Affordable Care Act Scene 2 - Insurance Premiums

Parent Cafe
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<p>Yes, those struggling the most with copayments and any payments will have the largest bills. That has always been the case. But when you have no insurance, you get treatment, if you CAN get treatment and you owe $60K that you can’t pay–that’s money that either the hospital has to work out some payment arrangement/break/low income charity fund or they dunn you for the next 6 years for it hurting your credit and going after any money that is open to judgement. We are talking $60K here which is not going to be doable for someone who is strapped. </p>

<p>With health insurance, if that same person is covered even by the Catastophic plan, first of all he is paying some premium in the system, or getting federal coverage of premium which does offeset some of the cost. He is also then on the hook for $6K which is a whole other story over $60k. There may be some charity money in the pot to help offset some of that and some payment agreement might be met for the rest. Family might even chip in too. You throw your hands up and run at the first amount, but the second might be manageable and there is some feeling that you are getting a hell of a deal of getting a fairly major issue taken care of for that amount.</p>

<p>I’m a Mom of a young adult who makes very little money, and I can tell you that we can probably work out some payment of $6K for a medical problem and would do so over having it hanging over my son’s head. $60K? No can do. And the way bills work, it isn’t much help to pay 10% of the bill, unless you can get reduced that low. Though billing departments have some flexibility, they aren’t likely to go write off $54K, but half of the $6K, for immediate payment, now they’ll consider that. They’ll probably take it. </p>

<p>What I am hoping, as many are hoping who take the lower cost plans, is that there are no huge costs. So far that has been the case, and young adults do have age and stats in their favor. So whatever money my son does give in premiums is more than the zippo he would be paying if he just could not afford insurance, which is the case pre ACA. No way someone making $16K can pay $6K in insurance premiums year in and year out, without some outside factore. but $1000 over the year, again, we can talk turkey now. And throw in some parents who might pitch in the that kind of money,you can pass the gravy too.</p>

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<p>CF, the insurance options, the employer offered are identical to those on the market. Identical. When I click on them, they all take MSK and other options that I tested out. A number of NY hospitals and doctors, most of them with good reps, and high end clientale. They will take my insurance which is identical to that shown on the NY exchange under ACA, but those are not showing the same participation. So I called to ask. And I was told that this has not happened yet, but with the employer paying and having the system, they have already signed on. </p>

<p>Due to certain private information I can’t really give out as much detail as I would like to do so, but,yes. I have a Silver plan that is set up identically to that of the NY exchanges but I selected it thorugh a major employer’s portal and it covers everything I asked about including MSK. Doesn’t do it when i check NY state. I also had all of this info prior to the great unveiling of ACA options but was not sure it would be identical until I could get on the NY exchange and check, but I had been told that it would be. This is the case for a number of companies, by the way. So, yes, the hospitals and doctors will be made to heel in time. It makes no sense otherwise. How is it that my identical insurance, down to the company is taken by a hospital because the premium to the insurance company is paid by company instead of by individual. </p>

<p>I am not a cheerleader of all of this for a number of reason that are not permitted to be discussed here and for some other reasons that have to do with my fears of where this is leading in terms of quality of medical care. But for now this is the way it’s going to go, and anyone who felt it was not going to be a mess this first year, is a fool. It’s going to take time to get this all worked out, and the fact of the matter is that a lot of doctors and healthcare organizations are going to drag their feet. The same thing happened when managed care hit a lot of the health care world. Those who can keep their patients, practices and income will stay out of the system rather than taking cuts. But many will find that when it comes to the final reckoning, people will go to where they are covered rather than pay a premium, unless forced by need, and then these hospitals often have to eat their surrchages.</p>

<p>I paid out of network charges for years to MSK because the protocol and doctor who treated my son was there and then my DH switched companies and our insurance did not have MSK as in-network. I could not get an exception for long term follow up visits which meant hefty payments out of pocket and also paperwork. SOme of which I paid, and some that I negotiated with MSK and the doctors and billing agencies involved. A big pain in the neck but I did it, and I also paid, Because I could do both. Many others simply did not go to the long term follow ups or did it elsewhere with other doctors and hospitals which I can assure is no where near the quality and does not add anywhere near the info thta it does when you stick with the place where you were treated. But, yes, most people walked rather than pay or wrangle. Since then, MSK has loosened up and added more insurances as in network and the last few years we were covered. We are still covered, but I’m telling you right now the exact same option on the ACA menu is not. So you go figure. I think it’s going to be fixed.</p>

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An independent insurance agent will NOT cost you any money. Agents do NOT get paid by their clients, they get paid by commissions from the insurance companies. They also can enroll you in exchange-subsidized plans – and get a commission from those sales as well. </p>

<p>There could be some bias creeping into the agent’s recommendations because of differences in commission structures – obviously it is in the agent’s interest to sell you the plan with the highest commissions – but I think that you will find that most agents work to try to save you money and get you the best fit plan. Most independent insurance agents sell other products besides health insurance, so they are going to want to build trust and keep you as a client. </p>

<p>But the point is, getting an agent to help will not cost you anything. (If an agent DOES ask for a fee - find another agent.)</p>

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<p>calmom - I didn’t know that. I’ve always bought it myself. Good to know!</p>

<p>I think my choice is being narrowed down for me. Out of every single plan available in my state, of which there aren’t that many anymore, only ONE insurance company covers any out of network. The rest is all 100% my pay with unlimited out of pocket max. This kind of blows. Anyone ever heard of CoventryOne? I’ve never used them. Are they any good?</p>

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<p>This is INCORRECT. Anyone with income over 100% of the FPL is eligible for the exchange. </p>

<p>100-138% of FPL is ALSO eligible for FPL. </p>

<p>There is an overlap – but if you think about it, that makes some sense, given that incomes can easily fluctuate a little up or down over the course of a year. </p>

<p>I can’t promise Romani that the healthcare.gov web site will work properly, so it might just be safer to go with the higher figure – she’ll still qualify for generous subsidies with the higher figure – but the point is that she is eligible to sign up for the exchange at 100% FPL.</p>

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<p>Sounds like “in practice”, BCBS is violating the law. If you are able to buy directly from the exchange without dealing with the agent you might get a different answer. </p>

<p>I’ve posted above – there is NO possibility that I can figure that anyone would ever have to pay money back if their income comes under estimates. (I’m confident about my opinions because I am relying on reading the words of the statute and government regulations, not on the words of agents.). </p>

<p>Practically speaking, you might as well just go with the 138% FPL estimate rather if that’s what you need to do to get the policy written – sometimes you just need to go along to get along – but the law sets subsidy eligibility at 100%, no matter what any agent claims.</p>

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<p>I am going to go with the 12k figure. That’s roughly what I made this year before leaving my ft job so it’s not an unreasonable number. If bsbc doesn’t want to cover me there are other options.</p>

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<p>I think the employer insurance plan looks the same as an exchange plan to you as a consumer, but has different reimbursement rate to the doctors than exchange plan. This is probably due to difference in insurance premium. At the end of the year take a look at your H’s W2 and see how much your H’s employer contribution was and add it with your H’s contribution. I bet the overall premium is going to much higher than exchange plan.</p>

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<p>I don’t know what Congress was thinking, but I can think of many good reasons.</p>

<p>To start with, the ACA subsidies are keyed to annual income, whereas Medicaid makes a determination based on monthly income. It could create quite a mess if people whose incomes hovered near the poverty line were coming on and off Medicaid based on minor fluctuations in income. So if there’s a little bit of wiggle room near the boundaries, the system will function more smoothly. </p>

<p>Also, at least in theory, people with jobs can expect to improve their earning capacity over time. So the person who is at 100% FPL now could very well be at 150% FPL at the end of the year. So it makes sense to allow someone who anticipates that their income will improve over the year to apply to the exchange. </p>

<p>I think the actual legislative reason may be a result of other, unrelated technicalities. I’m just pointing out that there is a benefit of giving some wiggle room.</p>

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<p>Slight correction: the W2 has the total premium, the sum of the employer portion and the employee portion. So just look at the W2, and that is what the insurance company is getting for your insurance premium.</p>

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<p>Just as a follow-up, I talked to my insurance agent today to review/confirm my options for health insurance viz-a-viz ObamaCare. I buy in the individual market from Anthem Blue Cross. My current plan is a very high deductible plan than costs $435 a month. The closest comparable plan on the ACA exchange is $465 a month.</p>

<p>The only significant difference in the new ACA-compliant plans is a smaller network of providers. There are minor differences in deductibles and max out-of-pocket, but nothing that materially changes my coverage.</p>

<p>My options for my current non-grandfathered plan:</p>

<p>1) Cancel my plan early (Jan 1) and buy a new ACA plan, either through the exchange or direct from Anthem. My agent says that either way will cost the same ($465 month) and the new plan would have the new smaller provider network.</p>

<p>2) Do nothing until my current plan renewal date on July 1st. Continue paying $435 a month, with the old larger provider until July, when Anthem will roll me over into the closest ACA plan (which will be the $465 a month plan with the smaller network. The ACA prices are set for the calendar year, so the $465 price today will still be the price in July.</p>

<p>3) Do early renewal on my existing plan effective Dec 1st, which would keep my old plan grandfathered until Dec 1, 2014. I keep the old larger network longer, but the price increases immediately with the renewal to $465 a month (the same price as the new ACA plans).</p>

<p>So basically, the only advantage to renewing early is that I get to keep the larger provider network for an extra four months, but I have to start paying $30 more a month for the first six months of the year.</p>

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<p>Based on all that, I’m not doing the early renewal. I’m just leaving my current plan in place until it expires July 1st.</p>

<p>I don’t know if any of this is applicable to anyone else, but I figured I would share at least one person’s options. My insurance agent says it’s a nightmare. Three companies have pulled out of the New Hampshire market effective Jan 1st, leaving a lot of people without insurance. Although I haven’t seen this on Anthem’s website, my agent says that the same plans will be available at the same price, either direct from Anthem or from Anthem through the exchange. In that case, the only reason to go through the exchange would be if you qualify for the tax credit “subsidy”.</p>

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The premium policies are sold by the year, but payment is by the month. A person can always cancel-- but that person will not be able to get other insurance until the next open enrollment period. </p>

<p>(A person who needs surgery is often a person who may need followup care in case there are complications. But I guess you can’t fix stupid.)</p>

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<p>According to my insurance agent, the individual policy provider networks are changing (i.e. smaller, lower reimbursement rates, higher volume expectation) now. However, the group policy provider networks will also be changing in similar fashion, but that change will be a year down the road. Anthem is not going to administer different provider networks at different rates for long. It will move towards one provider network and one reimbursement rate, but will take a couple of years to get there.</p>

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<p>If that is true, and it sounds true to me, then the problem of large swathes of hospitals not being in any provider network will vanish. You can’t run a hospital with no patients who are covered by insurance. </p>

<p>Well, maybe there are a few hospitals like that, but very few hospitals can succeed that way. And I don’t think Memorial Sloan Kettering is one of them. Most people would want to get their cancer treated at MSK, if they had a choice, but most people couldn’t afford to pay out of pocket for it. And if it’s a matter of going to MSK for $150K, or going to Nice Local Hospital for $6K, patients are going to see the manifold virtues and convenience of Nice Local Hospital.</p>

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<p>I will do this if BCBS doesn’t want to do it at 100% of FPL and I can’t find anything comparable. Paying more than I can really afford is much, much better than nothing at all. If that’s the case, I would get on Medicaid after three months.
Ugh! Germany’s not sounding so bad…</p>

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<p>Exactly. My insurance agent said that the hospitals holding out now will perhaps lose a tolerable amount of business for now, since we are only talking about the individual market. But, as the noose tightens with group policies a year from now, they will face insurmountable pressure. I suspect that he is correct. I just do not see NH hospitals staying in business without being on Anthem’s exchange provider list. If more insurers compete, Anthem will have to bend. If not, the hospitals will have to bend to Anthem.</p>

<p>When we talked about the local hospital not being on Anthem’s new network, my agent immediately said, “for now…”</p>

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I hope that’s true for my state too. My issue has been finding a policy that will cover the doctors my daughter needs to see. It’s the reason I usually choose PPO - because they have better networks. Now, I am facing the same thing. Hardly any in network doctors and have to change. If it’s just one year and the policy type, networks, etc increase, that will be a very good thing. I pray that’s the case. We have two major hospitals in our area and only one of the insurers for individual insurance is in network for them (rather just one of them). Crazy.</p>

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<p>Even if more insurers compete, “you have to pay 30% more but you get more hospitals in your network” is going to be a tough sell. I know Goldenpooch would buy that policy, but most people and most employers are very price-sensitive.</p>

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<p>Are the actual benefits (coverage for certain medications, durable medical equipment, ect ect) different for different tiers of plans? Or is the only difference the deductible and copay? Basically, for someone with very high healthcare needs, who would wind up reaching the max out of pocket on any plan, would they be best served by buying the bronze plan?</p>

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<p>One fact everybody is conveniently forgetting, these great hospitals people want to go to when they get very sick are not going to be so great if they are forced to take medicaid-like reimbursement rates.</p>

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<p>partyhat, I can’t speak for every state, but in my state, it would be exactly the opposite.</p>

<p>However, I think a lot of this changes if you get subsidies. Depending on what your subsidies are, it seems as if the best deal for those who get the highest subsidies is silver?</p>

<p>If you don’t get subsidies, at least in my state, and you have a lot of need for medical attention, it might be best to go with gold. For us, no need, bronze is best, since the premiums are lowest. Either way, in our state, you will end up paying the same amount of money out of pocket (premium + deductible) before insurance kicks in at 100%</p>

<p>Good luck to you.</p>