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[UNKNOWN]: Thank you for watching.
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[SPEAKER_03]: Every year, tens of millions of Americans are denied the medical care they've already paid for, not by their doctors, but by their insurers.
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[SPEAKER_03]: Professor Miranda Yaver has spent years researching why and the answers are more systemic and more trolling than people realize.
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[SPEAKER_03]: In this episode of Kirtalk Professor Yavor, the author of the new book, coverage denied explains how ensures use rationing by inconvenience and what patients, advocates and policy makers can do to fight back.
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[SPEAKER_03]: Welcome to Care Talk Live, a weekly American healthcare policy show and podcast where we explain how healthcare works or doesn't work and get you answers.
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[SPEAKER_03]: I'm Laura Packard, Cancer Survivor and Healthcare Advocate here to help you.
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[SPEAKER_03]: Be sure to subscribe to my channel or podcast wherever you get your podcast to get future care talk shows.
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[SPEAKER_03]: If you or someone you love has been denied coverage, delayed treatment or buried in prior authorization paperwork.
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[SPEAKER_03]: This conversation is for you.
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[SPEAKER_03]: So welcome to Miranda Yaver PhD in Assistant Professor of Health Policy and Management at the University of Pittsburgh and author of the new book, coverage denied how health insurers drive inact inequality in the United States.
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[SPEAKER_03]: So Miranda tell us more about what is prior authorization.
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[SPEAKER_00]: Prior authorization is required health insurer,
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[SPEAKER_00]: For prescribed care so your doctor might say you need a costly medication and then you go to CVS thinking you can pick it up and then you realize that it has to go through some insurance hoops in order to demonstrate to your health and sure that it is actually medically necessary.
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[SPEAKER_03]: So your book coverage denied is about how insurers deny the care that people they need for all kinds of reasons.
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[SPEAKER_03]: And I personally went through this when I was diagnosed with cancer in 2017, I was going through chemotherapy.
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[SPEAKER_03]: My provider prescribed drug for me to help me recover faster from the chemotherapy, because chemotherapy wipes out your immune system and not having any immune system turns out to be really bad for you.
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[SPEAKER_03]: So they prescribed this drug to help me help my body repair faster and it was an expensive drug.
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[SPEAKER_03]: And that is a whole other issue, the high cost of prescription drugs that we're not talking about today, but we have a floor.
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[SPEAKER_03]: But because the struggle is so expensive, the insurance company said no, and because of that, I wound up in the hospital for a week and almost died.
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[SPEAKER_03]: So they ended up, you know, understandably, they didn't want to pay over $10,000 for this expensive drug.
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[SPEAKER_03]: ridiculous expense of drug, but instead want of costing over $100,000 for me to spend a week in the hospital.
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[SPEAKER_03]: So these sort of penny-wise pound foolish choices are being made not even always by doctors, right?
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[SPEAKER_00]: Yeah, so there are a lot of different factors that go into these reviews of medical necessity as well as cost containment
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[SPEAKER_00]: profit maximization considerations, a lot of these prescriptions are not being reviewed by physicians and the appropriate specialty.
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[SPEAKER_00]: So even if it is a physician, it might be a family medicine physician who is reviewing the necessity of an oncology drug, which they would not necessarily be used to prescribing at all.
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[SPEAKER_00]: They would refer up to an oncologist.
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[SPEAKER_00]: And so this can lead to even though most prior authorizations are approved, when they aren't, they can be immensely destabilizing.
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[SPEAKER_00]: And a lot of the laws that structure how these decisions are made can lead to erroneous denial, which is to say, not necessarily the the kinds of appropriate
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[SPEAKER_00]: to avoid over-prescribing, but actually getting it wrong and causing a lot of patient arm as I'm so sorry that your own experience really demonstrates.
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[SPEAKER_00]: And I also, and I know that, you know, this is not a discussion about the costs of drugs, but I actually do want to say that these are not unrelated stories, because prior authorization tends to be directed at costlier care, but all of the new drug development that we've done has
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[SPEAKER_00]: toward very efficacious new treatments that also come at a higher price tag, which essentially means that we're putting all of this resource.
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[SPEAKER_00]: These resources into this great drug development that then in turn is more likely to have all of these insurance barriers accompanying them.
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[SPEAKER_03]: And so there's a whole lot of separate but related things happening with, you know, like you said, expensive drugs more, more expensive care health care in America costs more than all of our similar first world countries and I can understand that insurance companies would say that prior authorization is a tool to make sure that there isn't, you know, fraud, waste and abuse.
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[SPEAKER_03]: But at the same time, it seems like it's reaching too far that people who need care are not being able to get care.
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[SPEAKER_03]: And is this even really significantly lowering the costs that we pay for healthcare?
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[SPEAKER_00]: Yeah, so one of the things that I think is helpful context is the prior art is meant to control
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[SPEAKER_00]: and related leads food to reduce over prescribing.
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[SPEAKER_00]: Their estimates out there that say that about 25% of medical care in the US is of low value, or questionable value.
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[SPEAKER_00]: And it comes with a pretty high price tag.
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[SPEAKER_00]: And so there are good reasons why we might want to address it.
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[SPEAKER_00]: The big question is, do we address it with a hammer or a scalpel?
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[SPEAKER_00]: address over prescribers without imposing these broad-based barriers to health care that my book works to show art so harmful and often do get it wrong.
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[SPEAKER_00]: And then to your question about is this really saving money?
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[SPEAKER_00]: It's a very difficult thing for us to assess.
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[SPEAKER_00]: One of the reasons is the bodies are complicated and it's hard to say definitively that someone is winding up in the
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[SPEAKER_00]: because they couldn't get a certain drug.
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[SPEAKER_00]: Sometimes you can, but not always.
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[SPEAKER_00]: Another issue is that even though a lot of denials are reversed upon a pill, such that in many cases, it's not so much a delay, but a denial, but a delay in care.
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[SPEAKER_00]: A lot of people, most people are never going to a pillage denial for a lot of reasons that my book gets into and then I'm happy.
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[SPEAKER_00]: to elaborate on but given that a lot of people opt out of these appeal processes that does seem to be some money savings but then the big issue to which you alluded in your experience is well what if someone winds up in the hospital because they were wrong they were denied medically necessary care and that's where the real question marks I think come in.
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[SPEAKER_00]: Because it can be pretty clearly established that if you're reducing low value care, you're saving money.
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[SPEAKER_00]: If people aren't appealing, you're probably saving money.
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[SPEAKER_00]: But then there are these additional costs.
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[SPEAKER_00]: And one of the things that ensures or counting on is the fact that we change health insurance a lot.
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[SPEAKER_00]: So by the time you're looking at potentially diabetes related complications,
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[SPEAKER_00]: because you weren't given a continuous glucose monitor and other things, you might not have no longer be a growing cost for a sure A, you might be on a sure B.
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[SPEAKER_00]: So there's a passing of the block as well.
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[SPEAKER_03]: Yeah, I hadn't really thought about that just like it's it's obvious to me that denying preventative screening denying care means people get sicker and they cost more when they do get care, but as you're pointing out insurers are playing to pass the book, they think maybe you won't be their customer anyway and it'll be a different insurance companies problem right and so they can be it can be causing more string to the system, but not necessarily that insurance actor.
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[SPEAKER_00]: And then also just sort of the fragmentation and broader healthcare delivery the people who are reviewing cost savings at one point of care might not be the same people who are viewing cost savings at a different point of care and so I think a lot of the challenges come down to this complexity and fragmentation that just doesn't make it easy to do a good accounting of what's going on.
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[SPEAKER_03]: And as you mentioned earlier, saving money is a good goal.
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[SPEAKER_03]: Um, you know, bringing down the cost of care so that people will pay less for insurance premiums, you know, that that is good, but how you get there, you know, a hammer versus a scalpel.
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[SPEAKER_03]: Do you have any thoughts or recommendations based on your research and in your book on ways to either improve the prior authorization process or something better than prior authorization?
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[SPEAKER_00]: Yeah, absolutely.
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[SPEAKER_00]: And this is something that I've, you know, been thinking about, obviously, um, you know, would not, especially both in the bucket and since then, um, because one of the challenges with prior authorization, so some of the issues are philosophical, um, you know, not really wanting.
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[SPEAKER_00]: of care where there isn't this evidence of overuse.
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[SPEAKER_00]: People in the country where insulin is notably more expensive than our high-income peers, people are not taking insulin just because they feel like it.
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[SPEAKER_00]: And so I think that that's a really good example of how even a good faith that's
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[SPEAKER_00]: And so in my, in my ideal world, we wouldn't have it.
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[SPEAKER_00]: So one of the, the alternative that I proposed in the book is to shift to an audit based model, which is to say audit the prescribing outliers, and then maybe to random audits of everyone else.
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[SPEAKER_00]: But the idea that if you know that you, your prescribing behavior can be audited,
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[SPEAKER_00]: will understand if you are prescript giving everyone a lower Lumbar spine MRI because they've before they've ever tried to school therapy, then maybe prior authorization becomes the penalty to rain in the prescribing and for the other next few years or a couple years rather than just being this and default barrier to care for everyone.
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[SPEAKER_00]: And then also sort of
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[SPEAKER_00]: lower level of policy intervention than doing a way with prior authorization and favor of this auditing, which I do think would get us more to the objectives of this policy, but at minimum, I think it can be right sized by ensuring a clear evidence basis of overuse.
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[SPEAKER_00]: So the fact that sometimes prep will have prior authorization,
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[SPEAKER_00]: is just mind-boggling to me.
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[SPEAKER_00]: This is not something that people are taking because it's a rainy day.
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[SPEAKER_00]: And so I think that being able to say that in the last five years, 10 years, there has been evidence of over prescribing or over use or abuse at some level.
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[SPEAKER_00]: And then there maybe can be prior authorization, but where this is clearly the standard of care,
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[SPEAKER_00]: And it is operating as intended.
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[SPEAKER_00]: It should not be applied because it is burdensome to both patients and physicians alike.
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[SPEAKER_00]: I think that that would at minimum get is in the right direction, but I do think that a broader shift in approaches would be to people's benefit.
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[SPEAKER_03]: Yeah, and thinking about the opioid epidemic, it was, it wasn't that all doctors were prescribing too many opioids.
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[SPEAKER_03]: There were a few doctors that clearly were prescribing so many more times that it seems like there was no auditing or there was no paying attention or, you know, like it would be better for patients and doctors and even insurance companies
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[SPEAKER_03]: the fraud and waste, rather than blanket, prior authorizing all procedures or all patients.
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[SPEAKER_03]: And in the end, stories like mine, it costs my insurance company.
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[SPEAKER_03]: Since it all happened the same year, it was the same company.
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[SPEAKER_03]: It cost them a whole lot more, plus me and a hospital for a week was not great outcome either.
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[SPEAKER_00]: No, not at all.
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[SPEAKER_00]: And I certainly interviewed for my book Patents
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[SPEAKER_00]: Um, I won, I interviewed one patient who, uh, was denied SCID for severe immunodeficiency and made the COVID pandemic and she had to go on over a dozen courses of antibiotics, well, she had this very protracted appeal.
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[SPEAKER_00]: That's extremely dangerous and someone else I interviewed, um, she was allergic to the one medication that would treat her stills disease and it would send her to,
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[SPEAKER_00]: anaphylactic shock that would require ICU admission and the insurance company didn't want to pay for the bone marrow transplant.
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[SPEAKER_00]: They were perfectly fine continuing to pay for repeated ICU admissions and there was this big underlying question of who was this helping because ICU admissions are extremely expensive.
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[SPEAKER_00]: The drug was that they were giving her was also still expensive.
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[SPEAKER_00]: Um, and over the course of a lifetime, you know, this is clearly going to add up to more than the transplant.
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[SPEAKER_00]: And so I think that, um, yeah, it's a really important reminder of that even though most of these things are approved are ultimately approved.
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[SPEAKER_00]: It is incredibly taxing for for patients.
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[SPEAKER_00]: Um, in the meantime, what especially when things are being judged incorrectly.
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[SPEAKER_03]: And do you have any final thoughts for people that are dealing with prior authorization right now that are not able to get the treatments or medication that their doctors are prescribing.
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[SPEAKER_00]: Definitely a peel.
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[SPEAKER_00]: And yeah, so one of the things that I found in the book was that the most common reason why people, people reasons why people didn't appeal, but they didn't understand that they could appeal.
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[SPEAKER_00]: and they didn't really value, I think that there was a value in appealing because they assumed that insurance always wins.
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[SPEAKER_00]: And the reality is that people went about half the time.
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[SPEAKER_00]: It's about a coin flip odds.
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[SPEAKER_00]: It doesn't mean that you're gonna win, but it does suggest that it's not going to be a waste of your time in order to get the treat.
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[SPEAKER_00]: And so, and of course, this is not costless.
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[SPEAKER_00]: coordinating between your insurer and your physician and maybe a special deep armacy.
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[SPEAKER_00]: But it is, there is a value there.
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[SPEAKER_00]: And there are, and I'm no fan of AI, as my students can attest to, but there are growing number of AI based tools to help craft an appeal letter.
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[SPEAKER_00]: So if you're someone who has never written an appeal letter before and don't really know where to start,
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[SPEAKER_00]: There are some templates out there, but there's also these ongoing numbers of online tools to help patients out.
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[SPEAKER_03]: Thanks.
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[SPEAKER_03]: And actually we had a episode on that a few weeks ago.
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[SPEAKER_03]: So thank you again and everybody be sure to check out coverage denied by a doctor.
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[SPEAKER_03]: Thanks for joining us.
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[SPEAKER_03]: Thank you so much.
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[SPEAKER_03]: I really appreciate it.
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[SPEAKER_03]: A reminder to everyone that we have free or low cost health care resources available on our website at healthcarevoices.org slash care talks so check it out.
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[SPEAKER_03]: Please text or call in your health insurance and health care questions at 202.
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[SPEAKER_03]: eight, three, eight, six, eight, three, seven, and we'll answer them in future episodes.
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[SPEAKER_03]: And now our experts will answer your health insurance questions.
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[SPEAKER_03]: So welcome to Louise Norris, health insurance and health care reform analyst at healthinsurance.org.
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[SPEAKER_03]: And Diane Archer, a founder and president of JustCareUSA.
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[SPEAKER_03]: So welcome, Diane.
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[SPEAKER_03]: You have some thoughts about prior authorization.
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[SPEAKER_02]: Build on,
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[SPEAKER_02]: What Miranda was saying, and my expertise is in Medicare, but it applies to commercial insurance as well.
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[SPEAKER_02]: And I want to start by saying and reminding everybody that insurers do prior authorization.
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[SPEAKER_02]: And when they do it, they maximize their revenue.
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[SPEAKER_02]: Because anytime they decide that care is not needed, it's money in their pockets.
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[SPEAKER_02]: and what we have allowed them to do and both in Medicare and in the commercial market is to decide when to use prior authorization.
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[SPEAKER_02]: And they'll use it sometimes in Medicare and for the most standard items, including insulin, and sometimes they'll use it for very, very costly items.
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[SPEAKER_02]: And we have no clue when they're using it.
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[SPEAKER_02]: Prior authorization can, as we know,
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[SPEAKER_02]: to keep people from getting unnecessary care.
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[SPEAKER_02]: But when it's used to keep people from getting necessary care, it's a problem.
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[SPEAKER_02]: And in Medicare, the Office of the Inspector General has found widespread and persistent inappropriate denials of care, which means that prior authorization is being used a lot of the time inappropriately.
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[SPEAKER_02]: by many insurers and Medicare advantage.
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[SPEAKER_02]: And I think we can extend that out to the commercial insurance marketplace.
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[SPEAKER_02]: So how does that affect patients?
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[SPEAKER_02]: As you guys have just discussed, it can really hurt patient care.
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[SPEAKER_02]: And while, yes, sometimes insurers end up paying more as a general proposition, they're making a ton of money off of this, because almost nobody appeals.
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[SPEAKER_02]: With Medicare, it's, I think, 10% of people appeal.
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[SPEAKER_02]: and actually way more than half the time they win on appeal.
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[SPEAKER_02]: But think about that 90% of the time when they're inappropriate delays and denials.
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[SPEAKER_02]: And the insurers are just pocketing the money they would have spent on people's care and people are going without care.
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[SPEAKER_02]: So that is a serious serious problem.
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[SPEAKER_02]: The other problem that people face is that they have no clue when they're choosing an insurance plan.
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[SPEAKER_02]: and how inappropriately as it being used is being used for the right reasons based on clinical evidence or for the wrong reasons.
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[SPEAKER_02]: And people are dying unnecessarily because too much prior authorization is being used.
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[SPEAKER_02]: And we have some evidence that the five percent of worse performing Medicare advantage plans in Medicare are responsible literally for thousands of inappropriate deaths a year.
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[SPEAKER_02]: There was a major study that looked into that.
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[SPEAKER_02]: So this is really, really serious.
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[SPEAKER_02]: So people cannot choose a plan and know whether it's a good one or a bad one.
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[SPEAKER_02]: They're literally gambling with their health because prior authorization is going to kill somebody if it was really, really sick.
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[SPEAKER_02]: So what's the solution here?
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[SPEAKER_02]: There's really a simple solution.
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[SPEAKER_02]: Prior authorization should be evidence-based.
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[SPEAKER_02]: all insurers because if it's something that's appropriate, every insurer should be doing it, and if it's inappropriate, no insurer should be doing it.
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[SPEAKER_02]: And everybody should know when it's being used and why it's being used, so we can question it if it's not what we think is appropriate.
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[SPEAKER_02]: So why not take prior authorization out of the hands of the insurers?
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[SPEAKER_02]: where who have a conflict of interest, right?
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[SPEAKER_02]: They want to do it as much as possible to save as much money as possible and put it in the hands of an independent agency.
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[SPEAKER_02]: It would save the insurers, all of the bureaucratic expense of doing prior authorization.
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[SPEAKER_02]: There'd be one uniform transparent organization doing it and people would be assured at least a level playing field.
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[SPEAKER_02]: And in the vast majority of the time, a fair application of prior authorization, meaning that people would get the care they need when they need it and wouldn't be denied care inappropriately.
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[SPEAKER_02]: Or if they were, it would be in a very rare instance.
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[SPEAKER_02]: And that seems to be, in my view, the simple solution, it would also give people,
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[SPEAKER_02]: the ability to choose a plan and not have to worry about whether one plan is doing prior authorization, inappropriately, and another plan that they're not in is the plan they should be in.
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[SPEAKER_02]: So taking it out of the hands of the insurers seems in my view to be, and in the view of several other experts to be the way to go to solve this problem, allow it to happen,
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[SPEAKER_03]: Thank you, Diane, and thanks for joining us.
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[SPEAKER_03]: And now some questions.
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[SPEAKER_03]: Let's start with a question from Reddit.
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[SPEAKER_03]: This person lives in New York and received a letter that the essential plan, 200-250.
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[SPEAKER_03]: I think maybe those are premium amounts is being removed.
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[SPEAKER_03]: I have my income listed at 32,000 in the cutoff for 200% of the poverty line is 31 little over $31,000.
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[SPEAKER_03]: Does this mean I would lose my insurance and what do I do?
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[SPEAKER_01]: Yeah, so this is a great question.
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[SPEAKER_01]: So the essential plan in is a New York specific health plan.
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[SPEAKER_01]: It is a basic health program under the Affordable Care Act.
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[SPEAKER_01]: Those only exist in a few states New York is one of them.
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[SPEAKER_01]: Under the Affordable Care Act, basic health programs go up to 200% in the poverty level, but a couple years ago, a New York did a waiver where they expanded it up to 250%.
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[SPEAKER_01]: of the federal poverty level.
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[SPEAKER_01]: And this is great because it's you don't pay a premium and it's very low out of pocket costs so it gave people all the way up to 250% of the poverty level really good health coverage.
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[SPEAKER_01]: Because of the HR one, the one big beautiful bill that was enacted last summer.
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[SPEAKER_01]: have so many funding cuts in it.
25:06.414 --> 25:13.723
[SPEAKER_01]: Unfortunately New York is having to go back to the way their essential plan used to be, which means it ends at starting in July.
25:13.743 --> 25:15.725
[SPEAKER_01]: It's going to end at 200% of the poverty level.
25:16.186 --> 25:26.378
[SPEAKER_01]: So all those people with income between 200 and 250% of the poverty level will no longer be eligible for the essential plan, which means they will have to migrate over to
25:26.358 --> 25:39.477
[SPEAKER_01]: a marketplace plan through New York State of Health, which they will get federal subsidies for that, but it will certainly be, they will start have to pay premiums and higher out of pocket costs.
25:39.497 --> 25:51.454
[SPEAKER_01]: In this person's example, the their income is 32,000 and the cutoff for the essential plan is going to be $31,920, so they're literally within $100 of the limit.
25:51.772 --> 26:02.567
[SPEAKER_01]: If you set up and contribute to a pretext retirement account, that reduces your income as far as these calculations are concerned.
26:02.947 --> 26:11.839
[SPEAKER_01]: So this person could literally, if they don't already have one open or an IRA, traditional IRA, it does have to be traditional not a Roth because it has to be pretext.
26:12.241 --> 26:24.516
[SPEAKER_01]: If they already have one, literally contributing a hundred more dollars this year assuming they aren't already contributing at the max would bring their income down into that 200% of poverty level range.
26:25.838 --> 26:40.155
[SPEAKER_01]: So they will need to update their income on the essential plan in their program and they may ask for proof of the income change, especially since this change is going to bump this person from going being slightly over the limit to slightly under the limit.
26:40.135 --> 26:47.703
[SPEAKER_01]: So, if you are doing that funding, I retirement plan with a hundred dollars, which should be manageable in order to keep your coverage.
26:48.364 --> 27:07.425
[SPEAKER_01]: But yes, if your income does go over that 31,920, then you lose essential plan coverage and you go into the marketplace instead where you can pick any of the available plans, but you will have premiums and out-of-pocket costs that are higher than they were owned by the essential plan.
27:08.401 --> 27:12.829
[SPEAKER_03]: Thank you, Louise, and another question from Reddit.
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[SPEAKER_03]: I never had a company offer me health insurance.
27:16.515 --> 27:18.519
[SPEAKER_03]: I was wondering, how does that typically work?
27:18.980 --> 27:22.866
[SPEAKER_03]: I'm looking for a new job, but now I have individual insurance, which costs a lot.
27:23.367 --> 27:30.139
[SPEAKER_03]: So if your workplace offers you health insurance,
27:30.119 --> 27:32.003
[SPEAKER_03]: Who pays for it?
27:32.223 --> 27:33.726
[SPEAKER_03]: Is it deducted from your paycheck?
27:33.927 --> 27:37.073
[SPEAKER_03]: Did they have different plans you can enroll like the marketplace?
27:37.914 --> 27:39.838
[SPEAKER_03]: Tell us how employer insurance works.
27:40.399 --> 27:40.600
[SPEAKER_01]: Sure.
27:41.121 --> 27:49.377
[SPEAKER_01]: So there is definitely no one size fits all here and so you're going to have to speak with your own HR department to find out.
27:49.677 --> 27:54.323
[SPEAKER_01]: how it works in your case, the it is payroll deducted.
27:54.583 --> 28:04.376
[SPEAKER_01]: So whatever plan you end up in rolling in through your employer, your share of the premium will be payroll deducted and you almost certainly will have a share of the premium.
28:04.777 --> 28:07.981
[SPEAKER_01]: It's pretty rare for an employer to pay the whole cost.
28:08.702 --> 28:17.473
[SPEAKER_01]: Some employers do, if you're really lucky, you might have an employer that's just fully covering the cost of your health insurance, if that's the case, then there won't be anything payroll deducted.
28:17.453 --> 28:21.886
[SPEAKER_01]: but almost everybody does have some premium payroll deducted.
28:22.588 --> 28:24.293
[SPEAKER_01]: That is payroll deducted pre-tax.
28:24.454 --> 28:30.231
[SPEAKER_01]: So you won't pay income tax or Medicare or Social Security tax on that bit.
28:30.532 --> 28:33.155
[SPEAKER_01]: premium that you pay which that is definitely a benefit.
28:33.936 --> 28:48.373
[SPEAKER_01]: As far as the price, the average, if we just look at across all employer sponsored plans, the average total premium for a single person is almost $800 a month.
28:48.413 --> 28:58.024
[SPEAKER_01]: It's about $777 a month with last year's number, but if we look at the share that employees pay, the average employee pays about $120 a month.
28:58.426 --> 29:06.636
[SPEAKER_01]: So you can see from that that the across all plans, the average employer is covering the majority of the cost.
29:07.056 --> 29:08.658
[SPEAKER_01]: But that doesn't mean your employer will.
29:09.719 --> 29:20.973
[SPEAKER_01]: Most health insurance companies, if your employer is buying coverage from an insurance company as opposed to self-insuring, they will generally have contribution minimums for the employer.
29:21.013 --> 29:23.115
[SPEAKER_01]: It's often at least 50% of the premium.
29:24.177 --> 29:26.239
[SPEAKER_01]: So it wouldn't be paying that whole,
29:26.219 --> 29:33.498
[SPEAKER_01]: If your employer had an average plan, $777 a month, but you could certainly be paying a lot more than $120 a month.
29:33.598 --> 29:36.786
[SPEAKER_01]: So again, you need to speak with your HR to find out.
29:37.222 --> 29:38.824
[SPEAKER_01]: the details for your situation.
29:38.844 --> 29:41.807
[SPEAKER_01]: As far as do they offer multiple plans.
29:42.167 --> 29:44.209
[SPEAKER_01]: Again, that varies from one employer to another.
29:44.249 --> 29:51.016
[SPEAKER_01]: In general, the bigger your employer is, the more likelihood there is that they're offering multiple plans.
29:51.597 --> 30:01.187
[SPEAKER_01]: Really large employers will often have several different options you can pick from, but if you're working for a very small employer and they do offer health insurance, which a lot of them don't.
30:01.167 --> 30:06.174
[SPEAKER_01]: If a small employer offers health insurance, they might just give you one plan and you can take it or leave it.
30:07.456 --> 30:17.189
[SPEAKER_01]: If you are offered health insurance by your employer, it's very unlikely that you would qualify for marketplace subsidies if you decided to decline that employers plan.
30:17.590 --> 30:23.698
[SPEAKER_01]: Because almost all employer sponsored plans do count as what's considered affordable minimum value coverage.
30:24.016 --> 30:34.388
[SPEAKER_01]: So as a general rule, if your employer is offering coverage, that is going to be your best option because if you decline it and go in the marketplace, you have to pay full price for that plan.
30:34.748 --> 30:36.310
[SPEAKER_01]: There are some rare exceptions.
30:36.731 --> 30:43.198
[SPEAKER_01]: Sometimes employers offer plans that aren't good enough to count as that minimum coverage.
30:43.879 --> 30:49.365
[SPEAKER_01]: And in that case, you can decline the coverage and go in the marketplace and potentially get a subsidy, but I will say that is really rare.
30:49.868 --> 30:55.835
[SPEAKER_01]: So you're generally your rule of thumb here is you're probably going to want to take an offer of insurance from your employer.
30:57.296 --> 31:03.644
[SPEAKER_01]: If they offer multiple options make sure you ask someone in HR to sit down with you and explain those different options to you.
31:04.124 --> 31:05.706
[SPEAKER_01]: So that you can figure out which one is best.
31:05.786 --> 31:09.170
[SPEAKER_01]: It's not necessarily going to be the one that has the smallest premium.
31:09.610 --> 31:13.615
[SPEAKER_01]: You might be better off paying a higher premium and getting better coverage.
31:13.595 --> 31:20.201
[SPEAKER_01]: So, all of these questions you'll need to talk to your HR about, but that's kind of a general overview of how it works.
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[SPEAKER_03]: Thanks, Louise.
31:21.443 --> 31:32.273
[SPEAKER_03]: And thank you everybody for joining us today to learn more about how insurance companies you prior authorization as bread tape to block care.
31:32.894 --> 31:40.581
[SPEAKER_03]: Be sure to check out more free or low cost healthcare resources on our website at healthcarevoices.org slash caretalk.
31:41.202 --> 31:49.792
[SPEAKER_03]: Please text or call in your health insurance and health care questions at 202-838-6837 and lens of them in future episodes.
31:50.212 --> 31:51.614
[SPEAKER_03]: Join us next week for more.
31:52.255 --> 31:55.699
[SPEAKER_03]: Be sure to subscribe to my channel or podcast wherever you get your podcasts.
31:55.979 --> 32:04.729
[SPEAKER_03]: My name is Laura Packard and this is Care Talk.
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[UNKNOWN]: You
00:02.714 --> 00:25.178
[UNKNOWN]: Thank you for watching.
00:30.288 --> 00:38.082
[SPEAKER_03]: Every year, tens of millions of Americans are denied the medical care they've already paid for, not by their doctors, but by their insurers.
00:38.623 --> 00:47.318
[SPEAKER_03]: Professor Miranda Yaver has spent years researching why and the answers are more systemic and more trolling than people realize.
00:47.298 --> 01:01.307
[SPEAKER_03]: In this episode of Kirtalk Professor Yavor, the author of the new book, coverage denied explains how ensures use rationing by inconvenience and what patients, advocates and policy makers can do to fight back.
01:01.388 --> 01:09.239
[SPEAKER_03]: Welcome to Care Talk Live, a weekly American healthcare policy show and podcast where we explain how healthcare works or doesn't work and get you answers.
01:09.740 --> 01:13.345
[SPEAKER_03]: I'm Laura Packard, Cancer Survivor and Healthcare Advocate here to help you.
01:13.385 --> 01:18.953
[SPEAKER_03]: Be sure to subscribe to my channel or podcast wherever you get your podcast to get future care talk shows.
01:19.714 --> 01:25.462
[SPEAKER_03]: If you or someone you love has been denied coverage, delayed treatment or buried in prior authorization paperwork.
01:25.623 --> 01:27.345
[SPEAKER_03]: This conversation is for you.
01:27.798 --> 01:41.715
[SPEAKER_03]: So welcome to Miranda Yaver PhD in Assistant Professor of Health Policy and Management at the University of Pittsburgh and author of the new book, coverage denied how health insurers drive inact inequality in the United States.
01:45.500 --> 01:51.828
[SPEAKER_03]: So Miranda tell us more about what is prior authorization.
01:52.889 --> 01:57.535
[SPEAKER_00]: Prior authorization is required health insurer,
01:57.886 --> 02:18.055
[SPEAKER_00]: For prescribed care so your doctor might say you need a costly medication and then you go to CVS thinking you can pick it up and then you realize that it has to go through some insurance hoops in order to demonstrate to your health and sure that it is actually medically necessary.
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[SPEAKER_03]: So your book coverage denied is about how insurers deny the care that people they need for all kinds of reasons.
02:30.172 --> 02:38.727
[SPEAKER_03]: And I personally went through this when I was diagnosed with cancer in 2017, I was going through chemotherapy.
02:38.707 --> 02:51.828
[SPEAKER_03]: My provider prescribed drug for me to help me recover faster from the chemotherapy, because chemotherapy wipes out your immune system and not having any immune system turns out to be really bad for you.
02:52.429 --> 02:58.960
[SPEAKER_03]: So they prescribed this drug to help me help my body repair faster and it was an expensive drug.
02:59.140 --> 03:05.170
[SPEAKER_03]: And that is a whole other issue, the high cost of prescription drugs that we're not talking about today, but we have a floor.
03:05.150 --> 03:14.247
[SPEAKER_03]: But because the struggle is so expensive, the insurance company said no, and because of that, I wound up in the hospital for a week and almost died.
03:14.788 --> 03:20.779
[SPEAKER_03]: So they ended up, you know, understandably, they didn't want to pay over $10,000 for this expensive drug.
03:21.181 --> 03:28.450
[SPEAKER_03]: ridiculous expense of drug, but instead want of costing over $100,000 for me to spend a week in the hospital.
03:29.070 --> 03:36.519
[SPEAKER_03]: So these sort of penny-wise pound foolish choices are being made not even always by doctors, right?
03:37.540 --> 03:45.990
[SPEAKER_00]: Yeah, so there are a lot of different factors that go into these reviews of medical necessity as well as cost containment
03:46.409 --> 03:56.605
[SPEAKER_00]: profit maximization considerations, a lot of these prescriptions are not being reviewed by physicians and the appropriate specialty.
03:57.026 --> 04:10.046
[SPEAKER_00]: So even if it is a physician, it might be a family medicine physician who is reviewing the necessity of an oncology drug, which they would not necessarily be used to prescribing at all.
04:10.907 --> 04:12.670
[SPEAKER_00]: They would refer up to an oncologist.
04:12.987 --> 04:24.240
[SPEAKER_00]: And so this can lead to even though most prior authorizations are approved, when they aren't, they can be immensely destabilizing.
04:24.280 --> 04:39.737
[SPEAKER_00]: And a lot of the laws that structure how these decisions are made can lead to erroneous denial, which is to say, not necessarily the the kinds of appropriate
04:40.055 --> 04:51.646
[SPEAKER_00]: to avoid over-prescribing, but actually getting it wrong and causing a lot of patient arm as I'm so sorry that your own experience really demonstrates.
04:52.426 --> 05:09.842
[SPEAKER_00]: And I also, and I know that, you know, this is not a discussion about the costs of drugs, but I actually do want to say that these are not unrelated stories, because prior authorization tends to be directed at costlier care, but all of the new drug development that we've done has
05:10.025 --> 05:20.141
[SPEAKER_00]: toward very efficacious new treatments that also come at a higher price tag, which essentially means that we're putting all of this resource.
05:20.402 --> 05:32.742
[SPEAKER_00]: These resources into this great drug development that then in turn is more likely to have all of these insurance barriers accompanying them.
05:33.160 --> 06:01.868
[SPEAKER_03]: And so there's a whole lot of separate but related things happening with, you know, like you said, expensive drugs more, more expensive care health care in America costs more than all of our similar first world countries and I can understand that insurance companies would say that prior authorization is a tool to make sure that there isn't, you know, fraud, waste and abuse.
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[SPEAKER_03]: But at the same time, it seems like it's reaching too far that people who need care are not being able to get care.
06:13.315 --> 06:19.183
[SPEAKER_03]: And is this even really significantly lowering the costs that we pay for healthcare?
06:20.184 --> 06:32.040
[SPEAKER_00]: Yeah, so one of the things that I think is helpful context is the prior art is meant to control
06:32.392 --> 06:36.015
[SPEAKER_00]: and related leads food to reduce over prescribing.
06:36.056 --> 06:45.845
[SPEAKER_00]: Their estimates out there that say that about 25% of medical care in the US is of low value, or questionable value.
06:45.885 --> 06:48.547
[SPEAKER_00]: And it comes with a pretty high price tag.
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[SPEAKER_00]: And so there are good reasons why we might want to address it.
06:52.631 --> 07:00.559
[SPEAKER_00]: The big question is, do we address it with a hammer or a scalpel?
07:00.860 --> 07:12.771
[SPEAKER_00]: address over prescribers without imposing these broad-based barriers to health care that my book works to show art so harmful and often do get it wrong.
07:13.432 --> 07:17.776
[SPEAKER_00]: And then to your question about is this really saving money?
07:17.816 --> 07:20.659
[SPEAKER_00]: It's a very difficult thing for us to assess.
07:22.080 --> 07:30.208
[SPEAKER_00]: One of the reasons is the bodies are complicated and it's hard to say definitively that someone is winding up in the
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[SPEAKER_00]: because they couldn't get a certain drug.
07:32.829 --> 07:34.532
[SPEAKER_00]: Sometimes you can, but not always.
07:34.572 --> 07:48.574
[SPEAKER_00]: Another issue is that even though a lot of denials are reversed upon a pill, such that in many cases, it's not so much a delay, but a denial, but a delay in care.
07:49.435 --> 07:57.428
[SPEAKER_00]: A lot of people, most people are never going to a pillage denial for a lot of reasons that my book gets into and then I'm happy.
07:57.712 --> 08:23.095
[SPEAKER_00]: to elaborate on but given that a lot of people opt out of these appeal processes that does seem to be some money savings but then the big issue to which you alluded in your experience is well what if someone winds up in the hospital because they were wrong they were denied medically necessary care and that's where the real question marks I think come in.
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[SPEAKER_00]: Because it can be pretty clearly established that if you're reducing low value care, you're saving money.
08:31.306 --> 08:34.769
[SPEAKER_00]: If people aren't appealing, you're probably saving money.
08:34.789 --> 08:38.634
[SPEAKER_00]: But then there are these additional costs.
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[SPEAKER_00]: And one of the things that ensures or counting on is the fact that we change health insurance a lot.
08:45.301 --> 08:50.787
[SPEAKER_00]: So by the time you're looking at potentially diabetes related complications,
08:51.037 --> 09:01.881
[SPEAKER_00]: because you weren't given a continuous glucose monitor and other things, you might not have no longer be a growing cost for a sure A, you might be on a sure B.
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[SPEAKER_00]: So there's a passing of the block as well.
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[SPEAKER_03]: Yeah, I hadn't really thought about that just like it's it's obvious to me that denying preventative screening denying care means people get sicker and they cost more when they do get care, but as you're pointing out insurers are playing to pass the book, they think maybe you won't be their customer anyway and it'll be a different insurance companies problem right and so they can be it can be causing more string to the system, but not necessarily that insurance actor.
09:34.017 --> 10:00.936
[SPEAKER_00]: And then also just sort of the fragmentation and broader healthcare delivery the people who are reviewing cost savings at one point of care might not be the same people who are viewing cost savings at a different point of care and so I think a lot of the challenges come down to this complexity and fragmentation that just doesn't make it easy to do a good accounting of what's going on.
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[SPEAKER_03]: And as you mentioned earlier, saving money is a good goal.
10:09.556 --> 10:21.231
[SPEAKER_03]: Um, you know, bringing down the cost of care so that people will pay less for insurance premiums, you know, that that is good, but how you get there, you know, a hammer versus a scalpel.
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[SPEAKER_03]: Do you have any thoughts or recommendations based on your research and in your book on ways to either improve the prior authorization process or something better than prior authorization?
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[SPEAKER_00]: Yeah, absolutely.
10:36.413 --> 11:03.373
[SPEAKER_00]: And this is something that I've, you know, been thinking about, obviously, um, you know, would not, especially both in the bucket and since then, um, because one of the challenges with prior authorization, so some of the issues are philosophical, um, you know, not really wanting.
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[SPEAKER_00]: of care where there isn't this evidence of overuse.
11:07.596 --> 11:17.747
[SPEAKER_00]: People in the country where insulin is notably more expensive than our high-income peers, people are not taking insulin just because they feel like it.
11:18.688 --> 11:30.660
[SPEAKER_00]: And so I think that that's a really good example of how even a good faith that's
11:31.113 --> 11:34.618
[SPEAKER_00]: And so in my, in my ideal world, we wouldn't have it.
11:35.799 --> 11:49.758
[SPEAKER_00]: So one of the, the alternative that I proposed in the book is to shift to an audit based model, which is to say audit the prescribing outliers, and then maybe to random audits of everyone else.
11:49.858 --> 12:00.833
[SPEAKER_00]: But the idea that if you know that you, your prescribing behavior can be audited,
12:01.184 --> 12:26.017
[SPEAKER_00]: will understand if you are prescript giving everyone a lower Lumbar spine MRI because they've before they've ever tried to school therapy, then maybe prior authorization becomes the penalty to rain in the prescribing and for the other next few years or a couple years rather than just being this and default barrier to care for everyone.
12:26.037 --> 12:30.162
[SPEAKER_00]: And then also sort of
12:30.513 --> 12:52.260
[SPEAKER_00]: lower level of policy intervention than doing a way with prior authorization and favor of this auditing, which I do think would get us more to the objectives of this policy, but at minimum, I think it can be right sized by ensuring a clear evidence basis of overuse.
12:53.541 --> 12:58.427
[SPEAKER_00]: So the fact that sometimes prep will have prior authorization,
12:58.660 --> 13:00.402
[SPEAKER_00]: is just mind-boggling to me.
13:00.442 --> 13:04.186
[SPEAKER_00]: This is not something that people are taking because it's a rainy day.
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[SPEAKER_00]: And so I think that being able to say that in the last five years, 10 years, there has been evidence of over prescribing or over use or abuse at some level.
13:19.101 --> 13:27.790
[SPEAKER_00]: And then there maybe can be prior authorization, but where this is clearly the standard of care,
13:28.090 --> 13:29.893
[SPEAKER_00]: And it is operating as intended.
13:29.913 --> 13:35.504
[SPEAKER_00]: It should not be applied because it is burdensome to both patients and physicians alike.
13:36.286 --> 13:45.964
[SPEAKER_00]: I think that that would at minimum get is in the right direction, but I do think that a broader shift in approaches would be to people's benefit.
13:46.282 --> 13:52.388
[SPEAKER_03]: Yeah, and thinking about the opioid epidemic, it was, it wasn't that all doctors were prescribing too many opioids.
13:52.408 --> 14:16.272
[SPEAKER_03]: There were a few doctors that clearly were prescribing so many more times that it seems like there was no auditing or there was no paying attention or, you know, like it would be better for patients and doctors and even insurance companies
14:16.690 --> 14:23.616
[SPEAKER_03]: the fraud and waste, rather than blanket, prior authorizing all procedures or all patients.
14:23.877 --> 14:29.322
[SPEAKER_03]: And in the end, stories like mine, it costs my insurance company.
14:29.902 --> 14:32.004
[SPEAKER_03]: Since it all happened the same year, it was the same company.
14:32.324 --> 14:40.111
[SPEAKER_03]: It cost them a whole lot more, plus me and a hospital for a week was not great outcome either.
14:40.131 --> 14:41.853
[SPEAKER_00]: No, not at all.
14:41.913 --> 14:46.157
[SPEAKER_00]: And I certainly interviewed for my book Patents
14:46.508 --> 15:02.712
[SPEAKER_00]: Um, I won, I interviewed one patient who, uh, was denied SCID for severe immunodeficiency and made the COVID pandemic and she had to go on over a dozen courses of antibiotics, well, she had this very protracted appeal.
15:02.772 --> 15:13.528
[SPEAKER_00]: That's extremely dangerous and someone else I interviewed, um, she was allergic to the one medication that would treat her stills disease and it would send her to,
15:13.880 --> 15:23.894
[SPEAKER_00]: anaphylactic shock that would require ICU admission and the insurance company didn't want to pay for the bone marrow transplant.
15:23.914 --> 15:36.992
[SPEAKER_00]: They were perfectly fine continuing to pay for repeated ICU admissions and there was this big underlying question of who was this helping because ICU admissions are extremely expensive.
15:37.854 --> 15:41.018
[SPEAKER_00]: The drug was that they were giving her was also still expensive.
15:41.521 --> 15:47.529
[SPEAKER_00]: Um, and over the course of a lifetime, you know, this is clearly going to add up to more than the transplant.
15:47.569 --> 15:58.144
[SPEAKER_00]: And so I think that, um, yeah, it's a really important reminder of that even though most of these things are approved are ultimately approved.
15:58.705 --> 16:01.569
[SPEAKER_00]: It is incredibly taxing for for patients.
16:02.370 --> 16:08.338
[SPEAKER_00]: Um, in the meantime, what especially when things are being judged incorrectly.
16:08.656 --> 16:18.127
[SPEAKER_03]: And do you have any final thoughts for people that are dealing with prior authorization right now that are not able to get the treatments or medication that their doctors are prescribing.
16:19.529 --> 16:20.590
[SPEAKER_00]: Definitely a peel.
16:20.650 --> 16:34.326
[SPEAKER_00]: And yeah, so one of the things that I found in the book was that the most common reason why people, people reasons why people didn't appeal, but they didn't understand that they could appeal.
16:34.778 --> 16:43.047
[SPEAKER_00]: and they didn't really value, I think that there was a value in appealing because they assumed that insurance always wins.
16:43.847 --> 16:46.350
[SPEAKER_00]: And the reality is that people went about half the time.
16:47.091 --> 16:48.472
[SPEAKER_00]: It's about a coin flip odds.
16:48.933 --> 16:57.101
[SPEAKER_00]: It doesn't mean that you're gonna win, but it does suggest that it's not going to be a waste of your time in order to get the treat.
16:57.982 --> 17:04.549
[SPEAKER_00]: And so, and of course, this is not costless.
17:04.917 --> 17:09.561
[SPEAKER_00]: coordinating between your insurer and your physician and maybe a special deep armacy.
17:10.282 --> 17:12.224
[SPEAKER_00]: But it is, there is a value there.
17:12.244 --> 17:24.916
[SPEAKER_00]: And there are, and I'm no fan of AI, as my students can attest to, but there are growing number of AI based tools to help craft an appeal letter.
17:24.936 --> 17:32.123
[SPEAKER_00]: So if you're someone who has never written an appeal letter before and don't really know where to start,
17:32.457 --> 17:39.505
[SPEAKER_00]: There are some templates out there, but there's also these ongoing numbers of online tools to help patients out.
17:40.506 --> 17:40.767
[SPEAKER_03]: Thanks.
17:40.987 --> 17:44.171
[SPEAKER_03]: And actually we had a episode on that a few weeks ago.
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[SPEAKER_03]: So thank you again and everybody be sure to check out coverage denied by a doctor.
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[SPEAKER_03]: Thanks for joining us.
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[SPEAKER_03]: Thank you so much.
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[SPEAKER_03]: I really appreciate it.
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[SPEAKER_03]: A reminder to everyone that we have free or low cost health care resources available on our website at healthcarevoices.org slash care talks so check it out.
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[SPEAKER_03]: Please text or call in your health insurance and health care questions at 202.
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[SPEAKER_03]: eight, three, eight, six, eight, three, seven, and we'll answer them in future episodes.
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[SPEAKER_03]: And now our experts will answer your health insurance questions.
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[SPEAKER_03]: So welcome to Louise Norris, health insurance and health care reform analyst at healthinsurance.org.
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[SPEAKER_03]: And Diane Archer, a founder and president of JustCareUSA.
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[SPEAKER_03]: So welcome, Diane.
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[SPEAKER_03]: You have some thoughts about prior authorization.
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[SPEAKER_02]: Build on,
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[SPEAKER_02]: What Miranda was saying, and my expertise is in Medicare, but it applies to commercial insurance as well.
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[SPEAKER_02]: And I want to start by saying and reminding everybody that insurers do prior authorization.
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[SPEAKER_02]: And when they do it, they maximize their revenue.
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[SPEAKER_02]: Because anytime they decide that care is not needed, it's money in their pockets.
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[SPEAKER_02]: and what we have allowed them to do and both in Medicare and in the commercial market is to decide when to use prior authorization.
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[SPEAKER_02]: And they'll use it sometimes in Medicare and for the most standard items, including insulin, and sometimes they'll use it for very, very costly items.
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[SPEAKER_02]: And we have no clue when they're using it.
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[SPEAKER_02]: Prior authorization can, as we know,
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[SPEAKER_02]: to keep people from getting unnecessary care.
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[SPEAKER_02]: But when it's used to keep people from getting necessary care, it's a problem.
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[SPEAKER_02]: And in Medicare, the Office of the Inspector General has found widespread and persistent inappropriate denials of care, which means that prior authorization is being used a lot of the time inappropriately.
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[SPEAKER_02]: by many insurers and Medicare advantage.
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[SPEAKER_02]: And I think we can extend that out to the commercial insurance marketplace.
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[SPEAKER_02]: So how does that affect patients?
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[SPEAKER_02]: As you guys have just discussed, it can really hurt patient care.
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[SPEAKER_02]: And while, yes, sometimes insurers end up paying more as a general proposition, they're making a ton of money off of this, because almost nobody appeals.
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[SPEAKER_02]: With Medicare, it's, I think, 10% of people appeal.
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[SPEAKER_02]: and actually way more than half the time they win on appeal.
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[SPEAKER_02]: But think about that 90% of the time when they're inappropriate delays and denials.
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[SPEAKER_02]: And the insurers are just pocketing the money they would have spent on people's care and people are going without care.
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[SPEAKER_02]: So that is a serious serious problem.
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[SPEAKER_02]: The other problem that people face is that they have no clue when they're choosing an insurance plan.
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[SPEAKER_02]: and how inappropriately as it being used is being used for the right reasons based on clinical evidence or for the wrong reasons.
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[SPEAKER_02]: And people are dying unnecessarily because too much prior authorization is being used.
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[SPEAKER_02]: And we have some evidence that the five percent of worse performing Medicare advantage plans in Medicare are responsible literally for thousands of inappropriate deaths a year.
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[SPEAKER_02]: There was a major study that looked into that.
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[SPEAKER_02]: So this is really, really serious.
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[SPEAKER_02]: So people cannot choose a plan and know whether it's a good one or a bad one.
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[SPEAKER_02]: They're literally gambling with their health because prior authorization is going to kill somebody if it was really, really sick.
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[SPEAKER_02]: So what's the solution here?
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[SPEAKER_02]: There's really a simple solution.
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[SPEAKER_02]: Prior authorization should be evidence-based.
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[SPEAKER_02]: all insurers because if it's something that's appropriate, every insurer should be doing it, and if it's inappropriate, no insurer should be doing it.
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[SPEAKER_02]: And everybody should know when it's being used and why it's being used, so we can question it if it's not what we think is appropriate.
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[SPEAKER_02]: So why not take prior authorization out of the hands of the insurers?
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[SPEAKER_02]: where who have a conflict of interest, right?
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[SPEAKER_02]: They want to do it as much as possible to save as much money as possible and put it in the hands of an independent agency.
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[SPEAKER_02]: It would save the insurers, all of the bureaucratic expense of doing prior authorization.
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[SPEAKER_02]: There'd be one uniform transparent organization doing it and people would be assured at least a level playing field.
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[SPEAKER_02]: And in the vast majority of the time, a fair application of prior authorization, meaning that people would get the care they need when they need it and wouldn't be denied care inappropriately.
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[SPEAKER_02]: Or if they were, it would be in a very rare instance.
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[SPEAKER_02]: And that seems to be, in my view, the simple solution, it would also give people,
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[SPEAKER_02]: the ability to choose a plan and not have to worry about whether one plan is doing prior authorization, inappropriately, and another plan that they're not in is the plan they should be in.
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[SPEAKER_02]: So taking it out of the hands of the insurers seems in my view to be, and in the view of several other experts to be the way to go to solve this problem, allow it to happen,
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[SPEAKER_03]: Thank you, Diane, and thanks for joining us.
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[SPEAKER_03]: And now some questions.
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[SPEAKER_03]: Let's start with a question from Reddit.
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[SPEAKER_03]: This person lives in New York and received a letter that the essential plan, 200-250.
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[SPEAKER_03]: I think maybe those are premium amounts is being removed.
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[SPEAKER_03]: I have my income listed at 32,000 in the cutoff for 200% of the poverty line is 31 little over $31,000.
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[SPEAKER_03]: Does this mean I would lose my insurance and what do I do?
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[SPEAKER_01]: Yeah, so this is a great question.
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[SPEAKER_01]: So the essential plan in is a New York specific health plan.
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[SPEAKER_01]: It is a basic health program under the Affordable Care Act.
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[SPEAKER_01]: Those only exist in a few states New York is one of them.
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[SPEAKER_01]: Under the Affordable Care Act, basic health programs go up to 200% in the poverty level, but a couple years ago, a New York did a waiver where they expanded it up to 250%.
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[SPEAKER_01]: of the federal poverty level.
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[SPEAKER_01]: And this is great because it's you don't pay a premium and it's very low out of pocket costs so it gave people all the way up to 250% of the poverty level really good health coverage.
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[SPEAKER_01]: Because of the HR one, the one big beautiful bill that was enacted last summer.
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[SPEAKER_01]: have so many funding cuts in it.
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[SPEAKER_01]: Unfortunately New York is having to go back to the way their essential plan used to be, which means it ends at starting in July.
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[SPEAKER_01]: It's going to end at 200% of the poverty level.
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[SPEAKER_01]: So all those people with income between 200 and 250% of the poverty level will no longer be eligible for the essential plan, which means they will have to migrate over to
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[SPEAKER_01]: a marketplace plan through New York State of Health, which they will get federal subsidies for that, but it will certainly be, they will start have to pay premiums and higher out of pocket costs.
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[SPEAKER_01]: In this person's example, the their income is 32,000 and the cutoff for the essential plan is going to be $31,920, so they're literally within $100 of the limit.
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[SPEAKER_01]: If you set up and contribute to a pretext retirement account, that reduces your income as far as these calculations are concerned.
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[SPEAKER_01]: So this person could literally, if they don't already have one open or an IRA, traditional IRA, it does have to be traditional not a Roth because it has to be pretext.
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[SPEAKER_01]: If they already have one, literally contributing a hundred more dollars this year assuming they aren't already contributing at the max would bring their income down into that 200% of poverty level range.
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[SPEAKER_01]: So they will need to update their income on the essential plan in their program and they may ask for proof of the income change, especially since this change is going to bump this person from going being slightly over the limit to slightly under the limit.
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[SPEAKER_01]: So, if you are doing that funding, I retirement plan with a hundred dollars, which should be manageable in order to keep your coverage.
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[SPEAKER_01]: But yes, if your income does go over that 31,920, then you lose essential plan coverage and you go into the marketplace instead where you can pick any of the available plans, but you will have premiums and out-of-pocket costs that are higher than they were owned by the essential plan.
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[SPEAKER_03]: Thank you, Louise, and another question from Reddit.
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[SPEAKER_03]: I never had a company offer me health insurance.
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[SPEAKER_03]: I was wondering, how does that typically work?
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[SPEAKER_03]: I'm looking for a new job, but now I have individual insurance, which costs a lot.
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[SPEAKER_03]: So if your workplace offers you health insurance,
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[SPEAKER_03]: Who pays for it?
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[SPEAKER_03]: Is it deducted from your paycheck?
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[SPEAKER_03]: Did they have different plans you can enroll like the marketplace?
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[SPEAKER_03]: Tell us how employer insurance works.
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[SPEAKER_01]: Sure.
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[SPEAKER_01]: So there is definitely no one size fits all here and so you're going to have to speak with your own HR department to find out.
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[SPEAKER_01]: how it works in your case, the it is payroll deducted.
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[SPEAKER_01]: So whatever plan you end up in rolling in through your employer, your share of the premium will be payroll deducted and you almost certainly will have a share of the premium.
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[SPEAKER_01]: It's pretty rare for an employer to pay the whole cost.
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[SPEAKER_01]: Some employers do, if you're really lucky, you might have an employer that's just fully covering the cost of your health insurance, if that's the case, then there won't be anything payroll deducted.
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[SPEAKER_01]: but almost everybody does have some premium payroll deducted.
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[SPEAKER_01]: That is payroll deducted pre-tax.
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[SPEAKER_01]: So you won't pay income tax or Medicare or Social Security tax on that bit.
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[SPEAKER_01]: premium that you pay which that is definitely a benefit.
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[SPEAKER_01]: As far as the price, the average, if we just look at across all employer sponsored plans, the average total premium for a single person is almost $800 a month.
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[SPEAKER_01]: It's about $777 a month with last year's number, but if we look at the share that employees pay, the average employee pays about $120 a month.
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[SPEAKER_01]: So you can see from that that the across all plans, the average employer is covering the majority of the cost.
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[SPEAKER_01]: But that doesn't mean your employer will.
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[SPEAKER_01]: Most health insurance companies, if your employer is buying coverage from an insurance company as opposed to self-insuring, they will generally have contribution minimums for the employer.
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[SPEAKER_01]: It's often at least 50% of the premium.
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[SPEAKER_01]: So it wouldn't be paying that whole,
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[SPEAKER_01]: If your employer had an average plan, $777 a month, but you could certainly be paying a lot more than $120 a month.
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[SPEAKER_01]: So again, you need to speak with your HR to find out.
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[SPEAKER_01]: the details for your situation.
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[SPEAKER_01]: As far as do they offer multiple plans.
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[SPEAKER_01]: Again, that varies from one employer to another.
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[SPEAKER_01]: In general, the bigger your employer is, the more likelihood there is that they're offering multiple plans.
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[SPEAKER_01]: Really large employers will often have several different options you can pick from, but if you're working for a very small employer and they do offer health insurance, which a lot of them don't.
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[SPEAKER_01]: If a small employer offers health insurance, they might just give you one plan and you can take it or leave it.
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[SPEAKER_01]: If you are offered health insurance by your employer, it's very unlikely that you would qualify for marketplace subsidies if you decided to decline that employers plan.
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[SPEAKER_01]: Because almost all employer sponsored plans do count as what's considered affordable minimum value coverage.
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[SPEAKER_01]: So as a general rule, if your employer is offering coverage, that is going to be your best option because if you decline it and go in the marketplace, you have to pay full price for that plan.
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[SPEAKER_01]: There are some rare exceptions.
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[SPEAKER_01]: Sometimes employers offer plans that aren't good enough to count as that minimum coverage.
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[SPEAKER_01]: And in that case, you can decline the coverage and go in the marketplace and potentially get a subsidy, but I will say that is really rare.
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[SPEAKER_01]: So you're generally your rule of thumb here is you're probably going to want to take an offer of insurance from your employer.
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[SPEAKER_01]: If they offer multiple options make sure you ask someone in HR to sit down with you and explain those different options to you.
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[SPEAKER_01]: So that you can figure out which one is best.
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[SPEAKER_01]: It's not necessarily going to be the one that has the smallest premium.
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[SPEAKER_01]: You might be better off paying a higher premium and getting better coverage.
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[SPEAKER_01]: So, all of these questions you'll need to talk to your HR about, but that's kind of a general overview of how it works.
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[SPEAKER_03]: Thanks, Louise.
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[SPEAKER_03]: And thank you everybody for joining us today to learn more about how insurance companies you prior authorization as bread tape to block care.
31:32.894 --> 31:40.581
[SPEAKER_03]: Be sure to check out more free or low cost healthcare resources on our website at healthcarevoices.org slash caretalk.
31:41.202 --> 31:49.792
[SPEAKER_03]: Please text or call in your health insurance and health care questions at 202-838-6837 and lens of them in future episodes.
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[SPEAKER_03]: Join us next week for more.
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[SPEAKER_03]: Be sure to subscribe to my channel or podcast wherever you get your podcasts.
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[SPEAKER_03]: My name is Laura Packard and this is Care Talk.
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