Statewide farm editor identifies self-employed workers' problems with Obamacare, and hers with Congress

Farmers and other self-employed people may have special trouble maneuvering through the process of obtaining health insurance on the state exchange, writes Sharon Burton, editor and publisher of The Farmer's Pride, Kentucky's statewide agricultural newspaper.

Sharon Burton

"The first thing I realized is the system doesn’t know how to deal with people who are self-employed," Burton writes. "I figure that’s just about every farmer in the commonwealth" of Kentucky, which is operating its own exchange, Kynect.

"My husband is a owner/operator commercial truck driver, so his income can fluctuate from year to year. When I adjusted our income based on that fluctuation, the system was not happy with me because I estimated our 2014 income to be different than our 2012," Burton writes, adding that her kynector, a state-paid adviser who helps people use the exchange about it, "She said she too had problems signing up anyone who was self-employed. She also warned me that we should notify Kynect if our income varied even within $1,000 or could face serious ramifications at the end of the year."

Kynect spokeswoman Gwenda Bond told Kentucky Health News, "If self-employed individuals have variable incomes there might be an extra step for them to accurately verify income. They would have to submit additional information, in some cases, because the income verification system accepts the amount reported only if it is within 10 percent of what the IRS has on file for the most recent year."

Burton adds, "There are a lot of bugs in the system. For one, if your spouse’s employer offers family coverage – even if they don’t pay any portion of it – you are not eligible for any subsidies. We all know insurance offered through companies often provides family coverage but it isn’t affordable.
Now you will be disqualified from Obamacare because that unaffordable plan is out there."

Burton has also lost patience with Congress. "The ones who voted for it spend all their time defending it, and the ones who voted against it spend their time trying to make sure it fails," she writes. "Just fix it people. Get on with it. It’s like starting a business. You have a plan, but where you end up often looks a lot different than where you start because you make changes as needed. This is a starting point; let’s move on to the next stage and stop bellyaching." (Read more)

McConnell shares excerpts from letters he received from Kentuckians who are frustrated by health-reform law

By Melissa Patrick
Kentucky Health News

Continuing his attack on Obamacare, Senate Republican Leader Mitch McConnell took to the floor last week to read excerpts from letters he received from Kentuckians who are angry about the Patient Protection and Affordable Health Care Act. UPDATE, Dec. 17: He did so again today; video is here.

Generally, the main issues cited by McConnell are frustration with President Obama's promise that people happy with their health insurance could keep it; anger that their premiums and deductibles had increased under new policies that meet the law's requirements; and dissatisfaction with their inability to choose and pay for only the services they wanted. For example, several constituents said they did not have children, but were required to pay for pediatric dental care and maternity care.

A 35-year-old college graduate and married father of two from Bowling Green told McConnell that his plan, which he said best met his family's needs, had been canceled. As he sought a new plan that met the requirements, he was told it would cost 124 percent more. He noted that Vice President Joe Biden said Sept. 27 that a family of four with $50,000 income could get health insurance for "as little as $106 per month." McConnell said the Bowling Green man was quoted a price eight times that amount and asked him, "Why should the price of a product be based on my ability to pay?" The law provides subsidies for insurance coverage based on income and the type of plan purchased through the state insurance exchange, Kynect, up to $94,000 for a family of four.

Sherry Harris of Nicholasville told McConnell she was concerned that Lake Cumberland Hospital in Somerset was not on the Anthem network, "which means anybody in Pulaski and surrounding counties that qualify for a subsidy and want to use it will have to drive to London, Corbin or Lexington to get care" if they have an Anthem policy. Insurance companies are being more selective about their care networks in an effort to reduce costs; for details, click here.

A "Mr. and Mrs. Spears" of Louisville told McConnell that when they signed her up for the Kentucky Health Cooperative plan on Kynect, they did not sign up for a subsidy and thus were told no income verification was necessary.  Since then, they have received mailings from the insurance exchange declining coverage unless they sent income verification.

Exchange spokeswoman Gwenda Bond told Kentucky Health News in an email, "A request for additional documentation related to income verification might be generated, if they are likely to qualify for a subsidy based on the information provided on the application. Everyone is eligible to purchase a qualified health plan at sticker price at any time." The sticker price is the amount before the subsidy is subtracted.

Mrs. Spears also questioned the exchange's request for her voter-registration information. Bond said the federal "motor voter" law requires public-assistance agencies to ask applicants if they would like to register to vote. "Because Kentucky’s exchange is a single streamlined system for both Medicaid and subsidies, applicants are asked if they would like to register to vote," she said. "A voter registration form is mailed to them if they request one. There is no follow-up related to whether an individual registers or not, and it does not have an impact on coverage."

Mike Conn of Prestonsburg was upset that a policy with similar coverage to his previous policy would cost double.  He told McConnell that he was informed by the individual who helped him find coverage that it was because he lived in Eastern Kentucky and his old insurance company was "apparently not available there." Humana Inc. chose not to offer plans in all parts of the state.

Newspaper in Alabama, a similar state in many ways, gives its readers a look at Kentucky's embrace of Obamacare

The latest newspaper to look at Kentucky's embrace of Obamacare is in Alabama, a state that offers almost a mirror image of Kentucky: another Southern state with a very high poverty rate and very low health outcomes.

"Politically, both are deeply conservative, and both are home to wide expanses of rural poverty," writes Tim Lockette of The Anniston Star. But Alabama's approach to Obamacare "couldn't be more different," because it has rejected Medicaid expansion and a state-run insurance exchange.

The difference in Obamacare outcomes really is as stark as it looks, Douglas Scutchfield, a professor of health services research at the University of Kentucky, told Lockette. Scutchfield, who taught in Alabama for years, said that in demographic terms, "The only real difference is that most of your uninsured folks are black, and most of our uninsured folks are white. We have the Appalachians, you have the Black Belt." In politics, the states' governors have made a big difference.

While Democratic Gov. Steve Beshear expanded Medicaid and set up an exchange, Republican Gov. Robert Bentley and other state officials rejected both the Medicaid expansion and an exchange, citing costs.

Bentley cited the state's struggle to even cover the new enrollees that had been added since the Great Recession. Some Kentuckians are concerned about how the state will pay for its expansion. The federal government will pay all the cost of care for the newly eligible from 2014 through 2016, when the state will increasingly pick up part of the tab, rising to 10 percent by 2020. Beshear, citing a study, has said the expansion will expand the state's health-care industry enough to pay for it, and make the state more attractive to employers in the long run.

Bentley told Lockette that Alabama could not have had success with its own exchange because there is basically one major insurance company in Alabama, Blue Cross Blue Shield. But Alabama could have had more competition if the state had set up a nonprofit, cooperative insurance company, which Kentucky did.

"In Kentucky, everybody has an option," Cara Stewart, a fellow at the Kentucky Equal Justice Center, told Lockette. "Unless you're undocumented or in jail, there's something for you," she said.

Still, Stewart "said she’s run into difficulty working with people who already have employer-provided insurance, but want to switch to the exchanges to cover family members," Lockette report. Also, "The Kentucky system has refused to recognize some enrollees because they don’t have a credit history, health care advocates say." (Read more)

Kentucky's health-insurance exchange has covered a greater share of population than any other state-based exchange

Kentucky has registered more people for Medicaid and private health insurance than any other state with its own exchange created under the federal health-reform law, Christine Vestal reports for Stateline, in a story explaining why Kynect and some other state exchanges are working well.

“Our system doesn’t have a lot of bells and whistles,” Carrie Banahan, executive director of the Kentucky Health Benefits Exchange (the formal name of Kynect), told Vestal. “There aren’t a lot of graphics that would take a lot of bandwidth.”

"Kentucky and other top-performing states enable consumers to browse the various plans available on the exchange without first having to set up a password-protected account," Vestal notes. "That step alone spared those exchanges a lot of error messages and screen freezes experienced by people using the federal site," Healthcare.gov.

"Successful states also devoted months, not weeks, to exhaustive, round-the-clock testing," Vestal writes. "Kentucky tested for three months, while the U.S. Department of Health and Human Services reportedly devoted only the last two weeks of September to testing Healthcare.gov before its Oct. 1 launch."

The four most successful states – Connecticut, Kentucky, Rhode Island and Washington – all contracted with the consulting firm Deloitte "to manage and develop their sites," using federal funds, Vestal reports. Kentucky's expenses for its exchange were higher than average. (Stateline chart)

UPDATE: As of 7 p.m. Thursday, Dec. 5, after 10 days of increased traffic and enrollments, the exchange said it had enrolled 71,955 people, 56,437 of them in Medicaid and 15,518 in private plans. Most of the 28,307 who had been found eligible for a subsidy to buy a private plan had not chosen a plan yet. Dental plans had 5,074 enrollees.

Free clinics are wary of how health reform will affect them

By Melissa Patrick
Kentucky Health News

Free health clinics for the uninsured face an uncertain future as the Patient Protection and Affordable Health Care Act is implemented. Kentucky has more than 50 such clinics.

The Anderson County Community Medical Clinic, which just celebrated its one-year anniversary this month, serves uninsured people in its community and faces a "threat with the power to close its doors for good: Obamacare,"  Meaghan Downs of The Anderson News reports. Still, several board members told Downs that they do not expect to have to "shut down anytime soon" because some people will remain uninsured even though the health-reform law requires all Americans to sign up for health insurance or face a penalty.

“As long as the people qualify as living in Anderson County and having no insurance, we’re going to serve them,” Opal Phillips, the non-profit clinic's board chairman, told Downs. “If we are at the end of our usefulness, we will be there until we are no longer needed.”

Since it opened, the clinic has seen about 175 uninsured patients with chronic illness, Phillips told Downs. Lately, he said, the clinic has encouraged patients to sign up for coverage through the state's health-insurance exchange, Kynect.

The state says Kentucky has more that 640,000 uninsured citizens, or 15 percent of its population, and 308,000 will qualify for the expanded Medicaid program, but only about two-thirds of those people are expected to sign up.

Funding is another concern for free clinics under the reform law. Jane Bennett, the Anderson County clinic board's secretary for the last three years, told Downs that she is "extremely concerned about the health-care law and how that will affect fundraising for the clinic in the new year."  After the initial start-up funding from donations, the clinic must continue to find ways to pay for all of its services.

Bennett also told Downs that board members at the clinic may need to change the way it does business by changing the requirements on the types of patients they see. She went on to tell Downs that the uncertainty of how many will be uninsured after the exchange closes and taking into consideration the "blips" that occurred in the roll-out, the implementation of the law will take time.

Laura Ebert, president of the Kentucky Free Health Clinic Association, told Downs that she estimates it will be "at least two years before clinics like Anderson's will see any impact from Obamacare."  Many lower-income people, she said, "may not even take the first step to sign up for exchanges because of a lack of access to technology or education about the new health care law. There will still be a great need for clinics like hers and Anderson County’s."  She said "22 million Americans will still be uninsured even after every element of the federal and state exchanges are put into place," Downs reports.

Ebert is also the executive director of Surgery on Sunday, a clinic in Lexington that performs free outpatient surgeries for free to income-eligible individuals and their families. She told Downs that future considerations for this clinic and the other 54 free clinics across the state will be whether they will have to start accepting Medicaid patients or any patients eligible for state or federal assistance or allow the local health department to take over their services. The Owensboro health department and Danville's Ephraim McDowell Regional Medical Center "are two medical facilities that have absorbed formerly non-profit clinics," Downs reports.

Family Health Centers, which has seven community health clinics in Louisville, is free for those who are unable to pay, but it also accepts insurance. Its primary concern is how their business will need to change in order to not lose patients to local private practices that only accept insurance, Abby Goodnough reports in The New York Times.

"They expect their patient load to double, even as they struggle to recruit doctors and other staff members," Goodnough reports.  The clinics have focused on improved customer service and efficiency as they prepare for the expected changes the health care reform will bring. These efforts include: installing an appointment system instead of the current first-come, first-serve system, improving their facilities through the money allotted in the health care reform and converting to electronic medical records.

UPDATE, Dec. 21: The New Hope Clinic in Bath County "expects to continue serving patients who fall through the cracks," reports cn|2, a service of Time Warner Cable. Clinic Director Bill Grimes told senior reporter Don Weber that the expansion of Medicaid to households with incomes up to 138 percent of the federal poverty level will cover about 2,000 of the clinic's 2,700 patients. "Julia Maness, a nurse practitioner who is one of the New Hope Clinic’s co-founders, says she expects the first year under the Affordable Care Act to expose many issues that cause individuals to fall through the cracks," Weber reports.

Beshear says other governors will follow his lead on Medicaid

Associated Press file photo

Gov. Steve Beshear says states that have not expanded the Medicaid program under the federal health-reform law, as he did, will do so in the next few years because their voters will demand it.

“I believe the pressure will be so great over the next three or four or five years, on the states that haven’t gone in this direction, that they will end up just where Kentucky is,” Beshear told Alexander Burns of Politico, in the governor's latest appearance in a national publication.

Burns writes, "It’s precisely the message national Democrats are aching to hear, even – or perhaps especially – from a source as unexpected as a pro-gun, pro-coal, red-state governor who once endorsed using state tax incentives to build a creationist theme park."

The story, headlined "Kentucky's unlikely health care heartthrob," focuses on Beshear's high national profile stemming from his expansion of Medicaid to people earning up to 138 percent of the federal poverty line and the state's successful rollout of a website that is enrolling about 1,000 people a day in Medicaid or private insurance -- unlike the federal government's site, which seems to be getting in order after a disastrous rollout that made many Democrats nervous. He is the only Southern governor to take both steps.

"For anxious national Democrats who have pined for a white knight in the health-care reform debate, Steve Beshear is starting to look like the one they’ve been waiting for – implausible as that development may be," Burns writes. "Amid a torrent of negative national headlines about the Affordable Care Act, the 69-year-old Kentucky governor – a canny Southern operator who’s spent his career at arm’s length from the [national] Democratic base – has charged out of Frankfort as a kind of ambassador-by-default for the controversial law."

Burns says the verdicts on the state and national programs are "far from decided, but Beshear says his mind is entirely made up on both the merits and the politics of health care. From his perspective, voters’ opposition to the ACA is driven largely by a sense of anxiety about how the program may change their lives. If they find a year from now that the law has left their personal care unchanged, or even improved it, public opinion could shift quickly."

State Senate Republican Floor Leader Damon Thayer, "a leading Obamacare critic in the state, said Democrats would pay a price for Beshear’s decision to 'channel his inner liberal Democrat with no election ever facing him again in the future'," Burns writes, quoting Thayer: “While it appears that Kentucky has done a competent job implementing a website, it’s still a bad policy. . . . The people of Kentucky don’t like the fact that he has unilaterally implemented Obamacare without legislative approval, and they don’t like Obamcare.” (Read more)

Anthem says Kynect has delivered inaccurate enrollment forms, but is nevertheless a model for insurance exchanges

Some health-insurance companies say Kentucky's Kynect exchange for acquiring coverage is giving them inaccurate or incomplete enrollment forms, and that is also a problem in other state-operated exchanges, Kyle Cheney and Jason Millman reported for Politico Dec. 4.

"It’s a new twist in the unfolding saga of so-called 834 forms — industry jargon for the application files that insurers receive when someone signs up for coverage through an exchange," the reporters write. "Insurers in Kentucky and New York, for example, say they’ve received flawed 834 enrollment forms from their local exchanges, though the extent of the errors is unclear. Washington state has already had to correct thousands of 834s with faulty information about federal tax credits. . . . It’s uncertain how deep the problems go, in part, because the states themselves aren’t sure — and are reluctant to divulge much about their technical challenges."

As for Kentucky specifically, "Although a Kynect spokeswoman said the exchange has dealt with only 'minor issues' since it started sending enrollment files to insurers a month ago, she didn’t indicate whether those issues had resulted in flawed forms or if they’d been resolved."

Tony Felts, a Kentucky spokesman for Anthem Blue Cross and Blue Shield, told Politico that it's too early to say if the problems have been solved: “In general, the situation is the same for the state-run exchanges as it is for the federally facilitated exchanges. As far as the quality of the data that’s coming in, I can’t say that everything has been completely accurate.” Still, he told Kentucky Health News Dec. 9, "There is no question that Kentucky's exchange is performing substantially better and is a model for how the exchanges could be running."

Robert Zirkelbach, spokesman for America’s Health Insurance Plans, a lobbying group, told Politico, “While there is significant variation from state to state, health plans in many state-based exchanges are seeing similar problems with enrollment files.” (Read more)

Beshear says Ky. is 'gold standard' for implementing Obamacare, trades shots with McConnell in Washington

"Kentucky has become the gold standard when it comes to implementing the Affordable Care Act, and I'm very proud of that," Gov. Steve Beshear said Thursday morning at a press conference in Washington with Democrats in the U.S. House.

"There is a tremendous pent-up demand in Kentucky for affordable health care," Beshear said. "People are hungry for it." Citing studies that led him to expand the Medicaid program under the reform law, he said that "will generate $15 billion for Kentucky's economy and create 17,000 new jobs," Jennifer Bendery reports for The Huffington Post.

Beshear also took a shot at Republican Sen. Mitch McConnell, who calls for repeal of the law: "I have a U.S. senator who keeps saying Kentuckians don't want this. Well, the facts don't prove that out." He said more than 550,000 people have visited the state's health-insurance exchange website since it launched on Oct. 1, and about 69,000 have signed up for coverage, 41 percent of them under 35.

"Asked if he thinks Obamacare will be a factor in McConnell's reelection campaign in 2014, Beshear said 'It may well be,' but perhaps not in the way McConnell hopes," Bendery reports. The governor said, "I predict it will be an issue where people start looking at the critics and say, 'What was all that yelling and screaming about? I think you must have misinformed us about the Affordable Care Act.'"

Wednesday night, McConnell called the law a "catastrophic failure" for people everywhere," Bendery notes. "This is beyond fixing. It needs to be pulled out root and branch and we need to start over," the Senate minority leader said on Fox News Channel's "On The Record With Greta Van Susteren."

"McConnell spokesman Don Stewart responded by citing an article about 280,000 Kentuckians being forced to give up their current insurance policies as a result of Obamacare requiring stricter guidelines for coverage," Bendery reports. McConnell later issued a statement saying in part, "The things my constituents now have to put up with as a result of this law are simply unacceptable." (Read more)

Websites that misled Kentuckians seeking health insurance are taken down, blocked or corrected

Three websites that were misleading Kentuckians about the Patient Protection and Affordable Care Act and about the state's health-insurance exchange have either been taken down, corrected or blocked by the state attorney general's Office of Consumer Protection, the office said.

Kentucky consumers who are attempting to obtain insurance under the federal health-reform law need to make sure they are connected with the official health insurance exchange website kynect.ky.gov, the office advised.

A "copycat website," Kynect101.com, was removed after the office complained that it was "deceptively similar" to Kynect.ky.gov. Search engines steered customers to this site and provided false information about their options under the Act, according to the release. This site has now been taken down and no longer appears on Google, which had ranked the copycat site first and worked with the office to block access to the site.

Google has also removed healthcaregov.net from its search engine because it created the misleading impression that it was a government health exchange and did not offer clear information for consumers on how to access the official Kentucky exchange, the release said. A third site, healthcare.com, has made corrections to its site to make sure Kentuckians will be able to link to the state's official site Kynect.ky.gov.

The Office of Consumer Protection offers these tips to protect yourself from misleading websites:
• Make sure you're working with a registered insurance agent or certified kynector, a person paid by the state to help users with the exchange. A list of approved agents and kynectors maintained by the Cabinet for Health and Family Services can be found online or by calling 1-855-4kynect (459-6328).
• Protect your personal information. Only a registered insurance agent, a certified kynector, or contact center customer service representative should ask for your personal information to help you apply.
• Do not pay for help. Insurance agents and kynectors will not solicit money.
• Remember that you can only get tax credits through Kynect, and there is no charge to apply for the credits.
• Beware of phishing scams online. Consumers should be cautious of any email claiming to be connected to the Affordable Care Act, including any emails claiming to be affiliated with kynect and asking for personal information.
• Ask questions. Don't sign anything you don't fully understand, and verify the answers you get with trained kynect representatives.

Consumers who are aware of questionable practices are encouraged to contact the attorney general’s office at 888-432-9257 or consumer.protection@ag.ky.gov. If you think your personal information has been compromised, visit www.ag.ky.gov.

Beshear's office says he is considering 'various ideas' for financing Ky. insurance exchange, not just a 1% fee on policies

"Gov. Steve Beshear’s administration is reconsidering how to pay for the Kentucky Health Benefit Exchange amid increased criticism from some Republicans in the legislature and a court case challenging a fee Beshear created through executive order," Ryan Alessi reports for cn|2's "Pure Politics," a service of Time Warner Cable.

“Various ideas for a sustainability plan for the exchange are being discussed, and such a plan will be finalized for implementation before current funding expires in 2015,” the governor's office told Alessi. Current funding comes from the federal government.

Beshear's plans have called for the exchange to be financed with a 1 percent fee on policies bought through the exchange, to be paid by insurance companies using it. "But in a statement in response to questions from Pure Politics, the governor’s office said it’s suddenly considering other ways to pay for the exchange," Alessi reports, adding that the office didn't respond to his follow-up question about whether legislative approval would be needed for whatever plan was adopted.

House Speaker Greg Stumbo, a Democrat from Prestonsburg, said during a Kentucky Hospital Association panel last month that the fee does not require approval of the General Assembly. Senate Health and Welfare Committee Chair Julie Denton, R-Louisville, told Alessi that it does. Here's a video clip:

Not only may you not get to keep your plan under Obamacare, you might not be able to keep your doctor; there are reasons

By Molly Burchett
Kentucky Health News

Part of the sales pitch for the federal health-care reform law was that people could keep their doctors, but many Americans and some Kentuckians won't because insurers are excluding some hospitals and doctors from policies in an effort to make the new, standardized plans on the insurance exchanges more affordable.

Eleven Kentucky hospitals have filed complaints with the state Department of Insurance, saying Anthem's policies on the state's exchange include only a narrow network of providers, excluding them. Limiting the number of providers on the exchanges is one seldom-mentioned way insurers are trying to reduce premiums for new policies.

The department upheld three of the complaints because the hospitals said they would be able to serve at least four of the state's eight Medicaid regions, a concern that led to their original exclusion. The department has since ordered Anthem to accept applications from those hospitals- UK Healthcare, Our Lady of Bellefonte in Ashland and Highlands Regional Medical Center in Prestonsburg, reports Mike Wynn of The Courier-Journal.

Insurance-company research shows that consumers’ highest priority when shopping for insurance is price. To compete on price, insurers contract with doctors and hospitals who charge them the lowest fees. Some prestigious and well-known academic medical schools that charge higher prices are being excluded from exchange plans, Forbes magazine reports.

These same market forces may also limit the ability for small hospitals and providers to provide care through exchange plans if their health systems lack economies of scale that enhance their negotiating power. UK has already negotiated a deal with Anthem, and the company's negotiations with Highlands and Bellefonte are ongoing.

Anthem is not the only insurance company with narrow networks. Stephen Miller, vice president of finance for the Kentucky Hospital Association, said other Kentucky insurers are also using network restrictions to "steer patients to hospitals with the best rates for the insurer," Wynn reports. Around the country, many plans have more narrow networks than previous plans in order to limit premiums, Politico reports.

This tactic lowers expenses for the insurers by bypassing higher-priced health systems but means that some patients may have to change doctors or hospitals, report Sandhya Somashekhar and Ariana Eunjung Cha in The Washington Post: "The result, some argue, is a two-tiered system of health care: Many of the people who buy health plans on the exchanges have fewer hospitals and doctors to choose from than those with coverage through their employers."

Consumer advocates say tighter networks will disrupt care and limit access for middle-and lower-income consumers, who may be sicker than the average consumer, reports Kaiser Health News: "Narrow networks present the opportunity for lower costs via discounts from select hospitals and doctors in return for patient volume. But smaller networks can require members to travel farther for care or make it hard to get appointments."

Anthem says limiting networks helps insurers save money, which is passed on to patients through reduced premiums. Critics say healthy people must pay more than their fair share to help provide coverage for sicker people. Health-reform advocates say the law's trade-offs are acceptable costs in exchange for getting health coverage to more needy people, but some wonder about that if they have to drive 30 miles to get it.

What is a narrow network?

An insurance company's health-care network is a group of physicians, hospitals and other providers that agree to provide medical services at pre-negotiated rates. The wider the insurance company's network, the more doctors and hospitals from which you can choose without paying more to see an out-of-network provider.

Anthem spokesman Tony Felts said the smaller networks are an attempt to keep exchange plans affordable and that the company worked hard to design products that would attract consumers to them. Four other companies are offering policies on Kynect, the state exchange: Humana, United Healthcare, Bluegrass Family Health and the Kentucky Health Cooperative. Anthem and the cooperative are the only two insurers offering individual plans statewide.

"Many companies have selectively entered the exchanges because they are concerned that they will be dominated by risky, high-using populations who wanted insurance and couldn't afford it" before the law took effect, Gail Wilsensky, a UnitedHealth director, told U.S. News. "They are pressed to narrow their networks to stay within the premiums."

The reform law requires insurers to provide enough doctors and hospitals to ensure quality care, but the federal government offers little guidance on how this is defined. The Kentucky Heath Benefit Exchange says at least 20 percent of available essential community providers in an exchange service area must be in its network, and insurers must contract with at least one of these providers in each county in the service area. However, these regulations don't specify a penalty for not adhering to the recommendation, and there is no guarantee that the network includes your doctor.

Consider a plan's network, premiums and out-of-pocket amounts

Patients may not realize whether or not their doctor is in a plan's network until January, when the new policies take effect. Therefore, consumers should be careful to check the details about an exchange plan's network. Consumers should also be aware of the plan's out-of-pocket costs; the cheapest exchange plans have high deductibles.

On Kynect, insurance shoppers can filter plans to see if a specific provider is included. Insurance Department spokeswoman Gwenda Bond said the agency relies on insurance companies to provide network information to be posted on the exchange. She said the department has experienced some minor issues with this process due to insurers using different names for the same provider.

To address this problem, Kynect also provides a link to each issuer’s web site for their provider directory, said Bond. "The issuer’s provider directory web site should contain the most current list of providers available in the issuer’s network. We continue to work with insurance companies to improve the lists," she said.

"Under Obamacare’s exchanges, people who really want to keep their doctor, at any price, will often have to pay higher premiums for the privilege. And people who prefer lower premiums, above all, might need to choose a different doctor," writes Avik Roy of Forbes.

As Medicaid enrollment grows, fewer providers accept it

At the same time some providers are being excluded by insurance companies or are choosing to exclude themselves, some providers are opting out of the exchanges and are not accepting Medicaid patients. A recent survey by the Medical Group Management Association found that 40 percent of its members are still deciding if they are going to accept insurance offered on the Obamacare marketplaces, CNN reports.

About 56,000 Kentuckians have enrolled in Kynect plans as of Nov. 22, and 82 percent of those are Medicaid plans. According to the Centers for Medicare and Medicaid Services, which administers the Medicaid program, three times more doctors are refusing Medicare patients than three years ago.

Doctors cite Medicare's increasing rules and lowered payment rates as reasons for not accepting Medicaid, and those who will see some Medicaid patients are limiting the number, reports The Wall Street Journal. Doctors also say administrative hassles and delays in getting paid also discourage them from accepting Medicaid, says the Center for Studying Health System Change.

Hospitals across the state have expressed concern about delayed payments from Kentucky's managed care companies as a result of the state's quick transition to a managed care model, and state officials are working to address this problem. Still, Kentucky's Medicaid payment rates are about 72 percent of Medicare rates. The reform law raised Medicaid fees to match what Medicare pays primary-care doctors, but only for two years and after much administrative hassle.

Haynes asks hospitals for a truce as they and state work through problems with managed-care Medicaid

Health and Family Services Secretary Audrey Haynes won a smattering of applause from Kentucky hospital officials Thursday as she called for "not a surrender, but a truce" as her cabinet continues to address the hospitals' complaints about the state's managed-care system for Medicaid, which recently entered its third year.

Haynes drew the ire of hospitals last month when she said some needed to change their business models to emphasize prevention and wellness, not cashing in on Medicaid payments for emergency-room care. Thursday, she said in a speech to the Kentucky Hospital Association in Louisville that she wants "to work more closely together, not only to improve your business practices," but to improve the health of Kentucky.

Haynes also called on the hospitals to join Appalachian Regional Healthcare and the University of Kentucky hospital in contacting past patients who lacked insurance and urge them to sign up for expanded Medicaid or private insurance on the state's Kynect website, under federal health reform. "I need your help," she said. "we're very excited about the opportunity for dramatic improvements in Kentucky's health status."

Also at the meeting, state Rep. Jimmie Lee, D-Elizabethtown, the House's health-care budget subcommittee chair, said he thought Haynes and the administration of Gov. Steve Beshear had largely resolved the "prompt pay" problems of hospitals not getting money they are owed by insurance companies. But Senate Health and Welfare Committee Chair Julie Denton, R-Louisville, called for more action on the subject, such as an independent review panel to review disputed claims.

Beshear and two other Democratic governors say Obamacare is working in their states, and cite examples

Gov. Steve Beshear continues to be a major national cheerleader for the federal health-reform law, citing Kentucky examples in an op-ed piece he and the Democratic governors of Connecticut and Washington circulated to newspapers this week.

"People keep asking us why our states have been successful," they write. "Here’s a hint: It’s not about our websites. Sure, having functioning websites for our health-care exchanges makes the job of meeting the enormous demand for affordable coverage much easier, but each of our state websites has had its share of technical glitches. As we have demonstrated on a near-daily basis, Web sites can continually be improved to meet consumers’ needs. The [Patient Protection and] Affordable Care Act has been successful in our states because our political and community leaders grasped the importance of expanding health-care coverage and have avoided the temptation to use health-care reform as a political football."

All three governors expanded the Medicaid program to include people with incomes up to 138 percent of the federal poverty line. Beshear cites two independent studies that showed Kentucky "couldn’t afford not to expand Medicaid. Expansion offered huge savings in the state budget and is expected to create 17,000 jobs." The state will have to start helping pay for the expansion in 2017, but Beshear has argued that the economic activity from more health care will cover that bill.

At least one of Beshear's co-authors, Washington Gov. Jay Inslee, is not allowing insurance companies to renew policies that don't comply with the law, as President Obama allowed last week. But they wrote, "What we all agree with completely, though, is the president’s insistence that our country cannot go back to the dark days before health-care reform, when people were regularly dropped from coverage, and those with 'bare bones' plans ended up in medical bankruptcy when serious illness struck, many times because their insurance didn’t cover much of anything.
Thanks to health-care reform and the robust exchanges in our states, people are getting better coverage at a better price."

As an example, Beshear cited Howard Stovall, whose sign and graphics business in Lexington "has paid half the cost of health insurance for his eight employees" since it opened in 1998. "With the help of Stovall’s longtime insurance agent and Kentucky’s health exchange, Kynect, Stovall’s employees are saving 5 percent to 40 percent each on new health insurance plans with better benefits. Stovall can afford to provide additional employee benefits, including full disability coverage and part of the cost of vision and dental plans, while still saving the business 50 percent compared with the old plans." (Read more)

At least one insurance company will let Kentuckians keep their health insurance plan for another year if they like it

By Molly Burchett
Kentucky Health News

At least one insurance company, Humana, will be allowing Kentuckians to keep their insurance coverage for another year if they like it, even if the policies aren't compliant with the Patient Protection and Affordable Care Act.

Partially owning up to his reforms' rocky rollout last week, President Obama said people whose policies were being cancelled because they didn't comply with the law could renew their policies for another year -- if insurance companies are willing to do so and state regulators allow it. Kentucky is among the states allowing them to do so, and Humana is going along.

Humana -- and Anthem Blue Cross, if it follows suit -- will be required to tell such policyholders "what protections these renewed plans don't include" and that they have alternatives that may be better and cheaper on insurance exchanges, Obama said.

“Humana has been educating people about the full range of options, including the ability to retain their current coverage, in accordance and coordination with state law," a Humana spokesperson told Kentucky Health News. An Anthem spokesperson said the company is still reviewing its options.

About 280,000 Kentuckians -- almost all those in individual and small-group insurance market -- faced policy discontinuation, requiring them to get different insurance coverage.

Experts say there are a number of obstacles that could keep insurers from letting customers renew old policies, including the concern that the risk pools of the state's health-insurance exchange will be skewed. And, insurers will have to calculate how much they plan to charge for policies that were going to be discontinued.

“Changing the rules after health plans have already met the requirements of the law could destabilize the market and result in higher premiums for consumers,” Karen Ignagni, the president of America’s Health Insurance Plans, a lobbying group, told The New York Times.

Some insurers say the president's move is adding to the confusion that surrounds the health-care law and adding uncertainty to the insurance market. This may discourage participation from a key group, young and healthy people who are needed to make insurance exchanges sustainable, reports The Washington Post.

There is doubt that insurance companies can do all of this in less than a month to ensure coverage is in place by Jan. 1. It is unclear how, as a practical matter, the changes proposed by the president can be put into effect, National Association of Insurance Commissioners President Jim Donelon said last week. And, even if they do, the proposed changes only last a year.

Pike County officials urge newly eligible residents to sign up for health insurance before Dec. 15

A call to action.

That's what Pike County officials are calling their efforts to encourage citizens to sign up for health care insurance, as called for by the Patient Protection and Affordable Care Act, reports Russ Cassady of the Appalachian News-Express in Pikeville.

The act and the state's expansion of Medicaid under the law have made an estimated 9,915 people in the state's easternmost and geographically largest county eligible to receive health insurance, county Social Services Commissioner Carol Napier said at a Fiscal Court meeting last week.

“Of that number, 5,127 are now eligible for Medicaid,” she said, adding that 3,984 others are eligible to get subsidies for private health insurance.

The call to action also reminds people to apply before Dec. 15 to assure that their coverage will begin Jan. 1, Cassady reports. “There’s still yet those individuals that are under the impression that they don’t qualify,” Napier said.

Judge-Executive Wayne T. Rutherford, at the same meeting, reminded Pike County residents who apply through the state insurance exchange that they will not have to go through the national system, Cassady reports.

Kentucky's online health insurance exchange, Kynect, hailed by some as the best Obamacare website, is available to all Kentucky residents to explore their options, find out if they qualify for subsidies, and sign up for health insurance.

Cassady's story gives a list of local Kynect assistance sgencies, where people can call to ask questions or request help:
 • Pike County Health Department, (606) 437-5500
 • Mountain Comprehensive Care Center, (606) 432-3143
 • Big Sandy Area Development District, (606) 886-2374
 • Appalachian Research and Defense Fund of Kentucky, (606) 886-3876
Citizens of Pike County can also call the county Social Services office at (606) 432-6246 with questions about their eligibility for health insurance under the Patient Protection and Affordable Care Act. (Read more; subscription may be required)

FactCheck.org finds little support for Sen. Rand Paul's claim that Medicaid expansion will 'bankrupt' Kentucky hospitals

U.S. Sen. Rand Paul said on ABC's "This Week" Sunday, Nov. 3 that the federal health-reform law may "bankrupt" rural Kentucky hospitals "by overwhelming them with Medicaid patients." However, health-care leaders in the state "say its hospitals stand to benefit, since the expansion would provide insurance to those who otherwise wouldn’t be able to pay their hospital bills," reports FactCheck.org, a nonpartisan service of the Annenberg Public Policy Center at the University of Pennsylvania.

Sen. Rand Paul (ABC News)

Paul made his remarks when host George Stephanopoulos asked him if the successful launch of the state's insurance exchange showed that Obamacare can be successful. "Well, nearly 90 percent of them are signing up for Medicaid, free health insurance from the government," Paul replied. "My concern is not that we shouldn’t help people. I do want to help these people to get insurance. But there is going to be a cost. And in my state, we have a lot of rural hospitals that teeter in the balance. My fear is that these hospitals may be bankrupt by overwhelming them with Medicaid patients."

At the time Paul spoke, the latest figures were that 85.7 percent of Kentucky enrollees were in Medicaid. A week later, the figure had declined to 82 percent of a total of 40,572. Exchange Director Carrie Banahan said Nov. 10 that she expects the Medicaid percentage to be about 70 percent by Dec. 31. She noted that Medicaid qualification is faster than enrolling in a private health plan because the income qualification is automatic, and 16,425 people have been determined eligible for subsidies for private plans through the exchange.

Gov. Steve Beshear announced in May that the state would expand Medicaid to people with incomes up to 138 percent of the federal poverty level; the previous threshold was 69 percent.

Eugene Kiely of FactCheck notes that the Robert Wood Johnson Foundation and Urban Institute said in March 2013 that hospitals should expect more revenue from Medicaid expansion; that the month before, Kentucky Hospital Association President Michael Rust said likewise; and so did Foundation for a Healthy Kentucky President Susan Zepeda several months earlier.

"That’s not to say there are no concerns in Kentucky about expanding Medicaid," Kiely writes. The state does not have enough medical providers to serve its population, even without the 300,000 residents who are newly eligible for Medicaid. In an email to Kiely, Zepeda said the foundation "remains very concerned about the capacity of the state's health-care system, particularly in rural areas, to cost effectively care for a much larger number of patients."

Zepeda also noted the problems that hospitals have had being paid by insurance companies that are now managing Medicaid for the states, but the foundation "still believes the state’s residents and hospitals will benefit from the expansion," Kiely reports.

Paul's staff did not respond to inquiries from FactCheck. For its analysis, click here.

Friedell Committee will consider what it will take for Kentucky to become a healthier state at meeting Sunday and Monday

What will it take for Kentucky to become a healthier state? That will be the question at the fall meeting of the Friedell Committee for Health System Transformation, at the Marriott Griffin Gate in Lexington Sunday, Nov. 10 and Monday, Nov. 11. Participants will examine how the committee can work with communities and individuals to create a Kentucky that is “healthier, wealthier, and wiser,” a possible motto for a campaign the committee is considering.

“We have learned that building a healthier Kentucky will depend largely on what we do beyond the health-care system,” said Richard Heine, executive director of the committee. ”Efforts to promote good health must take place in the environment where people live, work, and play. For Kentuckians to be healthier, we must address the factors behind the problem of poor health, such as lack of education, poverty, poor nutrition, lack of employment, violence, transportation, and housing.”

Topics at the meeting include the state Health Benefit Exchange, managed-care Medicaid, the state’s financial situation, successful local policy changes, and the prevention and control of Kentucky’s major health challenge: diabetes.

Lee Todd, former president of the University of Kentucky, will be the keynote speaker Sunday evening and will introduce components of the committee’s campaign for a healthier Kentucky, now being formulated. Monday’s morning sessions will focus on public health, with discussions of county health rankings, public health partnerships with communities, and opportunities for progress in the health of Kentucky. Afternoon sessions will look at education partnerships and Kentucky’s workforce.

This meeting is funded in part by a grant from the Foundation for a Healthy Kentucky. For a copy f the full agenda, click here. For more on the committee, click here.

280,000 Kentuckians, almost all those with individual and small-group insurance policies, will have to change under Obamacare

By Molly Burchett
Kentucky Health News

About 280,000 Kentuckians will have to give up their current insurance policies, which are being discontinued because they don't comply with the Patient Protection and Affordable Care Act, according to the state Department of Insurance.

Department spokeswoman Ronda Sloan said individual policies for about 130,000 people and small-group policies for about 150,000 more will be discontinued. This means that almost all Kentuckians in the individual (134,086) and small group (153,943) private insurance market segments will face policy discontinuation, requiring them to get different insurance coverage even if they like their current coverage.

These Kentuckians join the millions of Americans who are getting or will get cancellation letters for their health insurance under Obamacare. An estimated 50 to 75 percent of the 14 million consumers who buy their insurance individually can expect to receive this type of letter over the next year because existing policies don’t meet the standards mandated by the health care law, reports NBC News.

NBC says the Obama administration has known this would happen for three years, despite President Obama's statement that people who liked their health insurance would be able to keep it under the health law.

The plans that are being discontinued do not meet the requirements of the law, which standardized policies and set minimum standards. "This is not a ‘cancellation’ or a ‘termination.’ No one is losing coverage,” Sloan  said in an email to The Associated Press. Discontinuation letters will offering a compliant plan that the consumer can switch to upon renewal, she said.

The consumer can also take this opportunity to shop around for other options through an insurance agent or on the state's Kynect website, where they may qualify for a subsidy or Medicaid coverage, Sloan noted.  Kentuckians should be sure to purchase a plan that is from a licensed Kentucky company and is a qualified health plan, she said.

The health law requires all plans to offer 10 essential benefits, such as mental health care, prescription drug coverage and maternity and newborn care. Plans that don't cover such services typically have lower premiums.

In the small-group market, businesses can shop for employee coverage in the same way that individuals shop for coverage, through an insurance company, agent or Kynect.

Small employers have expressed concern about being able to afford coverage for their employees, citing rising premiums, and Sloan says there is no way for the Insurance Department to know whether or not an employer is planning to continue offering coverage to employees whose policies are being discontinued. "If not, those employees could purchase coverage on the individual market," she said.

Humana's misleading letter to policyholders

After Humana Inc. sent discontinuation letters to 6,543 policyholders, the Insurance Department fined it $65,430 because the letters were misleading. They called for customers to renew their plans for 2014 within 30 days or choose a more expensive option that complies with the health law, and didn't clearly say that policyholders could compare and choose competing plans, for which they could possibly qualify for federal subsidies. In addition, they said that a customer could get the cheaper premium option by agreeing to changes not yet approved by the Insurance Department.

“The Department of Insurance fined Humana for providing members with a policy amendment form that was not approved. This was a clear-cut violation of Kentucky’s insurance code,” Insurance Commissioner Sharon Clark told Chris Kenning of The Courier-Journal.

State officials are also reviewing a letter sent by Anthem Blue Cross Blue Shield that asked people to "call now to lock in "today's affordable rates,", reports USA Today. The insurance department determined that the letter was marketing to potential customers, and thus did not violate the insurance code. "Humana’s letter, by contrast, went to current policyholders," Kenning reports.

Latest New York Times look at Obamacare in Kentucky examines highs and lows of enrollees and people helping them

 Navigator Kelli Cauley helps an applicant. (Luke Sharrett, NYT)

While many states have suffered through complications in signing up uninsured people for health insurance under the Affordable Care Act, Kentucky has been leading the way in efficiency, enrolling about 1,000 people per day. Abby Goodnough of The New York Times was already using Kentucky as a lens to view the rollout of health reform, and in her latest story looks at major players in the enrollment process -- including the navigators for the state's Kynect website, insurance agents, and the uninsured -- exploring the ups and downs of each group.

"Though people can sign up on their own, navigators can help those confused by the sea of insurance options," Goodnough writes. "The navigators listen to people voice their hopes and fears about the law, and their hard stories about being uninsured. Often hugs are exchanged. Sometimes tears flow." One such navigator, or Kynector, is Kelli Cauley. The Louisville resident has put 1,000 miles on her car in the last month, and the stress of the high pressure job has caused her to lose 12 pounds. As part of her job, Cauley is one of eight Kynectors who have "to enroll 699 people per month in Medicaid or private plans through the exchange. They are required to hold educational events around the region, and the agency’s phones have been ringing nonstop with requests for enrollment help at health fairs, cultural festivals and other events that the uninsured might attend."

Cauley, a former home-economics teacher, said she "expects the job to get harder as she comes under pressure to help people who might be more reluctant to sign up than the early enrollees," Goodnough writes. "But she has some strategies: visiting small day-care centers, for example, where workers are likely to be uninsured. For now, just meeting the initial flood of requests is a strain." Cauley told Goodnough, "You do have to be on your A game constantly." The reward, though, is that she has been able to help dozens of people get coverage.

Insurance agents aren't getting the same warm feeling. Some agents "refuse to sell plans through the exchanges, which they see as a threat, and have instead focused on selling other insurance, like property and casualty," Goodnough writes. Some agents who are selling the plans, aren't seeing a silver lining in the results. Donald Mucci, who has been "an insurance agent for more than three decades, has yet to get comfortable with the new system and does not much like it. (He) resents that the health care law prompted insurance companies to cut commissions paid to agents. And he thinks the exchange website makes it hard for people to understand the pros and cons of various plans, such as which hospitals and doctors they cover. Yet Mucci, an affable man in monogrammed shirt cuffs, said he wants the system to work."

Mucci, whose firm, the Garrett-Stotz Co., has been in Louisville 82 years, has only enrolled a few customers in exchange programs. During a recent enrollment, his commission was $18, far less than what he normally gets, Goodnough writes. "The law requires insurers to spend at least 80 percent of money from premiums on medical care instead of on administrative costs, which include commissions to agents and brokers. Consequently, some insurers cut commissions, infuriating many agents and brokers."

Despite the long hours put in by navigators, and the concerns of insurance agents, the plan appears to be helping people in dire need of insurance. And in some instances, people are getting what they need, without feeling like they're being handed charity. One such case revolves around a woman Cauley helped, who would identify herself only as Kay. The well-dressed substitute teacher "learned that she would be eligible for Medicaid under the new law, but she was unwilling to enroll because of what she saw as a stigma attached to the program," Goodnough writes. She told Goodnough, “I don’t want to be a freeloader.”

But the cheapest option for Kay "through the exchange would be a plan with a $356 monthly premium and a $6,300 deductible," Goodnough writes. With that amount being too high, Cauley was able to find her an alternative. "Kay could sign up for Medicaid, but only use it in catastrophic events. For checkups and other routine care, Kay could pay her own way, perhaps negotiating a discount with her doctors." She summed up her situation, and perhaps the point of what health reform hopes to accomplish, saying, “You’re giving me an alternative I can live with." (Read more)

15 to 25% of uninsured Kentuckians may be eligible for free, non-Medicaid coverage, but watch those out-of-pocket costs

Millions of Americans who don't quite qualify for Medicaid could still get free health insurance through federal subsidies, but this free coverage hasn't gotten much attention, since most of the zero premium plans come with some trade-offs.

An analysis by an independent consulting firm, McKinsey and Co., found that 5 to 6 million uninsured Americans will qualify for subsidies greater than the cost of the cheapest "bronze" or "silver" plan. However, many insurers have been careful not to publicize this free coverage because these plans have high out-of-pocket costs and some people will be better off paying higher premiums to get more coverage, reports The New York Times.

In a zero-net-premium plan, the federal subsidy covers the entire premium, but many people still face significant out-of-pocket costs for health services. Most zero-net premium plans are bronze plans, which are the least expensive available on exchanges and cover about 60 percent of a person's medical costs; the consumer must pay for the remaining 40 percent. So, choosing this type of plan means that you may sacrifice coverage compared to other plans on the exchange.

As the metal level increases in value from bronze to platinum, so does the percentage of medical expenses that the plan will cover. Silver plans cover about 70 percent, gold plans cover about 80 percent and platinum plans cover about 90 percent of medical costs. Regardless of the plan tier, all plans must cover standard benefits like prescription drugs, maternity care and mental health treatment. Preventive services are free in all plans.

The McKinsey report says 15 to 25 percent of Kentucky's non-elderly uninsured will be eligible for a zero-net-premium plan that will either be a bronze or silver plan. Nationwide, about half of the individuals who qualify for a zero-net-premium plan are younger than 39 and are uninsured.

Individuals with lower incomes are more likely to be eligible for these plans and most will have income levels not far above the Medicaid coverage threshold, which is 138 percent of the federal poverty level. Remember persons with income up to 400 percent of the poverty line qualify for federal tax subsidies to assist with premium payment.

Experts say the higher deductibles and higher annual out-of-pocket costs of the bronze plans may not be suited for someone with a lower income. “They may be getting zero premiums, but they’re also leaving a lot of money on the table if they don’t enroll in a silver-level plan,” Sabrina Corlette, a professor at Georgetown University’s Health Policy Institute told The New York Times.

Low-cost plans may encourage younger, healthier people to enroll in Obamacare, but they have the highest out-of-pocket cost limit and highest deductible amounts. Out-of-pocket costs, including the deductible, co-payments and co-insurance (a percentage of charges), are limited to $6,350 for individuals and $12,700 for families in bronze plans. So, for some, the silver plan may be a better option, and some individuals may also qualify for a zero-net premium silver plan.

When choosing a lower-tier plan, be ready for significant cost sharing, and be careful to check that your doctors and nearby hospitals are in the plan's network. When it comes to health insurance coverage, for individuals who don't qualify for programs like Medicaid and Medicare, there's free coverage but no free lunches.