Category Archives: Kaiser Insurance News

Viewpoints: The Meaning Of Skyrocketing Premiums; Congress’ Inaction On Zika

The RNC Ignores Actual Science, But Embraces Pseudoscience

As 9 p.m. approached on the Wednesday of the 2012 Republican National Convention, delegates in Tampa, Florida, heard from South Dakota Sen. John Thune and Ohio Sen. Rob Portman. On Wednesday, as that same hour approaches in Cleveland, Republican delegates will hear a speech from someone named Michelle Van Etten, the senior vice chairman marketing director for a company called Youngevity. Whatever your political leanings may be, Thune and Portman were at least sitting elected officials with a public track record. Youngevity sells vitamins, purported weight-loss pills, and, also, dog shampoo. While Thune and Portman themselves have a shaky relationship with science, by the standards of the company Van Etten works for, those guys were basically Watson and Crick. (Jeremy Samuel Faust, 7/20)

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Congressional Republicans Ask Administration To Reject Calif. Request On Immigrants’ Insurance

Morning Consult:
California Reps Ask Feds To Reject Plan To Cover Illegal Immigrants

If California is granted such a waiver, it would be the first state granted the ability to offer insurance on its exchange to undocumented immigrants. Under the Affordable Care Act, undocumented immigrants are not eligible to purchase health insurance from states’ exchanges. … The letter was signed by California Republicans Darrell Issa, Tom McClintock, Ken Calvert, Dana Rohrabacher, Duncan Hunter, Doug LaMalfa, Paul Cook, Ed Royce, and Mimi Walters. (McIntire, 6/29)

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Ga., Calif. Hospitals Sue Blue Cross Plan For Sending ER Reimbursements To Patients

Blue Cross and Blue Shield of Georgia faces separate lawsuits accusing it of sending reimbursement money for emergency room care directly to patients — and not to the hospital because it isn’t part of the insurer’s network.

That’s costing the hospitals money since patients don’t always turn over the funds, according to the lawsuits, filed by Polk Medical Center in northwest Georgia and Martin Luther King, Jr. Community Hospital in Los Angeles — 2,000 miles apart. Each suit also says some patients have sought to profit from receiving the direct payments for their ER care.

By sending money directly to patients, Polk Medical Center says the insurer forces the hospital to find ways to collect it. Even though patients are obligated to pay the facility the amount sent to them by Blue Cross, in some cases they have spent the money, according to the lawsuit.

The Polk lawsuit said that Blue Cross, in its new payment process, was pursuing “retaliation’’ for the Cedartown, Ga., hospital’s not agreeing to “unreasonable and unfair” terms in order to be part of the insurer’s network. Hospital officials said the payment shift has hurt the hospital financially.

“Blue Cross insures a significant number of individuals in Polk County,’’ said Tommy Manning, the attorney for the Floyd Medical Center system, of which Polk Medical Center is a part.

Manning said that Blue Cross has sent ER payments to patients for several months.

And he said he was unaware of the Los Angeles lawsuit prior to the filing of the Polk complaint.

The lawsuit from Martin Luther King, Jr. Community Hospital alleges that “most of the MLK patients who receive checks from [Blue Cross of Georgia] are unaccustomed to receiving payments in such large amounts. Some of these patients do not know that they are required to endorse those checks over to MLK. Other patients know that they should endorse those checks over to MLK but instead use such funds to pay for their personal expenses. When MLK attempts to collect the amounts from these patients, the money is often spent.”

Emergency DepartmentIn the case of patient “B.G.,’’ the suit alleges that the patient went to the MLK emergency room 11 times between Oct. 19 and March 27 for various ailments, including complaints of chest or back pain. Blue Cross of Georgia paid the patient a total of more than $70,000 for these visits to MLK, according to the lawsuit.

The lawsuit said the practice overall has caused MLK to suffer damages in excess of $350,000.

Blue Cross declined comment on the lawsuits, citing pending litigation.

Patients are protected under federal law when seeking care in hospital emergency rooms. Under the Emergency Medical Treatment and Labor Act (EMTALA), they must at least be stabilized and treated, regardless of their insurance status or ability to pay.

Manning said this month that he’s not aware of any other insurer in Georgia paying the patient instead of the hospital.

At least one other major hospital that is not part of the suits has reported difficulty in getting payments from Blue Cross when it was out of the insurer’s network. Officials at Grady Memorial Hospital in Atlanta said that when it was out of Blue Cross’ network for the four months ending in March 2015, the insurer sent reimbursement payments to some patients and not to Grady.

Daron Tooch, a Los Angeles attorney representing MLK Hospital, said other Blue Cross plans in the United States use similar tactics. The Los Angeles patients worked for a company that has Blue Cross of Georgia coverage, he said. MLK is out of network for the Blue Cross plans in California.

“This is not unique to MLK,’’ said Tooch. “This happens to all out-of-network providers for Blue Cross of Georgia.”

Going after the patients for payment instead of the health plan simply hasn’t worked, attorneys for MLK said. The patients “are typically unable or unwilling to pay MLK for the medical services received,” according to the suit.

Manning agreed. “We will continue to pursue collection with patients, but filing numerous lawsuits would not be fruitful, particularly given that Blue Cross Blue Shield is the party ultimately at fault,” he said.

Asked about the Blue Cross of Georgia payment strategy, the national Blue Cross Blue Shield Association, through a spokesman, declined comment. Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group, said that those types of reimbursement arrangements would vary by plan and by contract. She added that she did not have details on other plans that may do the same.

Paying patients directly is an insurer tool used more commonly in the West, “particularly when non-network facilities are unwilling to negotiate reimbursement related to out-of-network service,’’ said Janet Guptill of the Tatum firm, which provides interim chief financial officers and other executives to health care organizations.

“The insurer takes the position that the provider claim is a private pay issue between the provider and the patient, so the facility has the responsibility to collect the payment from the patient,’’ Guptill said.

Guptill said that when a hospital isn’t in network, its charges for ER and other care tend to be higher than the charges from facilities in the insurer’s network.

For insurers, paying patients directly is “a clever and probably effective tactic,’’ said Chris Kane, a consultant with DHG Healthcare. The hospital, he said, may already be dealing with other collection challenges, including those involving high-deductible health plans.

A hospital attempting to collect the money may end up alienating the patient and thereby discouraging future visits, Kane said.

And patients pocketing the money is another problem, he added. “It’s more troubling if a patient views this as a source of cash.’’

This story was done in partnership with Georgia Health News.

Categories: California, Health Industry, Insurance, Syndicate

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Catastrophic Insurance Could Help With Long-Term Care Expenses: Studies

As aging baby boomers swell the ranks of elderly Americans, we’re nowhere near a solution to providing the long-term care services many of them will need.

“Do you use those resources to assist people who might be able to take care of themselves, or do you use it to help people who couldn’t realistically be expected to take care of themselves?” asked Howard Gleckman, a senior fellow at the institute who has co-authored studies on the subject.

Adult Daughter Helping Senior Tie Shoelaces

The problem is large and growing. Researchers estimate that about half of people who are 65 today will need help with daily activities such as bathing or eating at some point in their lives. Most will need help for less than two years, but about 1 in 7 will have a disability that lasts for more than five years.

Even though many people rely on unpaid family help, a growing number will need care provided by home health aides or nursing homes. Someone who turns 65 today can expect to rack up about $138,000 in long-term care costs over the rest of her life, according to the Urban researchers. Once people exhaust their own resources, they often turn for help to Medicaid, which covers 40 to 60 percent of long-term care services in this country, providing nursing home and other services to low-income people who have few other assets.

In a recently released issue paper and in a study in the journal Health Affairs last year, the Urban researchers modeled the spending impact of two programs that each paid a $100 daily benefit, with a 3 percent annual inflation adjustment. The first would pay at the beginning — 90 days after someone needed help with at least two “activities of daily living” — for up to two years, while the second would pay at the end — for an indefinite period — after someone had needed assistance for at least two years.

The spending impact on consumers’ out-of-pocket costs and the Medicaid program would vary depending on when the coverage kicked in.

The program that paid on the front end would have a bigger effect on individuals’ out-of-pocket spending for long-term care services. Forty-five percent of spending on the front-end program would displace out-of-pocket spending by individuals, compared with displacing 33 percent of out-of-pocket spending in the back-end program. That makes sense, since many people pay for long-term care services on their own until they can no longer afford to do so and then turn to Medicaid.

Conversely, the insurance program that paid out on the back end after two years would be more advantageous for Medicaid. That program would displace 38 percent of Medicaid spending, compared with just 15 percent for the front-end program.

Consumer advocates have long championed plans to establish some sort of national insurance program to help cover long-term care services. But costs and political differences have stymied the efforts. The Urban researchers, in the most recent brief, suggest that although more studies are needed, the back-end program they modeled “could reduce Medicaid spending, providing financial relief to hard-pressed states” and “reduce out-of-pocket spending for families.”

Insurance is only one piece of the puzzle, said Bonnie Burns, a policy specialist and long-term care expert at California Health Advocates, a Medicare advocacy organization.

“What we need is a coordinated system of care,” she said. “We’ve spent 30 years of looking at this problem. There’s lots of data but there’s no action.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

Categories: Aging, Cost and Quality, Insurance, Insuring Your Health, Medicaid, Syndicate

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Viewpoints: Time For A Change In Course For FDA?; A Key Moment For The Health Law’s Medicaid Expansion

The Wall Street Journal:
It’s Time To Radically Change How The FDA Approves Drugs

I’m a big fan of the U.S. Food and Drug Administration (FDA) and the vital mission it has been performing since 1962: ensuring that all medications sold in the United States are both safe and effective. Everyone should want the FDA to succeed — now and in the future — because, without a strong FDA, being sick would be massively more horrible than it already is. But, although a fan, I think the FDA should change course. Specifically, the FDA should adjudicate new drug applications with a Consumer Reports approach, not its current approach, which copies Roman emperors who signaled a gladiator’s fate with either a thumbs-up or thumbs-down, and no other choice. (John Sotos, 6/29)

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Opponents Of The Aetna-Humana Merger Urge DOJ To Take Action

The CT Mirror:
Merger Opponents Ask DOJ To Block Aetna-Humana, Anthem-Cigna Deals

Opponents of the planned Aetna-Humana, Anthem-Cigna mergers have asked the U.S. Justice Department to block them in a letter that alludes to the controversy over Connecticut Insurance Commissioner Katharine Wade’s lead role in state regulatory approval of one of the deals. Many of the 43 signers of the letter to Renata B. Hesse, head of the DOJ’s Antitrust Division, were state medical societies, including the Connecticut State Medical Society. The Universal Health Care Foundation of Connecticut, the Connecticut Citizen Action Group, several other consumer groups and the United Methodist Church also signed the letter. (Radelat, 6/29)

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For Many In Baltimore’s Growing Latino Community, Health Care Is A Challenge

Cecilia Ramirez is worried about her weight and troubling symptoms that hint of diabetes, but she won’t seek medical help because she can’t afford it.

“I don’t go to the doctor when I’m sick — it’s too expensive,” she said.

Though she is a sales worker at an insurance agency in Highlandtown, an East Baltimore neighborhood that has seen an influx of Hispanic immigrants in recent years, Ramirez, 23, has no health insurance.

Her predicament is shared by thousands of Hispanic immigrants in East Baltimore, and millions nationally, who cannot afford regular medical services and are uninsured because they lack the benefits attached to legal U.S. residency and citizenship.

Ramirez’s parents came illegally to the U.S. from Mexico when she was 10. Her immigration status now — “lawfully present” — allows her to work and study here without fear of deportation, but she has no path to citizenship. She is ineligible for health coverage under the Affordable Care Act or any public insurance program.

(The Supreme Court’s decision last week in a related immigration case did not change this.)

Her $23,000 annual income would easily qualify her for Medicaid, but only her two young children can get it. Ramirez’s employer can’t afford to offer her private health insurance either, and even if it did, she doubts she could afford it. So, how can Ramirez deal with the hacking from her lungs?

“Vicks VapoRub,” offers her boss, David Rosario, drawing cynical laughter from Ramirez and others in the office.

Latinos, uninsured or not, face many challenges when it comes to finding medical care. Many have trouble speaking and understanding English, are poor and undereducated, or lack transportation. Others come from cultures where health care is a luxury they don’t regularly seek out.

Cecilia Ramirez and her two daughters, Jenny Rodriguez-Ramirez, 7, and Kimberly Gonzalez-Ramirez, 3. The girls qualify for Medicaid because they were born in the U.S., but their mother does not because of her immigration status. (Doug Kapustin for KHN)

Cecilia Ramirez and her two daughters, Jenny Rodriguez-Ramirez, 7, and Kimberly Gonzalez-Ramirez, 3. The girls qualify for Medicaid because they were born in the U.S., but their mother does not because of her immigration status. (Doug Kapustin for KHN)

But the inability of non-citizens to join affordable health plans remains the primary stumbling block separating people from Mexico, Central America and South America from care.

“What we’re seeing across the country is that the undocumented are one of the most vulnerable groups out there when it comes to insurability,” said Steven Lopez, manager of the health policy project at the National Council of La Raza, the largest Latino advocacy group in the U.S. “The opportunity to get regular health care is the key to finding greater opportunity. If you don’t have your health, you’re not going to progress in life.”

Nationwide, more than 5 million people living in the U.S. illegally are without medical coverage, with indications that most are Hispanic, according to an Urban Institute report released in March. Nearly half of all immigrants living here without permission are uninsured, compared with 10.5 percent of U.S. citizens and roughly 15 percent of non-citizens living here legally, the report noted. Hispanic adults’ uninsured rate fell to 28 percent last year — 13 percentage points below 2013 — but remains far higher than those of non-Hispanic whites, blacks and Asians, according to federal statistics released in May.

“This is the tricky part for us,” said Leana Wen, Baltimore’s health commissioner. “The Affordable Care Act excludes these individuals” who lack authorization to live in the U.S. “They fall through the cracks.”

They have done so even as Mayor Stephanie Rawlings-Blake works to draw more immigrants here in the hope they will repopulate hollowed out inner-city blocks. Latinos, who figure prominently in the mayor’s drive to recruit 10,000 new families, continue to filter into several older East Baltimore neighborhoods, including Fells Point, Greektown, Highlandtown and Patterson Park.

Baltimore’s population includes around 30,000 Latinos, up from just 9,000 15 years ago, city officials say. Medical providers and Latino advocates say that 40 to 60 percent of them live in the U.S. illegally, a range close to the Urban Institute’s national estimates.

Health is a major concern. Baltimore Latinos are twice as likely as non-Latinos to say they have poor or fair health, according to a city health department survey in 2011.

There is insufficient data to make judgments about the health of the city’s Latinos or compare them to other groups. But death from cardiovascular disease and cancer were the two leading causes of death among the city’s Latinos in 2012, according to a 2014 report by the department. Unintentional injury and chronic liver disease or cirrhosis tied for the fourth leading cause of death among the city’s Latinos, but they were much less common among white and black populations, the report found.

“People can start businesses and buy homes, but they can’t get medical insurance,” said Rosario, who serves as board president for the Latino Providers Network, an organization that links Hispanics to services.

Working out of an office within Johns Hopkins Hospital's Bayview Medical Center in Baltimore, Centro SOL social worker Flor Giusti converses with Latino patients in her office there. (Doug Kapustin for KHN)

Working out of an office within Johns Hopkins Bayview Medical Center in Baltimore, Centro SOL social worker Flor Giusti converses with Latino patients in her office there. (Doug Kapustin for KHN)

As a result, health providers say that when they see people come into their offices or clinics, they are often in advanced stages of illness.

“Typically, we see a lot of diabetes and obesity-related diseases, like high blood pressure,” said Kathleen Page, an infectious disease specialist at Johns Hopkins Hospital and a cofounder of Centro SOL, a Bayview clinic and outreach program that treats Hispanic clients at reduced prices. Baltimore Latinos suffer higher rates of those disorders despite being younger as a group than the rest of the city’s population. Chronic infections and mental health problems such as anxiety and depression run rampant, Page added.

About 95 percent of the Hispanic patients she sees at her HIV clinic are living here illegally and lack health insurance.

Latinos’ ability to find treatment is tied directly to their immigration status.

Some people in the U.S. without documentation can receive payments for baby deliveries through Emergency Medicaid. Federally qualified health clinics offer basic medical care to thousands of the uninsured at reduced rates, with no questions asked about status, but the federal government offers no insurance options for those living in the U.S. without permission.

Insurability can vary even within households, reflecting mixed immigration status among family members. Cecilia Ramirez’s mother, who does not have permission to live in the U.S., long remained uninsured, putting off treatment for uterine fibroids for years because she was worried about the cost of care.

Meanwhile, Ramirez’s children, 7-year-old Jenny and Kimberly, 3, receive insurance through Medicaid. Because they were born in the U.S., giving them citizenship, and they meet Medicaid’s eligibility standards, they are able to see primary care physicians and get other care if needed. Much of it is paid for, unlike their mother’s.

Dr. Sarah Polk, a pediatrician, provides care at the Centro Sol clinic in Baltimore to patients like Janexy Marquez-Ramirez. (Doug Kapustin for KHN)

Dr. Sarah Polk, a pediatrician, provides care at the Centro SOL clinic in Baltimore to patients like Janexy Marquez-Ramirez. (Doug Kapustin for KHN)

As a foreign-born child of immigrants who entered the U.S. without permission, Ramirez’s access to health care is problematic. She applied for and received “lawfully present” status under a 2012 Obama administration policy that allowed people who arrived in the U.S. before age 16 and are now under age 35 to work and study in the U.S. without fearing deportation. Some 665,000 others have also received such status nationwide, according to figures from the Department of Homeland Security. But they were also excluded from gaining health insurance under the Affordable Care Act by a related policy of the Department of Health and Human Services. Some states, including California and New York, have softened their standards and enrolled some people here illegally in Medicaid. But nationally, most remain without coverage.

To help people like Ramirez and other low-income people without permission to live here, several institutions in East Baltimore have cobbled together an array of medical services outside of typical hospital settings. Baltimore City, Johns Hopkins Bayview, two federally subsidized clinics and one charity-run clinic offer bilingual interpreters, health providers who speak Spanish and, perhaps most importantly, low fees and sliding scales for care.

The Access Partnership, or TAP, a Johns Hopkins charitable program, offers diagnostic tests and visits to specialists for very low fees, usually no more than $20. The program serves people who lack insurance, make 200 percent or less of the federal poverty level and have been local residents for six months. More than 90 percent are Hispanic, and none are asked if they are living in the U.S. illegally, said Barbara Cook, the group’s medical director.

Cecilia Ramirez’s mother got diagnostic tests and subsequent surgery a little over a year ago to remove her uterus with help from TAP. Nonetheless, Ramirez wonders if the outcome would have been better if she had gotten help earlier.

“If she had had insurance, she might have sought out care, instead of having to wait so long that they had to remove part of her body,” she said.

This story was supported in part by a grant from the Annie E. Casey Foundation.

Categories: ‘Baltimore’s Other Divide’, Insurance, Public Health, Syndicate, The Health Law

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State Highlights: Ill. Weighs In On Aetna-Humana Merger; Allina Proposes New Terms To Minn. Nurses; Calif. Hits HIV Targets Early

California Healthline:
Old Motels Get New Life Helping Homeless Heal

Just up the freeway from Disneyland, in the Orange County city of Buena Park, Paul Leon stood outside the beat-up remnant of a seedy motel. Above him, a faded pink sign advertised the Coral Motel, whose rooms back in its prime cost 35 bucks a night. “This particular motel was going to be taken back by the city of Buena Park, because of the drugs, alcohol, prostitution,” Leon explained. But Leon, CEO of the Irvine-based Illumination Foundation, a homeless services nonprofit, had a different idea. He proposed turning the motel lobby into a triage center and converting the rooms into clean recovery facilities for homeless people recently discharged from the hospital. And that’s what he did. (Gorn, 6/28)

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States Offer Privacy Protections To Young Adults On Their Parents’ Health Plan

The health law opened the door for millions of young adults to stay on their parents’ health insurance until they turn 26. But there’s a downside to remaining on the family plan. Chances are that mom or dad, as policyholder, will get a notice from the insurer every time the grown-up kid gets medical care, a breach of privacy that many young people may find unwelcome.

With this in mind, in recent years a handful of states have adopted laws or regulations that make it easier for dependents to keep medical communications confidential.

The privacy issue has long been recognized as important, particularly in the case of a woman who might fear reprisal if, for example, her husband learned she was using birth control against his wishes. But now the needs of adult children are also getting attention.

“There’s a longstanding awareness that disclosures by insurers could create dangers for individuals,” said Abigail English, director of the advocacy group Center for Adolescent Health and the Law, who has examined these laws. “But there was an added impetus to concerns about the confidentiality of insurance information with the dramatic increase in the number of young adults staying on their parents’ plan until age 26” under the health law.

Federal law does offer some protections, but they are incomplete, privacy advocates say. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a key federal privacy law that established rules for when insurers, doctors, hospitals and others may disclose individuals’ personal health information. It contains a privacy rule that allows people to request that their providers or health plan restrict the disclosure of information about their health or treatment. They can ask that their insurer not send the ubiquitous “explanation of benefits” form describing care received or denied to their parents, for example. But an insurer isn’t obligated to honor that request.

In addition, HIPAA’s privacy rule says that people can ask that their health plan communicate with them at an alternate location or using a method other than the one it usually employs. Someone might ask that EOBs be sent by email rather than by mail, for example, or to a different address than that of the policyholder. The insurer has to accommodate those requests if the person says that disclosing the information would endanger them.

A number of states, including California, Colorado, Washington, Oregon and Maryland, have taken steps to clarify and strengthen the health insurance confidentiality protections in HIPAA or ensure their implementation.

In California, for example, all insurers have to honor a request by members that their information not be shared with a policyholder if they are receiving sensitive services such as reproductive health or drug treatment or if the patient believes that sharing the health information could lead to harm or harassment.

“There was concern that the lack of detail in HIPAA inhibited its use,” said Rebecca Gudeman, senior attorney at the National Center for Youth Law, a California nonprofit group that helps provide resources to attorneys and groups representing the legal interests of poor children. She noted that HIPAA doesn’t define endangerment, for example, and doesn’t include details about how to implement confidentiality requests.

Concerns by young people that their parents may find out about their medical care leads some to forgo the care altogether, while others go to free or low-cost clinics for reproductive and sexual health services, for example, and skip using their insurance. In 2014, 14 percent of people who received family planning services funded under the federal government’s Title X program for low-income individuals had private health insurance coverage, according to the National Family Planning and Reproductive Health Association.

Even though most states don’t require it, some insurers may accommodate confidentiality requests, said Dania Palanker, senior counsel for health and reproductive rights at the National Women’s Law Center, a research and advocacy group.

“Inquire whether there will be information sent and whether there’s a way to have it sent elsewhere,” Palanker said. “It may be possible that the insurer has a process even if state doesn’t have a law.”

Insurers’ perspective on these types of rules vary. In California, after some initial concerns about how the law would be administered, insurers in the state worked with advocates on the bill, Gudeman said. “I give them a lot of credit,” she said.

Restricting access to EOBs can be challenging to administer, said Clare Krusing, a spokesperson for America’s Health Insurance Plans, a trade group. A health plan may mask or filter out a diagnosis or service code on the EOB, but provider credentials or pharmacy information may still hint at the services provided.

There’s also good reason in many instances for insurers and policyholders to know the details about when a policy is used, experts say. Policyholders also may have difficulty tracking cost-sharing details such as how much remains on the deductible for their plan.

In addition, “if a consumer receives a filtered or masked EOB, he or she has no way of knowing whether their account has been compromised or used as part of fraudulent activity,” Krusing said.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Insurance, Insuring Your Health, Syndicate, The Health Law


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Speculation Over Anthem-Cigna Deal Mounts

Los Angeles Times:
Blue Shield Faces New Criticism Of Shortchanging Consumers In California

Blue Shield of California, already under scrutiny by state officials, is facing new criticism that it didn’t adequately pay back policy holders for excessively spending on administrative costs in 2014. Officials from the health insurer strongly rejected the allegation, made by a former company executive in a complaint to state regulators. But if substantiated by investigators, the accusation could force the insurer to pay additional rebates to customers. (Levey, 6/28)

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