Surprises In Healthcare Coverage For 2016

This past Sunday’s Parade article, 12 Tips to Get Your Best Healthcare in 2016, provided surprising news about where and how to get the best healthcare.  The suggestions consisted of employers encouraging you to go overseas for surgery, going to a corporate hospital or paying yourself.

For example, if you work for Lowe’s or Wal-Mart, then the corporation may have relations with particular hospitals where procedures can be covered, or discounted.

Some employers may incentivize you to engage in what is called “medical tourism,” where Americans travel to developing countries for procedures, stay in luxury hotels and end up paying a fraction of what they would have for just the procedure in the U.S.

Lastly, in the event you are priced out by the changes in plans and premiums and coverage (because the health insurance companies retained that power and are unrelated by State Commissioners), you may have to take a self-insured or Health Savings Account route to cover your care in the U.S.

For those residing in Washington state, here are two resources to use in comparing healthcare insurance options:

  1. Washington Health Plan Finder
  2. Washington Health Benefits Exchange

Copyright 2015 The Filutowski Law Firm, PLLC. Disclaimer: This page is intended for general information purposes only and should not be construed as legal advice or legal opinions on any specific facts or circumstances. An attorney-client relationship is not created or continued.

How To Calculate Your Health Insurance Premium Under Obama Care

obamacareIn less than three months, Obama Care takes effect.  What does this mean for you?

It may mean an increase in a premium, a decrease, or a penalty if you refuse to purchase insurance.

You may recall that the intention of Obama Care was to federally mandate every individual to pay into a national health care network so as to increase the access to affordable health care for every individual residing in, or is a citizen of, the United States.

This all sounds, good, but the Patient Protection and Affordable Care Plan (“ACA” also known as Obama Care) led to a heated political debate.  Many said this was a socialist campaign where the hard-working would end up paying for the non-contributing members of society.  The ACA is a daunting nearly 1,000 pages long.

Supreme Court Upholds Law Because of the “Tax”

The debate over the constitutionality of requiring individuals to purchase insurance was taken to the Supreme Court of the United States (“SCOTUS”).  SCOTUS upheld Obama Care under the Commerce Clause of the U.S. Constitution.   It was found that imposing a “tax” on individuals and employers of 50+ employees who neglect to buy insurance is within the power of the federal government.

The penalty for individuals ranges from $95-$750 per year; for employers, it may be up to $2,000/employee per year.

Some small businesses said they will reduce their staff or employees’ hours to avoid the insurance requirement or penalty.  The federal government announced earlier this month that it will postpone the enactment of the employer penalty by a year.

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New York Times: Read Your Health Insurance Plan’s Fine Print

Excellent advice in today’s New York Times regarding changes to your health insurance plan. This is the time of year that health insurers change the terms and increase premiums. It is estimated that premiums will increase by 8.8%. Thanks to the new healthcare law, employers must extend health insurance coverage to uninsured dependents up to age 26, eliminate any lifetime caps on coverage, and pay 100 percent of the cost of annual physicals and some other preventive care. Read the New York Times article for more detailed information.

Some Courts Find Obama’s New Healthcare Law May Be Unconstitutional

The New York Times reported October 14, 2010 that an onslaught of cases filed against the U.S. for Congress’ new healthcare reform law may continue on grounds that the law may violate the U.S. Constitution. For additional legal commentary by Alexandra Filutowski, visit Washington Legal Times: Is Obama’s New Healthcare Law Unconstitutional? Some Courts Think So.

The New York Times article:

In a foreboding ruling for the Obama administration, a federal judge in Florida decreed Thursday that a legal challenge to the new health care law by officials from 20 states could move forward and warned that he would have to be persuaded that its keystone provision a requirement that most Americans obtain insurance is constitutional.

At this stage in the litigation, this is not even a close call, wrote Judge Roger Vinson of Federal District Court in Pensacola, Fla., before asserting that the insurance mandate was an unprecedented exercise of Congressional authority.

Pfizer Liabilities Continue to Grow


Robbins Geller Rudman & Dowd LLP today announced that a class action has been commenced in the United States District Court for the Southern District of New York on behalf of shareholders of Pfizer Inc. Pfizer is a pharmaceutical company engaged in the discovery, development, manufacture, and marketing of prescription medicines for humans and animals worldwide. The lawsuit announced today alleges that Pfizer misled investors by failing to disclose that they were engaged in an ongoing course of conduct designed to illegally promote the sale of Pfizer drugs, including Bextra, Geodon, Zyvox and Lyrica. By such conduct, Pfizercaused hundreds of millions of dollars in false or fraudulent claims to be submitted to several federal healthcare programs, thus exposing the Company to untold legal liability.

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Health Care Beating People Into Personal Bankruptcy

TThe NYTimes featured a story that we all too frequently hear: healthcare bills are pushing people into financial hardship. Bankruptcy attorneys are increasingly seeing that it is unpaid medical bills that cause the personal bankruptcy.

Uninsured Children Have 60% Increased Chance of Dying

A recent John Hopkins study confirms that children who are uninsured are more likely to die in the hospital. This is not a matter of the child not receiving adequate care or priority treatment at the hospital, but rather an issue of adequate, routine care leading up to the hospital visit.

Uninsured children do not regularly see a pediatrician for routine check-ups. It is not until the children’s health conditions reach an emergency situation that their parents take them to the hospital, when often it is then too late.

Sources that also covered this issue: Newsweek, US News Health Blog, BusinessWeek

Battle of Insurance Coverage: Workers’ Compensation v. Health Insurance

Another debate regarding which insurer should pay for the medical bills makes headlines. On April 12 nad 14, 2009, Pasadena hospital nurse, Amelia Mendoza, suffered traumatic brain injury when a patient repeatedly violently struck her in the head. A week following the attacks, Amelia (52 years old) collapsed with a stroke.Amelia’s private insurer, BlueCross is denying coverage, stating that it was an on-the-job-injury. Amelia’s employer, Huntington Memorial Hospital, is also denying coverage, stating that the stroke, which occurred on April 20, was not due to the patient’s attacks.

As Amelia remains in a vegetative state and her husband cares for her through feeding tubes, hopefully the courts will get involved quickly enough to help interpret the California workers’ compensation statute.

Similar coverage principles apply in Washington State.� If one is injured on the job, treatment for those injuries must be paid by workers’ compensation.� If not an on-the-job injury, then health insurance should cover the treatment for the injury.

Coverage issues are common in automobile cases, specifically where the health insurance carrier paid out benefits before learning that the injuries were caused by a car accident and that there was an alternative form of primary insurance available, e.g., personal injury protection (PIP). In these situations, the PIP carrier reimburses the health insurer and everyone is satisfied. No courts. No delays. No issues.

Until the law changes, insurance carriers will continue to deny coverage unless a court orders otherwise.

To prevent an impasse with your insurance carrier, you should be careful with paperwork. Most paperwork you complete at a doctor’s office and any records the office completes on your behalf are sent to your insurance company for consideration of paying for your visit (claim). You probably recall in-take sheets asking you if the injuries are due to a car accident, on-the-job injury, or other. If you are unsure, before checking the box, have an open conversation with your health care provider about the issue. Only once you feel comfortable with the origin of your injury, report it on the intake form with the health care provider’s office. This can save major future financial headaches.

The Facts On Tort Reform & Health Care Costs

While the U.S. remains divided on the efficacy of health care reform, an article in today’s Business Week outlines valuable research from Harvard and other research institutions on the true cost of health care and its unrelatedness to tort reform. Medical malpractice lawsuits and the practice of defensive medicine account for a nominal percentage of the overall cost of national health care. Proponents of tort reform, who think that changing state laws to limit the amount recoverable by damaged plaintiffs will make health care more affordable for others, must take a harder look at the facts.

Each year 100,000 individuals die from medical errors committed in the U.S. Only 4% of the surviving heirs pursue legal action.

Moreover, malpractice lawsuits are only one of a number of factors considered in the insurance premium equation. The cost of malpractice insurance premiums are determined by the underwriter for the insurance company who runs a risk assessment of the doctor’s specialty, history, patient demographic, among other factors. These all affect the size of the premium. The more errors previously committed by the doctor, the higher the premium.

In assessing the overall cost of health care, experts say medical malpractice premiums only account for 5% of the cost of health care.

To avoid errors, many doctors practice what we have heard in the media called “defensive medicine” – taking additional care to ensure no malpractice lawsuit will be brought against the doctor. This defensive practice actually leads to more attentive, thorough health care. e.g., when involved in an automobile collision and paramedics arrive to the scene – your blood pressure is taken at least 3 times to ensure your systems are properly functioning. e.g., when you arrive to the ER with complaints of whiplash symptoms following a rear-end collision, x-rays of your head, chest and neck are taken to ensure there are no broken bones. Better to be comprehensive with your health, rather than sorry and discover something later that should have been properly detected and treated earlier.

No one disagrees that health care is a necessity. This country is privileged to have talented physicians, who unfortunately are placed under great pressures by the insurance companies (like the rest of us). Insurance companies offer one-sided rules to physicians in how they must document treatment, submit bills with appropriate diagnosis codes, ensure they are an “in-network” provider or “preferred” provider, etc. Doctors stress about which form of insurance will be accepted; whether they are going to get fully paid by the insurance company or at a reduced, “contract” rate; whether the provided treatment is “covered” under the policy, or excluded since it was for a “pre-existing condition,” etc.

These stresses pressure doctors to operate quickly and with a high-volume of patients, so that they can submit enough claims to their patients’ insurance companies in order to make overhead that month. Whether someone may sue the doctor is a secondary fear that arises as a result of the pressures doctors undergo in the day-in, day-out practice of pushing papers to insurance companies.

Most physicians want a public option.

Many people are quick to discuss health care reform & tort reform in the same breath, but the two are like comparing apples to oranges. Texas passed tort reform three years ago, yet continues to have the nation’s most expensive health care.

Confusing issues does not lead to viable solution or even a reasonable debate. The hard data and statistics must be fully explored by experts to determine what the *real* cost of health care is and the best way to resolve hte issue. The U.S. sometimes forgets that hundreds of other nations share this world. And those other nations, including developing nations, have higher-ranked health care systems than the U.S.’s, according to the World Health Organization (WHO).

No effective answer will develop overnight. Rather, a transparent dialogue among policy makers, insurance companies, doctors and patients is necessary to create a reasonable solution.

Insured & Bankrupt – NYTimes article

According to Harvard Medical School Professor, Dr. David Himmelstein, 62% of the 1.4-1.5 million bankruptcy filings in the U.S. are due to burdensome medical bills.