What the Federal 'No Surprises Act' Means in California

KFF Health News, January 26, 2022

The federal law that took effect Jan. 1 protects more than 100 million people enrolled in self-funded health plans across the nation.

This article was published on Wednesday, January 26, 2022 in Kaiser Health News.

By Bernard J. Wolfson

Betty Chow, a Los Angeles resident, had a cervical disc replaced in August 2020 at a surgery center that was part of her Anthem Blue Cross PPO network.

Thirteen months later, she was blindsided by a bill for nearly $2,000 from the anesthesiologist who was on her surgical team but was not contracted with her PPO, or preferred provider organization.

Chow, a 35-year-old veterinarian, says she discussed the bill with her boyfriend, a registered nurse. He told her about a California law that took effect in 2017 and prohibits such "surprise bills" from out-of-network medical providers who work at in-network facilities.

Unfortunately, that law does not protect Chow or nearly 6 million other Californians who get health coverage through employers that pay employee medical bills out of their own treasuries. These "self-funded" plans are regulated by the U.S. Department of Labor — and thus are beyond the reach of state law.

But a federal law that took effect Jan. 1 bridges that gap for the more than 100 million people enrolled in such health plans across the United States, including those nearly 6 million Californians. And it covers millions more in the 32 states that have no laws against surprise bills or have laws offering only partial protection.

The new federal law, the No Surprises Act, also protects nearly 1 million Californians not covered by a 2009 California Supreme Court ruling that prohibits emergency room doctors and other providers of emergency services from billing HMO patients for out-of-network charges not paid by their insurers — a practice known as balance billing.

"Millions more Californians will now be protected against these bills that are not just unfair but put families' economic security at risk," says Anthony Wright, executive director of Health Access California, a consumer advocacy group.

It's high time. Surprise bills have inflicted financial pain on millions of Americans for far too long.

When patients are seen by out-of-network providers they didn't choose, it is often a double whammy: They pay more out-of-pocket — even if their health plan covers some out-of-network care — and they may later receive balance bills from providers that can total thousands of dollars.

Research shows that surprise bills are common among the nearly 200 million U.S. residents enrolled in private health plans.

A 2020 study found that 20% of privately insured patients who had elective surgery at a hospital that was in their insurance network received surprise bills from providers who were not. Bills from anesthesiologists averaged $1,219. Bills from surgical assistants averaged more than twice that amount.

"When patients pay their insurance premiums, they presume — and I believe fairly presume — that they will be covered financially," says Katie Berge, director of federal government affairs at the Leukemia & Lymphoma Society.

The No Surprises Act covers all privately insured people in employer-sponsored and individual/family health plans. Medicare and Medicaid already protect their enrollees against nasty billing surprises.

The new federal law, which is largely in sync with California's, bans balance billing for nonemergency care by out-of-network providers at in-network facilities and for most emergency room care at any facility. Insurers must cover those services at in-network rates, and providers may not bill patients for any amounts beyond that. Providers and health plans must negotiate how much the plan will pay, leaving patients out of the fray.

The federal law also protects against outlandish bills from out-of-network air ambulance services. A California law that took effect in January 2020 does the same thing. But it doesn't cover the millions of people in federally regulated health plans and has been vulnerable to a possible legal challenge because it may conflict with the 1978 deregulation of airlines, which included air ambulances.

In cases where its provisions are stronger, the federal law will trump state laws.

What about enforcement? The federal government will defer to states in cases that involve state-regulated plans, and in those that involve federally regulated ones if the target of the complaint is a provider, says Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy. But the federal government will step in if states refuse or cannot enforce the law, he says.

Federal health officials are sending letters about enforcement to the governors of every state.

California, with its strong laws against surprise billing, certainly has the means and experience for enforcement, though it has not seen a huge number of cases. In the past four years, the Department of Managed Healthcare has resolved 1,006 consumer complaints about balance billing, and 467 of them yielded total reimbursements of nearly $1 million to enrollees, says Rachel Arrezola, a department spokesperson.

Of course, not all bills that surprise patients are regulated by state or federal law. Sometimes people owe more than they thought on their deductible, or their cost sharing was higher than they realized, or their procedure wasn't covered by their health plan, or the facility they chose wasn't in their network.

So, bone up on your insurance policy. Know what and who it covers, which facilities are in the network, how much your out-of-pocket costs are, and how much of your deductible remains to be paid.

That will help you determine whether a bill is illegitimate. And there still will be illegitimate bills — because people make mistakes. And some medical professionals act in bad faith.

When you get a bill, don't pay it right away. Ask questions. Compare it with the explanation of benefits you receive from your insurer — and if that hasn't arrived yet, wait for it. If there's a discrepancy between what your provider and your health plan say, call them both, and try to iron it out.

If that doesn't work, don't get discouraged. You can file a grievance with your health plan. And if that doesn't resolve your problem, contact the Department of Managed Healthcare to open an appeal, either on its website (www.healthhelp.ca.gov) or by calling 1-888-466-2219. The department also has a fact sheet that may answer some of your questions about California's surprise billing law.

The federal government has launched a website (www.cms.gov/nosurprises) that may answer many of your questions about the No Surprises Act and will enable you to lodge a complaint or dispute a bill. You can also contact a federal "no surprises" help desk at 1-800-985-3059.

If you are simply befuddled by medical bills or lack the confidence to contest one on your own, the Health Consumer Alliance is a great resource. Find an office near you by going to www.healthconsumer.org or calling 1-888-804-3536.

Chow, a native of Hong Kong who has been a patient in the single-payer system there and in the United Kingdom, says she is baffled by the U.S. system, "where you pay for medical insurance, but then you have to pay more."

Although California's law does not protect her from the anesthesiologist's $2,000 bill and the new federal law is not retroactive, she nonetheless appears to be headed toward a happy ending.

After three collection attempts by the anesthesiologist and several phone calls by Chow, Anthem agreed to knock the bill down to $83 and to update the anesthesiologist's billing office. That still hasn't happened, but Chow is hopeful.

"I don't really understand what I'm responsible for," she says, "except $83 is a lot less than $2,000."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

With a Vaccine Mandate Looming, Nursing Homes Face More Staffing Problems

KFF Health News, January 25, 2022

Healthcare sites in states that challenged the federal requirement have until March 15 for their staffs to be fully vaccinated.

This article was published on Tuesday, January 25, 2022 in Kaiser Health News.

By Eric Berger

ST. CHARLES, Mo. — Jamie Smith, a staffing agency nurse who loves end-of-life care, said she has been warmly welcomed by staffers and residents at Frontier Health & Rehabilitation in this conservative St. Louis suburb.  

That's even though she has not been vaccinated against COVID-19.

But leaders of the nursing home, where 22 residents died from COVID before vaccines were available, likely won't be able to employ unvaccinated people like Smith for much longer. The U.S. Supreme Court on Jan. 13 upheld a federal mandate requiring healthcare workers at facilities that receive Medicaid or Medicare funding to be fully vaccinated. If all staffers — excluding those with approved religious or medical exemptions — aren't fully vaccinated, the facility will lose that money.

Healthcare sites in Missouri and other states that challenged the federal requirement have until March 15 for their staffs to be fully vaccinated, according to the Centers for Medicare & Medicaid Services, while facilities in states that didn't sue to block the mandate have a Feb. 28 deadline.

That poses a challenge for Frontier and its residents because the nursing home already doesn't have enough staffers. And it is in the state with the lowest rate of fully vaccinated nursing home healthcare workers, 67% as of Jan. 9, according to CMS data. Frontier's reported staff vaccination rate was just 30% at the start of the year.

That compares with a national rate of 81%, according to the federal data.

Although the mandate ensures that unvaccinated staff members are not caring for some of the people most vulnerable to the virus, not enough workers are willing to take the low-paying, challenging jobs. If they quit to avoid getting shots or are fired because they won't get them, nursing home residents might not be any safer — because of lack of care.

"Obviously we need good staff members to take care of residents, but the residents need to be safe as well," said Marjorie Moore, who supports the mandate and is executive director of Voyce, a St. Louis nonprofit that advocates for nursing home residents and their families.

"A person who lives in their own home has the chance to say, 'I don't want somebody in my home who isn't vaccinated,'" she added. "In a nursing home, they don't have the opportunity to say, 'I don't want somebody who is unvaccinated coming up and feeding me.'"

The problem of inadequate staffing at nursing homes predates the pandemic, and it's gotten worse.

In March 2020, 3.3 million people were employed at U.S. nursing homes and residential care facilities, according to the Bureau of Labor Statistics. In December 2021, that number had dropped to 2.9 million, a loss of 400,000 workers.

Nursing home operators can't find enough staffers because they often don't pay much. The mean hourly wage for nursing assistants in Missouri was $13.33 in 2020, according to the statistics bureau. And the homes require employees to take on a slew of responsibilities, including feeding residents, changing adult diapers, and caring for residents who have dementia and may become combative.

Nursing assistants "can typically find a job with better pay that is less physically and emotionally demanding," said Brian McGarry, a University of Rochester professor who studies long-term care. "Somebody's life and dignity is in your hands, and it's a huge responsibility, and you are not getting paid commensurate with that responsibility."

Those downsides of the job often lead to significant turnover. In 2017-18, the turnover rate among nursing home employees in Missouri was 138%, the fourth-highest in the country, according to a study in the journal Health Affairs. Frontier had a rate of more than 300%, according to Huizi Yu, one of the study's authors.

The nursing home's management declined to comment.

Smith, the nurse who works for a healthcare staffing agency, said she has not been vaccinated against COVID because she had a rare cancer in 2017 and is "very particular about what I put in my body."

She said, "I'm not sure if I would be able to get it just to keep a job."

But, she noted in a text message, "I still practice safely."

And, indeed, no Frontier residents have died from COVID since the outbreak at the start of the pandemic, according to the federal data. But the center reported having seven new confirmed cases among its residents and 10 new cases among its staff as of Jan. 9. At the beginning of the year, 89% of residents were fully vaccinated against COVID.

Low vaccination levels among staffers place residents at greater risk, according to a recent analysis in The New England Journal of Medicine. Facilities in high-COVID counties with an average staff vaccination rate of approximately 30% had nearly three times as many COVID deaths among residents as facilities where about 82% of employees were vaccinated, the analysis found.

"An unvaccinated or low-vaccinated staff, I think, pretty clearly puts residents at risk — even if they are vaccinated," said McGarry, one of the analysis's authors.

The vaccination rate has increased from fewer than half of Missouri nursing home staff members when President Joe Biden announced the mandate for nursing homes Aug. 18 to about two-thirds of staffers now, according to the federal data.

Like Frontier, Northview Village does not have enough staffers, and most people who work there have not been vaccinated. The facility — a nursing home in a predominantly Black, low-income north St. Louis neighborhood — held a vaccination drive in December to increase its roughly 20% staff vaccination rate, but the numbers did not rise, according to the federal data. And only half of residents were fully vaccinated.

The Northview management declined to comment.

Kimberly Watkins, a technician who works to keep Northview residents active, was reluctant to get any of the shots, in part because she heard the conspiracy theory that they contained a tracking chip. But she said she decided to go ahead and get vaccinated because she has asthma and high blood pressure. Co-workers told her their doctors said that they didn't need the vaccine or that they may be allergic to it.

Now with the mandate taking effect, Moore, of the nonprofit Voyce, thinks most local nursing home staffers will comply.

She highlighted Mary, Queen and Mother Center, a Catholic nonprofit nursing home in St. Louis County, that announced its own mandate in August. Before its Sept. 30 deadline, the nursing home saw its staff vaccination rate increase from 67% to 92%, with the remainder being those with a medical or religious exemption, according to the organization. The facility retained almost all its staff.

Not everyone is worried about nursing home staffers being vaccinated, in part reflecting the community around them. Just 55% of Missourians are fully vaccinated.

"I'm not into forcing stuff on people," said Antuan Diltz, a St. Louis firefighter whose mother is a 64-year-old retired nurse with dementia and diabetes living at Frontier. She received the vaccine; Diltz had not.

But others, like Bill Talton, who have family at Frontier hope more staffers will get the shots. Talton, a 77-year-old retired computer programmer, said he is happy with the care his younger brother, who has dementia, has received, although he sometimes couldn't visit him during COVID-related lockdowns.

"It's kind of late in the game," said Talton, who is fully vaccinated and received a booster. "They'll get it done — I hope."

KHN data editor Holly K. Hacker contributed to this report.

Pharmacies Are Turning Away Immunocompromised Patients Seeking 4th COVID Shot

KFF Health News, January 25, 2022

Many pharmacists are unaware that the CDC's vaccine guidance has changed.

This article was published on Tuesday, January 25, 2022 in Kaiser Health News.

By Liz Szabo    

Patients with weakened immune systems — who are at high risk from COVID-19 — say pharmacies are turning them away when they seek additional vaccine doses recommended by federal health officials.

Alyson Smith became eligible this month for a fourth vaccine dose because her medications leave her immunocompromised.

Although the Centers for Disease Control and Prevention encourages most adults to receive a total of three mRNA vaccines — two "primary" vaccinations and a booster — the agency now advises people with weak immune systems to receive three primary shots plus a booster, for a total of four doses.

Many people are confused about the difference between a primary vaccine series and a booster. A primary vaccine series helps people build antibodies to a new pathogen, while a booster combats waning immunity.

As Smith learned, many pharmacists are unaware that the CDC's vaccine guidance has changed.

Smith booked her vaccine appointment online. But when she showed up at a Chicago-area Walgreens for the appointment Jan. 19, an employee told her the pharmacy chain wasn't administering fourth doses to anyone.

Smith said she's frustrated that vulnerable people are being forced to make multiple visits to crowded pharmacies and supermarkets, where many customers are unmasked.

"I feel for the pharmacists, because they're overwhelmed like everyone else," said Smith, 52. "But two years into the pandemic, there is a corporate responsibility to take action when the guidance comes down."

In a written statement, Walgreens said it has administered thousands of fourth doses to immunocompromised people. "As vaccination guidelines continue to evolve, we make every effort to continuously update our pharmacy teams."

The confusion stems from recent updates in vaccine advice for immunocompromised people, as well as a change in the interval between the end of a primary vaccine series and a booster.

  • In August, the CDC began allowing immunocompromised people to receive a third dose of mRNA vaccine as part of their primary vaccination.
     
  • In October, the CDC quietly updated its website to allow people with suppressed immune systems to receive a fourth shot as a booster.
     
  • In January, the agency shortened the time that anyone must wait for a booster from six months to five.

People who received the one-dose Johnson & Johnson vaccine are eligible for a single booster, for a total of two shots, according to the CDC.

Given how often vaccine guidelines have been revised in recent months, some pharmacists have had a hard time keeping pace, said Mitchel Rothholz, chief of governance and state affiliates at the American Pharmacists Association. Pharmacy employees have coped with an ever-expanding workload but a deepening shortage of employees during the pandemic, he said.

"I don't know any provider who wants to turn away a patient," Rothholz said. "The CDC continues to make updates, and it's becoming very difficult for providers at the grassroots level to keep up. I can understand why a pharmacist would say, 'Corporate hasn't given us the green light.'"

Confusion about who is eligible for a fourth shot "was inevitable, although I'm not saying it's right or wrong," he said.

Yet many patients and their doctors are frustrated.

If patients keep up with the latest guidelines, they ask, why can't their pharmacy?

"It's ridiculous," said Dr. Dorry Segev, a transplant surgeon and researcher at Johns Hopkins University. "CDC makes it very clear that it's allowed, and even people who print out the CDC guidance and take it to their pharmacies are being turned away."

Charis Hill, 34, joined a chorus of immune-suppressed people venting their concerns on social media in recent days. When Hill tweeted Jan. 21 that Rite Aid should better educate its staff, the retailer tweeted back that day, saying, "We're very sorry you didn't have a great experience, Charis. Please check back with us early next month for more information regarding the fourth dose."

In a written statement, Rite Aid said it continually educates its staff as CDC advice changes, and "is looking into the response that was provided to the customer on social media."

Dr. Shikha Jain, an assistant professor of medicine at the University of Illinois Cancer Center in Chicago, said patients in rural areas often drive long distances to look for vaccines. One of her patients was "almost in tears" after being turned away. Jain tried to help by calling the pharmacy but was on hold so long that she had to hang up to see patients.

Jain said the CDC needs to do a better job educating doctors, pharmacists, and patients.

The CDC did not respond to a request for comment before publication.

Teresa Strahlman, 61, said she's immune-compromised due to medications she takes for lupus, an autoimmune disease. But the Maryland woman said she didn't realize she was eligible for a fourth dose until reading a KHN post on Facebook. "I had no idea, and I have a million doctors," Strahlman said. "No one has said anything to me."

The CDC estimates that 2.7% of adults — or 7 million people — are immunocompromised, a group that includes people with medical conditions that dampen their immune response, as well as those taking immune-suppressing drugs because of organ transplants, cancer, or autoimmune diseases.

Some immunocompromised people say that being turned away from a pharmacy is especially frustrating, given all that they have sacrificed during the pandemic.

Linda Rushing, 74, has given up attending church services in person, although she's deeply religious, because of a weakened immune system that leaves her prone to a variety of infections.

Rushing made three visits to local pharmacies before finding someone to administer her fourth shot.

"It's a tragedy to need help and not be able to get it," said Rushing, of Rowlett, Texas, whose daughter and granddaughter are also immunocompromised. "I don't want COVID. I don't want to give it to anybody, and I'm trying to do everything I can not to die from it."

Liz Szabo: lszabo@kff.org, @LizSzabo  

Opinion: I Write About America's Absurd Healthcare System. Then I Got Caught Up in It.

KFF Health News, January 25, 2022

A pharmacist in St. Louis said my new employer-provided insurance wouldn't cover insulin without something called a prior authorization.

This article was published on Tuesday, January 25, 2022 in Kaiser Health News.

By Bram Sable-Smith  

I got a hurried voicemail from my pharmacist in Wisconsin the day before Thanksgiving letting me know my insurance was refusing to cover my insulin.  

I had enough of the hormone that keeps me alive to last 17 days.

In my 10 years living with Type 1 diabetes, I've never really struggled to access insulin. But in my job reporting on the people left behind by our country's absurdly complex healthcare system, I've written about how insulin's steep cost leads to deadly rationing and about patients protesting to bring those prices down.

For the most part, though, I've been spared from the problems I cover. Maybe that's why I waited over a week to call my new pharmacy in St. Louis, where I recently moved for this job with KHN.

I'd been waiting since September for an appointment with an endocrinologist in St. Louis; the doctor's office couldn't get me in until Dec. 23 and wouldn't handle my prescriptions before then. When I finally called a pharmacy to sort this out, a pharmacist in St. Louis said my new employer-provided insurance wouldn't cover insulin without something called a prior authorization. I've written about these, too. They're essentially requirements that a physician get approval from an insurance company before prescribing a treatment.

Doctors hate them. The American Medical Association has a website outlining proposed changes to the practice, while the insurance industry defends it as protecting patient safety and saving money. It feels like a lot of paperwork to confirm something we already know: Without insulin, I will die.

I knew right away the prior authorization would be a problem. Since it was a Saturday when I learned about the need for the authorization, my best option was to call my old endocrinologist's practice that Monday morning and beg his staffers to fill out forms for their now former patient.

I had enough insulin to last seven days.

But late that afternoon, I got an automated message from the pharmacy about an insurance issue.

After spending 45 minutes on hold the next morning, I finally got through to the pharmacist, who said my insurer was still waiting for a completed prior authorization form from my physician. I called the doctor's office to give a nudge.

Four days' worth of insulin left.

The price of my prescription without insurance was $339 per vial of insulin, and I use about two vials per month. Normally, I pay a $25 copay. Without the prior authorization, though, I'm exposed to the list price of insulin, as is anyone with diabetes who lacks insurance, even if they live in one of the states with copay caps intended to rein in costs.

I called the pharmacy again on Thursday at 7:30 p.m., figuring it'd be less busy. I got right through to the pharmacist, who told me my insurer was still waiting on the prior authorization form. Friday morning, the diabetes nurse at my doctor's office said she'd check on it and call me back.

I'd be out of insulin the next day.

By this time, I was live-tweeting my attempt to refill my prescription and started to get the kind of messages that are familiar to anyone in what's known as the "diabetes online community." People in Missouri offered me their surplus insulin. Some suggested I go to Walmart for $25 insulin, an older type I have no idea how to safely use.

My new strategy was to use one of the programs that insulin manufacturers started recently to help people get cheaper insulin. The very same day, the U.S. House Committee on Oversight and Reform's Democrats released a report deriding these types of assistance programs as "tools to garner positive public relations, increase sales, and raise revenue."

But before I tried that option, I heard back from the nurse who had called the pharmacy (she had spent 25 minutes on hold) and learned that my new insurance wouldn't cover the brand of insulin I was using. The pharmacist was checking on a different brand.

Soon the pharmacist called: My insurance would cover the other brand. But the pharmacy might not have enough to fill my order. She said I should call a different branch of the chain. The first location I called was also out but pointed me to another one that had it.

With 12 hours' worth of insulin left, I walked out of that third store with my medicine in hand.

It took 17 days and 20 phone calls. But I know I'm lucky. My insurance really is exceptional, recent events aside. My boss insisted that being alive was part of my job as I spent hours on the phone during the workday. And my job is to be persistent as I puzzle through the labyrinth of U.S. healthcare.

The time wasted by me, the pharmacists, the nurses and probably some insurance functionaries is astounding and likely both a cause and a symptom of the high cost of medical care. The problem is also much bigger than that.

Insulin is the single most important resource in my life, and this is what I had to do to get it. But I know not everyone has my good fortune. I've interviewed the loved ones of people with Type 1 diabetes who could not get insulin, and it's not hard to imagine how my story could have ended just as tragically.

On Dec. 23, I finally saw my new doctor, who sent in a new prescription. That night, I got a message that my insurer was waiting on a prior authorization.

I had 17 days' worth of insulin left.

Bram Sable-Smith: brams@kff.org, @besables

Why Medicare Doesn't Pay for Rapid At-Home COVID Tests

KFF Health News, January 24, 2022

Finding the tests will be hard enough, but Medicare beneficiaries face an even bigger hurdle: The administration's new rule doesn't apply to them.

This article was published on Monday, January 24, 2022 in Kaiser Health News.

By Michelle Andrews

What group is especially vulnerable to the ravages of COVID-19 even if fully vaccinated and boosted? Seniors. And who will have an especially tough time getting free at-home COVID tests under the Biden administration's plan? Yes, seniors.

As of Jan. 15, private insurers will cover the cost of eight at-home rapid COVID tests each month for their members — for as long as the public health emergency lasts.

Finding the tests will be hard enough, but Medicare beneficiaries face an even bigger hurdle: The administration's new rule doesn't apply to them.

It turns out that the laws governing traditional Medicare don't provide for coverage of self-administered diagnostic tests, which is precisely what the rapid antigen tests are and why they are an important tool for containing the pandemic.

"While at this time original Medicare cannot pay for at-home tests, testing remains a critical tool to help mitigate the spread of COVID," a statement from the federal Centers for Medicare & Medicaid Services said. Medicaid and CHIP cover at-home COVID tests, with no cost to beneficiaries, based on a 2021 Biden administration mandate.

Medicare patients are left to seek free tests other ways, including through the administration's new website, COVIDtests.gov, and at community centers. The Medicare program does cover rapid antigen or PCR testing done by a lab without charging beneficiaries, but there's a hitch: It's limited to one test per year unless someone has a doctor's order.

More needs to be done, advocates say.

The administration has changed some Medicare rules during the pandemic, including improving access to telehealth services and nursing home care, said David Lipschutz, associate director and senior policy attorney at the Center for Medicare Advocacy.

"We know that the Medicare program has significant flexibility relative to the public health emergency, and it has demonstrated it has the ability to alter the rules," Lipschutz said. "We think they should find the flexibility to offer the COVID at-home tests for free."

Q: Why can't the Medicare program reimburse beneficiaries for the over-the-counter tests or pick up the tab at the pharmacy as commercial health plans will do?

The services the Medicare program pays for are spelled out in federal law.

"It generally excludes over-the-counter things," said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group. 

The public health emergency was recently extended 90 days, through mid-April, and the administration could yet decide to expand coverage. Some lawmakers in Congress are reportedly urging the administration to cover the tests.

It may not be a simple change, as these tests appear to fall into coverage gaps. Medicare Part A covers hospitalization, and Part B generally covers provider-based services like doctor visits and lab tests. Part D covers drugs.

"So there's a little bit of a question of where this type of benefit would fit," Schwarz said.

People in private plans sometimes pay upfront for services and then are reimbursed by their health plan. But that's not how Medicare works. The program pays providers, not beneficiaries. So that's another wrinkle that would have to be ironed out.

Q: So how can a Medicare beneficiary get free at-home COVID tests?

There are a couple of options. This week, the Biden administration launched a website, COVIDtests.gov, where anyone, including Medicare beneficiaries, can order free at-home COVID tests. One billion tests eventually will be available. Each residence initially can receive four tests.

Four tests is a far cry from the eight monthly tests that people with private insurance can be reimbursed for. But it's better than nothing, experts say, especially when preventing the spread of COVID requires repeated testing over a period of days.

"Four tests is not a lot of tests," said Juliette Cubanski, deputy director of the program on Medicare policy at KFF. "This is one of the most at-risk populations, and to not have the opportunity to buy at-home tests and get reimbursed puts this whole population on their back foot."

The Biden administration is also providing up to 50 million additional free at-home tests to community health centers and Medicare-certified health clinics.

But 50 million tests won't even provide one test apiece to the 62 million Medicare beneficiaries, Lipschutz said.

About 4 in 10 Medicare beneficiaries are in Medicare Advantage managed-care plans. These private plans may offer free at-home tests to members, but it's not required. Enrollees should check with their plans to see whether that's an option.

Q: What other free COVID testing options are available to Medicare beneficiaries?

In traditional Medicare, beneficiaries can get rapid antigen or PCR diagnostic tests without paying anything out-of-pocket if the test is ordered by a doctor or other healthcare provider and performed by a lab.

The federal government has set up more than 10,000 free pharmacy testing sites across the country that Medicare beneficiaries can visit as well.

With the recent extension of the public health emergency, the situation is fluid, and Medicare beneficiaries may yet get coverage for at-home COVID tests that's comparable to what privately insured people now have.

"This is all a moving target," Lipschutz said.

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

Vaccine Wars Ignite in California as Lawmakers Seek Stronger Laws

KFF Health News, January 24, 2022

Vaccine opponents say Democratic-led efforts to adopt stricter vaccine requirements are only helping propel their movement, handing them unparalleled momentum to build their ranks both in California and nationally.

This article was published on Monday, January 24, 2022 in Kaiser Health News.

By Angela Hart

SACRAMENTO — California is poised to become the front line of America's vaccination wars.

State lawmakers are drafting the toughest COVID-19 vaccine legislation in the country, backed by a new pro-vaccine lobbying force promising to counter anti-vaccine activists who have threatened government officials and shut down public meetings across the state. Legislators want to require most Californians to get the shots — not just schoolchildren and healthcare workers — and eliminate the exemptions that would allow many people to get out of them.

But vaccine opponents say Democratic-led efforts to adopt stricter vaccine requirements are only helping propel their movement, handing them unparalleled momentum to build their ranks both in California and nationally.

Vaccine opponents are focusing their ire on Democratic state Sen. Richard Pan of Sacramento, a pediatrician and the driving force behind three state vaccination laws passed since 2012. Prompted by outbreaks of pertussis and measles, the laws make it harder for schoolchildren to get out of childhood vaccinations.

"We have to be willing to take a stand," said Pan, who is developing legislation to crack down on COVID vaccine exemptions. "We need to be able to respond to this pandemic and future pandemics, but there is this asymmetrical warfare going on right now, and we're seeing the anti-vaccine movement trafficking in misinformation, threats, and violence."

The coming fight in California foreshadows looming vaccine battles across the country. President Joe Biden and Democratic governors are pressing vaccination as the most crucial public health measure for combating the coronavirus pandemic — while some prominent Republican governors cast doubt on the safety and value of vaccines, inciting anti-vaccination activists.

In California, the ultimate decision on toughening state vaccination laws will fall to Democratic Gov. Gavin Newsom, who is facing reelection in November after defeating a recall attempt last year.

Newsom has played to both sides recently. He has pushed tough vaccine mandates for groups such as healthcare workers, children, and teachers. But in nearly every pandemic-related press conference since October and on national TV, he has also reassured the public that they can receive medical, religious, and personal belief exemptions from his mandates.

"He's trying to be comforting and non-confrontational, but it sends a message that if you don't want to get the vaccine, don't get it," said Catherine Flores Martin, executive director of the California Immunization Coalition. "Gov. Newsom struggles with this — he's trying to have it both ways."

Pushing Mandates 'Aggressively'

Anti-vaccine demonstrations dominated Sacramento during California's last big vaccination fight, in 2019. In weekly rallies outside the Capitol, hundreds of activists railed against lawmakers, toting a portrait of Pan's face splattered in red. They shouted down lawmakers in legislative hearings and at one point hurled menstrual blood at state senators.

The fight that year was over Pan's bill to crack down on bogus medical exemptions for common childhood vaccinations against measles, polio, and other infectious diseases, which are required to attend in-person public and private school in California. Four years earlier, he spearheaded a law to ban personal belief exemptions for childhood vaccines.

But under state law, personal belief exemptions must be allowed for any newly required childhood vaccine unless the legislature passes a new law banning them.

Newsom issued a directive in October 2021 adding COVID vaccines to the list of required childhood immunizations — once federal officials fully authorize them for children. But because the legislature has not yet acted, Californians will be able to opt out by claiming the vaccines violate personal beliefs.

Pan and other Democratic lawmakers want to close that loophole this year, and potentially eliminate religious exemptions that healthcare workers can claim. They're also considering requiring a broad swath of Californians to get COVID vaccines to participate in much of daily life.

Lawmakers are still hashing out details but are expected to propose legislation requiring COVID vaccines for people to be in workplaces, schools, and public venues like malls, museums, and restaurants — without allowing them to avoid the shots through exemptions. Pan, who is leaving the legislature after this year because of term limits, may also push legislation to hold tech companies more accountable for spreading misinformation on social media platforms.

"Do you have the right to be safe at school? Do people deserve to be safe at work? Are businesses responsible for creating an environment that won't injure or harm you? This has to be part of the conversation," said Pan, who was shoved by a protester near the Capitol in 2019.

Last year, Buffy Wicks, a Democratic Assembly member from Oakland, and Evan Low, a Democratic Assembly member from Campbell, tried but failed to muscle through legislation establishing COVID vaccine mandates for workers and businesses. But the ongoing challenges of the pandemic have "reenergized" Democratic lawmakers this year, said state Sen. Scott Wiener (D-San Francisco), who is carrying legislation to lower the age at which someone can consent to a vaccine without parental permission from 18 to 12.

"It's important that we continue to push for vaccine mandates the most aggressively we possibly can," said Wicks, who faced death threats over her vaccine legislation last year. "We can't let ourselves be held hostage by these right-wing conspiracy theorists who are perpetrating hate and violence."

'The Firestorm Is Here'

Anti-vaccine activists acknowledge they may not succeed at defeating new legislation but welcome state lawmakers' attempts to impose stricter rules — they argue it helps them build a larger movement in California, on social media, and in other states.

"What they don't realize is the point of these rallies and protests is to bring more people into the fold, from all around the country," said Stefanie Fetzer, a chief organizer of the 2019 anti-vaccination demonstrations at the state Capitol. "Senator Pan galvanized a larger anti-vax movement that wouldn't have happened without him."

Scientists and health officials blame California's stagnating COVID vaccination rate largely on the anti-vaccine movement, which is peddling misinformation and lies. The share of Californians who are considered fully vaccinated is 69%, and booster shots are lagging — even though the state and local governments have plowed tens of millions of dollars into vaccination campaigns.

"What you see now is this movement being taken over by Republicans and this libertarian right-wing notion of individual rights and 'get government off my back.' They're believing and spreading this misinformation even though it's disproven," said Dr. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia. "Trying to stop it is like trying to stop Niagara Falls."

Vaccine opponents have also shut down government meetings and lobbed violent threats at officials backing mandates.

The Los Angeles Unified School District delayed its student vaccine mandate after anti-vaccine demonstrations, in an effort to keep unvaccinated students from dropping out. In Stockton and elsewhere, vaccine opponents have shouted down proposed school vaccine mandates.

Joshua Coleman, who organized hundreds of protesters in 2019 under his group V Is for Vaccine, has held rallies in Sacramento this year, again targeting Pan with a 10-foot poster and his image smeared in red.

"There will be constant pressure," Coleman said. "This is happening more and more all over the country, but we are building a movement out of California. Being forced to take a vaccine in order to participate in society is absolutely totalitarian."

Vaccine supporters realize they must fight back and are launching a lobbying campaign, led by political heavyweights from Sacramento and Washington, D.C., to combat vaccine opponents with some of their own tactics.

"The firestorm is here. This is ground warfare that the anti-vax extremists are bringing, and I think we need to be able to match it," said Crystal Strait, the former president and CEO of Planned Parenthood Affiliates of California who is leading the campaign under the group ProtectUS.

Campaign leaders are organizing students, parents, and pro-vaccine activists to counter anti-vaccination demonstrators in cities and counties across California and to debunk misinformation while giving state lawmakers political cover to enact tougher laws.

"We need to draw a really bold, bright line and let these extremists know that we will not be silent," Strait said.

The campaign emerged quietly last year, sponsoring a new law to limit protests outside vaccination clinics — which has since been blocked in court — and will launch ground-game political efforts this year.

"The science is on our side, and there's a silent majority on our side, but we're being drowned out in public forums where these decisions are being made," said Rose Kapolczynski, a longtime political consultant to former U.S. Sen. Barbara Boxer, who is working on the campaign. "We're going to activate the pro-vaccine majority when policies are being considered at the state and local levels."

Whither Newsom?

Newsom is also wading into the fray.

His administration has plowed $145 million into a campaign to increase COVID vaccinations and fight misinformation, in part by monitoring social media posts and flagging vaccine myths to social media companies. The administration is also developing a pro-vaccine counternarrative based on the misinformation.

"We want to be proactive about what the truth is and put it out there while debunking misinformation," said Dr. Mark Ghaly, secretary of the state's Health and Human Services Agency.

More than half a dozen public health experts interviewed for this story said that vaccine mandates work and that Newsom can boost the state's faltering vaccination rates by eliminating exemptions.

But since Newsom announced the COVID vaccine mandate for schoolchildren, he has publicly promoted exemptions.

"The mandate we put in place for the state of California includes personal exemptions," Newsom said during an appearance on "Good Morning America" in December. "There's plenty of latitude for families to make decisions."

Newsom has declined to say whether he would support legislation banning exemptions but said he'd work with lawmakers. "We can discuss the merits and demerits" of allowing exemptions, Newsom said this month. "We did what we felt was appropriate."

Barbara Ferrer, the public health director for Los Angeles County, which has recorded nearly 28,000 COVID deaths, more than a third of the state's total, called on Newsom and state lawmakers to adopt mandates without exemptions.

"If you allow that, you may as well not have a vaccine mandate," she said. "If you don't want your child to get vaccinated, then your child doesn't have to go to school. And you don't have to go to a restaurant. I'm not trying to be mean to people. I'm just saying there are some things you shouldn't be able to do if you're not vaccinated."

Angela Hart: ahart@kff.org, @ahartreports

The Doctor Didn't Show Up, but the Hospital ER Still Charged $1,012

KFF Health News, January 24, 2022

Many patients don't understand that they can rack up huge bills almost as soon as they walk through the doors of an ER.

This article was published on Monday, January 24, 2022 in Kaiser Health News.

By Noam N. Levey

Dhaval Bhatt had been warned about hospital emergency rooms.

"People always told me to avoid the ER in America unless you are really dying," said Bhatt, an immigrant from India who got a Ph.D. in pharmacology in the U.S. and is now a research scientist at Washington University in St. Louis.

But when Bhatt's 2-year-old son burned his hand on the kitchen stove on a Wednesday morning in April, the family's pediatrician directed them the next day to the local children's hospital.

Bhatt was traveling. So, his wife, Mansi Bhatt, took their son to the hospital and was sent to the emergency room. A nurse took the toddler's vitals and looked at the wound. She said a surgeon would inspect it more closely.

When the surgeon didn't appear after more than an hour, Bhatt's wife took her son home. The hospital told her to make a follow-up appointment with a doctor, which turned out to be unnecessary because the burn healed quickly.

Then the bill came.

The Patient: Martand Bhatt, a toddler covered by a UnitedHealthcare insurance plan provided by the employer of his father, Dhaval Bhatt.

Medical Service: An emergency room visit for a burn sustained when Martand touched an electric stove.

Total Bill: $1,012. UnitedHealthcare's negotiated rate was $858.92, all of which the Bhatts were responsible for because their plan had a $3,000 deductible.

Service Provider: SSM Health Cardinal Glennon Children's Hospital, one of 23 hospitals owned by SSM Health, a Catholic, nonprofit health system with more than $8 billion in annual revenue.

What Gives: Many patients don't understand that they can rack up huge bills almost as soon as they walk through the doors of an ER.

Unlike a restaurant or a mechanic who won't charge if someone gets tired of waiting for a table or an inspection of a rattling engine, hospital emergency rooms almost invariably charge patients as soon as they check in.

And once they register, patients will be billed — often a lot — whether treatment was rendered or not.

Martand Bhatt received almost no medical service. A nurse practitioner looked over the toddler, listened to his heart and stomach, and looked in his nose, mouth and ears, according to provider notes prepared by the hospital and shared with KHN by Bhatt.

The nurse didn't change the dressing on the wound or order any testing.

"My objection to this is that there was no care provided," Bhatt wrote to Bill of the Month.

"My wife did not drive for 45 minutes to get to an ER and wait for an additional 1½ hours for someone to tell me that our child's vitals — weight, height, temperature and blood pressure — were OK," Bhatt continued. "We already knew that. … It is absolutely ridiculous and unethical."

When the Bhatts left the emergency room, Martand was "alert, active and well-appearing," according to the notes.

The nurse's assessment of Martand cost $192, which was discounted by UnitedHealthcare to a negotiated rate of $38.92. The bulk of the Bhatts' bill — $820 — was something called a facility fee.

Hospital officials defend these fees as necessary to keep the emergency room open 24 hours a day as a community asset.

SSM Health spokesperson Stephanie Zoller Mueller declined to discuss the details of Martand's medical condition even though the Bhatts gave their permission for the hospital to do so.

In an email, Zoller Mueller said the charges were "appropriate" based on the "acuity of condition, discharge instructions, vital sign monitoring, traumatic wound care (and) numerous assessments."

She added: "A patient does not have to receive additional treatment — procedure, labs, x-rays, etc. — to validate an ED [emergency department] level charge."

But some patient advocates say these facility fees are applied much too widely and should be limited to patients who actually receive medical care.

"It's just not appropriate for someone to be charged if they're not provided treatment," said Adam Fox, deputy director of the Colorado Consumer Health Initiative. "Patients aren't availing themselves of a facility if they don't get care."

At the very least, hospitals could communicate more clearly to patients about the fees they may be charged for coming to an emergency room, said Maureen Hensley-Quinn, senior program director at the National Academy for State Health Policy.

"People should know that when they walk in to receive care, there is this fee that they will be assessed," Hensley-Quinn said.

Hospitals could also post at the entrance to the ER standard fees for different levels of emergency care.

Bhatt's fee still could have been lower if the hospital had classified his son's injury as minor. But, again, the hospital billing process worked against the family … and in favor of the hospital's bottom line.

Emergency visits are usually classified for billing on a scale from 1 to 5. Level 1 is minor and routine; Level 5 requires complex care for life-threatening conditions. And hospitals are increasingly using the highest-severity codes to classify emergency visits, research shows.

"There are financial incentives for billing at a higher severity," said Aditi Sen, who directs policy and research at the nonprofit Healthcare Cost Institute, which has studied emergency room coding.

Despite the lack of severity of Martand's wound and the absence of medical care, his visit was classified as Level 3, a moderate severity problem.

Resolution: Incensed that he'd been charged so much, Bhatt made numerous attempts to get the hospital to reduce the charges. He also appealed to UnitedHealthcare to review the charges.

His efforts failed. In August, Bhatt received a letter from an SSM Health "patient advocate" informing him that the hospital would not adjust the bill and instructing him to contact patient billing to arrange for payment.

While Bhatt was trying to reach the patient advocate by phone, his bill was sent to Medicredit, a collection agency, which began sending him notices and calling him.

After KHN contacted SSM Health, Bhatt received a call from someone who worked on "patient financial experience" issues at the hospital.

The hospital agreed to forgive the $820 facility fee. Bhatt agreed to pay the remaining $38.92, the professional fee for the ER nurse's work. Bhatt also received a notice from Medicredit that it would take no further action against him.

The Takeaway: The Bhatts did what most parents would do when a pediatrician advises them to take their child to the hospital.

But emergency rooms are among the most expensive places to get care in the U.S. health system.

If you have a relatively low-level issue, think twice before even registering at the front desk, the act that initiates the billing process. If your doctor doesn't have same-day appointments or after-hours service, think about urgent care, which is often much cheaper if the center isn't attached to a hospital.

And remember that if you go to a hospital emergency room with a relatively minor issue, chances are that you'll have to wait, as the Bhatts did. Patients with more serious problems will be seen first.

Once you're taken past the front desk, you will almost certainly be hit with a substantial facility fee even if you don't receive care.

Appealing that fee to the hospital can occasionally be successful, but there are no guarantees. And, as Bhatt learned, don't expect the health insurer to offer much help. Most insurers won't challenge how a medical visit is coded except on extremely expensive medical claims that will cost them money.

In this case, Bhatt was on the hook for the whole fee because he had a high-deductible plan, so the insurer had little incentive to take up his cause.

For now, patients' best hope, many advocates believe, is to publicize the high prices that hospitals charge for their services, inside and outside the emergency room.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Send Us Your Medical Bills

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR 'Bill of the Month' Club and tell us about your experience. We'll feature a new one each month.

Submit Your Bill

Noam N. Levey: nlevey@kff.org, @NoamLevey

Patient, Beware: Some States Still Pushing Ineffective COVID Antibody Treatments

KFF Health News, January 21, 2022

Use of the newly ineffective treatments produced by Regeneron Pharmaceuticals and Eli Lilly and Co. is highest in a dozen states.

This article was published on Friday, January 21, 2022 in Kaiser Health News.

By JoNel Aleccia

As the omicron variant completes its sweep across the U.S., states with scarce supplies of monoclonal antibody therapies continue to use two treatments that federal health officials warn no longer work against the highly contagious version of the virus that causes COVID-19. The antibody treatment now most recommended is sotrovimab from GlaxoSmithKline and Vir Biotechnology, and it's in short supply.

Use of the newly ineffective treatments produced by Regeneron Pharmaceuticals and Eli Lilly and Co. is highest in a dozen states. They include several Southern states with some of the nation's lowest vaccination rates, but also California, which ranks in the nation's top 20 for fully vaccinated residents, a KHN analysis of federal data shows. Many hospitals and clinics are still infusing the costly treatments — often charging hundreds of dollars a session — that public health officials now say are almost certainly useless.

That's because of the near-total dominance of omicron, which accounted for 99.5% of new COVID infections in the U.S. during the week that ended Jan. 15, according to the Centers for Disease Control and Prevention.

That point was underscored this week by updated guidelines from the National Institutes of Health that now recommend sotrovimab as the primary monoclonal treatment for the disease.

Unless providers are certain they are still treating patients infected with the delta variant, they shouldn't use the others, said Dr. Mark McClellan, director of the Duke-Margolis Center for Health Policy, who is also a former commissioner of the FDA and former administrator of CMS. And the delta variant is increasingly rare, accounting for 3% of cases in Louisiana, 7% in California, and 10% in Ohio, as examples.

"There's not a medical justification based on the evidence on the Regeneron and Lilly products," McClellan said.

Determining which patients are infected with the delta vs. omicron variant is complicated, said Dr. Christian Ramers, chief of population health and an infectious disease specialist at Family Health Centers of San Diego.

His clinic is one of the few sites in the nation using laboratory screening of positive PCR COVID tests that can tell whether patients are infected with delta vs. omicron — and then treating them accordingly. "Otherwise, you're giving this false sense of security to a patient that they're getting treatment," Ramers said. "I don't think it is ethical, and it goes against the principle of doing no harm."

Overall, U.S. hospitals used about 72,000 doses of the Regeneron and Lilly monoclonal antibody therapies from Jan. 5 through Jan. 18, according to the latest figures from the Department of Health and Human Services. Data regarding hospital-level use of sotrovimab, which became available more recently than the other products, is not yet available on the HHS site.

By comparison, hospitals used about 153,000 courses of the Regeneron and Lilly treatments from Dec. 22 through Jan. 4. They used about 169,000 courses from Aug. 26 through Sept. 8, near the height of the delta surge.

On Jan. 19, hospitals still had about 295,000 doses of the Regeneron and Lilly treatments on hand.

Nationwide, the federal government is distributing more than 50,000 courses of sotrovimab per week, though it remains in short supply. The Biden administration has agreed to buy about 1 million doses, including about 600,000 promised by March, GSK officials said.

Respectively, Michigan, Florida, Indiana, Missouri, Louisiana, California, Oklahoma, Kansas, Georgia, Ohio, New York, and Mississippi used the most courses of the Regeneron and Lilly treatments from Jan. 5 through Jan. 18, KHN's analysis showed.

In Florida, which used more than 5,200 courses of the outdated treatments during that two-week period, Republican Gov. Ron DeSantis has said he is not convinced that the Regeneron and Lilly products don't work against omicron. In Florida, omicron accounted for 97% of cases as of Jan. 20; delta accounted for 3%.

"We have had practitioners give both of those to people with omicron who said the symptoms got resolved," he said in a Jan. 5 speech provided by his spokesperson, Christina Pushaw.

Federal health officials managing allocation of the monoclonal antibody therapies paused shipments of the Regeneron and Lilly treatments on Dec. 23, after laboratory tests showed they were less effective against the surging omicron variant than the delta variant. But the Biden administration resumed shipments on Dec. 31, after complaints from DeSantis and some doctors that those therapies could still help people in places where the delta variant persisted.

Regeneron itself has said its antibody treatments are ineffective against the omicron variant. It contains more than 30 mutations in the virus's spike protein, which makes the variant better at dodging the monoclonal antibody treatments.

"It's really not justified at this point unless there's some other underlying secondary gain, political pressure, or perhaps the providers are truly not in touch with the reality of the variant proportions," Ramers said.

Earlier this month, HHS officials indicated that shipments of the three monoclonal antibody treatments would continue through Jan. 31, despite the growing proportion of omicron cases. A department spokesperson on background said the agency would continue to assess "any impacts to COVID-19's therapeutic allocations."

Monoclonal antibody treatments are lab-based molecules that mimic the body's immune response to infection. They are most often given through IV infusion, though some can be delivered with an injection. The federal government has agreed to purchase millions of doses of the Regeneron and Lilly products at a cost of about $2,100 per dose. The medicines are free to consumers, though hospitals and clinics do charge fees for administering the drugs and monitoring patients during the process.

Other treatments expected to be effective against omicron in high-risk, non-hospitalized patients include AstraZeneca's Evusheld, a long-acting injectable monoclonal antibody for immunocompromised people, and a three-day infusion of Gilead Sciences' remdesivir, which is approved by the FDA. New oral antiviral pills also are expected to be effective, although they, too, remain in short supply.

Providers in several states that have continued to use the Regeneron and Lilly products have offered varied reasons. Some said they believed delta infections continued to circulate locally; others said they felt desperate to try something.

Officials in Michigan, which used more than 5,800 doses of the Regeneron and Lilly products during the most recent two weeks, and California, which used more than 3,400, have allowed healthcare providers to use their clinical judgment about which treatment to prescribe.

But in Mississippi, where omicron is rampant and fewer than half of residents have been fully vaccinated, state health officer Dr. Thomas Dobbs called for an end to the use of the treatments.

"We will be recommending that clinicians and physicians do not use these products right now based on the distribution of omicron vs. delta," he said during a recent press conference.

At Ramers' clinic in San Diego, care providers have been dispensing scarce doses of the monoclonal antibody treatments only when they're confident they'll help. That has meant sending batches of positive PCR tests to a laboratory in nearby Irvine, where they are screened to see whether one of three target genes is not detected, a known marker for an omicron infection.

Patients infected with the delta variant were able to be treated with REGEN-COV, the Regeneron product, preserving sotrovimab for the growing number of omicron cases, said Pauline Lucatero, the clinic's director of nursing.

"Looking into my patients' eyes and seeing fear, just fear, all I could tell them is we believe this treatment works and we're going to do everything we can to save as many people as we can," she said.

Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Wildfires and Omicron Prompt a Special Health Insurance Enrollment Period in Colorado

KFF Health News, January 20, 2022

The move underscores how much industry attitudes toward the Affordable Care Act have changed.

This article was published on Thursday, January 20, 2022 in Kaiser Health News.

By Markian Hawryluk

A wildfire displaced thousands of Coloradans just as the omicron surge began sweeping through the state, so health insurance was likely not on many people's minds when the regular enrollment period for the state's health insurance marketplace ended Jan. 15. But now, because of those twin emergencies, everyone in the state will get another chance to sign up.

State officials on Wednesday launched a special marketplace enrollment period, through March 16, open to all uninsured Coloradans regardless of whether they've been directly affected by the fire or the COVID-19 surge.

The Marshall Fire started on Dec. 30, just two weeks before the deadline to sign up for a 2022 plan. The fire destroyed more than 1,000 houses and businesses, quickly becoming the state's most destructive fire by number of structures lost. 

"It's such a disruption to people's lives," Colorado Insurance Commissioner Michael Conway said. "It's not just the people who lost their homes — it's across the board, affecting the entire community."

Meanwhile, the emergence of the omicron variant of the coronavirus caused COVID cases to spike to record levels in January, stressing hospitals and health systems.

"These folks are just trying to put their lives back together," said Kevin Patterson, CEO of Connect for Health Colorado, the state's health insurance marketplace, created under the Affordable Care Act. "So giving them some additional time seemed like a reasonable and thoughtful thing to consider."

In addition to providing immediate relief to Coloradans in a crisis, the move underscores how much industry attitudes toward the Affordable Care Act have changed. Insurance companies were initially skeptical about the financial risks and worried that consumers would game the system. But the insurers have largely embraced the exchanges and are working to sign up as many people as possible. After experiencing few problems during the special enrollment period held last year because of COVID, health plans have agreed to the removal of safeguards — such as a limited window of time to sign up for coverage — that regulators once required.

"Amid the recent COVID-19 surge and tragic wildfires, it is important that people in Colorado have the opportunity to obtain healthcare coverage," Patrick Gordon, CEO of the Rocky Mountain Health Plans, said in an email.

Special enrollment periods have been used in California because of wildfires, in Maine when strong winds knocked down power lines, and in Gulf states hit by Hurricanes Harvey, Irma, and Maria. 

Such periods have often been limited in scope and sometimes required people to provide proof they had been affected.

Colorado state officials are taking a different route. They opted to make signing up for coverage as easy as possible and are not requiring consumers to demonstrate they qualify.

"It didn't seem like something that was necessary, especially when we look at our experience over the last year," Conway said. "The vast majority of the year was effectively a special enrollment period, and there wasn't that much disruption in the market."

Insurance analyst Charles Gaba said there are three primary reasons for limiting health plan sign-ups to an open enrollment period.

The first is that deadlines spur people to sign up. Each year, enrollment numbers spike in the final days of the sign-up period. 

Second, insurance companies need time to analyze their revenue and costs to set premiums for the following year. That process, Gaba said, typically begins in March. 

Third, and most importantly, insurance companies initially lobbied for a limited open enrollment period to keep people from waiting until they are sick to buy insurance. That changed during the pandemic. Colorado and most other states that run their own exchanges held special enrollment periods in 2020 and 2021 because of COVID. When the Trump administration declined to do the same for the federal exchange, health insurance trade groups urged it to reconsider. The incoming Biden administration agreed and extended the enrollment period through August 2021 — and more than 2.8 million additional Americans signed up for coverage.

Conway said no evidence exists that consumers waited until they were sick to buy coverage last year. With so many consumers eligible for no-cost or low-cost plans because of more generous subsidies, there is little reason for them not to sign up immediately.

"As health policy folks, sometimes we get into our heads and we see monsters under the bed that simply are not there because of the complexity of the system," Conway said.

Health plans in Colorado were largely supportive of the move. John Roble, president of Cigna's Mountain States market, said the company is allowing early prescription refills and is working with local hospitals to transfer patients to help alleviate crowding at overwhelmed facilities.

Past special enrollment periods largely attracted a healthier population than standard open enrollment periods. Those with chronic health conditions, who face the potential of high medical bills, usually enroll early in the standard open enrollment period. 

"They are first out of the gate," said Louise Norris, who operates a Colorado health insurance brokerage with her husband. "They're ready to sign up Nov. 1."

The procrastinators are those generally less concerned about their health and more apt to leave things to the last minute, she said. The added time will also help people who chose to go without insurance but then experience a significant medical problem after the standard open enrollment period closes, she said.

State officials said new health concerns stemming from the fires and the omicron surge may also make health coverage more important for some Coloradans.

Consumers benefit when more people, particularly more healthy people, enroll. "The more people that get covered, the more stable the overall risk pool is, the more stable the premiums are for consumers," said Adam Fox, deputy director of the Colorado Consumer Health Initiative, a nonprofit consumer advocacy group. "All of those things help people stay covered."

States that run their own exchanges often extend the deadline for signing up another week or two to give late-comers extra time. But it's not clear whether any other states will follow Colorado's example and provide a two-month or longer window in response to the omicron surge.

"Without the fires, I'm not sure that they would be thinking about it," Conway said.

Markian Hawryluk: MarkianH@kff.org, @MarkianHawryluk

5 Things You Should Know About 'Free' At-Home COVID Tests

KFF Health News, January 19, 2022

You can either get a test without any out-of-pocket expense from retail pharmacies that are part of an insurance company's network or buy it at any store and get reimbursed by the insurer.

This article was published on Wednesday, January 19, 2022 in Kaiser Health News.

By Damon Darlin  

Americans keep hearing that it is important to test frequently for COVID-19 at home. But just try to find an "at-home" rapid COVID test in a store and at a price that makes frequent tests affordable.

Testing, as well as mask-wearing, is an important measure if the country ever hopes to beat COVID, restore normal routines and get the economy running efficiently. To get Americans cheaper tests, the federal government now plans to have insurance companies pay for them.

The Biden administration announced Jan. 10 that every person with private insurance can get full coverage for eight rapid tests a month. You can either get one without any out-of-pocket expense from retail pharmacies that are part of an insurance company's network or buy it at any store and get reimbursed by the insurer.

Congress said private insurers must cover all COVID testing and any associated medical services when it passed the Families First Coronavirus Response Act and the Coronavirus Aid, Relief and Economic Security, or CARES, Act. The have-insurance-pay-for-it solution has been used frequently through the pandemic. Insurance companies have been told to pay for PCR tests, COVID treatments and the administration of vaccines. (Taxpayers are paying for the cost of the vaccines themselves.) It appears to be an elegant solution for a politician because it looks free and isn't using taxpayer money.

1. Are the tests really free?

Well, no. As many an economist will tell you, there ain't no such thing as a free lunch. Someone has to pick up the tab. Initially, the insurance companies bear the cost. Cynthia Cox, a vice president at KFF who studies the Affordable Care Act and private insurers, said the total bill could amount to billions of dollars. Exactly how much depends on "how easy it is to get them, and how many will be reimbursed," she said.

2. Will the insurance company just swallow those imposed costs?

If companies draw from the time-tested insurance giants' playbook, they'll pass along those costs to customers. "This will put upward pressure on premiums," said Emily Gee, vice president and coordinator for health policy at the Center for American Progress.

Major insurance companies like Cigna, Anthem, UnitedHealthcare and Aetna did not respond to requests to discuss this issue.

3. If that's the case, why haven't I been hit with higher premiums already?

Insurance companies had the chance last year to raise premiums but, mostly, they did not.

Why? Perhaps because insurers have so far made so much money during the pandemic they didn't need to. For example, the industry's profits in 2020 increased 41% to $31 billion from $22 billion, according to the National Association of Insurance Commissioners. The NAIC said the industry has continued its "tremendous growth trend" that started before COVID emerged. Companies will be reporting 2021 results soon.

The reason behind these profits is clear. You were paying premiums based on projections your insurance company made about how much healthcare consumers would use that year. Because people stayed home, had fewer accidents, postponed surgeries and, often, avoided going to visit the doctor or the hospital, insurers paid out less. They rebated some of their earnings back to customers, but they pocketed a lot more.

As the companies' actuaries work on predicting 2023 expenditures, premiums could go up if they foresee more claims and expenses. Paying for millions of rapid tests is something they would include in their calculations.

4. Regardless of my premiums, will the tests cost me money directly?

It's quite possible. If your insurance company doesn't have an arrangement with a retailer where you can simply pick up your allotted tests, you'll have to pay for them — at whatever price the store sets. If that's the case, you'll need to fill out a form to request a reimbursement from the insurance company. How many times have you lost receipts or just plain neglected to mail in for rebates on something you bought? A lot, right?

Here's another thing: The reimbursement is set at $12 per test. If you pay $30 for a test — and that is not unheard of — your insurer is only on the hook for $12. You eat the $18.

And by the way, people on Medicare will have to pay for their tests themselves. People who get their healthcare covered by Medicaid can obtain free test kits at community centers.

A few free tests are supposed to arrive at every American home via the U.S. Postal Service. And the Biden administration has activated a website where Americans can order free tests from a cache of a billion the federal government ordered.

5. Will this help bring down the costs of at-home tests and make them easier to find?

The free COVID tests are unlikely to have much immediate impact on general cost and availability. You will still need to search for them. The federal measures likely will stimulate the demand for tests, which in the short term may make them harder to find.

But the demand, and some government guarantees to manufacturers, may induce test makers to make more of them faster. The increased competition and supply theoretically could bring down the price. There is certainly room for prices to decline since the wholesale cost of the test is between $5 and $7, analysts estimate. "It's a big step in the right direction," Gee said.

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