Women have been conditioned to
figure it out, so you just maybe
haven't had to, you know, yeah.
I guess so. It's my right side, not
my left side.
Yeah.
Any questions for me
before we start?
I don't think so.
Just in case,
I'm going to have you take the
slightest shift
this way.
More? Like the whole chair?
Yeah, yeah, they're perfect.
Okay.
Oop, back.
A little more.
This thing's getting all messed up
on me.
Little more this way.
A tiny bit.
One thing I don't
have, like I might mention,
contact our office.
We have people who can provide
assistance.
I don' have all of our numbers
memorized.
Oh, yeah, yeah.
So like if you guys, you know, in
the store, you can like put that up
on the screen, like OCI, consumer
affairs, contact number, that type
of thing.
Unfortunately, we don't have like a
good like 1-800 like.
Yeah.
Health help or something yeah it's
like just you
know what it is
It is a 1-800-something.
Yes, I know.
That's as far as I always get to,
like 1-800-some.
And then we do have like a 608
direct number.
I know, but that's just confusing to
like rattle it off.
It would be great if it was actually
1-800-something because that would
be so easy to use.
We have heard something.
Okay.
Um, so I'll just
start with, um,
you know, name, title and
what your world does.
I'm Nathan Hodek.
I'm the Insurance Commissioner for
the state of Wisconsin.
And our office, the Office of the
Commissioner of Insurance, regulates
insurance companies in the state.
So, specific to health
insurance, can you provide some
examples of health insurance
claim disputes that
your office receives from Wisconsin
residents?
Anytime there's a
dispute over maybe
coverage or
whether a claim should be paid,
our office can help answer
questions and help resolve those
issues. We have a team of people
on our consumer affairs team that
are here to help answer questions
for people because we know health
insurance can be complicated and
confusing.
And oftentimes people don't know
where to turn if they have questions
about their health insurance.
Or if they need help resolving
an issue or a coverage dispute
with their health insurance company.
And it's important to know that our
office is here to
be a resource, and we have people
who are trained and experts
in helping resolve coverage
issues or claim issues.
And so on the whole, would you say
it's common knowledge for
people that they can
file a complaint,
appeal a denial, or dispute
a claim?
Yeah, unfortunately, too
many people just don't know what
their rights are if they do have
a claim denied.
And there are ways for
people to dispute a claim
denial or coverage denial, and
our office can help with that.
They can help answer questions, help
people walk through that process,
and actually be
a resource in helping
file the necessary
paperwork and kind
of appeal coverage denial.
Uh... And try to get people
the care and coverage that they need
and that they have a right to and
unfortunately uh...
Studies have shown that all
the coverage and claim denials only
a small percentage are
uh... Appeal and that's
really because people don't know
what their rights are people don'
know that there is a place where
they can turn to answer questions
to be a resource and
our office is here to help
with that.
So, switching gears a
little bit, can you describe the
authority OCI has
over self-funded plans,
and any kind of
interactions OCI has with
self-funding plans?
So, again, we know
health insurance is complicated,
it's confusing.
People oftentimes don't know where
to turn if they have questions
or if they need assistance.
And what makes it even more
confusing for people is that
health insurance is really regulated
by a number of different agencies
at both the federal and state
levels.
So, for example, you have
Medicare, which is health insurance
for older people.
That is regulated at the
federal level by CMS.
You have Medicaid, which is
public health insurance for
lower income individuals, people
with certain disabilities.
And that's regulated at a state
level by the Department of Health
Services.
But then you also have the
commercial market.
And in the commercial you have
what's commonly referred to as
the individual health insurance
market. That's kind of the
Affordable Care Act market.
There's the boat.
Little over 300,000 people who
are enrolled in coverage through
that market.
And then you have what's referred to
often as the employer-sponsored
coverage.
And what a lot of people don't
understand if they have employer-
sponsored coverage is whether
that's fully insured coverage
or whether that is self-funded
coverage. And so,
often times people will have a claim
dispute or a coverage dispute
and
They can contact our office, we
can provide assistance, but
if it's a self-funded plan,
those plans are actually regulated
by the Federal Department of Labor.
So that's a challenge because people
don't always know the difference
between self-fund coverage
and fully insurance.
So I guess you answered this
a little bit, but what
do you do when someone comes to you
with a complaint about a self-funded
plan?
Sure. So we always encourage anyone
who has a question or
potential dispute with their
insurance company to contact our
office. We have a team of experts
who are trained in helping people,
answering questions, resolving
disputes.
Now, sometimes we can provide direct
assistance if a
person has the type of insurance
that we directly regulate.
But if someone
has health insurance coverage
through a self-funded plan...
Then we will kind of hand them off
to, we like to refer to as kind
of a warm handoff to the Department
of Labor, because it's the federal
Department of labor that actually
regulates self-funded plans.
So we still encourage people,
if you don't know if you have fully
insured coverage or self-funding
coverage, you can still contact
our office, we can be a resource,
but we may end up kind
of handing you off in
terms of the assistance
that would be provided.
At the federal level instead of by
our office.
So because of that handoff, I guess
you don't necessarily see how
some of these are resolved.
And that frankly can
be a challenge.
So for example, last year,
our consumer affairs team, which
is our team that
really the experts that help people
if they have questions or
any problems with their
health insurance company.
So our consumer Affairs team
provided assistance to
over 1,600 people who
called our office with issues with
their Health Insurance.
Now the challenge is that about a
quarter of those, a little over 400.
Were self-funded coverage.
So we did help those people
make contact with the Department
of Labor and get the assistance that
they need, but ultimately that's
outside of our regulatory
jurisdiction.
So we don't know how those issues
or disputes are ultimately
resolved.
Is it your understanding that
the Department of Labor is pretty
responsive because you are doing
that warm handoff?
You do at least have an idea that
they're connected with someone.
That's our understanding.
I mean, we try to facilitate a warm
handoff, make sure people know
who they can contact at the
Department of Labor, and try to make
that connection as much as we can.
But once that connection is made,
you know, it's really up to the
Department Of Labor in terms of how
they handle it from there.
So, as I've
discovered talking to patients, in
many cases,
people have an insurance card
that has the name of
an actual health insurance company
on it, but
they don't realize that they
actually have a self-funded plan.
So for example, United Healthcare
owns UMR,
and UMR is the third-party
administrator. How
Confusing is it for consumers
to understand what
kind of plan they have, what that
means, how difficult is it?
Yes, there's a lot of
consumer confusion,
and the system is
admittedly very complicated.
And if you have your health care
coverage through your employer,
if you're fully insured, you would
have an insurance card, and
it's the insurance company that
essentially bears the risk for
paying for health care-related
claims. If your employer
self-funds that coverage.
Usually still contract with
an insurance company or what's
called a third party administrator
and oftentimes as an employee you
still receive a card from the
insurance company that is serving as
a third-party administrator so
from the employee experience
you know you're still paying claims
from the employees experience
you're Still paying premium and
you have cost sharing and
really it looks the same whether you
have fully insured coverage or
self-funded.
And again, you have that
card that can be from an insurance
company either way.
So you really don't know.
And it's important for
individuals who have coverage
through their employer to really
understand that difference.
To really understand is this
fully insured coverage or
is it self-funded coverage.
Because the way those two types of
coverage are regulated are
very different.
One advocate I spoke
with said some of this feels
like it's designed to
obfuscate how
to navigate the
system,
what's your reaction to that?
I mean, I think we've
heard comments made.
I know when the Affordable Care Act
was being debated,
oftentimes in Congress and at
the federal level, when there have
been efforts to enact major
health insurance and health care
reform, you often hear comments
to the effect of, we would never
design a system like this from
scratch.
There's so many different
government agencies that have
regulatory oversight.
There's so much complexity,
whether it's Medicare,
Medicaid, individual insurance
market, group
self-funded, group
fully insured.
All of those different types of
health care coverage have different
regulatory bodies, different rules.
So it's really a system that
if you're a consumer,
understandably it's complicated,
it's confusing, and
you just don't know where to
turn when you have issues.
Um,
can you talk about OCI's
oversight over pharmacy-benefit
mechanics?
So a few years ago,
there was a law enacted that gave
OCI kind
of a limited authority,
regulatory authority, over pharmacy
benefit managers.
So pharmacy benefit manager, or
PBMs as we call them,
now have to be licensed by
our office.
And there are certain reporting
and disclosure requirements.
And there also certain
prohibitions on kind
of what's called gage clauses.
So pharmacists are now able to
basically tell someone at the point
of sale if there's a lower
cost option in using their insurance
or just other
lower cost options for paying for
their pharmacy or their
pharmaceuticals.
I think there's more that we could
do in terms of oversight
of PBMs and
more that we could in terms
addressing some of the
kind of anti-consumer
practices of PPMs.
And I know there's been a lot of
discussion about that in the
legislature and the governor
actually in his state budget
put forward a number of additional
provisions that would provided
more consumer protections for
people. In terms of interacting
with PBMs and making sure they can
get lower cost prescription
And so your website says the
goal of this
increased oversight is to increase
transparency, control costs, protect
consumers.
Has it done that to
your knowledge?
You know, the challenge is that
prescription drug pricing, the
prescription drug supply chain is
so complicated.
And I think the
law that's been enacted
to require PBM licensure
and some level of oversight
by our office is an
important step forward, but there's
more work that can be done.
And we all know that
there's that needs to be done in
terms of bringing down the price of
prescription drugs overall.
I think there's more that we could
do at the state level.
We know at the federal level there's
been a lot of discussion on
different prescription drug reform
initiatives.
So our office and the oversight that
we have of PBMs has
provided kind of an important step
but there's some more steps that we
need to take in order to really
address the high cost of
prescription drugs.
Would Senator or I
guess Senate President Felskowski's
bill do
more of what you're
speaking of?
I know the Senator's bill is really
focused on addressing some of
the more concerning practices
related to PBMs and really
trying to make sure consumers
are protected in getting the lowest
cost prescription drugs
available to
them. In terms of
additional steps that can be taken.
I know Governor Evers also
had provisions in his budget that
would have required PBMs to have
a fiduciary duty.
He also would have required
PPM brokers and consultants
to be licensed.
So I think there are more steps that
we can take.
Other states also have
have taken more action in
terms of more oversight of PBM.
So there's a lot of different
options out there and I think it's
important that we have that
conversation.
And really look at what can we do to
make sure ultimately the consumer
benefits.
And kind of another
consumer information
question, you know, there's
also, in
addition to PBMs, there's
alternative funders,
there is
accumulator maximizer,
and
sometimes all of these are
so tangled up with
one another, and some
of these are part of fully insured
plans, as well as
self-funded plans,
again, how are
consumers supposed to make informed
decisions?
Again, it's challenging for
a consumer because health insurance,
prescription drug coverage, it's so
complicated, it can be so confusing.
There are resources out there for
people to turn.
If you do get your insurance through
your employer, whether it's fully
insured or self-funded,
your employer can provide
information about your benefit
design and the types of prescription
drugs that are covered, the
formulary.
So that would be the first place
to go in terms of getting
information.
If you do have
an interaction or
if you do have an issue
with an insurance company, you feel
that a claim is being
improperly denied or
a service is not being covered,
you can contact our office.
And we encourage people to contact
our office to help resolve those
claim and coverage disputes.
Is there anything else you would
like to add?
The other thing we like to always
talk about is the importance
of being aware of scams.
You know, there are a lot of health
insurance and prescription drug
scams out there.
So if people receive an
unsolicited phone call,
email, text messages,
whatever it might be, just be
cautious about that.
You know and if you are contacted
by someone who's trying to sell
you insurance coverage or
prescription drug coverage,
You know, ask questions.
You can ask for their, what's called
their NPN.
Their,
I forget what that stands for.
Anyway, you can ask questions to
make sure that it is a legitimate
source that's contacting you.
And you can also contact our office
and we can help answer questions.
We just want to make that people
don't end up signing up for
improper health insurance coverage,
improper prescription drug coverage.
And there's a lot of people out
there, unfortunately, who are trying
to take advantage of people.
And so we just always try
to raise awareness and make sure
people are being smart about that.
Um, those are all the questions I
have.
Um, one thing that, um,
you know, you don't have to
answer, but I'm just curious,
because it's come up a couple times
as I've been working on this.
Um, have you
learned of AI denials,
and is that-
a problem people have
voice concerns about.
What I would say is,
I know there have been news stories
about health insurance
companies that have been
utilizing AI to
essentially deny claims and
make decisions about coverage or
claim payments.
But we, you know, two things.
One, insurance companies
have to abide by the laws of
the state regardless of how
they're making decisions about
coverage or paying claims.
And whether that's using AI,
using a human, you know
whatever that process is
that they're using to make a
decision, they still have to follow
the laws of the State.
And if someone feels that
their claim has been denied
improperly, again,
they can contact our office.
And we recently put out
a bulletin that
essentially is a
It's a bulletin to all insurers
in the state about how they
should be using AI
and using it in a way that complies
with the insurance laws and
regulations of the state.
So essentially saying, you know, we
know AI is a new technology,
right? We know companies are
utilizing it across all lines of
insurance.
And there's a lot of benefit to
consumers.
And we know that that's gonna be a
technology of the future, right.
But as companies are using
this new technology.
They still have to make sure they're
complying with existing laws and
regulations.
Thank you.
Extra question.
Yeah.
That's all I have.