Saturday, October 27, 2018
As self-employed individuals with access to employer-based health insurance plans we closely watch developments related to the Affordable Care Act (ACA) in Washington. To understand our choices for 2019 it’s important to understand what’s happened with the ACA:
First, the current administration effectively ended the tax penalty for not having an ACA compliant health insurance plan. I won’t get into the technicalities but you won’t incur any penalty if you indicate you had no health insurance, or any other non-compliant ACA plan, on your 2018 tax return. What’s an ACA compliant health plan? Essentially anything sold on the ACA exchange () and employer-provided health insurance plans. Recall, however, customers of Christian healthcare ministries had been exempt from this penalty based on the original ACA rules.
Second, the fact you won’t be penalized for not having an ACA compliant plan created the opportunity for the administration to adjust access to non-compliant health insurance plans:
Short term health plans – In short (pun intended), these plans have traditionally provided shorter term (~30 days) health insurance coverage for those changing jobs or in another situation requiring short term insurance. They are not new. They do not cover the 10 essential categories of an ACA compliant plan (i.e. pre-existing conditions, mental health, maternal care, etc.). So what’s new? Short term plans, dependent on state rules, can now have terms for a year and in some cases be renewable for up to 3 years. In Ohio, short term plans are available for 360 days (I won’t get into the technicalities of being 5 days short of a year). There’s been no change to what short term plans do or don’t cover but the ability to have this type of plan for a full year makes it an option. Due to the fact these plans do not cover pre-existing conditions, and other essential categories, the cost is far lower than ACA compliant plans (at least for those not receiving subsidies).
Association health plans (AHPs) – We haven’t done as much research on association health plans but we understand the basics. These plans have always allowed employers, or self-employed individuals with employees, to join together to buy health insurance. In fact, self-employed individuals with no employees can now participate in AHPs. “Associations” are generally people with a common interest – whether that be economical, through a business, geographically, etc. AHPs cannot exclude individuals with pre-existing conditions but, as we understand it, do not need to cover the 10 essentially categories of an ACA compliant plan. For example, certain AHPs may choose to exclude prescription drug benefits. We have not found relevant AHPs for our purposes but it is an option that seems more accessible under current standards.
Of course, the same options as last year exist as well: (a) self-insure and purchase no health insurance (not an option) (b) continue with Liberty and (c) purchase an ACA compliant plan on the health insurance exchange.
We just wanted to outline the choices we are considering for 2018. We have been doing a lot of research on short term health plans. In our next post we’ll dive into the structure of these plans and the specific plans we are considering for 2019!
Wednesday, October 24, 2018
If you’ve been following along you understand our logic behind switching to Liberty and have a sense for how things have gone thus far. With annual enrollment upon us it’s a good time to summarize our experience to date from a pros/cons perspective.
The cost – our previous post outlined it well. We’ve saved thousands of dollars with Liberty as opposed to the least expensive plan we could find on the Affordable Care Act (ACA) Exchange. Of course, it helps to be relatively healthy and not experience a lot of out of pocket costs, but from a premiums perspective, the savings are significant.
Increased freedom – okay, so maybe healthcare isn’t the area you want to choose to “buck the system”, but if we are being honest we like being a little different here. We are self-employed so maybe it’s natural we like systems that offer us greater freedom. It’s nice to not have to worry about being restricted to a specific doctor or healthcare system because of your insurance.
Friendliness – I won’t dwell on this point because I believe it’s highly variable but the people we’ve spoken to at Liberty have generally been friendly. While they might not have been able to solve all the inefficiency they generally had positive attitudes and we appreciated that.
Our healthcare providers not working directly with Liberty – This has been the primary inefficiency we have experienced. Since we are recognized as self-pay customers we must pre-pay for medical appointments, go through an inevitable reconciliation of what we pre-paid vs. the actual cost, then submit a bill to Liberty. As we’ve clearly documented, navigating the back-office of a major medical provider is tedious at best.
Communication could use improvement – Once your bill is submitted we found that communication as to what is happening with your bill could be improved. This is probably not that difficult of a change. Instead of fairly ambiguous statuses provide a little more detail…or clearly explain what each of the statuses means. I’m sure this exists somewhere but it needs to be clearer to the customer. We had to call far to often to understand what was going on and in a couple cases, we learned they were waiting for something from us…but how were we to know.
Operational inefficiency – This relates closely to the previous point. Our gut feeling is that Liberty is a growing organization that is learning how to cope with a larger user base. A growing user base means interacting with more customers, more healthcare providers, having to process more bills, answer more questions – a higher degree of variation. Liberty has reported to members they are working to improve their billing processes with new systems, etc. and hopefully this will have a positive impact.
So, at this point, the million-dollar question: Would we recommend Liberty to someone asking? Here’s how we’d answer that:
Characteristics of people we’d recommend Liberty to:
- Use a healthcare provider that will send bills directly to Liberty
- Relatively healthy with no significant pre-existing conditions or medical needs
- Have the cash flow to cover a 60-90 day lag in being reimbursed
- Do not have a more affordable alternative
- Open minded and can handle learning and some inefficiency to start
Characteristics of people we’d recommend looking for other alternatives:
- Have a healthcare provider that treats you as self-pay and won’t send to Liberty
- Have pre-existing conditions of significant/more frequent medical needs
- Do not have the cash flow to cover a 60-90 day lag in being reimbursed
- Have access to an affordable alternative
So are there any affordable alternatives to Liberty? Health insurance options are rapidly evolving with the current administration so it’s important to understand what is new for 2019. We can’t make an informed decision without understanding our options so our next few posts will preview how we are thinking about 2019.
As we approach the end of October we thought it was a good time to determine how our switch to Liberty has impacted our finances. To be clear, a decision about your healthcare – whether it be insurance or the provider – is something that can’t be solely financially based. However, given our relatively good health and extremely high premium last year it’s worth noting the financial savings. At this point in 2017 we had spent $11,146 in medical expenses. To the same point in 2018 that total is $7,262. These totals include the following:
- Insurance/Liberty premiums
- Dental insurance premiums
- Out of pocket costs for doctor visits and prescriptions
Keep in mind, as noted above, we still expect to be reimbursed for a few of our doctor visits from Liberty. We are at about $4,000 in savings and will probably be a little north of $5,000 in savings by the end of the year. That’s a substantial amount of money.
A substantial amount of money, but is it worth some of the inefficiencies we’ve dealt with…especially if we had to deal with those inefficiencies during a major medical event? We’ll continue to share our thinking on this question as we move forward.
We’ve had two appointments this year that were with providers other than our normal healthcare provider. One was a Minute Clinic appointment at our local CVS drugstore for an ear infection and another was a dermatology appointment for my wife. In each of these cases, the provider indicated they would send the bill directly to Liberty. Here’s how each provider managed Liberty:
Dermatologist – At the time of check-in they asked for my wife’s insurance card. She indicated we were with Liberty to which the receptionist indicated, “OK, we’ll submit the bill directly to them.” My wife was charged $75 at check-in for the appointment. A bill for $115 did arrive in our ShareBox for the appointment. Liberty processed the bill with $91.28 going to our Annual Unshared Amount (AUA) and $23.72 being classified as the “Adjusted Amount” which is defined as “Improper Balance. Member not Responsible.” (Again, on the communication side, it would be nice to better understand why these get pushed to the “Adjusted Amount” category and don’t count towards our AUA). I can guess what that means but it would simply be guessing. All we know is that it seems we paid $75 for an appointment that apparently cost $115. Since this isn’t a reimbursable charge it is highly possible we’ll receive a bill for $40 ($115 total cost of the appointment minus the $75 we already paid) from the dermatologist. The appointment occurred in July and we haven’t received any further bills so we aren’t sure what will happen.
CVS Minute Clinic – This appointment was for a basic ear infection for our son. In this case, we didn’t pay anything at the appointment. CVS indicated they would send the bill directly to Liberty (not sure if they knew who Liberty was or not). This appointment occurred in late August and as we approach late October we have still not seen the bill arrive in our ShareBox. We have no idea what happened.
So we haven’t had a ton of experience with providers submitting directly to Liberty but we did want to share these limited experiences. We can see how the efficiency of Liberty would improve if your healthcare provider submitted bills directly to Liberty. That said, the lost bill from CVS and the chance we’ll still hear that we have additional charges at the dermatologist could add some inefficiency. We’ll keep you updated on whether there is any change to this situation.
We’ve mentioned in previous posts that your membership to Liberty comes with access to the SavNet prescription savings card. We just wanted to provide an update on whether we’ve found this useful. Fortunately, our prescription drug needs have remained very basic: a routine prescription for my wife and medicine for a couple of minor issues for my 4-year-old. What we’ve noticed is that as a self-pay customer the pharmacy generally has their own discount card that was better than SavNet. We also realized it pays to call around when you have a higher cost prescription. One of my son’s prescriptions was over a little over $100 at most of the local pharmacies (within a $10-15 range of each other) but then the pharmacist at the local grocery store checked GoodRx.com for us and found a discount that took the price down to $40. We had known about GoodRx before but hadn’t thought to check it out.
In our experience, the SavNet discount card won’t earn you a more significant discount than those that can be provided by the pharmacy or GoodRx. Of course, this may vary by prescription and location so give it a try but this was our experience!
In July of this year, we received the e-mail below from Liberty announcing an increase in monthly prices as well as an increase in the Annual Unshared Amount (AUA) for members. Monthly share amounts increased by $50 to $499 for our family and our AUA would not be $2,250.
I can’t say we were shocked to receive this e-mail. As we documented in an earlier post, Liberty proactively reports their numbers and there were multiple months in a row in which monthly medical needs exceeded the amounts paid by members. This is a pattern that can’t last too long before a price increase is necessary.
The increase in price would not have changed our original financial analysis much and we joined Liberty because we respected the concept. I appreciate the way Liberty is transparent about their obligations to members and actually viewed this increase as a prudent way to improve their operations.
We forgot to share a quick story related to the very first bill we submitted this year – for my oldest son’s wellness visit. The bill submission to Liberty was rejected because they said we still had traditional health insurance and they wouldn’t reimburse us if we had traditional health insurance. We have no idea where this came from. The only way we found out was that we called to follow-up on why the reimbursement was taking so long and they indicated the bill wasn’t going to be reimbursed because we still had the insurance. If we would not have called we would have never known and continued to submit bills (another example where better communication during bill processing would save a ton of time). They seemed to indicate we should have received a notice in the mail but we never did.
In response to this, we needed to call our old insurance company and have them prepare a letter showing that our policy expired before we joined Liberty (there was no overlap). We submitted this to Liberty to get the situation cleared up. We only share this story so that you can double check whether you need to submit this type of letter upon joining. We saw no such notice at the time of joining and we are detailed enough to chronicle our experience here. Point is, double check.
Our medical visits thus far have included wellness visits for each of our boys and my wife and a couple of other fairly standard office visits (but not wellness visits). In all we had 7 visits requiring medical billing. As of this date in October of 2019 we have only been reimbursed for one of our medical expenses. This was for our 9 year old’s annual wellness visit. This bill was submitted on May 29 and paid July 17. Not bad for this one. The rest have been caught up in the Liberty blackhole.
As a reminder, one annual wellness visit per person is covered as part of your Liberty membership (up to $400). This means you should be reimbursed for this visit as opposed to it just going towards your Annual Unshared Amount (AUA). So as of this entry we are still waiting for 3 visits to be reimbursed. Two of those bills were submitted in July and one in August. We finally called last week to ask what the delay was and Liberty indicated they were surprised the bills hadn’t been processed and would expedite them. At this point, we are just hoping they are paid in the current year. It’s also important to remember we paid for these visits well before the actual visits, probably in the late Spring/early Summer. Thus, you’ll need the cash savings to take on these types of expenses up front and wait for reimbursement (thankfully our costs were relatively modest).
The other very confusing part of the reimbursement process is the relative radio silence from the time you submit the bill to when you are reimbursed. From time to time, you will get a notice like the one below related to your bill (this is an example of a notice we received recently after we called Liberty).
However, when you click on your ShareBox to understand what has occurred the status of your bill is very ambiguous. Here are a few of our current statuses and my interpretation:
Bill Created – I think this is the status it goes to once they review your bill submission and formally create a bill to be reimbursed. It sits here a while.
Submitted for Sharing | Reimbursed to Member – I am not sure what this means because I can tell you the bill with this status was not reimbursed to me. I would assume it means it’s going to be reimbursed at some point once the sharing is identified.
Completed | Reimbursed to Member – I am not sure what this means because, again, it wasn’t reimbursed to me.
Completed – One of our bills is in the plain Completed status. It is a bill that goes against our Annual Unshared Amount so I assume it just means it won’t be reimbursed (which would be correct).
Paid by Members (Check #XXXX) | Paid: July 17, 2018 | Reimbursed to Member – This is the status for the one bill that was actually reimbursed.
When you click on the e-mail notification from Liberty you need to locate the bill the e-mail relates to and review the status. I suppose as you gain more experience you would start to understand what the status is, but often times we didn’t even know what the status was before…let alone what the new status means. It’d be far more helpful if there was a description of the status so you didn’t need to call to understand it.
Liberty has stated in their monthly newsletter that they implemented a new billing system and are working on improving operating efficiency. It was clear they knew they were struggling a bit. That said, we’ve found the reimbursement process to be inefficient overall. People have been nice when we call to check-in but it’d be nice to not have to call at all. We will let you know if we get reimbursed before the end of the year. Fingers crossed!
Actually submitting bills (once you get one) to Liberty is a fairly easy process. From your ShareBox there is a link to submit bills. Clicking this link will take you to the simple form below. You can view a helpful demonstration video or just start working the form. We used the “Reason for Visit / Additional Comments” field to provide as much detail as possible. In some cases, this meant explaining why we were now submitting a second bill for the same visit (i.e. because we were billed more than our original estimate per the posts above).
Under the main form is where you are able to attach a copy of an electronic bill. In some cases, we received a bill via e-mail and just uploaded the attachment. In other cases, we took a photo of the bill with our iPhone and uploaded the picture directly to the site. Either way, it was very simple to submit a bill.
In our post highlighting cash flow considerations, we talked about the time lag between when we had to pay for an appointment vs. when we would be reimbursed by Liberty. We anticipated a lag but the reality was that the lag was much longer than we even anticipated. Let’s start with the date we thought we would have an itemized bill available from our healthcare provider.
As we have mentioned in previous posts we need to pre-pay for any services at our healthcare provider since we are designated as self-pay customers. Our primary healthcare providers in the area do not work directly with Liberty. Thus, we receive a 35% self-pay discount which is applied at the time we pre-pay for services. When we pre-pay we worked with a financial counselor who would estimate the cost of the services. We would then go to the actual appointment. In nearly all cases, as you might imagine, what actually occurred in the appointment was different than what we pre-paid for. Sometimes we paid too little, sometimes we paid too much but things were always off.
The financial counselor coming up with the pre-payment don’t really know what exactly will happen at the appointment…and these were the most routine wellness visit type visits that you could have. For example, at my 9-year-old son’s wellness visit they did some additional testing that the financial counselor was not aware of so our charge was higher. At the end of the day I think the financial counselor is doing the best job they can but inevitably there will be differences.
Ultimately, there were two outcomes based on this experience:
THE BAD: It took a really long time for the individual office within the healthcare provider to reconcile billing with the financial counselor. We could never just submit a bill to Liberty at the time of our pre-payment because we knew it would probably be different than what the ultimate cost is. This led to delays in submitting then obviously getting reimbursed.
THE GOOD: We’ve gotten a lot better at asking what procedures will be performed, what it costs, whether it’s truly needed, etc. If you are on traditional insurance it is a lot easier to not worry about what something costs, we are much more mindful now. Whether we stay with Liberty or not I feel this is a helpful skill to have developed.
My wife has gotten better at navigating this extremely complicated system but it’s come at the cost of hours on the phone. It’s comical seeing one person send you to the next, then send you back to the original (then repeat). Overall, inefficient, complicated and easy to see why healthcare costs so much. As a consultant, it’s a problem ripe for solving and I know there are many good ones trying to do just that.
Our Advice: If you will be moving to Liberty contact your healthcare providers to see how they interact with Liberty. If they submit bills directly to them it will make your life far easier (or would at least solve this problem).
I guess life just happened. With annual enrollment weeks away we wanted to make sure we update our experience and what we are thinking about for next year. So without further ado we present the last 6-7 months or our experience with Liberty Healthshare.
As background, we’ve had 7 medical appointments where we’ve needed to submit bills to Liberty. All of these have been pretty routine appointments. No major surgeries, etc. so the updates that follow are all based on these types of medical needs.