Affordable Care Act Scene 2 - Insurance Premiums

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8221

<p>Reimbursement rates for the exchange plans may well be lower than reimbursement rates for plans sold only off-exchange, on average. That in no way implies that the same plan pays a different reimbursement if the patient bought the plan on the exchange than if the patient bought the plan off the exchange. </p>

<p>Insurance companies can get doctors to agree to lower reimbursement rates if they promise some sort of exclusivity, because the insurers are in essence guaranteeing to send patients to the doctors. That produces low rates and small networks. On the other hand, if an insurer wants to have a plan with a broader network, they will not be able to use that negotiation technique, and will end up including doctors in their networks who demand a higher reimbursement. For that reason the broader networks will end up with higher reimbursement rates. This is not sinister. It’s just a fact about business.</p>

8222

<p>Does anyone know of any doctors who need more patients? I live in an area with a high concentration of doctors and while waits are not long (more than a few days) the doctor’s offices are always busy. Unless we’re talking capitation rates, like an HMO, for doctor’s to take a lower reimbursement in exchange for more patients is like that old saw “We lose money on every sale, but make it up in volume”.</p>

8223

<p>I am sure there are doctors that will take new patients.</p>

<p>I see hospitals expanding.</p>

<p>I have noticed that some of the older doctors are not quitting.
Some are becoming part timers instead.</p>

<p>Therefore, all older doctors will become part timers. :)</p>

<p>Obamacare is not that large…</p>

8224

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<p>CF. the SHOP exchange is for employers, so they are essentially group plans. However, I believe that rather than having to select a particular plan to use, an employer can sign up for SHOP and set a subsidy reimbursement rate, and then the employees can choose among the various plans that are available via SHOP. I may be mistaken about that, but I thought that was how it worked – if so that makes it something of a hybrid, because you could have a situation where there are 6 employees, and each chooses a different plan for themselves. </p>

<p>The risk pool is ALL of SHOP, which may or may not be combined with the individual state market risk pools, at the option of the state.</p>

<p>I’d also note that historically, rates for group plans have been set based on the particular employer group risk pool, so it may be that the average age of the employees in the group impacts the quote that is given to the employer. That is, if you hire youngsters and have 6 employees age 22-29, maybe you get offered something better than the employer with 6 employees age 45-60. But I don’t know the impact that NY law might have with respect to the group market in that state – NY does not allow for age rated premiums int the individual market.</p>

8225

<p>When I looked on Anthem to see which doctors were there in my area, most of the doctors were listed as taking new patients.</p>

8226

<p>We didn’t buy anything through SHOP exchange. We bought directly from MagnaCare via our broker.</p>

<p>Age was not taken into consideration. Quotes were given without age being considered.</p>

<p>Yes, we did have the option of getting different plans for our employees than what we (owners of business and employer) chose for ourselves. We could have chosen the cheaper bronze or silver for our employees, but we’re not jerks to our employees. Employees did not sign up on their own via SHOP exchange. Until you mentioned it, I’ve never heard of a SHOP exchange. We didn’t buy through SHOP. We (the owners) set up the plan–employees did not have a choice to sign up on their own and/or choose their tier. We did it via broker, not SHOP.</p>

<p>We pay 100% of our employees insurance premiums.</p>

8227

<p>In California, the networks for the insurance companies are the same for exchange and off-exchange plans in the individual marketplace. There are mirror and non-mirror plans off the exchange. The non-mirror plans have different deductibles and co-payments and are not identified as metal plans, although they do need to have the same actuarial payouts as the metal plans. They can have broader networks but the insurance companies voluntarily elected to keep the networks the same as the on-exchange plans, thus denying anyone in California who doesn’t have group coverage from having a broader network than what is offered on the exchange.</p>

<p>Every state is different and there are some that offer broader networks to subscribers of plans off the exchange. Some of our posters have said this is true in North Carolina. I think this is a serious problem with Obamacare and many who signed up for exchange plans are going to be shocked next year when they see how limited their networks and formularies are.</p>

8228

<p>NYsmile, my post wasn’t in response to you - I was responding to a question that CardinalFang asked. (That’s why I quoted CF’s question at the beginning, and began my sentence with “CF”)</p>

<p>CF, re my comment about the employees being able to choose from multiple SHOP plans, it appears that varies by exchange --See <a href=“http://marketplace.cms.gov/getofficialresources/publications-and-articles/key-facts-about-shop.pdf[/url]”>http://marketplace.cms.gov/getofficialresources/publications-and-articles/key-facts-about-shop.pdf&lt;/a&gt; - in particular questions 27 and 28.</p>

8229

<p>One obvious problem on this thread ( since I am catching up, this strikes me,) is that some here tell a fact and then follow it with non-facts. Leaves the next guy to research. Then #1 defends the original fact statement, leaving some here assuming the poster was right about the non facts, as well.<br>
Why don’t some of you speculators check before putting misinfo out there and wasting others’ time?</p>

8230

<p>Some small stories:</p>

<p>In WA the exchange plans are different than non-exchange plans. WA seems to have a pretty well constructed exchange interface. 2013 plans are not being offered in 2014</p>

<p>In AZ, they are using the federal exchange, it’s been rough. I have a client who completed the entire verification process in the first month the exchange opened, but waited to submit until December, as there was so much uncertainty he wanted to see how things worked out. In AZ, he could now keep his 2013 plan through 2014 at the 2013 premium. </p>

<p>Subsidies in AZ, like all states, are based on the 2nd lowest priced silver plan, but AZ offers many narrow network plans based on living in the Phoenix area, if one does not live in that area, that narrow network cannot be accessed so those plans are not practical. If you go to the insurance company website and put in your zip code, you will not see those plans, if you view them on the federal exchange, you will see all those plans that will not be smart to choose. If you are not working with an agent or are not quite savvy, you may well choose those low priced plans. That would mean physicians in your town are out of network. Also, if you choose the non-narrow network plans, you will pay a larger premium than one would think with subsidies as the out of Phoenix area plans cost much more, but the subsidy is based on the cheaper plans.</p>

<p>Several AZ companies say that other than the Phoenix based limited network, the rest are the same on and off the exchange.</p>

<p>In AZ, they are now saying a client has until January 21 to pay for the January premium.</p>

<p>As Calmom said earlier, your premium is the same with or without an agent. You might as well use an agent, especially if you already have a relationship. The agent commissions seem to be cut in about half of 2013 percentages, that will be interesting to see how it works for people who rely on those commissions for all their income, perhaps they will make up for it with volume.</p>

<p>Personally, I suggest a Blue plan (shield or cross) as that provides you with access to the Blue Nationwide Network of medical care “in network” even when out of state or even country.</p>

8231

<p>The AZblues are calling people, everyone I think, who has signed up via the exchange. They are checking that people are on the right plan, not the one without a good network for them, and they are asking if anyone needs to be seen in the next 90 days and offering assistance in connecting with a PCP and getting appointments. They are saying that doctors are filling up with new patients. Anyone heard anything about people with new plans having trouble getting new docs?</p>

<p>The caller is offering assistance with Rx needs and anything else to make the transition smooth. It seems above and beyond the old levels, but is smart!</p>

8232

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<p>I agree, nysmile. This is what we did even though we could have signed up directly on CoveredCA. I am not an expert on insurance, and it gave me peace of mind to KNOW what I was buying, rather than making layman’s assumptions. </p>

<p>I talked today to a rep from healthcare.gov, and learned something interesting. The marketplace isn’t just for purchasing insurance. It’s also for dealing with problems down the road. I was told that if Anthem ever refuses to pay for something that’s supposed to be covered (which has happened to us in the past), we can call healthcare.gov and they will go to bat for us. I guess I still haven’t fully wrapped my brain around the fact that we now have protections, because I was surprised (pleasantly). I’m still in the mindset that it’s us two little people vs. a corporate behemoth. No more. For the first time, we have an advocate!</p>

8233

<p>Actually California has a Patient Advocate service – see [Problems</a> And Complaints](<a href=“http://www.opa.ca.gov/Pages/ProblemsAndComplaints.aspx]Problems”>http://www.opa.ca.gov/Pages/ProblemsAndComplaints.aspx) –</p>

8234

<p>The SHOP exchanges will be able to offer employees of small businesses a choice of plans down the road, but not now. That part was delayed, because the coordination of premium delivery to different insurers isn’t operational yet. Also, paper applications have to be submitted. Apparently there hasn’t been much interest from small businesses in the SHOP. </p>

<p><a href=“Small Businesses Showing Little Interest in State SHOP Exchanges - The New York Times”>Small Businesses Showing Little Interest in State SHOP Exchanges - The New York Times;

<p><a href=“http://www.nytimes.com/2013/11/28/us/politics/years-delay-expected-in-major-element-of-health-law.html[/url]”>http://www.nytimes.com/2013/11/28/us/politics/years-delay-expected-in-major-element-of-health-law.html&lt;/a&gt;&lt;/p&gt;

<p>(I’m in a federal marketplace state and have interest in both the individual and SHOP exchanges – since I have concerns re the privacy aspects, we have put off further investigation at this time. We have coverage for most of 2014.)</p>

8235

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<p>Is that for everyone with individual plans?</p>

8236

<p>welcome back somemom. Did you make any money on ACA yet?</p>

8237

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<p>Good to know, calmom. The conversation I had with healthcare.gov was about Indiana, which doesn’t have a state exchange.</p>

<p>Fang, here’s what the website says.</p>

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<p>So it sounds like everyone with a new individual policy has appeal protections, except those whose state has its own exchange but doesn’t have a CAP. If that were me, I’d at least try healthcare.gov; this is a federal law, after all. Non-exchange states can go to healthcare.gov.</p>

<p>And grandfathered policies from before July 2011 aren’t protected. Those subscribers are on their own against the insurance company, just like the good old days, Goldenpooch. ;)</p>

<p>[Appealing</a> Health Plan Decisions | HHS.gov/healthcare](<a href=“http://www.hhs.gov/healthcare/rights/appeal/appealing-health-plan-decisions.html]Appealing”>http://www.hhs.gov/healthcare/rights/appeal/appealing-health-plan-decisions.html)</p>

8238

<p>Flossy, if you’re around, yesterday you said that if a doctor took a patient who had bought an exchange policy, the doctor would have piles of paperwork that wouldn’t exist for other patients. Can you point me to any documentation of that? I figured that if a patient comes in to the doctor’s office and they have insurance, the doctor’s office bills them in the usual way no matter where the insurance came from.</p>

8239

<p>[Top</a> Hospitals Opt Out of Obamacare - US News and World Report](<a href=“http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/10/30/top-hospitals-opt-out-of-obamacare]Top”>http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2013/10/30/top-hospitals-opt-out-of-obamacare)</p>

<p>From the article in the link:</p>

<p>“The result of our investigation: Many top hospitals are simply opting out of Obamacare.”</p>

<p>“Chances are the individual plan you purchased outside Obamacare would allow you to go to these facilities. For example, fourth-ranked Cleveland Clinic accepts dozens of insurance plans if you buy one on your own. But go through Obamacare and you have just one choice: Medical Mutual of Ohio.”</p>

<p><a href=“http://www.forbes.com/sites/jimpowell/2013/11/13/the-fourth-obamacare-shock-wave-is-about-to-reach-us/[/url]”>http://www.forbes.com/sites/jimpowell/2013/11/13/the-fourth-obamacare-shock-wave-is-about-to-reach-us/&lt;/a&gt;
Another interesting insite.</p>

<p>From the article in this link:</p>

<p>“Obamacare reimbursement rates are lower than Medicare. Obamacare has a special disadvantage, too: a 90-day grace period. This means people can buy an Obamacare policy, have costly procedures done and then cancel the policy within 90 days. If the cancellation comes during the first 30 days, the insurer is responsible for trying to collect payment, but after that, doctors are on their own. They would have to spend time and money chasing patients for payments. California Healthline reported that deadbeats “would not receive a fine, a premium rate increase or a repayment order. They also would not be barred from purchasing another subsidized plan during the next enrollment period.” No other type of health insurance has a 90-day grace period like this.”</p>

8240

<p>^^So if the information in nysmile’s post 8239 is accurate, the only reason you would possibly ever want to buy from the exchange is if you are getting a subsidy. And it seems that it would have to be a fairly substantial subsidy in order to make it worthwhile for lack of choice in doctors and hospitals.</p>

<p>I don’t know how much I’d trust the people at healthcare.gov to help me out with an appeal, as their competency seems to be lacking and their staff overloaded. That doesn’t seem like a reason to go through the exchange, unless you were planning on getting pricey procedures done, cancel your policy and become a deadbeat, knowing that people couldn’t come after you.</p>