<p>On a side note, what do you think was billed when my son had to go to the ER for 10 stitches below his knee recently?.. $2,700 . We have a $10k ded, but with the negotiated rates, we had to pay $890…but no wonder premiums are so high.</p>
<p>Thank, Calmom, for the suggestion about the SHOP/HSA – that sounds like it might be a good option to explore!</p>
<p>The pricing figures are an interesting. They charge so much because they expect a percentage of patients to pay at a discount, mostly through insurance, AND they expect a percentage of patients to skip and pay nothing or very little. The rates are set high enough that they invite negotiation: a high face value versus an expected recovery and that means people without insurance pay widely varying actual amounts. </p>
<p>The hospital associations put out estimates of unrecovered charges. These numbers are about as trustworthy as most industry numbers, which means they aren’t very, both because they’re simply untrustworthy and because we don’t know if they’re using face amounts they wouldn’t have recovered anyway. In California, for example, the hospitals stated losses from free loaders of over $11B - as of 2 years ago (because I don’t keep up with this stuff). I mention that to give some scope to the problem: even if you cut the number in half by saying they’d only recover half from payers, you’re still talking $5-6B a year. That’s a huge number. CA is the biggest state but it’s still just one state. Just to give context, the proposed cuts to food stamps would be $4B a year for the whole country.</p>
<p>I remember this article was interesting, re hospital pricing:</p>
<p>Hospital Billing Varies Wildly, Government Data Shows
<a href=“Hospital Billing Varies Wildly, U.S. Data Shows - The New York Times”>Hospital Billing Varies Wildly, U.S. Data Shows - The New York Times;
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<p>Geeps, that’s the other very clear but unappreciated benefit of insurance. One reason that am pretty confident that I won’t reach the price differential of $3600, much less a $4500 deductible – is that I will never see a bill for more than a fraction of the actual cost of services. And having the benefit of that pricing is actually much more valuable than the ostensible percentage that the insurance pays. </p>
<p>That is, the 40% of every bill that I will pay up after I’ve paid $4500 but before I reach my maximum out-of-pocket of $6350 isn’t 40% of the sticker price… it is 40% of deeply discounted price. In the example you gave, even at 100% responsibility - because you haven’t met your deductible – you only had to pay 33% of the bill. So when we compare the percentages in the various metal categories – if we assume an average similar reduction in cost – then rather than a 40% - 30% - 20% - 10% copay, the insured person is actually choosing between policies that require a patient outlay of roughly 13% - 10% - 7% - 3%. Obviously there is no guarantee of the discount on medical services being that deep … but that’s in line with what I typically see on just about any expense. </p>
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<p>If you go over a hospital bill carefully, you’ll see that a significant chunk of that are charges that are completely out of line in relation to actual out-of-pocket costs for the hospital – such as a charge of $100 for a piece of plastic tubing. </p>
<p>I understand why the hospitals do this – it is precisely because their risk of not being paid is so high – but this is a big part of what drives up medical prices in the U.S. In a sense, a significant part of our bill for any services is the hospital’s “insurance” against the prospect of not being paid, coupled with costs incurred for repeated billing and collection. They can agree to deeply discounted rates with the insurance companies in exchange for a guarantee that the money will be paid. </p>
<p>Unfortunately, I don’t think that the ACA is enough will resolve the problem. There’s still too much uncertainty. There will still be people who can’t afford the insurance even on the exchange; people who simply choose to pay the tax penalty rather than the insurance; people who buy insurance but then fall behind on premium payments and end up with lapsed insurance. So we are reducing the non-payment risk for the medical profession, but not doing enough to truly address the problem.</p>
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The 2014 plans on my insurance company’s web site are priced almost identically to the exchange plans – the price I am quoted by the company is 12 cents more than the price posted on the exchange web site, but I don’t know whether that is because the insurance company really wants that extra 12 cents or because the price posted on the exchange is rounded down.</p>
<p>My insurance company has a catastrophic plan posted on its site that isn’t on the exchange site which is about $30 less per month in premium cost – but that is clearly the plan that is allowed for the under 30’s and those who fit the hardship categories under ACA. It’s rather attractive in its simplicity: it’s got a $6350 deductible - same as Bronze level maximum out of pocket --same coverage as all the other policies for preventive care – everything else, the insurance pays nothing before the deductible, 100% after that. </p>
<p>My insurance company (Blue Shield of California) - actually has done something rather nice on their web site – for each of the metal categories, they post the minimum and maximum costs for the insured. The minimum is the premium amount; the maximum is the total premium costs plus the maximum out of pocket. So even if the policies are priced the same, it may be worth checking the insurer’s web sites simply for the benefit of getting the information presented in a somewhat different way. </p>
<p>My insurance company will automatically roll me over to the plan I want to buy without my doing anything – but I’d lose the potential tax credit that way. Even if I don’t qualify for the subsidy, there’s always the potential that I may qualify in the future. As I’ve posted before, the one thing that would be most likely to cause a significant loss of income for me would be a devastating injury or illness requiring extended treatment or hospitalization - so the year that I actually need my health insurance is also pretty certain to be the year that I qualify for a generous subsidy against the premium cost.</p>
<p>This month’s Consumer Reports has a nice overview of the ACA.</p>
<p>Something worth mentioning in regards to employer provided insurance and the 9.5% household income and subsidies…</p>
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<p>The biggest issue won’t be the price. It will be how extensive the networks are. How many doctors are on the particular network? Is your doctor there? How many specialists are on the network? Is the specialist type you need on that network? Is your local hospital part of the plan? Is the tertiary care hospital in your area on the network?</p>
<p>^^^Yep, yep and yep. I will reserve my judgements until I can see the provider lists.</p>
<p>That happens with company sponsored plans already. The company changes coverage or moves to an HMO and you need to find new doctors.</p>
<p>What provider networks? You buy insurance. It isn’t an HMO. Your doctor or any doctor either takes new patients or doesn’t. To that doctor, you are another person with insurance. </p>
<p>HMO’s will of course continue to exist. Some are great for doctors - mine loves it - but others aren’t. </p>
<p>Some of the results for doctors will be good and some bad.</p>
<p>I’ve just moved to a state that basically only has one carrier in most of the state. Fortunately, it’s the one we use. It will cost us 100 more a month for the 4 of us. </p>
<p>The great thing is that everyone in the state takes our insurance. There is no out of network. </p>
<p>Since we self insure, no taxes. I’m extremely pleased. And I was prepared to be annoyed </p>
<p>FWIW</p>
<p>In Covered California, the company and the plan level Bronze, Silver etc. determine which list of doctors and hospitals you can use. The choices are limited to keep costs down.</p>
<p>That has always been the case.</p>
<p>tom is right, that has always been the case. What’s different now is that if you don’t like your insurance company – provider network, claims process, the way they spell their name, anything at all – you are free to change. If you’ve never been trapped at an insurance company by pre-existing conditions, that may not sound like a big deal to you. But for those of us who have been so trapped, it’s huge.</p>
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All insurance plans are either HMOs or PPO’s. This is not new - it has been this way for about as long as I can remember. There is now something called an EPO, but I think that’s basically a smaller type of PPO.</p>
<p>With a PPO, you can choose to go to an “in network” doctor or an out of network doctor (or hospital, lab, etc…). The in-network providers are contractually bound to accept the amount that the insurance determines to be a reasonable fee, generally a significant reduction from the billed fee. The out-of-network providers have no such limits.</p>
<p>So if you have any insurance plan and you go to an in-network provider, here is how it usually works:</p>
<p>You go to the doctor and provide your insurance card.
If your insurance has a per-visit copay, you may pay that amount on the day of the visit.
If not, the doctor sends the bill to the insurance company.
In a few weeks you get an EOB (“explanation of benefits”) from the insurance company. It will list the amount billed (let’s say, $600), the amount “allowed” (let’s say $150), and a breakdown of how much of the “allowed” amount your insurance will pay. The remainder is either your patient co-pay amount or an amount that is applied to your deductible.</p>
<p>If you go to an out-of-network provider, here is what typically happens:</p>
<p>You go to the doctor and make whatever arrangements for payment that your doctor will accept.
You submit a copy of your doctor’s bill to your insurance company for processing.
The insurance company still determines the amount it will pay, however your deductible and out-of-pocket maximum for out-of-network providers is generally higher than your in-network limits. If you have not yet met your deductible, you will get nothing, but the amount that the insurance company decided was reasonable will be applied to your deductible against future expenses.
If you have met your deductible but not yet met your out-of-pocket maximum, the insurance company will send you a check that is some fraction of the amount they decided was reasonable. That may be a smaller fraction than they would pay for an in-network provider.
If you have met your deductible and exceeded the out-of-pocket maximum, then the insurance company will send you a check for the amount they determined was reasonable.
The doctor can still collect any balance due from you, as the doctor is not bound by any agreement with the insurance company.
So lets say that you went to that doctor, who charged $600. You negotiated with the doctor for a 10% discount if you paid cash up front, so you wrote a check for $540 the day you went to the doctor. The insurance company tells you that it will allow $150 – but because it is an out-of-network provider, they will only pay 60% instead of the 80% they would pay in-network under your Gold plan. So they send you a check for 60% of $150 -($90). Your actual out-of-pocket ends up being $450, but only $70 (the part of the allowed amount that the insurance didn’t pay) is credited toward your annual out-of-pocket maximum.</p>
<p>Again, this is not new, it is not Obamacare, it is the way that insurance has always worked. </p>
<p>Bottom line: you have right to see any doctor you want, but if you want the full benefit of the insurance you are paying for, you need to go in-network. </p>
<p>This is another reason a person might consider an HSA-compatible insurance. With an HSA, you can use the money in the HSA account to pay any provider, whether or not the person is in-network, and whether or not the particular treatment would be covered by your insurance. It is still money coming out of your pocket, but is coming from a tax-advantaged account – you get to write off all the money you put into the HSA as a credit to reduce taxable income every year. </p>
<p>As to checking whether a provider is in network – I would suggest that if you already have a doctor or facility you like, that you contact them to ask which insurances they will be accepting. The lists posted at the insurance web sites might not be complete – they probably have all the big facilities like hospitals correctly shown, but I am guessing that there are still many private physicians or smaller facilities that haven’t completed whatever paperwork is needed to get their name on the list.</p>
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But probably you will be able to do that only once a year, between October-December, during the open enrollment period.</p>
<p>Although I think that companies that sell off the exchanges will be able to sign you up any time. So that may be another way in which the other (non exchange) companies can drum up business. Those other companies are still required to sell policies that meet the other ACA provisions-- so really the only wiggle room they have to compete may be from details like being open to new subscribers when the regular exchanges are closed.</p>
<p>calmom, right, you can’t switch “anytime” on the exchange. But you’re not stuck with a carrier forever if you don’t want to be, as we have been. It’s going to be a great day for us when we have a choice.</p>
<p>well, Lasma, that’s not technically true. In more than one state, there are places where only one insurance company is even selling now. </p>
<p>In those places, you are hostage.</p>
<p>We’ll see how it goes. I’m happy for now.</p>
<p>^ How could you leave Chicago! :D</p>