Category Archives: Uncategorized

Rate Increases in New York

Rate Increases have started to come out for NY Small group and individuals for January 1, 2019.  Note that these are requests, not approvals.  That won’t happen until sometime in the fall.  Also note that these are averages across all that companies products.

With the elimination of the individual mandate under ObamaCare, the individual market is getting very large increases.  The baseline average increase was 12.1%, but an 11.9% additional increase has been applied for to cover the effects of the individual mandate being repealed.


Aetna                                         16.2%

Emblem                                     12%

Empire                                         6%

Healthfirst                                 21%

MVP                                              7%

Oscar                                            3%

Oxford                                        8.3%

United                                        7.2%



Emblem                                    31.5%

Empire Healthchoice            24.0%

Fidelis                                       38.6%

Healthfirst                                15.0%

MVP HealthPlan                       6.5%

Oscar                                          25.2%

United                                        23.6%




Right to try experimental treatments signed into law

From The Hill, 5/30:

President Trump signed a bill Wednesday allowing terminally ill patients access to experimental medical treatments not yet approved by the Food and Drug Administration (FDA).

Dubbed “right to try,” the law’s passage was a major priority of Trump and Vice President Pence, as well as congressional Republicans.

“Thousands of terminally ill Americans will finally have hope, and the fighting chance, and I think it’s going to better than a chance, that they will be cured, they will be helped, and be able to be with their families for a long time, or maybe just for a longer time,” Trump said at a bill signing ceremony at the White House, surrounded by terminally ill patients and their families.


Click here for the full article

When the “out-of-network” Maximum, isn’t…

Under ObamaCare, one of the good things is that it caps an individual out of pocket amount at a preset maximum, and you have a bad year, you know your worst-case scenario up front.  While plans with out-of-network coverage are harder to find, some people  still have them, and they mask a nasty surprise…

As long as you are in-network, your maximum out of pocket is set.  But if you go out of network, you have to look closely at how the plan pays.  Lets take as an example a plan that pays 60% for out of network coverage, after a deductible, and has a $10,000 maximum out-of-pocket cap.  What exactly is the 60% reimbursement based on?  There are a number of ways companies do this, but most common are two twists based on the Medicare Reimbursement Rate.  So if the plan pays based on 150% of Medicare, are you really getting 60%?   Probably not.

Looking at national averages, I looked at one common surgical event, where the MD and facility charges were $10,000.  Medicares allowable rate of reimbursement is $3530 for the same procedure, so the 150% rate would be $5,295.  The plan would pay 60% of THAT number, or $3,177 – 31%.  “For example, we know that if the individual enrolled in single coverage incurs a $75,000 inpatient out-of-network retail bill, the individual could easily end up owing the hospital and providers an amount vastly exceeding $10,000 (even after the insurer or administrator attempts retrospective negotiation).”

Remember that when you buy out-of-network coverage, you are paying (a lot) extra, for the right to go out of network and spend (a lot) more money.

Given that 85% of all employees have claims under $2000 per year, does paying a lot of extra premium make sense given all the facts?  Not usually.

2019 HSA Plan Limits Released


Rural hospital and MD shortage continues

In a recent story on CBS news (click here), some of the stresses, and resulting scandals, surrounding rural hospitals were revealed.   The struggle, with reduced reimbursements in the medical insurance industry and specifically following ObamaCare’s enactment, continues.    According to a 2015 article in HHN, “A March 2015 report by the Association of American Medical Colleges projects that the United States will face a shortfall of 46,000 to 90,000 physicians by 2025. The physician shortage remains especially problematic in rural areas, where more than 20 percent of the U.S. population resides but only 10 percent of physicians practice, according to a position paper by the American Academy of Family Physicians (AAFP).”

The CBS article states  “Rural hospitals across the country are closing at the highest rates in decades. Since 2010, 83 have shuttered. Desperate to stay open, some hospitals got caught up in dubious billing schemes. In March, CBS News investigated questionable billing at rural hospitals in Georgia and Florida.

“Insurance companies reimburse rural hospitals at higher rates to help keep critical healthcare in those communities. Those higher rates have made rural hospitals attractive targets for schemes that have generated nearly half a billion dollars in allegedly fraudulent billing.”

September 2018
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Reeve Conover is a Registered Representative. Securities offered through Cambridge Investment Research, Inc., a Broker/dealer member FINRA/SPIC. Cambridge and Conover Consulting are not affiliated. Licensed in SC, NC, NY, CT, NJ, and CA. - SIPC - Brokercheck