the OCR. OCR officials appeared at Dr. G's office to look into the matter, and after a thorough investigation, the OCR issued a letter of warning to the office manager, referred the office staff for HIPAA privacy training, and had the office revise the fax cover sheets to underscore that they contain a confidential communication for the intended recipient only.

Legal Background

The Health Insurance Portability and Accountability Act, commonly known as HIPAA, protects personally identifiable health information of patients, and specifies to providers how such information may be used. HIPAA has been in effect for about a decade, and in that time, the HHS has received a total of almost 80,000 complaints.

Of those, more than 44,000 were dismissed, 19,000 were investigated and resolved with changes to privacy practice, and 9,000 were investigated but no violations were found. 

According to HHS, private medical practices were the ones most often required to take corrective action as a result of enforcement. The top two compliance issues most frequently investigated are impermissible use and disclosure of protected health information and lack of safeguards for protected health information.

When a HIPAA complaint is filed with the HHS, the first determination made is whether there was a possible privacy violation and whether it was of a criminal nature. If it was determined to be criminal, the case is referred to the Department of Justice for investigation and possible prosecution. If it was determined that it was not a criminal issue (as in this case) the violation is investigated by the OCR. 

If it is determined that a HIPAA violation did, in fact, take place, the OCR can either obtain voluntary compliance, corrective action or some other voluntary agreement with the offender, or the OCR can issue a formal finding of violation and force the offender to change its practices.

In this particular case, the office manager and Dr. G recognized the mistake and immediately tried to take corrective action by apologizing to the patient. Dr. G's office also voluntarily agreed to extra compliance training for the staff and to a change in their faxing procedures to indicate that the faxed materials are confidential.

Protecting Yourself

This particular scenario was the result of a careless error. While a careless error can happen to anyone, one such as this could cause irreparable harm to the patient if his employer now views or treats him differently because of the new knowledge of his HIV-positive status.

Confidential patient records must be treated with the greatest of care as they contain information of an extremely personal nature. Many HIPAA cases have involved the unintentional divulging of the HIV or AIDS status of a patient. 

In a similar case, a dental practice was reported for using red stickers and the word AIDS on the outside of patient folders. And in a case that took place in a hospital, a nurse and orderly lost their jobs for discussing a patient's HIV status within earshot of other patients.

A good rule of thumb is to treat a patient's confidential information as you would want yours to be treated, and then add a little extra security for good measure.

This article originally appeared on RUN.

http://www.empr.com/fax-sent-to-wrong-number-results-in-hipaa-violation/article/310698/1/

JAMA: Researchers observed a 19.2% drop in AMI hospitalizations, but 16.5% increase in expenses

"The researchers observed a 19.2% decrease in the rate of AMI hospitalizations, but overall per-patient expenditures increased by 16.5%. About one-quarter (25.6%) of the total risk-adjusted increase in expenditures occurred within 30 days, and 74.4% occurred 31–365 days after the index admission. There were increases in spending per beneficiary within 30 days (7.5% increase; $1,560) and between 31 and 365 days (28% increase; $4,535). From 31–365 days after admission, the expenditures for skilled nursing facilities, hospice, home health agencies, durable medical equipment, and outpatient care almost doubled."

Importance 

 Medicare expenditures continue to grow rapidly, but the reasons are uncertain.

Objective 

 To compare expenditures from 1998 through 1999 and 2008 for Medicare beneficiaries hospitalized for acute myocardial infarction (AMI).

Design, Setting, and Participants  Cross-sectional analysis of a random 20% sample of fee-for-service Medicare beneficiaries admitted with AMI from 1998 through 1999 (n = 105 074) and a 100% sample for 2008 (n = 212 329).

Main Outcomes and Measures  

Per-beneficiary expenditures, standardized for price and adjusted for risk and inflation. Expenditures were measured across 4 periods: overall (index admission to 1 year), index (within the index admission), early (postindex admission to 30 days), and late (31-365 days).

Results  

Compared with the subjects from 1998 through 1999, those in 2008 were older and had more comorbidities but slightly less ischemic heart disease and cerebrovascular disease. Although there was a 19.2% decline in the rate of hospitalizations for AMI, overall expenditures per patient increased by 16.5% (absolute difference, $6094). Of the total risk-adjusted increase in expenditures, 25.6% occurred within 30 days (22.0% attributed to the index admission), and 74.4% happened 31 to 365 days after the index admission. Spending per beneficiary within 30 days increased by $1560 (7.5%), and spending between 31 and 365 days increased by $4535 (28.0%). Expenditures for skilled nursing facilities, hospice, home health agency, durable medical equipment, and outpatient care nearly doubled 31 to 365 days after admission. Mortality within 1 year declined from 36.0% in 1998 through 1999 to 31.7% in 2008; of the decline, 3.3% was in the 30 days following admission, and 1.0% was in days 31 to 365.

Conclusions and Relevance  Between 1998 and 2008, Medicare expenditures per patient with an AMI substantially increased, with about three-fourths of the increase in expenditures occurring 31 to 365 days after the date of hospital admission. Although current bundled payment models may contain expenditures within 30 days of an AMI, they do not contain spending beyond 30 days.

Between 2000 and 2010, the growth in Medicare expenditures per enrollee, without adjusting for inflation, was about 5.9% annually, considerably greater than the 2.8% annual growth in gross domestic product.1- 2 Given the large budget deficits in the United States and the high cost of caring for Medicare beneficiaries, unanswered questions remain: why have Medicare costs been rising so rapidly? Do reimbursement rates, or the mix of services per disease, account for increased expenditures? Alternatively, has the threshold for treatment decreased so that patients are treated more aggressively?

We addressed these questions with detailed Medicare claims data and focused on a well-defined index event: hospital admission for acute myocardial infarction (AMI). Patients with AMI are almost universally hospitalized (making this a reliable index event). The considerable technological progress in the treatment of AMI has improved survival rates.3 For the index admission, our hypothesis was that changes in both the technology of treatment and reimbursement rates led to increased costs. For the acute (within 30 days of the AMI) and longer-term (31-365 days) postadmission periods, our hypothesis was that treatment intensity increased for patients after their initial hospitalization.

Data

We used a random 20% sample of Medicare beneficiaries from 1998 through 1999 and a 100% sample for 2008. Eligible patients were fee-for-service Medicare enrollees with the diagnosis of AMI based on the presence of appropriate diagnosis codes from the International Classification of Diseases, Ninth Revision (410.xx [except 410.x2]), from 1998 through 1999 or 2008. Eligibility in the sample was limited to those (1) enrolled in Medicare (Part A and B, as identified through the Medicare denominator file) for the entire year beyond their index admission (or until the month of their death), (2) at least 65 years or older at the time of their index admission, and (3) enrolled in a non–health maintenance organization plan for more than 1 month during each of the 12-month periods (eFigure in the Supplement). Data from the Medicare Provider Analysis and Review files were linked to other Centers for Medicare & Medicaid Services files (Carrier file, Home Health Agency, Durable Medical Equipment, Outpatient, and Hospice) containing claims that represented services associated with the patient’s index admission and subsequent services (and expenditures) for a 1-year period following admission. Outpatient claims differ from physician claims; they include bills from rehabilitation facilities, hospital outpatient departments, and other institutional outpatient providers.

We excluded patients admitted to a non–acute care hospital with a primary diagnosis of AMI, those transferred to an acute care hospital with a primary diagnosis other than AMI, and those discharged alive with a total length of stay less than 1 day and who were not transferred. These exclusions left a total of 317 403 patients in our final sample (eFigure in the Supplement).

We defined a transfer as occurring if the date of discharge was the same as the date of admission between 2 mutually exclusive hospitals. The total length of stay for the index admission was defined from the date of admission to discharge, including any transfers.

Calculation of Expenditures

We report price-standardized Medicare payments for the index admission and postindex use up to 1 year following a patient’s hospitalization for AMI.4 Standardized Medicare payments adjust for differences across regions in reimbursement rates for Medicare services owing to costs of living, graduate medical education, and payments provided for serving a disproportionate number of low-income patients.

Hospital Payments

Hospital payments included the acute index hospitalization (diagnostic-related group [DRG] payment plus outlier payments when present) and other hospitalizations occurring within 1 year of the initial admission date. Expenditures included actual payments to providers but not amounts billed to patients or their supplemental insurance policies.

We disaggregated expenditures after the index admission into the specific categories of hospital use and accounted for changes in definitions of DRGs over time, including the (new) Medicare Severity–Diagnosis-Related Group (MS-DRG) categories (eTables 1 and 2 in the Supplement). Because of the difficulty of risk-adjusting each specific DRG/MS-DRG category in every period, we present unadjusted expenditures.

Physician Payments and Use

We provide use of and payments for physician services based on current procedural terminology and the Berenson-Eggers type of service codes.5 The Berenson-Eggers codes create clinically relevant service categories for analyzing Medicare expenditures.

Other Expenditures After the Index Hospitalization

We included expenditures for skilled nursing facilities, outpatient facilities, home health agency, hospice, and durable medical equipment.

Statistical Analysis

We calculated the population-based rates of AMI hospitalizations and total expenditures (index and postindex admission) for all fee-for-service Medicare beneficiaries. The 1998 through 1999 expenditures are expressed in terms of 2008 US dollars after adjustment for general inflation using the chain-weighted gross domestic product price deflator. We adjusted for age, sex, race, ST-segment AMI, and Charlson comorbidities (including 13 comorbid conditions previously predictive of long-term mortality).6 We used 2-sample t tests (for unequal sample sizes and unequal variances across periods). Although our study was not designed to test the causal effect of greater spending levels on health outcomes, we used a similar risk adjustment approach to compare 30-day rates from 1998 through 1999 with corresponding 31- to 365-day case fatality rates in 2008.

We identified 317 403 Medicare beneficiaries who were hospitalized for an AMI (105 074 from the 20% sample of enrollees in 1998-1999 and 212 329 from the 100% sample in 2008). These comprised 0.64% of all fee-for-service Medicare enrollees from 1998 through 1999 and 0.47% in 2008 (P < .001). Thus, there was a 19.2% decline in the incidence of AMI during the decade.

As shown in Table 1, patients in 2008 were older and sicker on average than patients in 1998 through 1999 and had more comorbid conditions, exclusive of less ischemic heart disease and cerebrovascular disease (all P < .001). There was a shift from coronary artery bypass graft (CABG) surgery during the index admission to percutaneous coronary intervention. Median length of stay was 1 day shorter in 2008 (5 vs 6 days in 1998-1999, P < .001). Reductions in length of stay were associated with concomitant increases in other expenditures, including a 75.4% increase in the use of skilled nursing facilities in the first 30 days (Table 2).

Overall, 1-year case fatality rates per patient with AMI declined from 36.0% from 1998 through 1999 to 31.7% in 2008; of the 4.3% decline, 3.3% was in the 30 days following admission (from 18.6% to 15.3%) and 1.0% was in days 31 to 365. The case fatality rate for days 31 to 365 (among patients surviving for 30 days after an AMI) declined from 22.3% to 20.2%. The available data did not allow us to measure changes in quality of life.

Adjusted 1-year expenditures increased 16.5% (absolute difference, $6094) for 1998 through 1999 compared with 2008 (Table 2). Spending per beneficiary within 30 days increased by $1560 (7.5%), and spending between 31 and 365 days increased by $4535 (28.0%). Medicare expenditures in the first 30 days accounted for 25.6% of the increase in spending (22.0% attributed to the index admission); expenditures between 31 and 365 days after admission accounted for the remaining 74.4%. The components of the 74.4% increase between 31 and 365 days were home health agency, hospice, or durable medical equipment (22.9%); skilled nursing facilities (17.3%); inpatient (12.8%) and outpatient (11.1%) services; and physician payment (10.4%).

Table 2.  Total, Index, and Postindex Admission Spending for Patients Admitted for Acute Myocardial Infarctiona

View Large  |  Save Table  |  Download Slide (.ppt)

Together, inpatient and skilled nursing facility spending accounted for the greatest absolute change in cost (total of $3033) during 1 year (Table 2) and the greatest proportion of the overall cost increase (48.8%). Growth in home health agency and hospice expenditures was not associated with declines in inpatient facility expenditures.

From 1998 through 1999, 33.9% of the cohort was rehospitalized within 3 months of the index admission (20.0% within 1 month) compared with 33.4% within 3 months in 2008 (19.8% within 1 month). Although overall rates of readmission did not change appreciably, the mean cost per readmission increased by 9.8% ($8991 in 1998-1999 to $9874 in 2008).

The greatest absolute increases (from 1998-1999 to 2008) in hospital facility expenditures during 1 year per patient with AMI were for percutaneous coronary intervention ($571) and cardiac defibrillator implantation ($541), the latter a technology not reimbursed by Medicare for coronary artery disease from 1998 through 1999 (Figure 1). Unadjusted expenditures for cardiac defibrillator implantation, rehabilitation, or septicemia accounted for 47.1% of the increase in hospitalization costs after the index admission.

Physician expenditures per beneficiary decreased by 1.0% during the index admission and were unchanged within the first 30 days (Table 2). Between 31 and 365 days, physician expenditures increased by $632 (21.8%), primarily because of a 43.5% increase in outpatient physician spending (Table 2). The greatest per-beneficiary increase in expenditures after the index admission, $498, was for durable medical equipment or “other services or exceptions,” such as ambulance transport and chiropractic care (Table 3). Expenditures in this category increased from $602 in 1998 through 1999 to $1100 in 2008.

Table 3.  Rates and Expenditures for Physician and Other Servicesa in 1998 Through 1999 and 2008 After the Index Admission for Acute Myocardial Infarction (AMI)b

View Large  |  Save Table  |  Download Slide (.ppt)

Physician expenditures for cardiac procedures after the index hospitalization declined from $1120 per patient from 1998 through 1999 to $803 in 2008, or by 28.3% (Table 3). The rate of rehospitalizations for percutaneous coronary interventions increased from 1.7 per 100 patients with AMI from 1998 through 1999 to 5.4 in 2008 (Figure 2). However, the rehospitalization rate for CABG surgery declined from 3.1 per 100 patients with AMI from 1998 through 1999 to 1.4 in 2008, or by 54.8%. Medicare’s cost per patient during 1 year for those undergoing inpatient percutaneous coronary interventions, with adjustment for inflation but not risk, was $12 327 from 1998 through 1999 and $14 385 in 2008, a 16.7% increase. Medicare’s cost per patient during 1 year for rehospitalizations in which a CABG was performed, with adjustment for inflation but not risk, was $31 727 from 1998 through 1999 and $30 686 in 2008. For both percutaneous coronary interventions and the rehospitalizations for CABG, the figures for cost per patient include the instances when a patient had more than 1 percutaneous coronary intervention or more than 1 rehospitalization for CABG within the year; the figures are not per percutaneous coronary intervention or per rehospitalization for CABG.

http://archinte.jamanetwork.com/article.aspx?articleid=1740698#ioi130100t2

3 companies plan to be in Alabama's health exchange

Blue Cross and Blue Shield of Alabama, UnitedHealthcare and Humana Inc. are the companies that have so far submitted plans to be offered on the health insurance exchange in Alabama.

Mark Fowler, a spokesman for the Alabama Department of Insurance, said his agency is reviewing the submitted plans from the three companies. He said the federal government will have the final say on which plans will be certified and offered on the exchange, an online marketplace that will allow individuals and businesses to shop for health insurance plans.

"Federal law requires that before any plan can be offered on the Federally Facilitated Marketplace in Alabama, the Alabama Department of Insurance must review it and make sure that it complies with state law," he said in an e-mail statement. "The federal government, however, could reject any plan the state might approve as meeting state law."

Fowler said the Department of Insurance anticipates approving the submitted plans by Oct. 1.

Open enrollment in the health exchanges is slated to start on Oct. 1, and individuals will be able to start receiving coverage on Jan. 1, 2014. Alabama is among the states that have decided to let the federal government run its exchange.

As I have reported in the past, Alabama has one of the least competitive health insurance markets in the U.S. According to a 2012 report from the American Medical Association, 88 percent of the state's market is controlled by Blue Cross while UnitedHealthcare sits at a very distant second with 5 percent.

I have also reported that 642,738 Alabamians are uninsured and eligible to shop on the marketplace. Of that amount, 608,430 may qualify for tax credits or enroll into Medicaid as part of a voluntary state-by-state Medicaid expansion. Alabama, however, has so far decided against taking part in the expansion.

http://m.bizjournals.com/birmingham/blog/2013/09/3-companies-plan-to-be-in-alabamas.html?r=full

17 Senators Ask HHS to Extend Stage 2 Meaningful Use

Seventeen Republican U.S. Senators have sent a letter to Health and Human Services Secretary Kathleen Sebelieus making a compelling argument for implementing a one-year extension to Stage 2 of the electronic health records meaningful use program. Here is text of the letter, dated September 24:

“Dear Madam Secretary:

“The Electronic Health Records Meaningful Use Incentive Program has played a significant role in advancing the adoption of health information technology across the country. However, given the feedback from stakeholders on the timing of Stage 2 of the program, we respectfully request an extension of Stage 2 by one year for providers who need extra time to meet the new requirements. Providers who are ready to attest to Stage 2 in 2014 should be able to do so consistent with current policy.

“Starting in 2014, eligible hospitals and eligible professionals participating in the EHR incentive program for Medicare will have to progress to new Stage 2 regulatory standards in order to demonstrate growth in the use of EHR technology. All eligible hospitals and professionals will have to demonstrate achievement of Stage 2 meaningful use objectives for any quarter-based 90-day period of either Fiscal Year 2014 for hospitals or Calendar Year 2014 for physicians in order to avoid penalties in 2016. This requirement applies to those who began Stage 1 in 2012 or earlier. However, even providers that began Stage 1 in 2013 or will attest for the first time in 2014 will have to use 2014 Edition Certified EHRs to satisfy the revised set of Stage 1 objectives.

“Therefore, based on a wide range of feedback from providers, vendors and other stakeholders, we identity three key problems with the current timeline for Stage 2.

“First, we are concerned that the regulatory structure of the program has created significant time pressure in 2014, and progressing to Stage 2 may not be feasible for all participants. In one year, over 500,000 hospitals and physicians are required to upgrade their existing technology to demonstrate new standards of ‘meaningful use’ by the end of 2014 in order to be eligible for the corresponding incentive payments. Further, the vendors are under tremendous time pressures to ensure their products are certified for the 2014 Edition criteria and have sufficient time to upgrade their products for each hospital or physician client. This time pressure has raised questions about whether such a short period for Stage 2 is in the best long-term interest of the program.

“Second, we are concerned that the onset of Stage 2 may further widen the digital divide for small and rural providers who lack the resources of large practices and may not be vendors’ top priorities. Even if certified products are available to them, simply receiving the software update does not satisfy meaningful use requirements for a hospital or eligible provider. They also need assistance learning how to use the new technology and time to address how they will achieve the new standards of meaningful use.

“Third, an artificially aggressive Stage 2 timeline may have serious unintended consequences such as stifling innovation and increasing medical errors. Innovation in health information technology could be hampered, since vendors do not have the time to introduce administrative flexibility into their EHRs to best serve diverse practices. Medical errors could be increased inadvertently, because rushing through upgrades could introduce new risks in the technology that could cause errors or patient safety problems.

“If the goal is to improve care by achieving broad and meaningful utilization of EHRs, providing sufficient time to ensure a safe, orderly transition through Stage 2 is critical to having stakeholder buy-in, a necessary component of long-term success.

“We are not suggesting a delay of Stage 2 and the progress we have seen to date. Providers who are ready to transition to Stage 2 should do so and should receive incentive payments in 2014 and 2015 consistent with current policy. However, providers that are not yet ready to transition to Stage 2 should have a one-year extension before they must demonstrate Stage 2 meaningful use, consequently mitigating the threat of penalties while still abiding by the statutory deadlines.

“In future efforts, continued focus on achieving interoperability is critical. We believe that for this program to ultimately be successful, heeding stakeholder feedback on the current progress to achieving interoperability is imperative. It is critical to continue holding vendors accountable for providing products that advance the ability for unaffiliated providers to share information.

“We appreciate your attention to this request and urge you to move quickly with a decision so stakeholders have the clarity and certainty they need to plan. We look forward to your response by October 8, 2013.”

Signers of the letter were Sens. John Thune, Lamar Alexander, Tom Coburn, Mike Enzi, Richard Burr, Pat Roberts, Johnny Isakson, Patrick Toomey, Rob Portman, Mark Kirk, Saxby Chambliss, Jerry Moran, James Risch, John Barrasso, Lisa Murkowski, Daniel Coats and Roger Wicker.

http://www.healthdatamanagement.com/news/senators-ask-hhs-extend-ehr-meaningful-use-46649-1.html

Seattle doctor pleads not guilty in ND court to Medicare fraud charges

FARGO — A Seattle doctor accused of turning in phony Medicare claims that included nursing home visits to patients who were dead pleaded not guilty Wednesday in federal court.

A Seattle doctor accused of turning in phony Medicare claims that included nursing home visits to patients who were dead pleaded not guilty Wednesday in federal court.

John C. Chen pleaded not guilty to six counts, including health care fraud and false statements related to health care. Trial is scheduled for Nov. 19 in Fargo.

The case is being tried in North Dakota because Fargo-based Noridian Healthcare Solutions LLC processes and pays Medicare Part B claims in Washington state.

Authorities said many of Chen's claims for face-to-face appointments occurred when he was out of the country.

Chen, who appeared Wednesday via video from Seattle along with his lawyer, Robert Flennaugh II, faces a maximum penalty of 45 years in prison. Flennaugh did not respond to requests for an interview.

U.S. Attorney Timothy Purdon declined comment because the case has not been decided.

Authorities said Chen submitted 673 claims for medical services in the Seattle and Tacoma, Wash., area from 2007 through 2010, when he allegedly was out of the country. He is accused of turning in 212 claims between April 2007 and July 2012 for nursing home visits that never took place.

The indictment said Chen failed to keep accurate notes of patient records for services billed to Medicare and also submitted his own claims to the federal program.

The government is asking Chen to pay back any losses and forfeit all property and proceeds that were gained as a result of the scheme. Those damages were been specified.

U.S. Magistrate Judge Karen Klein ordered to Chen to remain on supervised release with conditions, including restriction of travel only to North Dakota. Chen had earlier surrendered his U.S. and China passports.

http://www.inforum.com/event/article/id/413271/group/News/

Five Miami residents arrested in $48M home health Medicare fraud

Five Miami residents were arrested Wednesday on charges of participating in a $48 million home health Medicare fraud scheme.

Charged in a grand jury indictment are: Marianela Martinez, 45; Mireya Amechazurra, 49; Lissett Jo-Moure, 55; Omar Hernandez, 48; and Celia Santovenia, 49.

Each of them faces up to five years in prison on charges of conspiracy to receive health care kickbacks and receiving kickbacks in connection with a federal health care program.

The five defendants allegedly referred patients to Miami agencies in exchange for kickbacks, including Caring Nurse Home Health Care Corp. and Good Quality Home Health Inc.

Previously, Rogelio Rodriguez and Raymond Aday, owners and operators of Caring Nurse and Good Quality, were sentenced to 108 and 51 months in prison, respectively.

The arrests were part of the Medicare Fraud Strike Force.

More options in Florida insurance marketplaces, Obama administration says

 

Buy Photo

Dr. Fleur Sack, right, talks with patient Caretha Lucas of Cutler Bay about her medical records and how she will be able to access her records through the cloud system during her doctor visit on Tuesday, February 19, 2013. 

CARL JUSTE / MIAMI HERALD STAFF

Related Content

• Sen. Marco Rubio plays tag team with Sen. Ted Cruz in slamming Obamacare on Senate floor
• South Florida insurance rates will be among lowest in state, report says
• Blog: Florida HealthWatch
• Health reform subsidy calculator
• Broward looks to defy Gov. Scott on Obamacare
• Miami-Dade weighs Gov. Rick Scott’s Obamacare ‘navigators’ ban

MORE INFORMATION

How to compare and shop for insurance through the federal Health Insurance Marketplace:

Sign on to healthcare.gov

Enter information about age, gender, location and current coverage

View plans that you qualify for, and choose one that works for you

Full plan and cost information will be available Oct. 1, the day the federally-run healthcare exchanges open. Enrollment runs from Oct. 1 through March 31, 2014. In order to be insured by Jan. 1, 2014, you must buy your plan no later than Dec. 15

Questions? Call 800-318-2596 or visitlocalhelp.healthcare.gov

Florida’s Division of Consumer Services will host two free web-based seminars – 3:30 p.m. Oct. 8 and noon Oct. 17 – for consumers to learn more about the healthcare exchanges, subsidies and the health reform law. For more information, visit freshfromflorida.com or call 1-877-693-5236.

BY EVAN S. BENN, PATRICIA BORNS AND KATHLEEN MCGRORY

EBENN@MIAMIHERALD.COM

An optimistic Obama administration touted a major phase of the Affordable Care Act — online health-insurance marketplaces — as having more options and lower premiums for consumers than originally projected.

Florida, where an estimated 3.8 million people live without health insurance, ranks near the top of the nation in terms of choices: Residents will have an average of 102 health plans to choose from when the federally run online marketplaces, or “exchanges,” go live on Oct. 1. That is second only to Arizona, where people shopping for insurance will have an average of 106 plans to consider.

A report released Tuesday by the U.S. Department of Health and Human Services also indicated that, nationwide, insurance premiums should come in about 16 percent lower than the government expected, with the average individual on a middle-tier plan paying $328 a month before tax credits. In Florida, a 27-year-old making $25,000 a year would, on average, pay a $218 monthly premium on the same health plan.

“Florida rates have actually come in quite well,” said Gary Cohen, director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services, in a conference call with reporters and Obama’s top health official, HHS Secretary Kathleen Sebelius.

Average monthly premiums in Miami-Dade County would range from as low as $72 a month after tax credits for a family of four earning $50,000 a year that opts for a low-cost plan to $799 for the same family on a middle-tier plan without tax credits. In Broward County, a family of four would pay $24 a month with tax credits for the low-cost plan and $722 a month for the middle-tier coverage without tax credits.

But Wednesday’s report fails to provide an under-the-hood look at what the insurance plans will offer — provider networks or deductibles or co-payments or any other coverage details.

For that, consumers will have to wait until Tuesday’s opening of the online exchanges. Cohen said they will have plenty of time to sort out the details because the enrollment period runs from Oct. 1 through March 31, 2014. Consumers must buy insurance by Dec. 15 if they want to be covered starting Jan. 1.

“Consumers and advocates will have a full six months to look at the options available to them and make a choice based on what they think is best for themselves and their family,” Cohen said. For people who want to be insured by the start of the new year, “they have all of October, all of November and half of December to go online, look at plans . . . think about it, come back and make a decision.”

The online exchanges will allow individuals and small-business owners to shop for insurance and find out whether they are eligible for federal subsidies — tax credits — to help cover the cost of coverage or whether they can apply for Medicaid, the insurance program for the poor. The subsidies will be paid by the federal government directly to the insurance companies.

Enacted in 2010, the Patient Protection and Affordable Care Act — Obamacare — has triggered several reforms that affect Americans’ healthcare coverage. Among them, insurance companies can no longer deny coverage based on pre-existing medical conditions; dependent coverage for adult children has been extended to age 26; and insurance plans must offer at least 10 “essential benefits” that include hospitalization, emergency and outpatient treatment, maternity and newborn care, prescription drugs, pediatric services and more.

The law’s individual-insurance mandate is aimed at providing care for the estimated 48 million Americans younger than 65 who do not have insurance. Most Americans, about 85 percent, have health insurance through their jobs and are unlikely to buy coverage through the exchanges; Americans older than 65 who are covered by Medicare do not need to enroll.

The government projects that about seven million people will buy health coverage through the insurance marketplaces in the next year, and about six million of them will receive tax credits to lower their costs.

The subsidies will be for low- and middle-income residents who earn between 100 percent and 400 percent of the federal poverty level. For 2013, that includes individuals who make from $11,490 to $46,000, two-person families earning between $19,530 and $78,120, and four-person families earning between $23,550 and $94,200 a year.

Some, however, will be left without any health insurance. Florida is one of more than 20 states that did not expand Medicaid. The Legislature’s decision not to accept more than $50 billion in federal funds over 10 years to bolster Medicaid has left an estimated 995,000 people — mostly Florida’s poorest residents — without options for medical coverage. Those in the “coverage gap” have poverty-level incomes but do not qualify for Medicaid and are not eligible for tax credits to help buy insurance on the exchanges.

And Americans who are eligible but opt not to buy health insurance for 2014 will be penalized 1 percent of their annual income or $95 per person per year, whichever is more. The penalties will increase each year.

The average prices released by the government on Wednesday are based on various coverage tiers — including gold, silver and bronze — that consumers will have to choose from on the exchanges. Higher-priced platinum plans also will be available, as will low-cost “catastrophic” coverage for young adults.

In Florida, the average monthly premium for the least-expensive bronze plan is $257. That’s an uptick from the $243 statewide average insurance premium from 2012, according to Florida’s Office of Insurance Regulation.  

The least-expensive plan in the silver tier would cost the average Floridian $304 a month, and the second-least-expensive silver plan would cost $328 a month, without tax credits.

The data released Tuesday offered examples of average premiums for 27-year-olds — the age at which adult children can no longer remain on their parents’ insurance plans — as well as for a family of four with an income of $50,000.

In the Miami-Hialeah metro area — the report offered a sampling of regional data — a 27-year-old earning $25,000 a year would pay $87 a month for the least-expensive bronze plan after tax credits. A family of four in the same area making $50,000 a year would pay $72 a month for the same plan after the subsidies.

In the Fort Lauderdale-Hollywood-Pompano Beach metro area, the 27-year-old would pay $74 a month and the family of four would pay $24 a month for the lowest-cost bronze plan.

Residents of Miami-Dade and Broward counties will have among the most plans to choose from of anywhere in the state — 137 and 132, respectively. Monroe County residents will have 18 coverage plans available.

“The fact that there are numerous plans available will enable competition between the plans to work on behalf of consumers,” said Ron Pollack, executive director of Families USA, a nonpartisan group that supports Obamacare. “As different plans compete with one another, they are going to have to provide a value to consumers, over and above what their competitors are providing. . . .

“One of the changes in the ACA is that it requires each of the plans to provide information in an understandable and rather uniform fashion, so consumers can compare apples to apples, something they have been unable to do in the past.”

Some insurance providers said they were eager for next week’s rollout of the online exchanges.

“We’ve long believed and hoped that we could provide affordable, competitively priced plans in a place like Florida,” Humana spokesman Mitch Lubitz said.

Others in the industry were skeptical.

“My understanding of the lowest bronze plan is that is has a $6,257 deductible. What does that mean to a 27-year-old?” said W. Adam Clatsoff, president of Coral Springs-based Adcahb Medical Coveragesand a member of the Florida Health Insurance Advisory Board, which makes recommendations to the state’s insurance office. “This is a very expensive health insurance program. We have not lowered the cost of healthcare.”

“They are not telling the whole story,” said State Sen. David Simmons, R-Altamonte Springs, a member of the Senate committee on the Affordable Care Act. “The numbers I am seeing from employers — numbers that are being quoted by health insurance brokers — show significant and material increases in premiums.”

Still, state Sen. Eleanor Sobel, D-Hollywood, who testified on Obamacare before Congress last week, said she was pleased by the fact that Floridians will have so many options when they start buying health insurance on the exchange.

“The principles of competition and transparency are actually working,” Sobel said. “I’m elated for the people of Florida that they will be able to access affordable and quality healthcare.”

This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

http://www.miamiherald.com/2013/09/25/v-fullstory/3648652/more-options-in-florida-insurance.html

Read more here: http://www.miamiherald.com/2013/09/25/v-fullstory/3648652/more-options-in-florida-insurance.html#storylink=cpy