Top 10 Health Services Commonly Excluded from Plans

The new Affordable Care Act law does not mean everything will change. Experts say many services that were excluded prior to the law remain unchanged. They examined over 3,000 health plans in 2014 to see which services were the most commonly excluded. Their data showed that about 80 percent of exclusions were unchanged prior to and immediately after the new law taking effect. The following were the top 10 services most commonly excluded.
1. Weight Loss Surgery
Nearly 60 percent of plans exclude this type of surgery following the new health care law taking effect. Prior to that, 90 percent of plans excluded weight loss surgery. Experts said they were surprised that 40 percent of programs still excluded the surgery and similar programs as well due to the high rate of obesity in the United States. However, counseling and screening for obesity is provided as preventative care without the need to pay upfront.

2. Eye Exams For Adults
Slightly more than 60 percent of plans exclude this benefit, which experts say is disappointing due to the many benefits of eye exams. They point out that optometrists can detect diabetes and other health problems early on with this simple type of exam. Not many providers offer standalone vision plans. While 50 percent of large employers offered standalone dental plans, less than 20 percent offered standalone vision plans.

3. Private Nursing Care
More than 65 percent of plans now exclude this benefit. However, that number improved within the span of one year. In the past, more than 90 percent of plans excluded private nursing care.

4. Infertility Treatments
Experts said more than 65 percent of plans exclude fertility treatments. This number was down from before. The amount of plans excluding these treatments before the new law took effect was nearly 95 percent. Since the average cost of each cycle is over $12,000 and most people need multiple cycles, the procedure was widely inaccessible for most people before the new law’s introduction.

5. Regular Foot Care
More than 70 percent of plans now exclude routine foot care, but the number was higher before the new law started. Researchers say that the law has a large influence on the individual market for health insurance, but they said the effect on most of the excluded services was less extensive.

6. Acupuncture
Nearly 85 percent of plans exclude acupuncture, but more than 90 percent of plans excluded it prior to the Affordable Care Act. Researchers said that acupuncture is a good solution for chronic pain. They think doctors should recommend it more often for arthritis or other ailments that are ongoing.

7. Weight Loss Programs
Less than 90 percent of plans cover weight loss programs, but nearly 95 percent excluded them before the new law’s beginning. Experts find this disappointing due to the many serious health problems that are related to obesity.

8. Dental Services For Adults
Slightly less than 90 percent of plans exclude adult dental care. This number is actually an increase from prior years. In 2013, barely more than 80 percent of plans excluded dental care for adults. However, the new law provides for pediatric dental and vision care.

9. Cosmetic Surgery
More than 90 percent of plans exclude cosmetic procedures. In the past, over 95 percent excluded it, so this is a slight improvement for people who may need cosmetic surgery.

10. Long-Term Care
Barely less than 100 percent of plans exclude long-term care. It was rarely included in health plans in the past, and it is still the most commonly excluded health care service. This type of coverage includes services for people who need to live in skilled nursing facilities for long periods of time due to disabilities or chronic conditions. While some younger individuals require this form of care, it is most common among the elderly.

Many people visit sites online to try to shop for insurance.  Please call us for a wide range of options.


Michael Braun


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Can you Really Keep your Doctor with a Narrow Network?

One of the key selling points of the Affordable Care Act was the promise that “you can keep your doctor, period.”

Not so fast.

In fact, millions of Americans who have or will be signing up for medical coverage via the online exchanges established by the ACA are due for a nasty surprise: Most of the plans available via the exchanges come with significant network restrictions, and in many case will not provide in-network coverage to the most sought-after hospitals, clinics and physicians in their markets.

The issue: In order to control costs, the Affordable Care Act relies a great deal on the managed care model employed by health maintenance organizations (HMOs) preferred provider organizations (PPOs). Here’s how it works:

Managed care organizations try to get as many subscribers as possible within a certain market, such as a city, state or zip code. They then approach the medical care providers in the community and use their large subscriber base as a bargaining chip. They offer the medical care provider or institution the prospect of a significant flow of referrals. In exchange, they ask hospitals and clinicians to take a much lower reimbursement rate.

The arrangement is known in health care circles as the “narrow network” concept. The smaller the network, the more value the stream of referrals has to those providers included in the network. Expanding the network to too many care providers also dilutes the value of the stream of providers.

The result: the system is skewed in favor of the lowest cost providers. Those with higher fees – the best specialists and hospitals in the greatest demand, and who have made the most investments in technology and training, for example – get locked out of the process. They cannot underbid the low-cost providers.

Exclusions Abound

Across the country, individuals purchasing or shopping for coverage via the networks are discovering that many or most plans don’t cover the best local hospitals. For example, the venerated Cleveland Clinic accepts dozens of private health plans offered via independent health insurance brokers and through carriers outside of the ACA exchanges. But if you buy your plan through the exchange in Ohio, only one exchange plan out of the twelve offered provides in-network coverage to the Cleveland Clinic.

As another example, Southern California Health Net has announced that individual plans sold via exchanges in that market will have access to less than a third of the number of doctors available via employer plans. Furthermore, while all the exchange plans include the Los Angeles County hospital system, most of them will not provide in-network coverage to the most respected private hospitals like Cedars-Sinai, or the top research hospitals like UCLA.

Additionally, Seattle Children’s Hospital – a popular and respected institution in Seattle, Washington, has filed a lawsuit against the state because it has been excluded from the exchanges. Of the seven plans available in King County, only two of them provide in-network coverage for Seattle Children’s Hospital.

“The notion that a major insurance plan is going to exclude us from their network is truly precedent-setting,” said Sandy Meltzer, a physician and the hospital’s senior vice president, in an interview with the Seattle Times. “[It] represents a new level of degradation in children’s access to care.”

 The Bottom Line

When it comes to health insurance, the monthly premium cost is only a small part of the big picture. The proper way to evaluate any health insurance policy isn’t just premium. Instead, you should consider how likely you are going to be to be satisfied with your care options in the event you have a claim. That’s why you should look carefully not just at your premium and deductible, but also read the fine print and find out whether you will have access to the best providers in your area.

It may well be that your independent insurance advisor has options for you that you would never find on the exchanges. Indeed, many carriers have opted out of the exchange system for a variety of reasons.

Please call us for a consultation to review networks and plans.

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Working with an Agent Instead of a Navigator has Multiple Benefits

Millions of people will be purchasing health insurance through marketplaces, which are part of the Affordable Care Act provision. In doing this, some consumers face problems with program access due to site failures on the Internet. One option most people forget about or are not told is available is the opportunity to purchase coverage through an agent or broker. These professionals can provide enrollment assistance and valuable advice, and they are able to answer most questions.

There are also navigators, which are not the same as professional brokers and agents. Navigators are paid by the government, and they are not able to provide as much assistance as a broker or agent could. These navigators are prohibited by law to make recommendations or give advice about policies. In the majority of states, navigators do not have to be licensed, and they do not have to comply with the same continuing educations requirements that professional agents are required by law to meet. In addition to this, navigators are not required to keep the professional liability coverage that agents must purchase.

Most independent brokers and agents have been trained to provide assistance to people who are trying to enroll in health plans. They are also able to make consumers aware of options that are not offered through exchanges. Experts point out that choosing a health plan is a serious step that should involve research. It should not be the same as going online and purchasing commodities. Buying inadequate coverage could cost a person his or her life or life savings if something goes wrong.

In addition to the problems consumers could face if they use navigators, experts point out that navigators cannot provide prompt assistance. With the many site issues online associated with the enrollment page, there is a backlog of people waiting for help. About $67 million was put into funding the enrollment efforts, but navigators still have to wait for issues to be fixed despite this investment. As they continue to sort through the piles of paper applications, they will slowly be able to provide limited help to consumers. People who are concerned about obtaining coverage in the time allowed will have better luck talking to a professional broker or agent. Since there is not a great deal of time left to purchase coverage, it is important to contact an agent or my firm as quickly as possible to discuss concerns and ask questions.

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Who’s Paying for it?

Who is going to pay the bills when they come due for insurance.    People that buy coverage through the and receive a subsidy will be allowed a 90 day grace period to pay premiums.    Typically, the insurance carrier will allow a 15 day grace period for unpaid insurance premiums.    

This new policy of 90 day grace periods will begin January 1 2014 with the Affordable Care Act.    When patients visit Dr’s offices they will be asked for their insurance cards and the Dr’s office will confirm eligibility with the various systems in place.   Since there is a 90 day grace period to pay insurance premiums, members in the plan will show active or eligible.   

What happens if they do not pay their premiums?  Who is paying for it?

Well under the Affordable Care Act, the insurance carrier will pick up the 1st months claims cost and the Drs and Hospitals will pick up the other two months.    Anyone who has been in the business knows that once one month goes by the likelihood of someone paying back premiums is very small.    This problem will compound the already heavy administrative burden on insurance carriers and medical administrators.    This problem will lead to the death spiral in rates.    Those who need care will pay premiums and those who do not need care will opt out.  This leaves a carrier with bad risk and rates will spiral out of control and will consume the whole market.   

Who’s paying for it?   This is an easy answer.   It is you.   

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Employer Mandate Delayed

As some of you may be aware the Employer Mandate is being delayed from 2014 till 2015.    This does not effect the individual mandate.  Individuals that do not have insurance will still be required to buy insurance for a start date of January 1, 2014.   If you do not purchase health insurance through your employer you will be required to buy insurance through a federal or state based exchange or broker.    Here are some other key pieces of information:

  • Enrollment will begin  October 1  for a January 1, 2014 start date. (we feel that this could delayed, we are less than three months away and there has been no training or testing be done with the marketplace.)
  • If you fail to purchase insurance, you will pay a tax of $96 the first couple years and then it indexes up in 2016.   Most people get a refund so it will be take out of your refund.
  • You may be eligible for a subsidy based on your household size and household income.    You can see if you are eligible for the subsidy by going to this link.

We think there is more information to come about federal based exchanges in the next couple of weeks.   There is a lot of work and there is a lot of to be done.

Mike Braun

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« The Worst Study Ever? Commentary Magazine

Great article.   Is equal distribution better or better outcomes?

Take a read and find out some real information.

« The Worst Study Ever? Commentary Magazine.

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Pay or Play

The IRS has issued long awaited regulations proving additional guidance for employers on the employer shared responsibility mandate (“Pay or Play”) of the Affordable Care Act (“ACA” or “Health Care Reform”). By way of background, the Pay or Play mandate requires that large employers, those with more than 50 employees, provide coverage to all full time employees (those working more than 30 hours per week) and their dependents beginning on the first day of the first plan year after January 1, 2014. Such coverage must also pass certain tests to ensure that such coverage is adequate and affordable in regard to the full time employee.
Please note that this new guidance provides some changes to previous assumptions regarding the Pay or Play Mandate that were widely accepted within the benefits community. It is also important to note that these are proposed regulations that could be subject to further change. Unless, or until, a change is issued, employers may rely on the proposed regulations.

Transitional Rule for Non-Calendar Year Plans
The IRS has delayed Pay or Play penalties for some employers with non-calendar year plans. This is a welcome relief since earlier guidance suggested that all plans would be subject to the Pay or Play mandate immediately on January 1, 2014. Rather, an employer will not incur a Pay or Play penalty for any month prior to the first day of its 2014 plan year if:
• The non-calendar year plan was in existence as of December 27, 2012;

• At least ¼ of the employees are enrolled in the mid-year plan or at least 1/3 of the employees were offered coverage under the mid-year plan during open enrollment; and
• The full-time employees, or full time equivalent employees (“FTE”) are offered affordable and adequate coverage no later than the first day of the 2014 plan year.

This communication is provided for informational purposes only and does not constitute legal advice. It contains only a summary of the applicable legal provisions and does not purport to cover every aspect of any particular law, regulation, or requirement.
Common Ownership Issues
• Companies under common control, or under common ownership, should be counted together for purposes of determining whether the employer is a “large employer” (over 50 employees) and thus subject to the mandate.

• Although employers need to count affiliated entities together to determine if it is a “large employer”, any penalties would be calculated separately for each entity.

Substantial Compliance / The De Minimus Rule / The 95% Rule
• An applicable large employer can avoid a penalty for not offering coverage so long as it offers coverage to 95% of its full-time employees (and the employees’ children)

• The failure to offer coverage to the other 5% will not trigger a penalty, regardless of whether the failure is inadvertent or by design.

• If a large employer has fewer than 100 full time employees, the employer can avoid penalty by offering coverage to all by five (5) of its full time employees, even if the offer of coverage would be less than 95% of the member’s full-time employees.

Requirement to Cover Dependents

• Large employers will have to offer coverage to the children (those 26 and under) of full time employees in order to avoid a non-coverage penalty

• Spouses are not considered dependents under this provision

• The children that will have to be covered include:
o Children by birth, adoption and placement for adoption;
o Stepchildren;
o Foster children
• If a plan currently does not offer to coverage to all such children listed (ex. Foster Children), a large employer will have until 2015 to change its definition of eligible children. This will also require an amendment to existing plan documents.

• A large employer will not be subject to a no-offer penalty for failing to offer coverage to a full-time employee’s children (as defined) until 2015 so long as efforts are undertaken in 2014 to cover those children.
• While an employer must offer coverage to these children, the employer is not under an obligation to offer unsubsidized family coverage. In other words, the coverage of the children need not meet the “affordable and adequate” standards required for single coverage.
Clarification of Measurement Periods, Stability Periods, Administrative Periods
• As set forth in detail, in prior guidance, employers will have to determine the status of variable hour and seasonal employees.

Safe Harbors to Determine If Health Coverage is Affordable
• The Pay or Play Mandate requires not only that large employers offer coverage to their full-time employees, but also that such coverage is “adequate and affordable” in order to avoid a penalty.

• “Affordable” is defined as the employee’s share for single coverage not exceeding 9.5% of the employee’s household income. Since it is nearly impossible to accurately determine an employee’s “household” income, the IRS has developed three safe harbor options to ascertain “affordable”:

o Form W-2 Safe Harbor. The employer can rely on Box 1 income for the months during which the employee was eligible for coverage.

o Rate of Pay Safe Harbor. A salaried employee’s monthly salary or an hourly employee’s rate of pay multiplied by 130 hours for the months during which the employee was eligible for coverage.

o Federal Poverty Line (“FPL”) Safe Harbor. The federal poverty line for a single individual. In 2012, the federal poverty line for a single individual was $11,170.

• While these safe harbors are used for determining whether a penalty will apply, these safe harbors will not be used to determine subsidies. Subsidies will be based solely on employee’s household income. Such amounts will be determined through the exchange.

Determining Full-Time Employees
• A “full-time” employee is a person who is employed an average of 30 hours per week.

• An employee’s hours of service include:
o Each hour for which an employee is paid, or entitled to payment for the performance of duties for the employer; and

o Each hour for which an employee is paid, or entitled to payment by the employer on account of a period of time during which no duties are performed due to vacation, holiday, illness, incapacity (including disability), layoff, jury duty, military duty or leave of absence).

• Proposed guidance sets for specific hours of service requirements for teachers, commissioned employees, adjunct faculty, transportation employees, temporary staff members, and other special employment situations.

Grace Period for Payment of Employee Contributions
• If an employee’s pay is not sufficient to withhold the employee’s contribution for health care coverage (e.g., tipped employees, reduced work schedules, leave of absence). An employer may bill the employee for missed contributions and will not be treated as failing to offer health coverage if the employer ends health coverage because the employee fails to pay the required contribution within a 30 day grace period. This rule is comparable to the grace period for COBRA premiums.

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Obamacare Tax

One of the many taxes this bill brings forth will be a tax on HMO plans of 3.5%. Starting on the February renewal cycle, there will be a 3.5% excise tax on carriers. Insurance carriers will bear the cost of the tax which will ultimately be paid by employers and consumers. This is on top of trend (year over year cost from the carrier) and any other increase employers will bear in this renewal season. The other taxes that are going to be into effect will be the 3.8% tax on unearned income for people earning $250,000 joint or $200,000 single.
The other tax is tax rate on wages for Medicare Part A from 1.45% to 2.35%. It is a .9% increase in this tax.
There will be other taxes felt in the marketplace for medical device manufacturers. This will be felt by insurance companies and paid for by employer groups and consumers. This tax will be 2.3% on devices sold.

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Health Reform Subsidy Calculator

Please follow the link to a Health Reform Subsidy Calculator from the Kaiser Foundation. It is a great tool to see whether or not you might be eligible for a subsidy.

The problem with Healthcare Reform is that it is constantly changing. This could be outdated by the end of the week. Many states are considering opting out of the Medicaid expansion of the Healthcare reform law. Medicaid is a state and federal partnership for funding, however in the PPACA law Federal funds dry up after a couple of years and the states are on the hook for the expanded medicaid costs.

There are a lot of factors that will determine whether or not you will be eligible for a subsidy including income, age, and family status.

Subsidies also depend on how much your current level of coverage costs and how much you pay for that coverage.

Take a poke at the calculator as I am curious to see what your thoughts are. Please post any comments you may have.

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Justices Expected To Reject Postponing Ruling On Healthcare Reform Challenge

The Supreme Court’s hearing Monday on whether it is proper for the justices to rule on the Affordable Care Act at this time generated extensive television, print and online coverage. Media analysts last night and this morning largely agree that the case will almost certainly move forward, as both the Administration and the plaintiffs have requested. While the three networks devoted more time to the hearing than any other topic — more than 12 minutes in total — the Trayvon Martin case was the chief topic of debate during the primetime hours on the cable news channels last night.

Much of the coverage last night and this morning focuses on the legal arguments made yesterday, as opposed to the likely political repercussions of the court’s eventual ruling. However, the CBS Evening News (3/26, lead story, 4:15, Pelley) and the New York Times (3/27, A17, Sussman, Cooper, Phillips, Subscription Publication) both have reports on their new poll that found 47% of the public disapproves of the ACA as a whole, while 36% approves. The poll also found large majorities support individual aspects of the ACA, including the ban on denying coverage to those with preexisting conditions, which had the support of 85% of respondents.

NBC Nightly News (3/26, lead story, 3:40, Williams) reported, “We begin tonight with a basic question for everybody: Can Congress force you to buy health insurance? More than that, can they charge you a penalty if you choose not to? That question of course is…at the crux of the health plan that may be known forever as ‘Obamacare.'” NBC (Williams) added, “Outside the court, passionate demonstrations, mostly supporting the law. … Rick Santorum even showed up to underscore the political stakes.”

Scott Pelley, at the opening of the CBS Evening News (3/26, lead story, 4:15), reported that the court will be answering the question: “Can the Federal government force you to buy something whether you want it or not?”

On ABC World News (3/26, story 2, 2:55), Dianne Sawyer noted that “some provisions of the healthcare law have already gone into effect. For instance, two and a half million young people have been added to their parent’s health insurance,” and it is now “illegal for children under the age of 19 to be denied coverage because of preexisting conditions.” Sawyer asked, “What will happen to the changes already in place?” Terry Moran replied, “If the court decides to strike down that individual mandate…they could decide that the whole law has to go,” or “the court could just strike down…that individual mandate,” but then “the insurance industry would rebel,” and “would lobby to get the rest of it changed.”

USA Today (3/27, Heath, Wolf) reports the Supreme Court “opened three days of historic oral arguments on the fate of President Obama’s health care law by skeptically questioning whether an 1867 law should bar them from even considering whether the government can require Americans to purchase health insurance.” According to USA Today, “Justices on the court’s liberal and conservative wings seemed doubtful that the law, known as the Anti-Injunction Act, would serve as a roadblock to deciding the constitutionality of one of the Obama administration’s signature accomplishments.”

The AP (3/27, Sherman) reports that the justices “signaled…they are ready to confront without delay the keep-or-kill questions at the heart of challenges to President Barack Obama’s historic health care overhaul. Virtually every American will be affected by the outcome, due this summer in the heat of the election campaign.” The AP adds, “Outside the packed courtroom, marching and singing demonstrators on both sides — including doctors in white coats, a Republican presidential candidate and even a brass quartet — voiced their eagerness for the court to either uphold or throw out the largest expansion in the nation’s social safety net since Medicare was enacted in 1965.”

Bloomberg News (3/26, Stohr) said Justices Breyer and Ginsburg “suggested they didn’t view [the] 1867 law as barring them from ruling immediately on the law’s requirement that Americans either get insurance or pay a penalty. The 1867 law blocks suits over taxes that haven’t been imposed, and Ginsburg questioned whether health-care penalties would be taxes. ‘This is not a revenue-raising measure,’ Ginsburg said. ‘If it’s successful, nobody will pay the penalty and there will be no revenue to raise.'”

Politico (3/27, Gerstein, Brown) reported that Justice Sotomayor “said she found at least four similar cases in which the Supreme Court had allowed such types of challenges, and questioned whether the penalty for not obtaining insurance was really meant to be a tax or an inducement for people to purchase coverage.”

According to USA Today (3/27, Heath, Wolf), “Some liberal justices indicated they were puzzled by 26 states’ contention they would be harmed by the law’s expansion of Medicaid. Although Washington would pay for those newly eligible, states would have to contribute to help those already eligible. ‘That does seem odd, to suggest that the state is being injured because people who could show up tomorrow with or without this law will show up in greater numbers,’ Justice Elena Kagan said.”

Yesterday, Politico (3/26, Haberkorn, Nocera, Millman) reported that “court watchers…are almost unanimous in their assessment: The justices will blow past the Anti-Injunction Act and decide the merits of the case.” The Los Angeles Times (3/27, Savage) also reports that the justices “gave no sign…they are inclined to put off a constitutional ruling on” the individual mandate. The Times adds, “During the 90 minutes of argument, none of the justices spoke strongly in favor of delaying a decision on the healthcare law.”

The Financial Times (3/27, Rappeport, Subscription Publication) and the Wall Street Journal (3/27, Bravin, Radnofsky, Kendall, Subscription Publication) offer similar reporting. The Baltimore Sun (3/27, Cohn) notes, “Monday’s 90 minutes of arguments are among a historic six hours allotted to the health care law over three days.”

Warren Richey, in the Christian Science Monitor (3/26), wrote, “In a somewhat unusual move, the court had earlier appointed a lawyer, Robert Long of Washington, D.C., and assigned him 40 minutes to argue why the AIA did in fact apply to the case.” Also reporting on the first day of arguments are CQ (3/27, Reichard, Subscription Publication), HealthDay (3/27, Esposito), Modern Healthcare (3/27, Carlson, Subscription Publication), Medscape (3/27, Lowes), MedPage Today (3/27, Walker), and WebMD (3/27, Lowes).

CBS/NYTimes Poll: 47% Disapprove Of ACA; 36% Approve. The CBS Evening News (3/26, lead story, 4:15, Pelley) noted that a new CBS News/New York Times poll “on views of the healthcare law finds that more Americans disapprove overall than approve, 47% to 36%. At the same time, many Americans approve of elements of the law. For example, 85% like the part that requires insurance companies to cover pre-existing conditions, and 68% like allowing children under 26 to stay on their parents’ health plan. But to pay for all of that, virtually everyone has to buy mandatory health insurance or pay a penalty, and more than half disapprove of the so-called mandate.”

The New York Times (3/27, A17, Sussman, Cooper, Phillips, Subscription Publication), in an article titled, “Most Oppose at Least Part of Overhaul, Poll Finds,” reports, “Two-thirds of Americans want the Supreme Court to overturn some or all of the health care law, even though large majorities support a few of its major aspects, according to a poll by the New York Times and CBS News .” According to the Times, “Keeping the law intact is preferred by a mere quarter of those surveyed, largely Democrats.” The Times adds that “the contrast between Americans’ overall view of the law and their view of its component parts suggests that opponents have had more success making their case to the public than the White House has.”

State Officials, Insurance Industry Mull Mandate Alternatives. The New York Times (3/27, B1, Abelson, Subscription Publication) reports, “State officials and insurance executives are devising possible alternatives” to the individual mandate, including “imposing state requirements that people get insurance, penalties for people who delay and automatic coverage enrollment.” The Times adds, “Some Wall Street analysts predict that if the federal mandate is struck down and the rest of the law is upheld, the industry will quickly shift its focus to alternatives, particularly those that enable the states to bolster enrollment, so enough healthy people sign up and premiums do not skyrocket.”

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