Substance Abuse and Behavioral Health – Front Line Intel Helping Drive Better Decisions

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Treatment facilities that can work with winning insurers and adopt new business practices will position their businesses to increase their market share, during this changing environment.

Very few treatment owners are taking a conscious and proactive look at the approaching storm clouds on the horizon. Things such as compliant client acquisition, documentation of processes and scalability are taking a back seat to business as usual. It is estimated that less than 15% of treatment facilities nationally have adapted to the new health care business model. That is an astounding 85% that potentially won’t make it.  In many cases, these vanishing businesses are ignoring basic business principles out of pure ignorance, but many of them simply have a myopic view of their businesses as it relates to the overall market landscape.

Health insurance distributors and health insurers are also not exempt from business life cycles. In fact, since the healthcare overhaul occurred in our country with the enactment of PPACA 2010 (Patient Affordability Care Act; AKA “Obamacare”), dozens of insurers have called it quits.

Some of the losers like Assurant, saw an early demise, while others like United Health Care are seeing are showing signs of weakness.  On the flip side, winners like Anthem, Kaiser Permanente, Tenet Healthcare and new comers like Oscar are capitalizing and gaining rapid momentum.

Private hospital owners have been some of the biggest winners. As a result they have seen a 24% increase in profits in 2015. Mainly due to rebalancing of their business models to accommodate a wider range of insurance policies.

Although most insurers have had the advantage of being subsidized by the federal government, a level playing field has not been the cure for all insurance companies.  Insurance carriers have medical loss ratios that must be maintained at a lower proportion than premiums coming in from policyholders.  Like with any business when expenses (loss ratios / claims) accelerate revenues (premiums), cut backs are inevitable.

Since the Affordable Care Act took effect in 2010, insurers have had to deal with claims deprived of empirical data.  United Health Care has decided to stop selling individual insurance coverage through the exchanges resulting from these losses.  It is no mystery why the decision by UHC was made to only allow verification of benefits to be controlled by the policyholders, insurance agents or billing companies.  When losses are up, companies get creative and implement new procedures to help mitigate losses.  For UHC, it happens to be, becoming their own gatekeeper.

In the insurance company’s defense, they had no way of calculating this new risk. Think about it from a practical standpoint.  If your business started to see unexpected losses resulting from a vendor payment that was a large new item on your balance sheet, would you question it, or at least get in the weeds to get a better assessment of the loss? Most businesses would. As PPACA continues to integrate into our new healthcare system, every business related to health care is forced to rethink, reassess and reengineer their business models in order to stay in the game.

Another example, Highmark Inc. BCBS of Pennsylvania, recently filed a law suit against the federal government on May 17, 2016.  The company and some of its subsidiaries and affiliates are seeking to recover damages they believe are owed by the federal government’s failure to honor its contractual obligations relating its participation in the health care exchanges.  Highmark Inc. BCBS of Pennsylvania claims the federal government is refusing to pay the full amount that the risk corridor program for the calendar year 2014 (“CY 2014”) implies in the statute, regulation, and contracts which induced Highmark insurers to participate in the ACA marketplace.  The lawsuit states that Highmark is owed nearly $223 million, less any prorated amounts actually paid by the government, which was reported to be only $27.3 million by Centers for Medicare and Medicaid Services (CMS).  Reading between the lines, Highmark BCBS of Pennsylvania are seeing a bit higher medical loss ratios then what they anticipated.

Anthem on the other hand, has reported earnings better than expected and added 1 million new customers since the end of last year, many of which were Obamacare enrollees.  Earnings for Anthem came higher than expected.  They beat estimates by more than 10 cents per share, coming in at $3.46 for the first quarter.  The company expects revenues for 2016 to range from $81 billion to $82 billion, up from its previous estimate of $80 billion to $81 billion.  In addition, Anthem plans to finalize its merger with Cigna in the second half of this year.  The story seems a quite different than UHC, Assurant and Highmark, Inc. BCBS of Pennsylvania.

Insurance is simply “a promise to pay”.  A policy is nothing more than a contract between an insured and an insurer.  The business structure of insurance is a collection of more policies and premiums than actual payouts.  When the market rules change, courtesy of the federal government, insurers without question have to adjust their promises.

Questions We Must Ask Ourselves

As these promises (insurance contracts) continue to evolve over the next 2-4 years, will your business parallel these changes?

As insurance companies modify their revenue models and continue to balance out their medical loss ratios in the new environment, will your business modify its revenue model to adapt?

So what is the solution for treatment facilities?  Change is never comfortable, no matter how big or small your business is.  Adopting new business practices and processes such as upgrading customer and lead management tools, auto dialer software, insurance rebalancing, state rebalancing and spreading levels of care will result in a different outcome.  As the saying goes; “The definition of insanity is doing the same thing over and over and expecting a different result”.

Historically, disruption is found in every single US business sector since WWII. Profitability and growth proceeding the disruptive era has always been far greater then all prior time periods leading to disruption. Why? Simply because the market has not gone away rather the number of players shrunk, leaving more profits for fewer players.

Now is the chance for treatment providers to take full advantage of the opportunity laid in their path.

Actionable Recommendations (we are closely monitoring these insurers medical loss ratios in the coming months)


  • Anthem, MLR Balance Stable (Gaining traction and playing a big part in the carrier consolidation. Have remained healthy in terms of market share. Reports show a stable MLR balance.
  • Aetna, MLR Balance Stable (Merged with Coventry and Humana in 2015. Reports show a stable MRL balance.)
  • Cigna, MLR Balance Stable (With the likely Anthem merger and with all the adjustments made last year, Cigna is starting to see more stability. Reports show a stable MRL balance.)Not all treatment centers have been eliminated.)


  • UHC, MLR Balance Unsustainable (reported losses and unbalanced MLR, more changes expected in 2016.)
  • Highmark BCBS of Pennsylvania, Delaware and West Virginia, MLR Balance Unsustainable

(Seeing unbalanced MLR, and in litigation with the federal government.)


  • No current data to support negative outlook on a specific insurer or state as of the writing of this report.
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Deadline Extended Healthcare – Sign up by Dec 17 for Jan 1 Coverage (

December 15th 2015

Santa has delivered an early gift to millions of Americans by extending the deadline to get coverage for January 1st. Obamacare officials extended the deadline by 48 hours late Tuesday night as a result of “unprecedented demand” during the current 2015 open enrollment.


The December deadline includes 38 states and California, the largest state run exchange. Officials have not indicated that an extension will be granted for the broader deadline of January 31st.

Get covered by January 1 and avoid the tax penalty of $695 or up to $2085+ per household.

A special number has been setup to fast track your application.


Avoid any wait times. Must call in the next 48 hours!

Millions of Americans Have Unclaimed Health Care Money

The 2010 passage of the Affordable Care Act extended a variety of health care benefits to different socioeconomic groups. Specifically, Obamacare sought to deliver reliable insurance coverage to lower-income, often uninsured groups. Subsidies, which are a part of the ACA, help to offset the costs of health insurance for individuals and families who meet specific income standards. Unfortunately, many people are unaware of the intricacies of Obamacare, including the access to subsidies, which results in billions of dollars of health subsidy money left untouched.

Health Subsidy Requirements

The annually established federal poverty level, or FPL, is the standard by which subsidies are assessed and distributed — for health insurance and beyond. The federal poverty level is set for a variety of family sizes, from individuals and married couples to families with one or many children. What percentage of income an individual, couple, or family brings in as it relates to the FPL determines what, if any subsidies, that they are eligible for. For example, the Affordable Care Act gives states the opportunity to offer Medicaid coverage to anyone who qualifies under 138% of the FPL. Those with incomes of up to 400% of the FPL may also have access to insurance coverage with lower deductibles and copayments, which can result in significant savings every month. In between those extremes, other subsidies exist as well.


One of the primary tenets of the Affordable Care Act was to give the uninsured access to affordable health care. Thus, the purpose of these subsidies is to help extend health coverage to those people who need it but cannot afford it. Individuals and families living at low and moderate income levels might struggle to piece together the money to secure health insurance. These subsidies make both health coverage and health care services more affordable, with a goal of increasing the number of insured individuals in the U.S. If you haven’t looked into your eligibility for subsidies, now is the time.

Recouping Your Subsidies

Determining whether you are eligible for subsidies begins with comparing your household income to the federal poverty level. Don’t be put off by this simple formula. Instead, visit the Jibe Health platform, where you can determine your subsidy eligibility in as little as 60 seconds. Just imagine in one minute, you might tap into unclaimed money that you deserve in accordance to the Affordable Care Act. We understand that researching these subsidies and assessing your eligibility might be confusing, especially for novices with health insurance. At Jibe Health, we are well versed in the many intricacies of the Affordable Care Act’s subsidies, and we can quickly assess whether your income level qualifies you for these reduced rates.

The federal government is sitting on billions of dollars in subsidies that have gone unused. Don’t let these potential savings go to waste another day. If you think that your family might be eligible for a subsidy, let help you minimize your health care expenses today. You’re just a few clicks away from increased savings and improved access to health care.

Why Your Generic Prescription Could Be Killing You

Opting for a generic prescription might seem like the smart choice. After all, you seem to be getting the same drug, only at a fraction of the price. However, generic drugs aren’t always what they seem. You could be putting your health at risk by choosing the more inexpensive option. Discover here why generic drugs could be a dangerous choice, one that can have serious and long-term consequences.

Bioequivalence: Not an Exact Science

While the U.S. Food and Drug Administration oversees the production of generic drugs and ultimately approves their usage, the FDA also acknowledges that reproducing a brand-name drug isn’t always an easy undertaking. As a result, when you choose the generic option, you’re opting for a drug that is not the biologic equivalent of the brand-name drug.

Here’s how the creation of generic drugs works. The generic drug manufacturer, by law, is mandated to use the same active ingredient in the brand-name drug. However, the FDA gives some leeway regarding just how precise the use of that active ingredient must be. Rather than precisely replicating the makeup of the drug’s components, the FDA allows generic drug manufacturers to create a drug that contains up to 20% less of the active ingredient in the brand-name drug. As a result, your generic drug just might be 20% less effective than the brand name.

Furthermore, Katherine Eban of Fortune Magazine, reports that the FDA’s rules surrounding the drugs other ingredients are far more lax. So, while the generic drug you choose may have some portion of the same active ingredient in the name brand, it also may include other ingredients not found in the pricier prescription. Logic tells you that if you’re paying less for this drug, the ingredients are probably of a lesser quality.

The Impact of Generic Drugs

Simply put, the generic drug you pick up at your pharmacy probably isn’t the same makeup as the brand-name drug. As a result, the switch from a brand-name drug to a generic one can dramatically impact your health. For example, even when the brand-name drug and generic drug have the same amount of active ingredient, the rate at which this active ingredient is released into your body may vary. You might notice unexpected side effects and reduced efficacy of the drug as a result. Moreover, the less-regulated excipients, or other ingredients, may contribute to a host of side effects as well. In one startling example, individuals who took the brand-name antidepressant Wellbutrin XL reported extreme depression and suicidal thoughts when they switched to the generic drug, according to ABC News.

Choosing Health Insurance with Prescriptions in Mind

Your health insurance should give you the freedom to choose brand-name pharmaceuticals. While Tier 1 and Tier 2 generic prescriptions might result in a lower copay, they also might be less effective, bring with them more side effects, or, in a worst-case scenario, negatively impact your health. matches individuals with health insurance plans based on their needs.  JibeHealth will match you with the right tier and identify health plans that meet your exact needs.  Tier 4 prescriptions include higher-priced, brand-name drugs. When choosing a health insurance plan, look closely at the prescription coverage to make sure you aren’t forced into opting for questionable generic alternatives. Maximize your health, and get matched with a plan that provides you access to Tier 4 brand-name drugs.

Why 85% of People Select the Wrong Health Plan

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The Affordable Care Act gave consumers the opportunity to choose health insurance plans in a competitive marketplace. However, selecting a health insurance plan isn’t a simple task, and the Health Insurance Marketplace, which is filled with many types of plans at many price points, can certainly lead to some confusion. Ultimately, consumers who have limited knowledge of health insurance may be led down a path toward a plan that simply doesn’t work for their lifestyle and health care needs.

Selecting the Wrong Plan

The Centers for Medicare and Medicaid Services and the U.S. Department of Health and Human Services reported that up to 85 percent of consumers chose the wrong plan in 2014. A poorly selected insurance plan can have several long-term consequences. Individuals might not have adequate coverage for their health care needs, or they might be limited in the checkups, procedures, and prescriptions that their insurance covers. Ultimately, these individuals might end up with significant medical bills due to this poorly selected insurance plan.

Common Causes

Selecting an insurance plan should always consider a variety of factors, but ultimately, many people tend to make decisions based on just one factor: price. Tight budgets and exorbitant healthcare costs may leave people looking for the inexpensive health insurance option–even if that option isn’t the best for their unique needs and may even cost more in the long run.

People shopping for health insurance often begin on a website to collect quotes after entering their zip code. This method can result in a poorly selected plan. These “zip code” insurance quotes consider only the individual’s location, and the quotes and recommended plans are not tailored with the individual’s healthcare needs in mind.

Health care and health insurance shopping is undergoing tremendous innovation.

New federally approved web broker platforms like  match consumers with health insurance plans based on their unique needs. Jibe health’s algorithm begins by asking a few simple questions and displaying plans that only match your unique health care needs.

Even more, most people aren’t well versed in insurance terminology. So, when they are perusing these “zip code” insurance quotes, they might not be quite sure what they are reading. Thus, they choose a budget-friendly plan without the confidence that the plan they chose will be sufficient for their healthcare needs. This uninformed and depersonalized method of insurance shopping certainly contributes to a high numbers of dissatisfied consumers.

Far-Reaching Impact

Choosing the wrong insurance plan affects more than just the individual. The federal government will take a hit as well. It stands to lose up to $9 billion in higher subsidy payments resulting from those consumers who chose the wrong plan. Choosing the wrong insurance plan isn’t just a personal problem–it’s a national one.

Tips and Tricks

Shopping for insurance doesn’t have to be confusing. The key to a successful insurance shopping experience is personalizing it. First, think carefully about what you need in an insurance plan. While you should certainly look broadly at the costs, including premiums, deductibles, and the cost of any hospital stays, you should also see what doctors and hospitals you will have access to under the new plan. Also, consider the type of prescription drugs that the plan will cover. Then, skip the “zip code” quotes and work on securing quotes for your unique needs. Using this method, you’ll be more pleased with your insurance plan, and you just might save the government some money along the way.

3 Mistakes to Avoid When Buying Health Insurance

Purchasing health insurance is a personal decision, one that should take into account your budget as well as your current and potential health care needs. However, many individuals make major mistakes when choosing a plan, which can result in higher costs, less coverage, and even the risk of a financial crisis should a critical illness occur. Avoid these three mistakes when buying health insurance.

Choosing a Plan on Price Alone

In the insurance industry, like many others, you get what you pay for. If you choose the most inexpensive insurance plan, you’re likely not receiving the coverage that you need. Choosing a plan based on price alone overlooks your unique health care needs. Failing to choose a plan that doesn’t consider precisely what you need for health coverage means that when a health incident occurs, you could be footing the bill. While price can certainly be one factor in your health insurance shopping decision, you should consider price only within the context of your health care needs. There is a new breed of innovative companies that are changing the way health insurance is purchased.

One such company is matching individuals with health plans based on their unique needs not their zip codes.  In short, price shouldn’t be a prohibitive factor in getting the insurance that you require.

Avoiding High Deductibles

Insurance shoppers might be scared off by high deductibles, but choosing the plan with the lowest deductible isn’t always the smartest choice. A National Bureau of Economic Research working paper revealed that while many individuals opt for higher monthly premiums to secure lower deductibles, doing so might not be the best financial move. Paper co-author Saurabh Bhargava, assistant professor of economics at Carnegie Mellon University indicated that the additional payment in monthly premiums surpasses any savings created by the lower deductive. As a result, higher monthly premiums result in higher healthcare costs overall, even if the deductible is lower.

Skipping Critical Illness Insurance

Just because you’re healthy today doesn’t mean a critical illness can’t impact you in the future. Rather than purchasing health insurance that covers everyday illness and well checks, you should shop with potential critical illnesses in mind. Critical illness are inevitably a part of many Americans lives. One in every three deaths in America is caused by heart disease, stroke, and other cardiovascular diseases. In 2011 alone, nearly 787,000 people died of these causes, according to the American Heart Association. The incidence of cancer in the U.S. is equally alarming. In 2015, the American Cancer Society projects more than 1.6 million new diagnosed cases of cancer, as well as almost 590,000 cancer deaths in the U.S.

Coverage for these critical illnesses can result in significant savings should you be affected by one of these conditions. Critical illness coverage guarantees you anywhere from $25,000 to $200,000 should you suffer from a heart attack or stroke or face a cancer diagnosis. Without this important insurance coverage, you may be left facing high medical bills and loss of wages, which can have a profound impact on your overall financial situation. As a result, critical illness coverage is imperative to ensure you are well protected should the unthinkable strike.


Smart shopping can lead to a better insurance plan.

By avoiding these mistakes, you’ll find a health insurance plan that is best suited to your needs, and you might save some money along the way.

3 Reasons your Health Insurance could land you in Prison

Almost a million people are set to lose their health insurance coverage because the information in their applications didn’t match the data that the federal government had on file; however, that’s not the scary part.

Last year, during open enrollment people were encouraged to apply for federal subsidies without providing any type of documentation: income verification, tax returns, citizenship or immigration documentation.

The end result was the government was unable to accurately determine the income of almost Two million individuals of the touted eleven million who enrolled.

The Affordable Care Act (ACA), aka Obamacare was passed to provide access to affordable health Insurance for all uninsured and underinsured US citizens. In simple terms, the ACA is an expansion of Medicaid.

Obamacare is supposed to make it affordable for lower income households to be insured by providing a subsidy to help cover the cost of the insurance.  In a nutshell, here’s how it works. If your household income is below a certain threshold, the government will write a check to the insurance company for the difference between what you pay and the actual price of your health insurance premium.

The old adage that nothing is free in this world is still true: not even Obamacare.

Reason # 1: You misstated your immigration status on your application

Knowingly or unknowingly making false statements on an application is a first degree felony, and is punishable by up to 5 years in prison. It also voids the entire insurance contract, all the way back to the effective date.

What the insurance company is going to do:

Any and all outstanding claims in process will not be covered, and the full financial responsibility of these medical bills will be placed on you.

– The insurance company will sue you for claims that they have previously paid, and they will request full reimbursement.

– Obtaining insurance in the future may be impossible, as fraud on your records will be seen by future insurance companies, and they may choose not to provide you with coverage.

REASON # 2: You misstated your income to obtain the subsidy and get a lower rate

What the IRS is going to do:

– It is estimated that 6,700 new IRS agent have been hired to enforce the individual mandate of Obamacare

– The IRS will flag your Social Security Number (SSN), along with other information on file, by matching your previous tax returns.

– If things don’t match up, they will cancel your subsidy, audit and/or fine you, and levy penalties and interest

– Also, you can face up to 5 years in prison

The IRS website states, “If advance payment of the premium tax credit was made but your income for the year turns out to be too high to receive the premium tax credit, you will have to repay all of the payments that were made on your behalf, with no limitation. Therefore, it is important that you report changes in circumstances that may have occurred since you signed up for your plan.”

REASON # 3: You unintentionally committed health care fraud

Health care fraud is the number one crime endangering the entire health care system. The IRS has recently made it clear that government’s key focus is on eliminating waste, abuse and cracking down on fraud everywhere. The federal government has informed insurance companies to terminate for those individuals who purchased their health insurance through, and have yet to provide the necessary documentation. Those terminations began as early as September 15, 2015.

Cancellation letters from various insurance carriers went out at the beginning of the month. This potentially leaves hundreds of thousands of individuals who were unable to provide the proper documentation in a far worse position than simply being uninsured.

What to do if you are in this situation

Federal officials are cracking down on individuals whose incomes cannot be verified. These people will lose their coverage, along with having to repay the government in full for all of the amounts paid by the government, including the subsidies. People whose coverage is terminated can apply to re-enroll for coverage at any point through platforms like Jibe health also has advocates on staff to help you sort out any issues free of charge. Jibe Health works with most insurance carriers such as,,, Coventry, Cigna and many others.

If you think any of these things may apply to you, don’t wait to be terminated by the insurance company. Call Jibe Health we will help you cancel your current coverage voluntarily, reapply with private insurance, and forgo the subsidy.

The moral of the story is simple: if you don’t really need the subsidy, don’t risk your liberty and freedom. It just isn’t worth it.

Jibe Health Inc. all rights reserved 2015

Will Your Health Insurance Pay for Your Weed?

Will Your Health Insurance Pay for Your Weed?


Whether taken legally in some states for medicinal purposes or recreationally and illegally in others, marijuana is the drug of choice for many Americans. In fact, research as recent as 2013 indicates that marijuana use is on the rise. With voters across the country approving the legal use of medicinal marijuana, those figures only look to increase. Medicinal marijuana even stands to impact the health insurance marketplace. You might be used to getting your prescriptions covered through your insurance, but will you now be able to find one that pays for your weed, too?

Marijuana Use in America

A 2013 study conducted by Gallup revealed some interesting statistics about marijuana use in the U.S. A reported 38 percent of Americans admitted to trying marijuana up from 33 percent in 1985 and 34 percent in 1999. Few age boundaries exist as far as Americans’ marijuana use is concerned. Almost half of all individuals who have experimented with marijuana tried it for the first time between ages 30-49. In fact, this age group is the one most likely to be smoking weed today. According to Gallup, more individual’s ages 30 to 64 are smoking weed than their younger generation, young adults aged 18 to 29.

The Gallup poll further revealed little differences in marijuana use among races, education, and income levels. These findings show that marijuana use is pervasive in the U.S., with individuals from a variety of backgrounds smoking weed. While most are doing it recreationally, some marijuana use is for medicinal purposes, especially with changing laws in some states.

Marijuana Legality in the U.S.

Twenty U.S. states permit legal marijuana use in some capacity. State laws vary widely in this area even states that permit medicinal marijuana use have different laws on how it can be obtained and used. Proposals, propositions, state bills, and initiatives have been placed on many state ballots in recent years, with voters approving the legality of marijuana. For example, Arizona approved Proposition 203 in 2010, which allows qualifying patients to purchase a medical marijuana registry identification card. This card gives the patient permission to smoke weed for medicinal purposes, as prescribed by his or her physician. Other states have similar cards, which ensure that the patient can smoke weed to ease the symptoms of a range of debilitating conditions without being arrested or charged with a crime.

Impact on Health Insurance

Recent trends show that more and more voters are saying “yes” to legalizing marijuana. With medicinal marijuana accepted a legal treatment option in 20 states, it’s time to consider its impact on health care. As it stands today, medicinal marijuana does not have to be covered by health insurance, and federally funded health care programs such as Medicaid do not cover medicinal marijuana. Checking out is not going to reveal an insurance plan that covers weed. So, while using marijuana for medicinal purposes is legal in many states, it still comes at the cost of the patient.

Looking Ahead

Platforms such as Jibe Health, match consumers based on their needs with affordable health insurance plans. Jibe Health also offers a variety of private health exchange plans options. Insurance Carriers include,,, Coventry, Cigna and many others.

However, even when you buy health insurance, you still have to pay out of pocket for medicinal marijuana because most laws state that insurance companies are not required to cover this treatment. So, for the time being, the answer to the question “Will my insurance pay for my weed?” is a resounding no.

That said, if marijuana is identified as an effective treatment for a range of conditions, proponents of medicinal marijuana have a valid argument in favor of insurance coverage. Research reveals that marijuana can help ease the symptoms and side effects of a range of conditions, helping individuals with cancer, HIV/AIDS, Lou Gehrig’s disease, Alzheimer’s disease, and a range of other chronic and debilitating conditions. If other prescriptions and treatments for these diseases are covered, why isn’t medical marijuana covered? In this form, weed is not an illegal drug being taken recreationally. Instead, it’s a prescription treatment just like your everyday antibiotic that is covered by health insurance. As the legality of marijuana shifts, will health insurance shift as well and, ultimately, cover weed as a treatment?

Those against insurance coverage would argue that the medicinal marijuana laws are open to fraud. Will individuals seeking easy access to weed fib about a health condition in order to get a legal prescription? Will unscrupulous health care practitioners seeking to increase their patient load readily dole out marijuana prescriptions? Will patients looking to score a weed prescription shop for doctors who are willing to prescribe marijuana for a range of benign medical issues, such as back pain or carpal tunnel syndrome? The mere potential for these problems to occur is enough for states and insurance companies to leave medical marijuana expenses up to the patient.


America’s views on marijuana legality are changing, and medicinal marijuana is a treatment option for an increasing number of citizens. This fluid situation will surely evolve over time, whether more states put medicinal marijuana on the ballot or insurance companies eventually cover this treatment or both.

JibeHealth Inc. all rights reserved 2015