Letter: More coverage needed on ‘off-market health plans’

Graphic by Lori Deaton

I am stating my concerns about overpromoting Blue Cross and Blue Shield of North Carolina’s health plans — especially as the “go-to” health plan — in the article “Coverage Connection: Residents May See Lower Rates, Plan Changes for 2020 Health Insurance” [Nov. 20, Xpress]. I am reaching out to those who get their plans through the Affordable Care Act via healthcare.gov. New competitors to Western North Carolina should not be totally discounted. We need more articles to further explain “off-market health plans” and what they do and do not mean. This article discounts the plans across the board with evaluation.

Only three U.S. states — California, Florida and Texas — have ACA exchange enrollment numbers higher than North Carolina. In 2018, the average number of participating insurers per state was 3.5, while North Carolina had one choice. Blue Cross and Blue Shield of North Carolina had at least 10 executives who were paid more than $1 million dollars, topped by the chief executive officer, who was paid $3.6 million dollars — and is essentially a monopoly in Western North Carolina.

Blue Cross financials are in plain English. In 2018, the leadership at Blue Cross chose to raise premiums 14.1%, resulting in their final report that “the Affordable Care Act line of business … performed better than forecasted” and was “a key driver of Blue Cross NC’s 2018 performance” (March 1, 2019, financial announcement). In fact, the 2018 profit was “too good” by federal law that it exceeded capped federal profits set by the U.S. government.

Since the federal government requires a correction, “$75 per person on average” was sent back via check to [about 700,000] customers for a total of [about $52.4 million] in “excessive premiums.” What’s most important, Blue Cross originally asked for a 22.9% rate increase and got the 14.1%, so that rebate check would have been bigger (8.8% more greed than the approved 14.1%).

Blue Cross could try to blatantly say — in plain English — “We saved you money,” but that’s not true. In this monopoly, Blue Cross collected too much of your dollars in the first place, and that’s the problem. We could have used that money for other bills. For 2019, the plans offered a 4.1% decrease in premiums. For 2020, an additional 3% decrease in premiums for individual plans (WNC). The pain point to one’s bank account: a 7% net increase in total premiums and severe restrictions to what is and is not covered (preapproval, denials, procedure limitations, out of network, in network, etc.).

Think about how much you spent in premiums, copays and deductibles. And, think about relating your dollars to Blue Cross “plain English” statement that the “average claims per person climbed to an average of $5,326 per fully insured person.” Blue Cross also grew its reserves from 3.7 to 4.81 months, which is higher than the three-[month] state minimum. That is your money being “saved” for future people instead of being used to provide you and your family health care that year.

If you feel the medical system is breaking your bank, here is the evidence. Blue Cross does everything in plain sight and in plain English. I find what’s happening is unbearable to people of Western North Carolina, and we need to talk about what’s happening. We need to continue to be educated. We need to let people know when there is choice and why it works for them and why there are risks. I do not think it’s fair to discount “off-market health plans” from a full discussion.

— Joel C. Harder

Editor’s note: Xpress always appreciates hearing feedback from our readers. In this case, though the article in question devoted more space to discussing BCBS’s plans, we don’t think we’ve given short shrift to covering off-market plans, which were explored extensively in last fall’s article, “To Your Health: Local Experts Explain Insurance Market Changes, Urge Enrollment Before Dec. 15 Deadline.” At this time, we don’t have plans for another article on the topic.


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2 thoughts on “Letter: More coverage needed on ‘off-market health plans’

  1. henry

    I was looking for at least a list of off-market plans, since that seemed to be the focus of this letter. Would inclusion of discussion of those plans be central here?

  2. joelharder

    Remember – Blue Cross/Blue Shield CHOSE to raise premiums SO HIGH that they were forced to SEND A REFUND CHECK to every customer for EXCESSIVE PREMIUMS.
    Remember – Blue Cross didn’t want to raise premiums 13% – they ORIGINALLY ASKED to raise premiums 22%. Blue Cross/Blue Shield is doing their work in PLAIN SIGHT and in PLAIN ENGLISH.

    UnitedHealthcare: https://www.uhc.com/individual-and-family/health-insurance-north-carolina
    UHC Golden Rule Insurance Plan is targetting the most healthy people (typically 19+ years olds) who don’t have pre-existing conditions (as defined in the Affordable Care Act), don’t need mental health service needs, are not substance abusers, don’t have dependents and don’t plan to become pregnant. Do some research on “Golden Rule Insurance Company.”

    The plan defines pre-existing condition as “a condition for which medical advice, diagnosis, care or treatment was recommended or received within 12 months immediately preceding the date the covered person became insured under this policy; a condition that had manifested itself within the 12 months immediately preceding the date the covered person became insured under this policy; or a pregnancy existing on the effective date of coverage.” Diabetes, Congestive Heart Failure, etc. should not apply.

    It’s “short-term,” used for up to 12 months in North Carolina, and has been used for both students post-college (just off their parent’s plan) and those who just lost their jobs. The problem (and it’s a big one) is that you are penalized for going out-of-network [so LOOK-UP the right doctor!].

    The gain for the average person is you are protected by negotiated in-network rates. You can read this plan and understand the terms and conditions. You can’t read Blue Cross/Blue Shield’s plan — I think they have GAMED us with coded language. A lot more procedures require pre-approval through Blue Cross and denial is happening all too often.

    Everyone’s situation is different. I was thinking about the average restaurant worker. When I looked, the most expensive plan for single person (non-tobacco user) is $7260/year, $2000 out-of-pocket maximum, $1000 deductible, 80/20 co-insurance- inpatient hospital/outpatient surgery/labs/x-rays. Urgent Care: $75 co-pay (no limits). 4x Doctors visits (no referral needed): $75 specifically for illness/injury ONLY (preventative care limited to mammography, pap smear and PSA). Emergency Care: $5K – includes everything (not a lot of $). Spine/Back Disorders: $2.5K for the term of the plan (in-patient). Home Healthcare $75 co-pay per visit. 7 visits per week. 365-lifetime maximum. $25 for prescriptions (up to $5K). Double Check the work. You can add: Telemedicine, Vision, Dental, and Accident.

    What I didn’t like: If you have a lot of prescriptions, this isn’t a good plan. If you have an accident, you are screwed by paying the costs. Nothing about imaging (MRI, CAT scans, etc.). You can’t go to the doctor for a wellness check. You can’t go to specialist for a pre-existing condition that occurred before 12 months. There is no mental health support.

    Why I think it’s important: I don’t think you can pay the insurance company, the high deductibles and not work anymore. It’s too much money compared to all the other expenses. For a single person, The Blue Cross/Blue Shield “Gold” Plan had a 7500K deductible plus nearly $700/month in Insurance Premiums. This didn’t include Dental, Vision, Telemedicine. Accident.

    I’m glad it was noted. Back in 2018: Mountain XPress and Pisgah Legal did speak to Off Market Plans in “Local Experts Explain Insurance Market Changes, Urge Enrollment Before Dec. 15 deadline” (December 1, 2018) (by Brooke Randle):

    The Reporter wrote:
    “Fifty-eight-year-old Asheville resident Colleen Troy, who owns a fitness cycling company for people 50 and older, says she switched to a short-term plan for 2018 when her small-business income exceeded what would qualify for subsidies under the Affordable Care Act. Without the subsidies, the costs of the plans rose out of reach.

    “The first two years, we were with the ACA, and so that worked out OK,” Troy says. “But this year, when I started looking at the plans back in December [2017], the Blue Cross Blue Shield plans that we had been with, the premiums were skyrocketing. We went from paying a couple hundred dollars a month in insurance to over $1,000.”

    Troy says that she and her husband, Mark, maintain active and healthy lifestyles, which allows them to feel confident in choosing plans that don’t include comprehensive coverage.

    “We’re both thankfully in very good health. We don’t have pre-existing conditions — that’s the biggest thing,” Troy says. “I’m glad to have the option.”

    I’m glad they posted my Letter To The Editor.

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