• Category Archives ACA Problems
  • Young Adults Can Face 41% Narrower Income Range for Obamacare Subsidies

    HealthPocket examined health plan premium subsidies for 18 to 34 year-olds in eight major cities across the country and found this age group could not obtain subsidies for health plans within the complete income range specified by the Affordable Care Act.

    The Affordable Care Act subsidies are designed to lower premiums for people with incomes between 100% and 400% of the Federal Poverty Level. However, for the eight cities studied, the average maximum income at which young adults qualified for a premium subsidy was $31,744, which is less than 277% of the Federal Poverty Level. This “Obamacare subsidy gap” occurs because the exchange benchmark premiums of younger people can fall short of the percentage of income necessary to trigger a subsidy.

    Moreover, HealthPocket found that the maximum income that qualified for a premium subsidy varied by $7,709 among the 8 cities examined. The table below ranks the cities by the highest income where 18 to 34 year-olds were eligible for a subsidy.

    Rank City
    1 Philadelphia, Pennsylvania ($36,013)
    2 Miami, Florida ($33,323)
    3 Los Angeles, California ($32,858)
    4 Atlanta, Georgia ($32,085)
    5 Houston, Texas ($31,732)
    6 Detroit, Michigan ($30,266)
    7 Chicago, Illinois ($29,374)
    8 Phoenix, Arizona ($28,304)

    HealthPocket’s analysis suggests that the premium subsidy design may be an important factor contributing to the under-enrollment of the young adult population, a population targeted for enrollment both for their typically good health as well as their propensity to be uninsured.

    The full results of the study, “18-34 Year-Olds Can Face 41% Narrower Income Bracket to Qualify for Obamacare Subsidies,” can be found at HealthPocket.com.

    HealthPocket.com is a free website that compares and ranks all health insurance plans available to an individual, family, or small business to allow consumers to make their best health plan decision and reduce their out of pocket costs. HealthPocket uses only objective data from government, non-profit, and private sources that carry no conditions that might restrict the site from serving as an unbiased resource. Learn more at www.HealthPocket.com.

    SOURCE HealthPocket

  • Puget Sound Physicians Rally Behind New Health Insurance Model Promising Better Care, Fairer Reimbursement, and Lower Costs for Employers

    Physician Care Direct partners with employers and health systems to make healthcare more affordable. We deliver the Employer Health Ownership Plan(TM) (EHOP(TM)) an innovative health plan solution that starts with personalized primary care, then adds physician and hospital networks for a comprehensive solution. Now businesses of all sizes can offer their employees meaningful healthcare benefits while controlling and reducing costs. For more information, visit www.physiciancaredirect.com. (PRNewsFoto/Physician Care Direct)Amid news that health insurance premiums will rise for nearly two-thirds of small businesses under the Affordable Care Act, Physician Care Direct today announced that Eastside Family Medicine Clinic has joined several other Puget Sound medical groups in adopting a health plan designed to better manage employer costs while benefiting patients and providers alike.

    The addition of Eastside, a nine-provider group in Bellevue, brings to over 60 the number of Puget Sound primary care providers who have agreed to participate in the Employer Health Ownership Plan™ (EHOP™).

    The EHOP is a healthcare purchasing strategy from Physician Care Direct that encourages greater use of primary care – low-cost medical services that address 90 percent of patients’ needs. Employers buy personalized primary care directly from providers and then add coverage for specialists and hospitalization. The approach ensures that primary care providers are fairly compensated for comprehensive care, while employers share in the savings from keeping employees healthy.

    “Many studies have shown that timely and excellent primary care reduces emergency department visits, specialist visits, hospitalizations and surgeries,” said Antony Engal, MD, president of Eastside Family Medicine Clinic. “It’s about time that someone developed a health plan that recognizes that fact. Physician Care Direct’s approach is unique and one that we hope many more Puget Sound physicians and employers will embrace as they seek to improve the quality of patient care while lowering its cost.”

    How the EHOP Works

    The majority of U.S. companies contract with insurers for healthcare benefits that remain a fixed cost throughout the term of the contract. If they reduce healthcare expenses by encouraging employee wellness, those savings benefit their insurance company. Employers’ premiums rise as health system costs increase, leaving them at the mercy of cost shifting in an inefficient market.

    The problem is especially acute for smaller businesses, which pay between 10 and 18 percent more for health insurance than larger companies, according to the Commonwealth Fund. Compounding the problem, the Centers for Medicare and Medicaid Services announced in late February that nearly two-thirds of small businesses that currently offer health insurance to their workers will pay more for coverage as a result of new rules in the healthcare law, as will millions of small-business employees and their family members.

    Self-insurance under the EHOP can help by converting approximately 60 to 70 percent of a company’s healthcare expense to a variable cost. As a result, when the company and the EHOP succeed in reducing healthcare spending, underwriting profits flow back to the employer not their insurance company. The EHOP can also include reinsurance to limit the employer’s financial risk.

    EHOP participants pay few if any out-of-pocket costs for primary care. Having comprehensive primary care available at no or little cost enables employees to better manage their health and reduce healthcare expenses.

    Hospitals and health systems can offer their own private-label EHOP to employers in their area. The approach lets hospitals become the center of a community-based solution to improve care coordination and health outcomes.

    “We know that timely primary care can improve the health status of Americans and lower costs, yet our healthcare purchasing methods are pricing employers out of business, causing physicians to abandon primary care, and bankrupting patients,” said William Lawson, M.D., CEO of Physician Care Direct. “With the Employer Health Ownership Plan, employers can save up to 30 percent of their costs, providers can practice medicine the way they’ve always wanted to, and employees can minimize their costs by engaging in healthy behaviors. It’s a common sense approach to a problem that’s been needlessly complicated by insurance companies.”

    Along with Eastside, two other primary care medical groups are participating in the EHOP – Family Care Network, based in Bellingham with clinics throughout Whatcom and Skagit counties, and Qliance, an innovative venture capital-backed company that operates five “direct primary care” clinics in the Seattle area.

    Upcoming Presentations on the EHOP

    Physician Care Direct will participate in three upcoming meetings on health insurance reform in Washington State:

    • March 12 at the Matrix Insurance Broker seminar in Seattle.
    • March 25 at the Washington Association of Health Underwriters (WAHU) Spring Symposium, held at the Hilton Seattle Airport & Conference Center in Seattle.
    • March 26 at the Washington Association of Health Underwriters (WAHU) Spring Symposium, held at the Lincoln Center in Spokane.

    At all three events, Christopher Shoffner, Chief Risk Officer for Physician Care Direct, will present “Changing the Way We Pay for Healthcare:  Aligning Incentives and Outcomes.” Shoffner will review the current state of employer health insurance and the benefits of the Employer Health Ownership Plan.

    About Physician Care Direct

    Physician Care Direct partners with employers and health systems to make healthcare more affordable. We deliver the Employer Health Ownership Plan™ (EHOP™)—an innovative health plan solution that starts with personalized primary care, then adds physician and hospital networks for a comprehensive solution.  Now businesses of all sizes can offer their employees meaningful healthcare benefits while controlling and reducing costs. For more information, visit www.physiciancaredirect.com.

    Press Contact:
    Todd Stein
    Amendola Communications

    Logo – http://photos.prnewswire.com/prnh/20140310/MM80608LOGO

    SOURCE Physician Care Direct

  • Pharmacists, Members of Congress Offer Support for Proposed Improvements to Medicare Part D

    National Community Pharmacists Association Logo. (PRNewsFoto/National Community Pharmacists Association)One hundred fifty-one (151) organizations, including the National Community Pharmacists Association (NCPA) and the National Rural Health Association, sent a letter today to Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner in strong support of a number of provisions included in the agency’s proposed regulation for 2015 Medicare Part D prescription drug plans. The letter comes as more Members of Congress contact CMS in support of its proposal to expand beneficiary choice by allowing independent community pharmacies the opportunity to participate as “preferred” providers if they are willing to accept the contract offered by a drug plan.

    “We want to take this opportunity to voice our strong support for certain proposed changes to the Medicare Part D prescription drug program that will allow more meaningful beneficiary choice and increased marketplace competition,” the organizations wrote in the letter on behalf of pharmacy providers and drug supply chain participants from across the country.

    Highlights from the letter include the following:

    • To increase beneficiary choice and enhance market competition, the groups noted that “We support CMS’ proposal to require Part D plan sponsors to offer terms & conditions for every level of cost sharing, including preferred cost sharing, to any willing pharmacy that will accept the terms.” They also noted that “although the agency was led to believe that its costs via preferred pharmacy networks to be uniformly lower, CMS’ own findings proved otherwise.”
    • Full support of CMS’ proposal to expand access to critical medication therapy management (MTM) services, which are “ideally provided face-to-face by a pharmacist” and “must become a cornerstone of the Prescription Drug Benefit.”
    • “We support CMS’ expectations that pharmacies should have current data on the amount of reimbursement they can expect, which in turn impacts costs that plan sponsors submit to CMS as well as prices displayed on Plan Finder.”

    The coalition letter comes in conjunction with a series of Congressional letters to CMS in support of the pharmacy choice and competition (or “any willing provider”) provisions within the proposed rule.

    U.S. Sen. Roger Wicker (R-Miss.) wrote to CMS that, “I have heard from many Medicare recipients who now have to travel to neighboring towns or counties to find new and larger preferred network pharmacies.  For many patients, the cost and physical strain associated with unnecessary travel may keep them at home. Last month, CMS released its proposed rule for Medicare Part D, and I was encouraged to see language that addresses the unintended problems that have developed with these preferred networks.  I thank you for your attention to this issue affecting America’s community pharmacists and Medicare patients.”

    In addition, U.S. Rep. Doug Collins (R-Ga.) recently wrote to CMS to follow up on a March 2013 letter he and 30 other Members of Congress sent the agency. This week he wrote that, “independent and community pharmacists have dedicated their careers to providing quality patient care, but exclusion from preferred networks has resulted in a strain on their patients and their businesses.  I was pleased to see that your agency’s proposed rule on Part D included promising language that addresses some of the concerns laid out” in the March 2013 letter.

    Earlier this year, U.S. Reps. Mike Rogers (R-Ala.) and Lynn Westmoreland (R-Ga.) sent their own letters to CMS in support of the any willing provider provision.

    The following organizations signed the letter to CMS:

    Alaska Pharmacists Association

    Alliance of Independent Pharmacists of Texas

    American Association of Colleges of Pharmacy

    American Pharmacies

    American Pharmacy Cooperative, Inc. 

    American Pharmacy Services Corp.

    AmeriClear Rx


    Arizona Pharmacy Association

    Arkansas Pharmacists Association

    Associated Fresh Markets

    Association of Community Pharmacists Congressional Network

    Astrup Drug, Inc.

    Aurora Pharmacies    

    Bartell Drugs

    Big Y Foods, Inc.

    Brookshire Grocery Company

    California Pharmacists Association

    CARE Pharmacies Cooperative, Inc.

    Cecil’s Pharmacy

    Chain Drug Marketing Association

    Community Pharmacy Prescription Network

    Compliant Pharmacy Alliance Cooperative

    Connecticut Pharmacists Association

    Dan’s Fresh Market

    Davis Food and Drug

    DiCello & Associates, Inc.

    Dick’s Fresh Market

    Digital Simplistics, Inc.  

    Discount Drug Mart, Inc.

    Drug Emporium Pharmacies  

    EPIC Pharmacies, Inc.

    EPIC Pharmacy Network, Inc.

    Fagen Pharmacy           

    FDS, Inc.

    Federation of Pharmacy Networks

    Florida Pharmacy Association

    Frank W. Kerr Co.

    Fresh Encounter, Inc.

    Fruth Pharmacy

    Garden State Pharmacy Owners, Inc.

    Georgia Pharmacy Association


    GPhA Academy of Independent Pharmacy

    Guardian Pharmacy


    Hartig Drug        

    Hi-School Pharmacy Inc.

    HomeTown Pharmacy Inc.

    Hy-Vee Pharmacies       

    Idaho State Pharmacy Association

    Illinois Pharmacists Association

    Independent Pharmacy Alliance

    Independent Pharmacy Buying Group, Inc.

    Independent Pharmacy Cooperative

    Innovatix, LLC

    International Academy of Compounding Pharmacists

    Iowa Pharmacy Association

    Kansas Independent Pharmacy Service Corp.

    Kansas Pharmacists Association

    Kelley-Ross Long-Term Care Pharmacy

    Kentucky Pharmacists Association

    Keystone Pharmacy Purchasing Alliance

    King Kullen Pharmacies

    Kinney Drugs, Inc.

    Kopp Drug

    La Farmacia de la Gente

    Lagniappe Pharmacy Services

    Lifecheck Pharmacies

    Lin’s Fresh Market

    Long Island Pharmacists Society

    Louisiana Independent Pharmacies Association

    Macey’s Supermarkets

    Mallatt’s Homecare Pharmacy 

    Managed Health Care Associates, Inc.

    Maryland Pharmacists Association

    Massachusetts Independent Pharmacists Association

    Massachusetts Pharmacists Association

    MedOne Healthcare Systems

    Merwin LTC Pharmacies

    Michigan Pharmacists Association

    Minnesota Pharmacists Association

    Mississippi Independent Pharmacies Association

    Missouri Pharmacy Association

    Montana Pharmacy Association

    Mutual Wholesale Drug Company

    National Alliance of State Pharmacy Associations

    National Community Pharmacists Association

    National Grocers Association

    National Rural Health Association

    Navarro Discount Pharmacies, LLC

    Nebraska Pharmacists Association

    New Jersey Pharmacists Association

    New Mexico Pharmacists Association

    Niemann Foods, Inc.

    North Dakota Pharmacists Association

    Northeast Pharmacy Service Corporation

    Northwest Specialty Pharmacy

    NoviXus Mail Service Pharmacy

    Ohio Pharmacists Association

    Osborn Drugs, Inc.

    Our Valley Pharmacy

    Pace Alliance

    Pakistani American Pharmaceutical Association

    Partners in Pharmacy Cooperative

    PBA Health/TrueCare Pharmacies


    Pennsylvania Pharmacists Association

    PerroneRX, LLC

    Pharmacists Society of the State of New York

    Pharmacists United for Truth and Transparency

    Pharmacy Plus Network

    Pharmacy Provider Service Corp.

    Pharmacy Society of Wisconsin

    Philadelphia Association of Retail Druggists

    PPOk RxSelect Pharmacy Network


    Progressive Pharmacies

    QS/1 Data Systems

    Quality Care Pharmacies

    QuickChek Pharmacies

    Raley’s Family of Fine Stores

    Ralph’s Thriftway Pharmacy

    Red Cross Pharmacy      

    Ritzman Pharmacies

    Rochester Drug Cooperative, Inc.

    RxPlus Pharmacies

    RxPreferred Benefits

    Sav-Mor Drug Stores

    Sav-On Drugs


    Smith Drug Company

    South Carolina Pharmacy Association

    Southern Pharmacy Cooperative

    Tennessee Pharmacists Association 

    Texas Independent Pharmacies Association

    Texas Pharmacy Association

    Texas Pharmacy Business Council

    Third Party Station

    Thrifty White Pharmacy

    Town & Country Markets

    United Drugs

    Value Drug Company

    Value Merchandiser Company

    Virginia Pharmacists Association

    Walker Drug                      

    Washington State Pharmacy Association

    Weis Markets

    West Virginia Pharmacists Association

    Woods Supermarkets

    Wray’s Marketfresh IGA

    For more information on the proposed rule, go to www.ncpanet.org/medicare.

    The National Community Pharmacists Association (NCPA®) represents the interests of America’s community pharmacists, including the owners of more than 23,000 independent community pharmacies. Together they represent an $88.7 billion health care marketplace, dispense nearly 40% of all retail prescriptions, and employ more than 300,000 individuals, including over 62,000 pharmacists. To learn more, go to www.ncpanet.org, visit facebook.com/commpharmacy, or follow NCPA on Twitter @Commpharmacy.

    Logo: http://photos.prnewswire.com/prnh/20100106/DC33253LOGO

    SOURCE National Community Pharmacists Association

  • What’s in Store for Health-Care Reform in 2014

    While the Affordable Care Act (ACA) became law in 2010, several of the more substantive provisions of the law don’t take effect until 2014. Here’s a review of some of the key parts of the ACA that are scheduled to begin in 2014.

    Individual mandate

    The ACA imposes a shared responsibility mandate, which requires that most U.S. citizens and legal residents of all ages (including children and dependents) have minimum essential health coverage or pay a penalty tax, unless otherwise exempt. The monthly penalty is equal to the greater of a declared dollar amount ($95 in 2014) or a percentage of the individual’s gross income.

    Note:   The employer’s mandate to provide coverage for employees was also scheduled to begin in 2014; however, the requirement will not be enforced until January 2015.

    State Exchanges

    The ACA requires that each state establish state-based American Health Benefit Exchanges for individuals and Small Business Health Options Program (SHOP) Exchanges for small employers. The Department of Health and Human Services will establish Exchanges in states that do not create the Exchanges. The general purpose of these Exchanges is to provide a single resource in each state for consumers and small businesses to compare health plans, get answers to questions, and enroll in a health plan that is both cost effective and meets their health-care needs.

    Exchanges may only offer qualified health plans that cover essential benefits, limit out-of-pocket costs, and provide coverage based on four levels of cost sharing–bronze, silver, gold, and platinum. Also, tax credits and cost-sharing subsidies will be available to U.S. citizens and legal immigrants who buy health insurance through the health Exchanges.

    Insurers must provide guaranteed issue and renewability of coverage

    All individual and group plans must issue insurance to all applicants regardless of health status, medical condition, or prior medical expenses. Insurers must renew coverage for applicants even if their health status has changed. Grandfathered individual plans are exempt from these requirements. Grandfathered plans are those that were in existence prior to the enactment of the ACA (March 2010) and have not been significantly altered in subsequent years.

    In the past, insurers used pre-existing medical condition provisions to deny coverage for care related to the condition (pre-existing condition policy exclusion), increased the premium to cover the condition, or denied coverage altogether. Beginning January 1, 2014, the ACA prohibits insurers in group markets and individual markets (with the exception of grandfathered individual plans) from imposing pre-existing condition exclusions.

    In keeping with the guaranteed availability of coverage, insurers may not charge individuals and small employers higher premiums based on health status or gender. Premiums may vary only based on family size, geography, age, and tobacco use.

    Essential health benefits

    All nongrandfathered small group and individual health plans must offer a package of essential health benefits from 10 benefit categories. The categories include ambulatory patient services, emergency services, hospitalization, laboratory services, maternity and newborn care, mental health and substance abuse treatment, prescription drugs, rehabilitative services and devices, preventive and wellness services, and pediatric services, including dental and vision.

    Other policy provisions

    The ACA also imposes several requirements and eliminates other provisions commonly found in insurance policies:

    • Group and individual policies (including grandfathered plans) may not impose waiting periods longer than 90 days before coverage becomes effective.
    • Annual deductible for small group (fewer than 50 full-time equivalent employees) health plans (excluding grandfathered plans) must not exceed $2,000 per insured and $4,000 per family. These amounts are indexed to increase in subsequent years.
    • The most you’ll pay annually for out-of-pocket expenses (deductibles, coinsurance, and co-pays) for all individual and group health plans (excluding grandfathered plans) cannot exceed the maximum out-of-pocket limits for health savings accounts ($6,350 for individual/$12,700 for family in 2014).
    • All group health plans and nongrandfathered individual health plans can no longer impose annual or lifetime dollar limits on essential health benefits.

  • Shopko Assists Customers With Delays Caused By The Health Insurance Marketplace

    Shopko pharmacies are prepared to assist individuals who are experiencing coverage issues now that the Affordable Care Act is underway.  With the many new insurance plans available from the Health Insurance Marketplace and the delays the Marketplace has experienced, some patients may encounter prescription coverage issues until they receive their new insurance card.

    “Consistent with our usual practice, Shopko will do what is needed to take care of the customer so they do not experience any delays filling prescriptions and getting necessary medications,” said Mike Bettiga, Chief Operating Officer.

    Shopko will assist patients with a valid prescription but who have not received their insurance card by providing an interim supply of prescriptions.  Proof of enrollment will be required.

    Pharmacy customers with questions are encouraged to contact their local Shopko pharmacy.

    Shopko is owned by an affiliate of Sun Capital Partners, Inc., a leading private investment firm focused on leverage buyouts, equity, debt, and other investments in market-leading companies.