Balance Billing by Health Care Providers: Assessing Consumer Protections Across States.

ISSUE: Privately insured consumers expect that if they pay premiums and use in-network providers, their insurer will cover the cost of medically necessary care beyond their cost-sharing. However, when obtaining care at emergency departments and in-network hospitals, patients treated by an out-of-network provider may receive an unexpected "balance bill" for an amount beyond what the insurer paid. With no explicit federal protections against balance billing, some states have stepped in to protect consumers from this costly and confusing practice. GOAL: To better understand the scope of state laws to protect consumers from balance billing. METHODS: Analysis of laws in all 50 states and the District of Columbia and interviews with officials in eight states. FINDINGS AND CONCLUSIONS: Most states do not have laws that directly protect consumers from balance billing by an out-of-network provider for care delivered in an emergency department or in-network hospital. Of the 21 states offering protections, only six have a comprehensive approach to safeguarding consumers in both settings, and gaps remain even in these states. Because a federal policy solution might prove difficult, states may be better positioned in the short term to protect consumers.

The use of genetic information in the insurance sector - a German perspective

El presente trabajo ofrece una introducción al marco normativo alemán relativo a la utilización de la información genética en el sector de los seguros. Se examinan los principales contenidos y los temas más controvertidos de la normativa en cuestión. El objetivo de esta norma es garantizar de dignidad humana, respetando el derecho a la autodeterminación informativa en relación con los datos genéticos, incluyendo el derecho del individuo a no saber acerca de sus características genéticas, habiendo una serie de cuestiones abiertas que han de ser abordadas. En este sentido, se examina la influencia de la prohibición de solicitar pruebas genéticas y de utilizar los resultados de dichas pruebas por la aseguradora. En examen lleva a algunos resultados explícitos, como la suposición de que, además de la prohibición del uso de las pruebas genéticas, el hecho de que las preguntas sobre el historial médico de la familia sean inadmisibles. Los autores abordan la definición de las pruebas genéticas y la cuestión de en qué medida los resultados de las pruebas genéticas de diagnóstico todavía puede hacerse uso de en el contexto de la obligación de la persona asegurada para mostrar condiciones y enfermedades preexistentes, en el momento de la celebración del contrato (...) (AU)

The following paper offers an introduction to the legal framework concerning the use of genetic information in the insurance sector in Germany. The main contents and the controversial issues of the key regulation are examined. The aim of this rule being to secure human dignity by respecting the rights to informational self-determination regarding genetic data, including the individual’s right not to know about their genetic characteristics, there are a number of open issues which are being addressed. For instance, the influence of the prohibition to ask for genetic testing and to use the results of any such testing by the insurer is examined. This examination leads to some explicit results, such as the assumption that in addition to the ban on the use of genetic testing no questions about family medical history are admissible. The authors embark on the definition of genetic testing and the question to what extent the results of diagnostic genetic testing may still be made use of in the context of the insured person´s obligation to display preexisting conditions and diseases when the contract is concluded (...) (AU)

Medicare Advantage update: benefits, enrollment, and payments after the ACA.

In 2012, the Medicare program paid private health plans $136 billion to cover about 13 million beneficiaries who received Part A and B benefits through the Medicare Advantage (MA) program rather than traditional fee-for-service (FFS) Medicare. Private plans have been a part of the program since the 1970s. Debate about the policy goals--Should they cost less per beneficiary than FFS Medicare? Should they be available to all beneficiaries? Should they be able to offer additional benefits?--has long accompanied Medicare's private plan option.This debate is reflected in the history of Medicare payment policy,and policy decisions over the years have affected plans' willingness to participate and beneficiaries' enrollment at different periods of the program. Recently, evidence that the Medicare program was paying more per beneficiary in MA relative to what would have been spent under FFS Medicare prompted policymakers to reduce MA payments in the Patient Protection and Affordable Care Act of 2010 (ACA). So far, plans continue to participate in MA and enrollment continues to grow, but payment reductions in 2012 through 2014 have been partially offset by payments made to plans through the quality bonus payment demonstration.This brief contains recent data on plan enrollment, availability, and benefits and discusses MA plan payment policy, including changes to MA payment made in the ACA and their actual and projected effects.

Medicare program; Medicare Advantage and prescription drug benefit programs. Final rule.

This final rule finalizes revisions to the regulations governing the Medicare Advantage (MA) program (Part C), prescription drug benefit program (Part D) and section 1876 cost plans including conforming changes to the MA regulations to implement statutory requirements regarding special needs plans (SNPs), private fee-for-service plans (PFFS), regional preferred provider organizations (RPPO) plans, and Medicare medical savings accounts (MSA) plans, cost-sharing for dual-eligible enrollees in the MA program and prescription drug pricing, coverage, and payment processes in the Part D program, and requirements governing the marketing of Part C and Part D plans.

The price is now right. UnitedHealth Group's settlement on benchmarking databases could make out-of-network care costs more transparent, equal, some say.

Disagreement surrounds the discussion of whether the demise of two Ingenix price databases will aid the provider-payer relationship. Karen Ignagni, AHIP's CEO, questions the objective, wondering why in some cases "billings so exceed reimbursement." However, AMA President Nancy Nielsen, left, retorts, "This is an attempt to divert attention from what was clearly a rigged scheme".