Medicare: Why an Advisor Makes All the Difference

Often those approaching Medicare eligibility are overwhelmed by the quantity of information available – and understandably so. As a form of insurance, Medicare is fundamentally different from other group/employer, individual, or family plans in that it is centered around the individual, yet any decisions made could potentially affect family members. In order to understand the costs, benefits, plans, and overall structure of Medicare, professional advice is strongly recommended when weighing options. That’s why, in this installation of CenterStage, Rob Glover, our Senior Solutions Advisor at Saxon, provided the following insightful information. Generally speaking, Medicare plans are explored during a significant lifestyle change. Having an insurance sales agent to facilitate retirement planning can help in adjusting Medicare options.

A Two-Way Relationship

Insurance agents are able to conform Medicare options around desired preferences and requirements. Each beneficiary is unique and therefore deserves a plan that delivers a standard of quality that is suited to varying budgets and ways of life. Agents can act as personal advisors and offer close collaboration when sifting through insurance plans. After becoming aware of defined healthcare coverage needs, Medicare advisors can narrow the search and find a solution that will safeguard both the individual and his or her family from looming financial damages.

It’s best to have a licensed agent with years of experience in Medicare. While textual knowledge is certainly important, learned wisdom is paramount in avoiding pitfalls throughout the process. Agents with real experience in the field are the best guides in navigating the processes, policies, and terminology of Medicare. Also, there are benefits in maintaining a relationship with them, since they are well-versed in the details of plans germane to the area. They are likely more familiar with supplier and provider networks and, using this knowledge, can provide guidance on which Medicare plan to choose.

The beneficiary-advisor relationship doesn’t end after the sale. In fact, they are often an advocate for many years after, offering consultations that address subsequent concerns with coverage. Medicare advisors can help review healthcare needs on a yearly basis to ensure the plan is lining up with changing criteria.

Services Worth Using

Independent advisors can offer many options across a multitude of carriers. Some agents are able to compare dozens of providers by contracting many different insurance companies. This method of contracting also aids in eliminating biases during plan research and comparison. The independent advisor can assist in making an informed decision on a Medicare insurance plan that is in line with the individual needs of the beneficiary. There aren’t any fees associated with merely utilizing an advisor. To elaborate, the rates linked to insurance plans already cover advisors’ commissions and thus render the decision on whether or not to employ one free from frugal urges. Therefore, there’s no reason not to seek the advice of a discerning sales agent to make the enrollment process easier. Licensed sales agents in the Medicare field take part in numerous hours of continued education and training annually. They are knowledgeable to pertinent information that could shape the decision-making process in addition to their understanding of a client’s defined parameters. Nevertheless, beneficiaries can only change insurance once within a year and can wind up “stuck” in a chosen plan unless the said beneficiary is eligible for a Special Enrollment Period. Regardless of position in the retirement process, time becomes increasingly more important. Utilizing an informed advisor will lead to time saved on plan comparison and research as they can help pinpoint a solution that fits the circumstances rather than waste time through trial and error. Licensed advisors are able to grant a one-stop shopping experience. Through innovative technology, they can access any and all relevant information at any time. Some create webinars regarding important issues, answer frequently asked questions, and elicit 24/7 assistance. Within some websites, beneficiaries can enroll in Medicare Advantage plans, request proposals, and research and compare options.

If you would like to learn more, contact Rob Glover at 513.703.7720 or rglover@gosaxon.com.


What’s the Deal With 529 Plans?

It’s never too early to invest. A 529 Savings Plan, prudent financial direction, and steady contributions are paramount to a successful college fund. Due to the intricacies of the financial instrument, an advisor is recommended to guide contributors throughout the process. In this installment of CenterStage, Cyrus Dhatigara – an investment advisor representative – has presented new contributors with his advice on 529 Savings Plans and how they can be beneficial for costly tuition fees.

How are they beneficial?

The 529 Savings Plan is a great way to save money for college. First, there are comparatively high limits on the amounts that parents or grandparents can contribute. Second, these plans are tax free: unlike with a tax-deferred 401(k), funds are exempt from taxation once they are eventually withdrawn. Third, mutual fund companies that are affiliated with state Tuition Trust Authorities are able to offer professional management leveraging a diverse array of funds. Fourth, 529 Savings Plans allow contributors to change the focus of their investments, typically starting with an aggressive strategy during a child’s younger years and moving towards a more conservative approach when he or she gets older.

How much to start?

Parents would naturally like to know how they can foster such an investment. Most have the basic idea of what a 529 Savings Plan is, but not much more. Seeking sound financial advice should fill any gaps in proficiency. Also, there’s no excuse to wait – it takes a mere $25 per month to initiate a plan. Further, 529s can make use of automated checking account withdrawals to enable healthy growth. This is a flexible product, though annual contributions will likely need to increase on that basis. The maximum limit per child is around $300,000; parents can contribute whatever they want and supplement the fund via one-off investments from grandparents.

What do they cover?

Anything that’s necessary for class is covered: books, tuition, fees, and computers or iPads, among other things. In fact, a 529 Savings Plan even covers grad school. Since the investments are earmarked for higher education, money is transferred directly from the mutual fund to the university without any contributor intervention. As a result, parents shouldn’t be concerned about quarterly or semester requirements, and there isn’t room for IRS violations since their only further interaction is taking a receipt.

How can Saxon help?

Cyrus crafts strategic savings plans around children to help fund college tuition, while providing the tools for protection and investment. His largest passion project is an extension of the daily work he does. He revels in contributing financial education to all ages. Saxon’s goal is simple, to mold this program to fit contributors’ individual needs, right from the beginning. We know college savings plans are not one-size-fits-all. Whether you are looking to save for tuition, room and board fees, books, supplies or required computer equipment and technology, Saxon can help.

Please contact Cyrus Dhatigara with any questions you may have on 529 Savings Plans. You can reach him at 513.236.9334 or send him an email at cdhatigara@gosaxon.com.

Download the PDF.


Fresh Brew With Tabitha McIntosh

Welcome to our brand new segment, Fresh Brew, where we will be exploring the delicious coffees, teas, and snacks of some of our employees! You can look forward to our Fresh Brew blog post on the first Friday of every month.

“Each client is different!”

Tabitha enjoys helping customers and prides herself on the understanding of their needs and the discovery of knowledge along the way. She especially enjoys following through with the customer and learning new things that will help her excel in her career and better service future clients.

Favorite Brew

Pumpkin Spice Latte

“I love grabbing this from either Starbucks or Royce Cafe in Lebanon!”

Get Directions

Favorite Snack

…Nothing!

“I like my coffee on it’s own. There are plenty of calories in each cup!”

Give It A Try & Share It!


LIMRA aims to shape benefits data exchange standard

How will LIMRA shape the benefits data exchange standard? Find out in this article from Benefits Pro.

LIMRA wants to help develop electronic data transmission standards for the employee benefits market.

The life and health market research group, has formed an alliance with the Object Management Group (OMG), a nonprofit technology standards group based in Needham, Massachusetts.

LIMRA has been working on the benefits market data standards issue for more than a year.

To help benefits market players develop standards, OMG has set up a Workplace Benefits Domain Task Force. The chairs of the new task force are Edie Bice of Unum; InAh Chambers of LIMRA; and Aaron Roby of Texas Life.

The task force organizers hope to develop data exchange standards for non-medical, non-retirement benefits.
The standards could apply both to group benefits and to individual benefits products sold at the worksite.

Organizers say the new task force will be open to benefits brokers, independent benefit plan administrators, benefits administration technology vendors, and insurers that offer non-medical, non-retirement employee benefits products.

The task force will start its first face-to-face meeting June 18, in Boston.

Source:
Bell A. (4 May 2018). "LIMRA aims to shape benefits data exchange standard" [web blog post]. Retrieved from address http://bit.ly/2wfIZey


These 3 industries are leading the way in HDHP adoption

Interested in knowing which industries are leadig the way in HDHP adoption? Check out this blog article.

Employers in the education, health care, manufacturing and retail sectors are using a variety of tactics to drive selection of HDHPs, with varying levels of adoption from employees, so says the report, based on anonymous employee benefit election data on the Benefitfocus Platform from more than 540 large employers in those sectors.

In the education sector, HDHPs are becoming less the exception, more the rule.

“Back in 2016, traditional health plans like PPOs and HMOs represented an overwhelming majority of health plan offerings and elections among employers in the education industry,” the authors write. “But just two short years later, things look completely different. In an industry known historically for its generous health insurance benefits, the HDHP has made remarkable gains in popularity.”

The share of employers in the education sector offering at least one HDHP has more than doubled since 2016, from 23 to 50 percent, according to the report. Employers have done a lot to make HDHPs attractive — they now pay 87 percent of the total HDHP premium and have doubled their contribution to employees’ HSAs since 2016. Their efforts have worked — 34 percent of employees selected an HDHP when given the choice for 2018, up from 20 percent two years ago.

In the health care sector, employers are encouraging consumer-driven plans with moderate success, according to the report.

“Over the past two years, employers in the health care industry have taken steps to shift more health insurance costs onto employees, while providing ways to help them manage the additional burden,” the authors write. “But there remains a long runway of opportunity for these organizations to boost adoption of the consumer-driven health care model.”

The number of employers offering HDHPs has nearly doubled in two years, with 73 percent offering at least one in 2018, up from 41 percent in 2016. However, despite there efforts, only 27 percent of employees selected an HDHP for 2018. Health care employers are likely trying to raise the adoption rate by transferring more PPO plan costs onto workers — the average employee premium contribution for a single-coverage PPO is up 24 percent from 2016.

In the manufacturing sector, despite boom in HDHP offerings among those employers, more of their workers are still opting for PPOs. “Manufacturing employers have displayed a particularly strong and growing enthusiasm for HDHPs in recent years,” the authors write. “But cost-sharing dynamics appear to be driving employees away from these plans and back into traditional health plans. Meanwhile, voluntary benefits maintain above-average popularity among both employers and employees.” The majority (88 percent) of employers in manufacturing now offer an HDHP, up from 54 percent in 2016. However, the percentage of employees electing an HDHP continues to decrease, while PPO participation grew from 36 percent in 2016, to 57 percent for 2018.

The report also found that voluntary benefits have become increasingly prevalent among manufacturers, with nearly 60 percent of employers offering at least one for 2018, up from 34 percent in 2016.

In the retail sector, employees shoulder more health plan costs, while more employers offer voluntary benefits to supplement coverage, according to the report.

“As employers in the retail industry look to keep benefit costs under control, health care is getting more expensive for their employees,” the authors write. “And while voluntary benefits offer additional financial protection for the majority of these workers, there remains a long runway of opportunity for health spending accounts to help them manage their out-of-pocket liabilities.”

Retail employers offering at least one HDHP increased from 55 percent in 2016 to 76 percent. Nearly half (40 percent) of their employees elected HDHPs, but premiums for these plans are rising, with the average annual employee contribution for a single-coverage HDHP up nearly 20 percent since 2016.

Despite HDHP prevalence, retail employers contributed 40 percent less to HSAs than the average for all employers, and employees contributed 20 percent less than peers in other industries. To supplement coverage, 56 percent of employers offered at least one voluntary benefit, up from 43 percent in 2016.

“Everywhere you turn there’s a story about rising health care costs,” says Ray August. “What employers in every industry have in common is the struggle to economically provide the best plans and care for their employees.”

Source:
Kuehner-Hebert K. (7 May 2018). "These 3 industries are leading the way in HDHP adoption" [web blog post]. Retrieved from address http://bit.ly/2FUf4Ii


4 actions HR departments should take to prepare for GDPR

In this article from Benefits Pro, we are going to take a look at the top four actions HR departments should take to prepare for GDPR. Continue reading:

A few years ago, Mark Cuban famously advised that data is the new gold. However, things have changed since the Cambridge Analytica and Facebook scandal as the public has become increasingly concerned with how companies are using their personal information.

As businesses prepare for the arrival of the General Data Protection Regulation (GDPR), leaders could be forgiven for thinking that data can become more of a liability than an asset – depending on its handling.

GDPR is a much-needed update to data protection that aims to strengthen and unify security for everyone in Europe. The legislation goes live on May 25, 2018 and will enforce all businesses to secure and manage the personal data of all individuals living within the European Union.

After years of gathering data, we are now entering a new era where trust and transparency are the new global currency. GDPR will affect all businesses that store any aspect of personally identifiable information of all individuals, both customer and employee, living in the EU, whether or not that business has an office there.

The scope of GDPR includes employee data, so it directly affects HR departments. As a result, companies need to update processes around the lifecycle of basic employee personal data such as health information and family details.There are many resources surrounding the topic; some on which include free, user-friendly materials published by the EU governments in addition to those that act as “scaremongers” seeking to try to trick companies into paying for compliance help. What makes it most difficult for HR professionals is interpreting the rule, which was written broadly to address any type of personal data and applying it to employee data and HR practices, specifically. Compliance cannot be achieved overnight or ready for the big “go live” in May either. An entirely new way of working to understand where every aspect of data is obtained, how it is used, and where it is stored needs to be put in place. In short, this is not a job for the IT department alone, but rather requires a highly collaborative effort across the company. Silos will need to be broken down to efficiently unify all departments such as sales, marketing, finance, IT, and legal to understand the scale of how much data businesses are actively storing. But what do HR professionals need to know?

1. Create new or updated privacy policies
New privacy policies likely need to be created and implemented to reflect the new rights of employees. Equally, all existing policies should to be reviewed to determine which ones require updating to fall in line with GDPR’s transparency and accountability requirements.

In addition, a key difference between the current EU data rules and the GDPR is the emphasis on individual rights. Employees can now request that their data be completely erased at any time or request a copy of their data thats on file. HR teams need to be prepared to uphold these demands.

2. Revisit outdated processes
Reviewing HR processes, like onboarding a new employee, will help reveal what data you’re collecting that you don’t necessarily have a need for. Minimization is key to successful GDPR compliance; less is more. Implementing minimization will likely require you to update protocols and rethink processes that include the requesting of personal data from employees. For example, the onboarding and transfer of employees will need to be revisited to ensure that data collection practices meet GDPR requirements. You may also need to revisit your record retention policies and processes for ex-employees.

Ask your partners and vendors for their GDPR and compliance plan as risk is shared when they handle employee data on your behalf…

3. Allow data access only to those who really need it
The rise of shadow IT and sensitive data being increasingly stored in the public cloud combined with malware in cloud SaaS applications are the more significant concerns. CIOs and IT leaders now have the power to implement stronger cybersecurity and secure data-management policies that will protect personal data now and in the future. Security elements of the legislation demand that appropriate technical and organizational measures are taken to ensure all employee data is kept safe. HR’s responsibility is to ensure that only those who need access to personal data to do their job have access to it. Making sure that the right people have the appropriate access levels within a digital HR platform – or keys to the file cabinet – is the secret to successful compliance.

4. Centralize your employee file management
Learning about and documenting every element of employee data, where it is stored, and who has access is a process made much easier with centralized digital files. Going forward, a digital system makes it possible for HR to implement and internally audit procedures that will ultimately provide them with the visibility into compliance as well as potential vulnerabilities. GDPR and employee expectations means companies need to shift from a reactive to a proactive approach. A digital system is necessary to enable HR with visibility across their data, securely manage access to the data and implement at scale and policy changes.. With GDPR, the stakes are increasing yet again for companies; HR now must think about collecting the least amount of data they need to get the job done and being completely transparent around its usage, rather than burying this information in complicated terms and conditions. Sure, this will dramatically change the way companies globally deal with EU citizens’ data, but it’s something to be embraced rather than feared. By showcasing implementation of these new data protection practices, a brand can actually build its reputation. While board members might fear the ramifications of the GDPR, we all know that the breach of company data is something far worse. For these reasons alone, GDPR should be seen as an opportunity for every employee to focus on protecting their personal data or at least understanding their responsibilities. And for employers, take this opportunity to become more open to a review of outdated practices and investing in and building technology that can complement this forward thinking approach. Data protection compliance is now an on-going priority and its beneficial for all to take seriously.

Source:
Gouchan A. (4 May 2018). "4 actions HR departments should take to prepare for GDPR" [web blog post]. Retrieved from address http://bit.ly/2wl6ZwU


10 states with the most Social Security recipients

Which state economies will face a greater impact when cutting social security payments? Find out in this article for BenefitsPro.

More than 51 million American retirees or their survivors collected Social Security benefits last year, according to the Social Security Administration.

Those payments function as the foundation for their economic security during retirement, providing 90% or more of the income of almost one-third of those beneficiaries and the majority of the cash income for about 60% of them, according to a new report from the Democratic staff of the Joint Economic Committee (JEC).

The report, “Social Security: A Promise to American Workers and Families,” focuses not only the benefits to recipients who depend on those payments but also the broader economic costs of reducing them, which has been a priority for the Republican leadership in Congress.

Democratic members of Congress expect Republicans will continue to push for those cuts especially because the U.S. deficit is expected to grow by more than $1 trillion over the next 10 years as a result of the recent tax cut legislation.

“Slashing Social Security would not only have a negative impact on beneficiaries and their families, but have a devastating impact on the economy as a whole,” said Sen. Martin Heinrich, D-N.M., ranking member of the JEC, in a statement accompanying the release of the report.
According to the report, Social Security supports about $1.4 trillion in goods and services in the U.S. economy, accounting for more than 9 million jobs nationwide. Reducing benefits by 25% across the board would cost $349 billion in economic output, 2.3 million jobs and about $83 billion in employee compensation, the report notes, adding that such cuts would also put pressure on the families of beneficiaries to make up the difference.

In the gallery above are the 10 states with the most Social Security recipients and their average monthly benefit.

Source:
Napach B. (7 May 2018). "10 states with the most Social Security recipients" [web blog post]. Retrieved from address http://bit.ly/2HWmHnt


Student loan benefits more popular with workers than employers

"While a student loan benefit is the most-requested financial benefit, it’s only third on the priority list for HR professionals." Find out more in this article.

If you ask them, 78 percent of employees laboring under a load of student debt will tell you that they want their bosses to provide a student loan benefit that will help them dig out.

Bosses, not so much. While a student loan benefit is the most-requested financial benefit, according to an HRDive report, it’s only third on the priority list for HR professionals.

Related: The problem with student-loan repayment benefits

It’s not just younger workers who want it, either. The 78 percent of employees who wish their jobs came with a student loan benefit includes 65 percent of workers over age 55 who have problems with current or future loan debt.

The report points to a CommonBond study that finds student loan benefits not only help to keep employees on the payroll and even better their job performance, but they also help in recruiting new talent. The study finds that 75 percent of all workers have paid for their own education via student loans, and 21 percent plan to take out student loans for a child or another family member in the next five years.

Oh, and another disconnect between boss and worker: while 75 percent of HR executives think their benefits offerings are innovative, only 50 percent of workers agree.

Money, of course, is a big worry for workers—and it’s not all about salary, with 44 million Americans weighed down by some $1.4 trillion in student debt. Worrying about lingering student loans also cuts productivity at work, in addition to subjecting workers to increasing stress, so it’s really an employer’s problem too.
Not only do students owe an average of more than $25,000 by graduation, figures from The Student Loan Report indicate that the loan default rate and delinquency rates are more than 10 percent and 5 percent, respectively—not exactly conducive to either peace of mind or high productivity at work. So employers are increasingly getting involved, considering tuition payment programs for employees who want to pursue a degree or add new skills.

And that can help both groups as employers become increasingly desperate for a more skilled employee base. It also helps employers as employee stress falls, potentially cutting health care costs as well and making workers more productive.

Source:
Satter M. (7 May 2018). "Student loan benefits more popular with workers than employers" [web blog post]. Retrieved from address http://bit.ly/2wi9yA0


Fresh Brew With Kevin Hagerty

Welcome to our brand new segment, Fresh Brew, where we will be exploring the delicious coffees, teas, and snacks of some of our employees! You can look forward to our Fresh Brew blog post on the first Friday of every month.

“Try to save what you can. You’ll be glad you did later.”

Kevin has been a Financial Advisor for 18 years specializing in financial planning solutions.

He and his wife Lori enjoy spending their free time involved in various school and sporting events with their two sons. They also enjoy spending time visiting family on the shores of Northern Michigan’s Lakes and working on various projects around the house like landscaping.

Favorite Brew

Flavored Coffee

“I just like it! Highly recommend Carabello Coffee for your flavored coffee needs!”

Get Directions

Favorite Snack

Breakfast Casserole

“A little breakfast casserole goes a long way!”

Get A Recipe

Give It A Try & Share It!


Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA

Data provided through two, large government surveys, The National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), Kaiser Family Foundation addresses the risk factors involved in repealing and repealing ACA.


Before private insurance market rules in the Affordable Care Act (ACA) took effect in 2014, health insurance sold in the individual market in most states was medically underwritten.1  That means insurers evaluated the health status, health history, and other risk factors of applicants to determine whether and under what terms to issue coverage. To what extent people with pre-existing health conditions are protected is likely to be a central issue in the debate over repealing and replacing the ACA. This brief reviews medical underwriting practices by private insurers in the individual health insurance market prior to 2014, and estimates how many American adults could face difficulty obtaining private individual market insurance if the ACA were repealed or amended and such practices resumed.  We examine data from two large government surveys: The National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), both of which can be used to estimate rates of various health conditions (NHIS at the national level and BRFSS at the state level). We consulted field underwriting manuals used in the individual market prior to passage of the ACA as a reference for commonly declinable conditions.

Estimates of the Share of Adults with Pre-Existing Conditions

We estimate that 27% of adult Americans under the age of 65 have health conditions that would likely leave them uninsurable if they applied for individual market coverage under pre-ACA underwriting practices that existed in nearly all states. While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting, these estimates quantify how many people could be ineligible for individual market insurance under pre-ACA practices if they were to ever lose this coverage. This is a conservative estimate as these surveys do not include sufficient detail on several conditions that would have been declinable before the ACA (such as HIV/AIDS, or hepatitis C).  Additionally, millions more have other conditions that could be either declinable by some insurers based on their pre-ACA underwriting guidelines or grounds for higher premiums, exclusions, or limitations under pre-ACA underwriting practices. In a separate Kaiser Family Foundation poll, most people (53%) report that they or someone in their household has a pre-existing condition. A larger share of nonelderly women (30%) than men (24%) have declinable preexisting conditions. We estimate that 22.8 million nonelderly men have a preexisting condition that would have left them uninsurable in the individual market pre-ACA, compared to 29.4 million women. Pregnancy explains part, but not all of the difference. The rates of declinable pre-existing conditions vary from state to state. On the low end, in Colorado and Minnesota, at least 22% of non-elderly adults have conditions that would likely be declinable if they were to seek coverage in the individual market under pre-ACA underwriting practices.  Rates are higher in other states – particularly in the South – such as Tennessee (32%), Arkansas (32%), Alabama (33%), Kentucky (33%), Mississippi (34%), and West Virginia (36%), where at least a third of the non-elderly population would have declinable conditions.

Table 1: Estimated Number and Percent of Non-Elderly People with Declinable Pre-existing Conditions Under Pre-ACA Practices, 2015
State Percent of Non-Elderly Population  Number of Non-Elderly Adults
Alabama 33%                   942,000
Alaska 23%                   107,000
Arizona 26%                1,043,000
Arkansas 32%                   556,000
California 24%                5,865,000
Colorado 22%                   753,000
Connecticut 24%                   522,000
Delaware 29%                   163,000
District of Columbia 23%                   106,000
Florida 26%                3,116,000
Georgia 29%                1,791,000
Hawaii 24%                   209,000
Idaho 25%                   238,000
Illinois 26%                2,038,000
Indiana 30%                1,175,000
Iowa 24%                   448,000
Kansas 30%                   504,000
Kentucky 33%                   881,000
Louisiana 30%                   849,000
Maine 29%                   229,000
Maryland 26%                   975,000
Massachusetts 24%                   999,000
Michigan 28%                1,687,000
Minnesota 22%                   744,000
Mississippi 34%                   595,000
Missouri 30%                1,090,000
Montana 25%                   152,000
Nebraska 25%                   275,000
Nevada 25%                   439,000
New Hampshire 24%                   201,000
New Jersey 23%                1,234,000
New Mexico 27%                   332,000
New York 25%                3,031,000
North Carolina 27%                1,658,000
North Dakota 24%                   111,000
Ohio 28%                1,919,000
Oklahoma 31%                   706,000
Oregon 27%                   654,000
Pennsylvania 27%                2,045,000
Rhode Island 25%                   164,000
South Carolina 28%                   822,000
South Dakota 25%                   126,000
Tennessee 32%                1,265,000
Texas 27%                4,536,000
Utah 23%                   391,000
Vermont 25%                     96,000
Virginia 26%                1,344,000
Washington 25%                1,095,000
West Virginia 36%                   392,000
Wisconsin 25%                   852,000
Wyoming 27%                     94,000
US 27%              52,240,000
SOURCE: Kaiser Family Foundation analysis of data from National Health Interview Survey and the Behavioral Risk Factor Surveillance System. NOTE: Five states (MA, ME, NJ, NY, VT) had broadly applicable guaranteed access to insurance before the ACA. What protections might exist in these or other states under a repeal and replace scenario is unclear.

At any given time, the vast majority of these approximately 52 million people with declinable pre-existing conditions have coverage through an employer or through public programs like Medicaid. The individual market is where people seek health insurance during times in their lives when they lack eligibility for job-based coverage or for public programs such as Medicare and Medicaid.  In 2015, about 8% of the non-elderly population had individual market insurance.  Over a several-year period, however, a much larger share may seek individual market coverage.2  This market is characterized by churn, as new enrollees join and others leave (often for other forms of coverage). For many people, the need for individual market coverage is intermittent, for example, following a 26th birthday, job loss, or divorce that ends eligibility for group plan coverage, until they again become eligible for group or public coverage.  For others – the self-employed, early retirees, and lower-wage workers in jobs that typically don’t come with health benefits – the need for individual market coverage is ongoing.  (Figure 1 shows the distribution of employment status among current individual market enrollees.) Prior to the ACA’s coverage expansions, we estimated that 18% of individual market applications were denied. This is an underestimate of the impact of medical underwriting because many people with health conditions did not apply because they knew or were informed by an agent that they would not be accepted.  Denial rates ranged from 0% in a handful of states with guaranteed issue to 33% in Kentucky, North Carolina, and Ohio. According to 2008 data from America’s Health Insurance Plans, denial rates ranged from about 5% for children to 29% for adults age 60-64 (again, not accounting for those who did not apply).

Figure 1: Employment Status of Non-Group Enrollees, 2016

Figure 1: Employment Status of Non-Group Enrollees, 2016

Medical Underwriting in the Individual Market Pre-ACA

Prior to 2014 medical underwriting was permitted in the individual insurance market in 45 states and DC.  Applications for individual market policies typically included lengthy questionnaires about the health and risk status of the applicant and all family members to be covered.  Typically, applicants were asked to disclose whether they were pregnant or contemplating pregnancy or adoption, and information about all physician visits, prescription medications, lab results, and other medical care received in the past year.  In addition, applications asked about personal history of a series of health conditions, ranging from HIV, cancer, and heart disease to hemorrhoids, ear infections and tonsillitis.  Finally, all applications included authorization for the insurer to obtain and review all medical records, pharmacy database information, and related information. Once the completed application was submitted, the medical underwriting process varied somewhat across insurers, but usually involved identification of declinable medical conditions and evaluation of other conditions or risk factors that warranted other adverse underwriting actions. Once enrolled, a person’s health and risk status was sometimes reconsidered in a process called post-claims underwriting. Although our analysis focuses on declinable medication conditions, each of these other actions is described in more detail below.

Declinable Medical Conditions

Before the ACA, individual market insurers in all but five states maintained lists of so-called declinable medical conditions.  People with a current or past diagnosis of one or more listed conditions were automatically denied.  Insurer lists varied somewhat from company to company, though with substantial overlap.  Some of the commonly listed conditions are shown in Table 2.

Table 2: Examples of Declinable Conditions In the Medically Underwritten Individual Market, Before the Affordable Care Act
Condition Condition
AIDS/HIV Lupus
Alcohol abuse/ Drug abuse with recent treatment Mental disorders (severe, e.g. bipolar, eating disorder)
Alzheimer’s/dementia Multiple sclerosis
Arthritis (rheumatoid), fibromyalgia, other inflammatory joint disease Muscular dystrophy
Cancer within some period of time (e.g. 10 years, often other than basal skin cancer) Obesity, severe
Cerebral palsy Organ transplant
Congestive heart failure Paraplegia
Coronary artery/heart disease, bypass surgery Paralysis
Crohn’s disease/ ulcerative colitis Parkinson’s disease
Chronic obstructive pulmonary disease (COPD)/emphysema Pending surgery or hospitalization
Diabetes mellitus Pneumocystic pneumonia
Epilepsy Pregnancy or expectant parent
Hemophilia Sleep apnea
Hepatitis (Hep C) Stroke
Kidney disease, renal failure Transsexualism
SOURCE: Kaiser Family Foundation review of field underwriting guidelines from Aetna (GA, PA, and TX), Anthem BCBS (IN, KY, and OH), Assurant, CIGNA, Coventry, Dean Health, Golden Rule, Health Care Services Corporation (BCBS in IL, TX) HealthNet, Humana, United HealthCare, Wisconsin Physician Service.  Conditions in this table appeared on declinable conditions list in half or more of guides reviewed.  NOTE: Many additional, less-common disorders also appearing on most of the declinable conditions lists were omitted from this table.

Our analysis of rates of pre-existing conditions in this brief focuses on those conditions that would likely be declinable, based on our review of pre-ACA underwriting documents. Our analysis is limited – and our results are conservative – because NHIS and BRFSS questionnaires do not address some of the conditions that were declinable, and in some cases the questions that do relate to declinable conditions were too broad for inclusion. See the methodology section for a list of conditions included in the analysis. In addition to declinable conditions, many insurers also maintained a list of declinable medications.  Current use of any of these medications by an applicant would warrant denial of coverage.  Table 3 provides an example of medications that were declinable in one insurer prior to the ACA. Our analysis does not attempt to account for use of declinable medications.

Table 3: Declinable Medications
 Anti-Arthritic Medications

  • Adalimumab/Humira
  • Cyclosporine/Sandimmune
  •  Methotrexate/Trexall
  • Ustekinumab/Stelara
  • others
 Anti-Diabetic Medications

  • Avandia/Rosiglitazone
  • Glucagon
  • Humalog/Insulin products
  • Metformin HCL
  • others
Medications for HIV/AIDS or Hepatitis

  • Abacavir/Ziagen
  • Efavirenz/Atripla
  • Interferon
  • Lamivudine/Epivir
  • Ribavirin
  • Zidovudine/Retrovir
  • others

 

Anti-Cancer Medications

  • Anastrozole/Arimidex
  • Nolvadex/Tamoxifen
  • Femara
  • others
Anti-Psychotics, Autism, Other Central Nervous System Medications

  • Abilify/Ariprazole
  • Aricept/Donepezil
  • Clozapine/Clozaril
  • Haldol/Haldoperidol
  • Lithium
  • Requip/Ropinerole
  • Risperdal/Risperidone
  • Zyprexa
  •  others
Anti-Coagulant/Anti-Thrombotic Medications

  • Clopidogrel/Plavix
  • Coumadin/Warfarin
  • Heparin
  • others
Miscellaneous Medications

  • Anginine (angina)
  • Clomid (fertility)
  • Epoetin/Epogen (anemia)
  • Genotropin (growth hormone)
  • Remicade (arthritis, ulcerative colitis)
  • Xyrem (narcolepsy)
  • others
SOURCE:  Blue Cross Blue Shield of Illinois, Product Guide for Agents

Some individual market insurers also developed lists of ineligible occupations.  These were jobs considered sufficiently high risk that people so employed would be automatically denied.  In addition, some would automatically deny applicants who engaged in certain leisure activities and sports.  Table 4 provides an example of declinable occupations from one insurer prior to the ACA.  Our analysis does not attempt to account for declinable occupations.

Table 4: Ineligible Occupations, Activities
Active military personnel Iron workers Professional athletes
Air traffic controller Law enforcement/detectives Sawmill operators
Aviation and air transportation Loggers Scuba divers
Blasters or explosive handlers Meat packers/processors Security guards
Bodyguards Mining Steel metal workers
Crop dusters Nuclear industry workers Steeplejacks
Firefighters/EMTs Offshore drillers/workers Strong man competitors
Hang gliding Oil and gas exploration and drilling Taxi cab drivers
Hazardous material handlers Pilots Window washers
SOURCE: Preferred One Insurance Company Individual and Family Insurance Application Form

Other Adverse Underwriting Actions

Beyond the declinable conditions, medications and occupations, underwriters also examined individual applications and medical records for other conditions that could generate significant “losses” (claims expenses.)  Among such conditions were acne, allergies, anxiety, asthma, basal cell skin cancer, depression, ear infections, fractures, high cholesterol, hypertension, incontinence, joint injuries, kidney stones, menstrual irregularities, migraine headaches, overweight, restless leg syndrome, tonsillitis, urinary tract infections, varicose veins, and vertigo. One or more adverse medical underwriting actions could result for applicants with such conditions, including:

  • Rate-up – The applicant might be offered a policy with a surcharged premium (e.g. 150 percent of the standard rate premium that would be offered to someone in perfect health)
  • Exclusion rider – Coverage for treatment of the specified condition might be excluded under the policy; alternatively, the body part or system affected by the specified condition could be excluded under the policy. Exclusion riders might be temporary (for a period of years) or permanent
  • Increased deductible – The applicant might be offered a policy with a higher deductible than the one originally sought; the higher deductible might apply to all covered benefits or a condition-specific deductible might be applied
  • Modified benefits – The applicant might be offered a policy with certain benefits limited or excluded, for example, a policy that does not include prescription drug coverage.

In some cases, individuals with these conditions might also be declined depending on their health history and the insurer’s general underwriting approach.  For example, field underwriting guides indicated different underwriting approaches for an applicant whose child had chronic ear infections:

  • One large, national insurer would issue standard coverage if the child had fewer than five infections in the past year or ear tubes, but apply a 50% rate up if there had been more than 4 infections in the prior year;
  • Another insurer, which used a 12-tier rate system, would issue coverage at the second most favorable rate tier if the child had just one infection in the prior year or ear tubes, at the fifth rate tier if there had been 2-3 infections during the prior year, and at the seventh tier if there had been 4 or more infections; for some conditions, this company’s rating might depend on the plan deductible – applicants with history of ear infections would be offered the second rating tier for policies with a deductible of $5,000 or higher;
  • Another insurer would issue standard coverage if the child had just one infection in the prior year or if ear tubes had been inserted more than one-year prior, apply a rate up if there were two infections in the prior year, and decline the application if there were three or more infections;
  • Another insurer would issue standard coverage if the child had fewer than 3 infections in the past year, but issue coverage with a condition specific deductible of $5,000 if there had been 3 or more infections or if ear tubes had been inserted.

In a 2000 Kaiser Family Foundation study of medical underwriting practices, insurers were asked to underwrite hypothetical applicants with varying health conditions, from seasonal allergies to situational depression to HIV.  Results varied significantly for less serious conditions. For example, the applicant with seasonal allergies who made 60 applications for coverage was offered standard coverage 3 times, declined 5 times, offered policies with exclusion riders or other benefit limits 46 times (including 3 offers that excluded coverage for her upper respiratory system), and policies with premium rate ups (averaging 25%) 6 times.

Pre-existing Condition Exclusion Provisions

In addition to medical screening of applicants before coverage was issued, most individual market policies also included more general pre-existing condition exclusion provisions which limited the policy’s liability for claims (typically within the first year) related to medical conditions that could be determined to exist prior to the coverage taking effect.3

Example of pre-existing condition exclusion Jean, an Arizona teacher whose employer provided group health benefits but did not contribute to the cost for family members, gave birth to her daughter, Alex, in 2004 and soon after applied for an individual policy to cover the baby.  Due to time involved in the medical underwriting process, the baby was uninsured for about 2 weeks. A few months later, Jean noticed swelling around the baby’s face and eyes.  A specialist diagnosed Alex with a rare congenital disorder that prematurely fused the bones of her skull.  Surgery was needed immediately to avoid permanent brain damage.   When Jean sought prior-authorization for the $90,000 procedure, the insurer said it would not be covered.  Under Arizona law, any condition, including congenital conditions, that existed prior to the coverage effective date, could be considered a pre-existing condition under individual market policies.  Alex’s policy excluded coverage for pre-existing conditions for one year.  Jean appealed to the state insurance regulator who upheld the insurer’s exclusion as consistent with state law. Source:  Wall Street Journal, May 31, 2005

The nature of pre-existing condition exclusion clauses varied depending on state law.  In 19 states, a health condition could only be considered pre-existing if the individual had actually received treatment or medical advice for the condition during a “lookback” period prior to the coverage effective date (from 6 months to 5 years).  In most states, a pre-existing condition could also include one that had not been diagnosed but that produced signs or symptoms that would prompt an “ordinarily prudent person” to seek medical advice, diagnosis or treatment.  In 8 states and DC, conditions that existed prior to the coverage effective date – including those that were undiagnosed and asymptomatic – could be considered pre-existing and so excluded from coverage under an individual market policy.  For example, a congenital condition in a newborn could be considered pre-existing to the coverage effective date (the baby’s birth date) and excluded from coverage.  About half of the states required individual market insurers to reduce pre-existing condition exclusion periods by the number of months of an enrollee’s prior coverage.

Example of policy rescission Jennifer, a Colorado preschool teacher, was seriously injured in 2005 when her car was hit by a drug dealer fleeing the police. She required months of inpatient hospitalization and rehab, and her bills reached $185,000.   Jennifer was covered by a non-group policy which she had purchased five months prior to the accident.   Shortly after her claims were submitted, the insurer re-reviewed Jennifer’s application and medical history.  Following its investigation, the insurer notified Jennifer they found records of medical care she had not disclosed in her application, including medical advice sought for discomfort from a prolapsed uterus and an ER visit for shortness of breath.  The insurer rescinded the policy citing Jennifer’s failure to disclose this history. Jennifer sued the insurer for bad faith; four years later a jury ordered the insurer to reinstate the policy and pay $37 million in damages. Source:  Westword, February 11, 2010.

Unlike exclusion riders that limited coverage for a specified condition of a specific enrollee, pre-existing condition clauses were general in nature and could affect coverage for any applicable condition of any enrollee.  Pre-existing condition exclusions were typically invoked following a process called post-claims underwriting.  If a policyholder would submit a claim for an expensive service or condition during the first year of coverage, the individual market insurer would conduct an investigation to determine whether the condition could be classified as pre-existing. In some cases, post-claims underwriting might also result in coverage being cancelled.  The investigations would also examine patient records for evidence that a pre-existing condition was known to the patient and should have been disclosed on the application.  In such cases, instead of invoking the pre-existing condition clause, an issuer might act to rescind the policy, arguing it would have not issued coverage in the first place had the pre-existing condition been disclosed.

Discussion

The Affordable Care Act guarantees access to health insurance in the individual market and ends other underwriting practices that left many people with pre-existing conditions uninsured or with limited coverage before the law. As discussions get underway to repeal and replace the ACA, this analysis quantifies the number of adults who would be at risk of being denied if they were to seek coverage in the individual market under pre-ACA rules. What types of protections are preserved for people with pre-existing conditions will be a key element in the debate over repealing and replacing the ACA. We estimate that at least 52 million non-elderly adult Americans (27% of those under the age of 65) have a health condition that would leave them uninsurable under medical underwriting practices used in the vast majority of state individual markets prior to the ACA. Results vary from state-to-state, with rates ranging around 22 – 23% in some Northern and Western states to 33% or more in some southern states. Our estimates are conservative and do not account for a number of conditions that were often declinable (but for which data are not available), nor do our estimates account for declinable medications, declinable occupations, and conditions that could lead to other adverse underwriting practices (such as higher premiums or exclusions). While most people with pre-existing conditions have employer or public coverage at any given time, many people seek individual market coverage at some point in their lives, such as when they are between jobs, retired, or self-employed. There is bipartisan desire to protect people with pre-existing conditions, but the details of replacement plans have yet to be ironed out, and those details will shape how accessible insurance is for people when they have health conditions.

Gary Claxton, Cynthia Cox, Larry Levitt, and Karen Pollitz are with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation.

Methods

To calculate nationwide prevalence rates of declinable health conditions, we reviewed the survey responses of nonelderly adults for all question items shown in Methods Table 1 using the CDC’s 2015 National Health Interview Survey (NHIS).  Approximately 27% of 18-64 year olds, or 52 million nonelderly adults, reported having at least one of these declinable conditions in response to the 2015 survey.  The CDC’s National Center for Health Statistics (NCHS) relies on the medical condition modules of the annual NHIS for many of its core publications on the topic; therefore, we consider this survey to be the most accurate means to estimate both the nationwide rate and weighted population. Since the NHIS does not include state identifiers nor sufficient sample size for most state-based estimates, we constructed a regression model for the CDC’s 2015 Behavioral Risk Factor Surveillance System (BRFSS) to estimate the prevalence of any of the declinable conditions shown in Methods Table 1 at the state level.  This model relied on three highly significant predictors: (a) respondent age; (b) self-reported fair or poor health status; (c) self-report of any of the overlapping variables shown in the left-hand column of Methods Table 1.  Across the two data sets, the prevalence rate calculated using the analogous questions (i.e. the left-hand column of Methods Table 1) lined up closely, with 20% of 18-64 year old survey respondents reporting at least one of those declinable conditions in the 2015 NHIS and 21% of 18-64 year olds in the 2015 BRFSS.  Applying this prediction model directly to the 2015 BRFSS microdata yielded a nationwide prevalence of any declinable condition of 28%, a near match to the NHIS nationwide estimate of 27%.

 

Methods Table 1: Declinable Medical Conditions Available in Survey Microdata
Declinable Condition Questions Available in both the 2015 National Health Interview Survey and also the 2015 Behavioral Risk Factor Surveillance System Declinable Condition Questions Available in only the 2015 National Health Interview Survey
Ever had CHD Melanoma Skin Cancer
Ever had Angina Any Other Heart Condition
Ever had Heart Attack Crohn’s Disease or Ulcerative Colitis
Ever had Stroke Epilepsy
Ever had COPD Difficulty Due to Mental Retardation
Ever had Emphysema Difficulty Due to Cerebral Palsy
Chronic Bronchitis in past 12 months Difficulty Due to Senility
Ever had Non-Skin Cancer Difficulty Due to Depression
Ever had Diabetes Difficulty Due to Endocrine Problem
Weak or Failing Kidneys Difficulty Due to Blood Forming Organ Problem
BMI > 40 Difficulty Due to Drug / Alcohol / Substance Abuse
Pregnant Difficulty Due to Schizophrenia, ADD, or Bipolar Disorder

In order to align BRFSS to NHIS overall statistics, we then applied a Generalized Regression Estimator (GREG) to scale down the BRFSS microdata’s prevalence rate and population estimate to the equivalent estimates from NHIS, 27% and 52 million.  Since the regression described in the previous paragraph already predicted the prevalence rate of declinable conditions in BRFSS by using survey variables shared across the two datasets, this secondary calibration solely served to produce a more conservative estimate of declinable conditions by calibrating BRFSS estimates to the NHIS.  After applying this calibration, we calculated state-specific prevalence rates and population estimates off of this post-stratified BRFSS sample. The programming code, written using the statistical computing package R v.3.3.2, is available upon request for people interested in replicating this approach for their own analysis.

This article was written by Gary Claxton, Cynthia Cox, Anthony Damico, Larry Levitt and Karen Pollitz on Kaiser Family Foundation. Published: Dec 12, 2016