<p>I would put money on it that a baby who needed to be in a NICU would be transferred and it’s care covered. </p>
<p>And if someone needs treatment that only a few doctors perform or that is only done at a specific hospitsl there is always an appeal process one can go through.</p>
<p>I was going to say the same thing: I would be astounded if there was any policy that didn’t include a Level 3 NICU for any baby that needed it. Astounded.</p>
<p>Goldenpooch, the insurance companies will offer plans if they feel there is a market for them. They certainly are free to do so. But if and when such a plan is offered, I think that you will have major sticker shock – their premiums will probably be much higher than what you see on the exchange. Even though the plans are new and offered off-exchange, they will still have to comply with ACA requirements that preclude them from excluding patients with pre-existing conditions or capping the benefits – so it is not going to be cost-effective to offer high end plans that would tend to appeal the most to moderately wealthy individuals who are battling cancer and brain tumors. </p>
<p>I have a question for you. You said that 2 years ago you had a different plan from BS that you shifted from because of a rate increase. Do you remember what the rate was then? if you were to add 15% per year to that amount, what would that rate be today and how would that compare to the exchange rates you are seeing? (If you or your wife graduated to a new age category in the interim, you’ll need to factor that in as well – if I look at the rate that B.S. was charging last year for 60-year olds on my non-grandfathered plan and increase that by 15%, it’s not that far off from what BS is charging for the equivalent Bronze HSA plan.)</p>
<p>Please understand: I am not pleased with what the insurance companies have done. That’s just one more reason I’m toying with the idea of Kaiser – I don’t think that B.S. was honest with me. Essentially they offered me a teaser rate on a policy in 2010 to draw me away from a grandfathered plan into a new plan, which I did not understand would not be grandfathered (certainly I wasn’t told by them). In July I called BS to ask if my plan was grandfathered and I was assured that absolutely it was – so I decided that I’d just keep my plan for the time being. It was only within the last 2 weeks that I became aware that my plan was being discontinued – and that was only because I happened to log into the web site to check on the progress of a claim. The only official notice I got from them arrived in the mail on Sept. 30th. I think that’s a lousy way to treat their customers.</p>
<p>But I think that’s the insurance companies behaving badly, not the law imposing bad behavior on them. I think they very deliberately decided to wait until the end of Sept. to push out large rate increases for those who are on grandfathered plans, as well as to pull the plug on the plans that are not grandfathered. </p>
<p>I do know that BS is operating at a very low profit margin. I’ve got my ACA rebate check each summer and the check hasn’t been very big. To get on the exchanges, the companies had to submit competitive bids, without knowing what the other companies would be bidding – but they knew that in the end that their plans would be displayed side by side on a web site with other companies offering identical plans – and they don’t want to be the highest priced program in that array. So they look for way to control costs on the spending end in order to offer a competitively priced premium to customers. </p>
<p>As to your question about getting services from your preferred hospitals and doctors: you might see some of those providers moving to a concierge model where they might essentially let you subscribe to a package for basic services. The problem you are going to run into with Cedars Sinai is that there are plenty of people living in Beverly Hills and Bel Air who can afford to pay top dollar out of pocket, and they exert a market force on a that particular hospital that is at odds with your needs. </p>
<p>But full-pay rates for medical services are always negotiable. My well-off friend with a pre-existing condition that kept her off of insurance told me that she routinely got 30% off of any bill by offering to pay cash up front. There’s a company called CareCredit.com that specializes in financing medical, dental, and veterinary costs – they are pretty liberal with credit and often work with providers to develop interest free financing plans. So it may make sense for you to go with a catastrophic plan as a backup and look for alternative ways to finance the high-end health care you would like to have.</p>
<p>Keep in mind that the insurance premium for the lowest priced Bronze plan on the exchange is more than 8% of your MAGI, you won’t be subject to any tax penalties for not buying insurance. (I’m not 100% percent sure that the exchange Bronze will be the cutoff – the test is whether or not you can get an policy for that amount anywhere – but I have a hard time seeing how they could determine what is available to you except by looking to the exchanges.). </p>
<p>The way the catastrophic policies that I’ve been seeing work is the deductible is the same as the maximum annual out-of-pocket. The insurance pays nothing until you hit that $6350 individual / $12700 family deductible, and then they pay 100%.</p>
<p>TatinG, I think that the policies on the California small business exchange are much nicer – I particularly like the Silver HSA – but the premiums haven’t been published yet as far as I know, and I’ll bet they come in significantly higher than the individual exchange.</p>
<p>Employees won’t feel the pinch and the employers will qualify for subsidies of their own, so it may end up being a win-win on for them – but I don’t think it will be an attractive option for individuals who are having a hard time stomaching the individual exchange rates.</p>
<p>Cal mom: whether you are rich or poor if you have a brain tumor, you want to be at a top hospital. The exchanges, in order to be worth the premium, have to cover them and treat them. I don’t get your point.</p>
<p>Many years ago when I worked for UCLA, our health plan (provided by UCLA) did not cover care at UCLA. Neither did my now-husband’s plan through his private employer. </p>
<p>I like UCLA. There are some things UCLA Hospitals and Clinics do really well, but they are a notoriously expensive institution. I’m not at all surprised that they’ve been dropped from a number of health plans. I don’t think they especially care. They make a gazillion bucks serving foreign and pavilion (concierge) patients, and have for many, many years. </p>
<p>I suspect they intentionally set very high fee schedules in order to minimize the volume of general patients they get.</p>
<p>My doctor’s office has materially changed their scheduling to handle a very significant increase in same-day appointments, explicitly to avoid ER and Urgent Care visits - it was something to do with the practice becoming a “medical home”. The practice is a group practice owned by the hospital. </p>
<p>It worked well for me last month – I had a problem, called in, and was offered an appointment for an hour later. Way faster than getting seen at Urgent Care (which, in my town, should probably be called Urgent-for-you-but-expect-to-wait-an-hour-or two-to-be-seen Care), I didn’t have to fill out extra paperwork, and it was much cheaper.</p>
<p>Tatin, I was responding to your post #629. </p>
<p>As to your other comment, I don’t get yours. The idea of “affordable health care” or “universal health care” doesn’t mean that everyone is entitled to be treated at the most prestigious hospitals any more than than the idea of making college affordable and available to all comers would mean that everyone gets to attend Harvard. </p>
<p>I’d measure the quality of a health care system by the quality of services that were available in the local community hospitals. You can’t expect everyone to be treated at a handful of select hospitals. That’s crazy.</p>
<p>I think it’s the lack of capping that makes the insurance more expensive. </p>
<p>Since end of life care costs are bankrupting people, this is significant. </p>
<p>I appreciate the reminder about the 85% rule. </p>
<p>This is true that if the premiums turn out to be too high, they will have to adjust accordingly.</p>
<p>The converse is that if the premiums are not high enough to cover costs, they will be increased in future years. Hence the pressure on insurance companies to focus on economy and efficiency in structuring their provider networks.</p>
<p>I wish my Mom had a medical home. She has various medical problems, and it seems like her doctors don’t talk to each other. With a medical home, one doctor is in charge of the patient, and the doctor is responsible for coordinating all the care the person gets from other specialists.</p>
<p>I bet a lot of you wish your parents, or other relatives with complex health needs like kids with severe asthma, had medical homes.</p>
<p>The ACA has various methods to encourage the medical homes system.</p>
<p>If your condition cannot be treated in network, then you don’t have health insurance. You are in the same position as an uninsured person. You’re paying $16,000 plus a huge deductible or similar price but if you get something worse than a routine condition, will you get appropriate care. </p>
<p>The lists of providers are supposed to be released next week. Well see.</p>
<p>TaninG – if a condition cannot be treated in network, then any insurance will pay for the person to get the specialized treatment that they need. A referral will be made and the patient will be taken to wherever is necessary. That is just the way it works. </p>
<p>But there is a difference between a situation where a doctor recognizes that a patient has unusual or extraordinary needs requiring specialized care, and a patient deciding that she wants to go to a more prestigious hospital because that’s where a world-famous cardiologist or oncologist happens to work. There is a difference between a want and a need. </p>
<p>The insurance companies are selling managed care. That’s all that they can sell because costs are too high to make it feasible to sell anything else. </p>
<p>Personally, after watching 8 seasons of House, I don’t think I would want to be treated by the world’s foremost expert in diagnosing and treating mystery diseases anyway. Somehow I think that if I was buying insurance in TV-land, I’d be very, very happy to learn that Dr. Gregory House and his hospital were not in-network.</p>
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<p>Yes. If your condition cannot be treated in-network, you will be referred to an out-of-network provider, and it will be covered.</p>
<p>In order to qualify as a small business off the exchange, I think the rules have changed in Ca. It use to be if you had one owner and employee (husband and wife) you qualified for a group plan. However, I don’t think a spouse can be included as an employee now. Does anyone know? </p>
<p>It is not just the prestigious teaching hospitals, in my community many providers are not in the PPO network anymore. There are many people who are very upset about this. My friend who is an optometrist was at a conference with his colleagues, and many of them who are self-employed were discussing this issue. Everyone was shocked. Like I said in my other posts, the largest outpatient clinic in my community is not in the network.</p>
<p>I don’t think the spouse can be the qualifying employee - there needs to be at least one full time employee who isn’t a spouse. </p>
<p>You seem to know what is covered for all the plans in your area – that info hasn’t been published here yet. I’ve talked to agents for both BS and Anthem and basically the web site databases aren’t up to date. I have been told over the phone by a BS agent that any private doctor on my old plan would absolutely be on the new plan, but I’ve been given so much misinformation by agents that I won’t trust it until I see it confirmed.</p>
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<p>In this case, they wouldn’t have gone to UCLA under ACA. Since it wsa undiaginized, they couldn’t get a referal to go out of network, I’d think.</p>
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<p>Does this mean we can drop bodily injury portion of our automibile insurance?</p>
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<p>How often did we reach the cap? I’d think it’s rare and the cost is diluted by all others, a huge majority who didn’t reach the cap. It doesn’t explain doubling the premium unless they are including end of life care. People may keep on life support forever since ther’s no cap.</p>
<p>To everyone tooting 85% rule, I hope it works. It sounds way too burearacratic to me. Bureaucracy is never good at cost control, a bit like a utility commission.</p>
<p>Obviously, your mileage may vary, and I’m reserving judgement until I see the fine print in November, but in our case, the SHOP rates for small business employers look on the face of it to be about 15% less if we chose a Silver HSA with 2000 ded. compared with what we’re paying for our current 80/20 1,000 ded plan.</p>
<p>If this proves to be true when the dust clears, I might be inclined to fund the deductible differential via HSA, which in effect, would be comparatively better for employees.</p>
<p>That said, our existing plan was already pooled care, and already vetted for low caps, etc. so its pretty much apples-to-apples. The premium differential between our existing plan and the silver HSA is likely spawned by the 80% vs 70% and out-of-pocket differential.</p>
<p>I think the premium increases some are seeing are connected more to variables in actual real world coverage, not just solely a function of extending the pool to include formerly excluded people. Eg. If a premium doubled, I suspect half of that might have even related to capping, and half to pooling.</p>
<p>And let me tell you, hitting the cap can happen pretty quickly. My chemo alone over the past eleven years has run over $1M. The heart attack cost my insurance company $225K last year – and that was the negotiated amount under the PPO. We were very thankful DH’s coverage has no lifetime limit, even before all this happened.</p>
<p>If my kids weren’t convinced of the need to have good medical coverage before, they sure are now.</p>
<p>calmom, a friend of mine uses Kaiser and has been very happy that everything is coordinated and in-house. I think if you have few medical issues (or common, chronic issues), it works well.</p>