<p>It sure can happen quickly, CountingDown. For people who don’t have major health problems, whose out-of-pocket costs consist of $40 office visits and $25 prescriptions and a test or a minor procedure here and there, it doesn’t seem possible that they could ever rack up $1M. And at that rate, they couldn’t. But that cap can be reached in one serious illness.</p>
<p>The ban on caps has been effective for a few years now. It went up in stages so Terwitt’s friend’s daughter should be ok as the cap has been $2M since 9/12 and will be completely eliminated as of Jan. 1st. </p>
<p>My neighbor’s H (MHRIP) battled mouth cancer for 2 years. Two major surgeries at Sloan Kettering, radiation and chemo and unable to ever go back to work. I never asked her what it cost but imagine well over $1M. One of his surgeries alone was over 11 hours and he spent months in the hospital over the course of the two years. He was only 55. :(</p>
<p>Elimination of caps will have little or no impact on insurance premiums. No insurance company bears the full cost of high pay-outs. Behind the scenes, your insurance company buys its own insurance to protect it against a catastrophic expense. They always have. So elimination of the cap, which is rare and only becomes real for patients like CountingDown’s issues (glad to see you doing well now, CD) costs each of us pennies in our premium since the insurance company pays a relatively small premium and it’s spread over every insured. </p>
<p>In fact, insurance for catastrophic pay-out is so important to the insurance companies’ financial health that they have to show they have it before any state will license them to operate. </p>
<p>On a different topic which is also going on behind the scenes: virtually every hospital and large physician group is looking into forming their own insurance company for medical benefits right now. As ararbrab mentions, many of them have had a program for their employees for many years. However now, because of ACA, most of them are joining together to form insurers that will cover employees, member of the community in their demographic catch basin, and even local businesses. </p>
<p>This is going on in every single large system in the country right now, and could potentially have a huge impact on choice and premiums as they compete with the United and Aetnas of the world.</p>
<p>Hitting the $1 mil cap was always one of our big concerns. I think it’s pretty easy and not just for the end-of-life or catastrophic cancer cases. D has a chromosomal condition. Daily growth hormone shots from age 3 -16. By the later years, the monthly cost was $9000. Add her other prescriptions and her monthly scripts were $9500. We were on many different insurances/different specialty care pharmacies. I was always amazed the cost was never over U & C.</p>
<p>I’ve mentioned before that the ACA law has a lot more in it than most of us see, and iI think it might be helpful to mention one of them now because of our current conversation. ACA has provisions in it that try to change the basis of provider pay. </p>
<p>In the past hospitals and doctors were paid by procedures. That incented doctors to order tests and visits, and hospitals to keep you in the bed. Then managed care came along and cut all that out. Everyone got paid by head so the more patients you saw, and the less you did for them, the more money they made. Good doctors, which means most of them, had to spend hours fighting for clearance from the insurance companies to give tests. Treating the patient became a cost driver not a benefit driver. </p>
<p>Under ACA, all that is changing - not completely but to a great extent. physicians and hospitals can coordinate and if they improve patient outcomes, they get payments for that. So if they persuade you to give up smoking, if they diagnose more accurately and give you better treatments, they benefit financially. The metrics include readmissions rates (they’ll track patients who are discharged, then have to go back in because their issue wasn’t correctly dealt with), mortality rates, etc. </p>
<p>No one knows if this will work. But I like the idea that my doctor has both a financial and a professional incentive to make me better.</p>
<p>A relative of mine is a doctor. She talks about patients who are just recalcitrant. They will not do anything to improve their own health. They don’t follow doctor’s orders, they don’t take their medication properly, they don’t eat right, exercise, etc. etc. Sounds like it would be in the physician’s interest to drop those people as patients. It’s much like paying teachers based on student test scores. There’s only so much the doctor/teacher can do.</p>
<p>Does anyone know when the provider lists for California will be available?</p>
<p>“But I like the idea that my doctor has both a financial and a professional incentive to make me better.”</p>
<p>As opposed to “patient satisfaction”? We’ll see. That has been a big driver for the last decade or so. </p>
<p>“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>Has anyone seen ths work for mental health? Kaiser got into some trouble with this. I believed it could work at first, then not so much. </p>
<p>Don’t get me wrong; I think we could be moving in the right direction. But of all the forums I frequent, CC has the broadest definition of what should be covered under mental illness. </p>
<p>The diagnosis that I think will test this resolve are “autism” (spectrum, if you like), ADHD, “bipolar disorder”, maybe even “just depression”, especially with a focus on psychotherapy benefits rather than visits coded like those with your pcp as “medication maintainance”.</p>
<p>I just spent 30 minutes waiting online for someone from the healthcare.gov to “chat” with me to answer my questions. Then we spent another 75 minutes “chatting”. During this time they were not able to answer any of my questions in a way that gave me any confidence whatsoever. They ended up referring me to a “Navigator” (I’ll have to wait till tomorrow to see if I can actually get an appointment - there’s only 1 to service my county and the neighboring one - in NJ).</p>
<p>Has anyone found written instructions for filling out the application? If I could find the rules written out somewhere I’d be much happier. Even if I could get to the online application, I have no idea how to answer the questions I expect to find on it. Is there site that has the application and instructions that I can print myself and mail in? </p>
<p>I’m on the borderline between expanded Medicaid and a subsidy. I want to get the application right, so I get the right insurance for 2014. I can’t even figure out whether I would prefer Medicaid or some form of subsidized insurance. I realize neither one will be fantastic, but at least they will be less expensive than what I have now. </p>
<p>With my medical history, I’ve never gone a day without insurance for fear of never getting it back. For those who are complaining about the cost of their coverage, be glad you’re not me. I’ve been paying over 60% of my income for health insurance since January, 2012. (That’s not a typo). I’ve met my OOP maximum several years in the last 5. I’ve gotten my money’s worth, but it’s been a huge financial burden nonetheless.</p>
<p>I know there are “few” doctors who take Medicaid, but are they all part of the same “network”? For example, if I have Medicaid through NJ, would a doctor in NY or PA who accepts Medicaid be “in network”?</p>
<p>I’m dismayed that in several attempts to get answers from healthcare.gov (both online and on the phone) have resulted in contrary answers, lack of information, and more confusion than when I started. Do I just guess and hope for the best? Is there a penalty for answering incorrectly when you can’t find out what the correct answer is??</p>
<p>TatinG, every physician has non compliant patients. You’re focusing on the small, peripheral issues and not commenting on the major issues.</p>
<p>Oh, and I wanted to add, if it wasn’t for this thread, and especially calmom, I would have NO idea about ACA. I’m not sure I would have known until yesterday (when I got a letter from BCBSNJ) that I needed to find new insurance for 2014. </p>
<p>I am so thankful to everyone for all the information, debate, questions, answers and advice on this thread.</p>
<p>
</p>
<p>Wait, what? Insurance companies have to buy reinsurance now because caps have been eliminated, when they didn’t have to buy reinsurance before, and that doesn’t make any difference? Yes, insurance companies reinsure, but they have to pay for reinsurance. It’s not free! It costs them money, and they will perfectly reasonably pass those costs along to customers.</p>
<p>From the point of view of an individual consumer, caps usually don’t make any difference at all. The vast majority of people never come close to a million dollars in lifetime health care costs. But to the insurance company, caps (or not having them) are huge. (And to the unlucky people with super-expensive conditions, caps also make a huge difference.)</p>
<p>Realize that every year, 5% of the population incur 50% of the health care costs, and 1% of the population incurs 22% of all costs. The insurance company wants to save money on the people who cost money, and that’s the sick people who are racking up all that expensive treatment. The rare person who reaches a yearly cap, or a lifetime cap, on health care costs is likely to reach the barrier and smash it. They’re not going to rack up 1 million and 1 dollars in costs; if a patient is unlucky enough to cost $1 million, they’re very likely to keep on getting expensive treatments and cost $1.25 million, or $1.5 million, or $2 million. Which the insurance company has to pay if the patient doesn’t have a cap. So, yes, caps make a huge difference in insurance costs.</p>
<p>We have insurance today (pre-ACA – it has basically been the same for the past five years) that gives the illusion of out-of-network coverage. First, there is a $16K deductible before out-of-network costs are covered. Then – and worse – United Healthcare reimburses only 70% of Medicare allowable charges, even though I’m not Medicare-eligible, and even though Medicare allowable charges are much, much lower than the actual charges. In many cases, that would mean that even after I met the deductible, UHC might reimburse only 20-35% of the doctor or hospital’s actual charges, and I’m on the hook for the rest. Most people aren’t familiar with Medicare’s allowed charges, and have no idea when they see that there is out-of-network coverage that it is an illusion. (Personally, I think they should be required to peg reimbursements to something related to actual charges – if they want to reimburse 30% of actual charges, at least they’d be dealing with people from a position of honesty rather than hiding behind a 70% number that doesn’t relate to anything anyone would actually have to pay.)</p>
<p>I looked at our state’s exchange prices in more detail, and it looks like a plan (unsubsidized) much like the one we have now costs within a couple hundred bucks per year of what DH’s employer spent for our coverage last year according to his W-2. (The amount your employer spent on health insurance for you is coded DD in box 12 of your W-2.) That’s for silver level plans. One notable improvement in the exchange plans is that copays on drugs count toward the out-of-pocket maximum – our our employer-provided health insurance, you keep paying drug copays no matter what. I didn’t check out what the plan would cost smokers. </p>
<p>The other thing I noticed is that all of the health plans in our state’s exchange seem to cover hearing aids at some level. That’s fairly new. Not sure if it is part of ACA in general, or something that is state-specific.</p>
<p>Calmom, if you go to the Blue Shield site and pick one of the 2014 plans, you can find all the providers. Never rely on the agents; they don’t know anything. In my case, none of the specialists I see are in the network. These exchange/off-exchange plans are useless to me.</p>
<p>Quoting arabrab
</p>
<p>In my experience, most out-of-network doctors are willing to accept a combination of whatever my insurance pays plus a copay from me that together equal what they typically get from their in-network patients (ie, way less than 100% of what they bill). It’s worth asking, in any case. I’ve even had out-of-network doctors accept <em>only</em> what the insurance pays, with no copay from me at all, making it less expensive than going in-network.</p>
<p>That’s a good point, axw. But I think it is a lot easier to negotiate that before you have received the service than after, and my gripe with out-of-network coverage is that the limitation is really hidden since UHC doesn’t explain how low the Medicare rates are vs. “real” rates.</p>
<p>
</p>
<p>Cardinal Fang, you totally missed the next sentence of my post:
. </p>
<p>For decades insurance companies have bought insurance for themselves to spread their risk. CountingDown’s insurer did not pay over a million dollars for her. They most likely paid only 100 or 250K. All of our premiums include money that goes to pay for that cost to the re-insurance. Since insurers already buy insurance for the amounts between 250k and a million, it costs incrementally less to buy the additional levels. Yes, it is cheap.</p>
<p>
They are supposed to be posted on the CoveredCa.com web site tomorrow (October 7).</p>
<p>Don’t hold your breath. </p>
<p>(An Anthem agent told me that their own site will be updated, maybe, by Tuesday (Oct 8). Blue Shield didn’t make any promises. Calling my doctor didn’t help either – the person who manages accounts and should know seemed clueless.)</p>
<p>
</p>
<p>Spreading the risk is not the same as reducing the average per person cost. The issue is that now insurance companies have to pay out more money, on average, per person. The insurance company has to charge subscribers the average health cost (plus some money for profit and administration); that is the way insurance works. When the average cost goes up, because people who go over the former cap still are incurring costs for the insurance company, then the premium has to go up.</p>
<p>Whether health insurance companies reinsure or not is irrelevant. They have to charge the average cost per subscriber (plus profit and administration) or they can’t stay in business. </p>
<p>The 1% of Americans with the highest health care costs in 2009 had an average cost of $170,000 apiece. That’s the average, but among those 1% the lowest cost was $51,000. So we can easily see that the highest cost would be well over a quarter of a million dollars. And that’s just for one year: some of those Americans are racking up those quarter million dollar expenses every year. And that was 2009; costs have only gone up since then.</p>
<p>Goldenpooch wrote:
</p>
<p>I was specifically told by a Blue Shield agent that the provider lists have NOT been fully updated for the new plans. If you think that what you are seeing on the Blue Shield site is current, you are probably mistaken. </p>
<p>I was also told by the same agent that if my personal doctor was on my old plan, then she will definitely, absolutely be on the new Bronze plan as well. The doctor’s office says that they are on all plans-- they are current on all their paperwork and have not decided to leave any plans. Her name shows up on a search of all the old plans, but not the new ones.</p>
<p>I’m following the trust, but verify approach. In other words, I’m not signing up until the databases are current, but I believe the agents when they tell me that the data is incomplete.</p>