Affordable Care Act Scene 2 - Insurance Premiums

Goldenpooch · December 29, 2013, 10:26pm

“we can imagine a scenario where the doctor who is out-of-network in the PPO is Tier 2 within an EPO”

My understanding of Anthem’s network is that a tier 2 provider in an EPO region is also a tier 2 provider in a PPO region. What we don’t really understand is what tier 2 means. I know it means less generous co-pays and negotiated rates, but it might also mean that none of the hospital’s doctors are covered. I cant seem to get a straight answer from Anthem on this point.

Most importantly, tier 2 hospitals are in-network and utilize the in-network deductibles and out-of-pocket maximums. Also, you don’t have the balance billing payment problem. This is a critical distinction and is the reason why Anthem’s network is far superior to BS.

dstark · December 29, 2013, 10:35pm

“I know it means less generous co-pays and negotiated rates, but it might also mean that none of the hospital’s doctors are covered”

Where did you get this idea?
Calpers had so many tier2s in their plan I find the above extremely unlikely".

From Cedar’s website…

"“Anthem Blue Cross’ new individual and family plans for 2014 will exclude the majority of Cedars-Sinai physicians from its new narrow network of providers.”

Majority is not all.

Goldenpooch · December 29, 2013, 11:41pm

“Where did you get this idea?”

Director of Sales, Western Region, Anthem

lookingforward · December 30, 2013, 12:29am

One problem here is that you’re trying to back into some sort of mega understanding through piecemeal bits of info. And, it’s complicated because these media reporters offer no guarantee they report totally accurately- after all, they are reporters, not often experts.

I don’t think it’s accurate to compare anything to “what medicare pays” because, (I believe and someone could verify this-- but it came up on the original thread,) I think Medicare billing is actually bundled. I’ll leave it at that, for now.

Negotiated rates, aiui, are maximums the docs agree to charge for various procedures. it’s not that the charge is $X and they only get y%. So, eg, the gyn billing rep explained: they “could” charge me $1250 for a procedure my D had. BUT, they have negotiated with, in this case, BCBS, to cap their billing charge at $125. From the get go. No mystery.

This ties into (or parallels) something Calmom mentioned, I think: under your insurer relationship, you don’t just go in and pay any wacko rate the doc wants to set, until you have met the minimum deductible. No, the master plan is that when the doc has agreed to the insurer’s cap, entered into that arrangement, the max she would charge, in my example, is $125. That’s regardless of whether you need to meet one deductible or another.

How this ties into what Texaspg is asking, I don’t know. Ie, why some docs appear in one plan and not another. But in my state, it boils down to: for BCBS, the doc is either in or not in- ie, either agrees to the caps (“negotiated rates”) or opts out of a BCBS relationship. If they accept BCBS, they work with agreed-upon negotiated rates. $125, for that service. If my plan says I have a 20% co-pay, in my case, that’s the payment I make, in the office. If the policy states a $40 fee, that’s what I pay. If it says the procedure is not covered, that’s what I am up against.

As for understanding what makes a doc a Tier 1 or 2 or whatever, you have got to clarify this with your insurer (not the exchange.) I got that explanation.

As for the “qualifications” question, I also found that in my documentation and, in my case, it is simply a mandate that they be certified for the service provided. A medical qualifications issue. You can see how your carriers explain.

And, having had kidney stones, sorry to say, the first initial step has no fancy protocol; it’s wait to see if it passes, unless the pain is so bad you require morphine. Been there. If it’s bad, you can get to ultrasounds et al, to examine the size, shape and placement, whether the dang thing is likely to pass through those narrow tubes or requires intervention. But there is no one automatic “thing” to be done.

calmom · December 30, 2013, 12:42am

GP, re your post 8360: I have posted about 6 times that the ONE best medical facility in my geographic area is on the Blue Shield network but NOT Anthem. It is a Sutter-affiliate – one of the 9 hospitals statewide that Anthem is not including in any of its networks. (And Anthem’s issues with Sutter predates ACA, going back at least to 2007).

You came to this forum weeks ago crying and moaning because BS was cancelling your cheap, $5000 deductible policy, ready to go sue BS to force them to allow you to stay on.

Now you’ve spent some time on the phone with an Anthem exec and you’ve become the world’s spokesperson for Anthem.

I realize that you have a black-and-white, all or nothing world view is around the assumption that you are the center of the universe and nothing possibly can be good for anyone unless it is good for you — but the fact is that the plan prices and networks are different in different regions, and people have different needs. I would have to GIVE UP access to the one medical facility I trust if I were to switch to Anthem, at least with the information that is available now. If Anthem were so incredibly wonderful, I think they would be able to figure out a way to post their network on their web site in this state. I don’t trust them.

If I didn’t go with Blue Shield, I’d go to Kaiser. I don’t want Kaiser and I don’t think Kaiser would give me the sense of control I want over my own health care decisions, but the local Kaiser facility is better than the hospital I would be stuck with if I opted for Anthem.

I’m not saying this to badmouth Anthem. I’m glad they have a network that is good for you. But I don’t know why you have suddenly decided to become the spokesperson for Anthem and bash Blue Shield. If you are so determined to improve networks, why don’t you call up your new-found friends at Anthem and suggest to them that they ought to include all Sutter facilities in their PPO networks? Because that’s a pretty big chunk of medical service providers that are in the Blue Shield network and not in Anthem. Like, to start with, the place I go to for my mammograms.

calmom · December 30, 2013, 12:57am

Not quite, because the doctors still “bill” their full rates – but they have agreed to accept the insurance company rate as full payment. So here is how it works in theory:

I go to the doctor.

The doctor submits a bill to the insurance company for $300.

The insurance company generates a document called an EOB (“Explanation of Benefits”) that says that the doctor has billed $300, but they are “allowing” only $125.

The EOB also tells me that I have not met my deductible, so therefore they will not pay the $125, but that amount is being applied to the deductible.

I then pay my doctor $125.

But that doesn’t change the fact that the doctor “bills” $300. They haven’t agreed to change their billing – they have just agreed to accept a lesser amount in full satisfaction of their charges.

lookingforward · December 30, 2013, 1:10am

I’ll take a look, calmom. I know I routinely see that for dental. In the gyn case, they made it clear from the get-go. I am willing to accept that may have been different, but will see what other EOBs look like.

Bigger issue for me is that, though they confirmed all was good as of the 20th, now they want me to verify our incomes for 2014 and our drop leaves it all less certain than someone who can just pull some pay stubs. I think I know what I have to do, but it’s a hassle. I have to call in, tomorrow.

calmom · December 30, 2013, 1:42am

I think that the doctor “bills” the full amount because it is easier to do that than to keep track of the various rate structures of different insurance companies, and also it protects the doctor in the event that the insurance company determines that a procedure or service is not covered at all. (Either because it is outside the scope of the policy or the insurance has been cancelled or lapsed).

I mean, the doctor can’t send a bill for $200 to the insurance company and then turn around and bill the patient $500 when the insurance company doesn’t pay. But a doctor who bills $500 in the first place is free to try to collect that amount from the patient, unless the insurance company determines that it is in fact covered and reports the negotiated rate.

Also, some people have multiple insurances and it is possible that one will pay and the other won’t – and each may have different negotiated rates. The doctor may not know which one will pay – so again, safest to bill the full amount and wait for the insurance company response.

On the income verification issue: keep in mind that the exchange needs a piece of paper it can point to for their records. You can give that to them in the form of a signed statement or affidavit – you don’t have to “prove” everything with a bunch of bank records or other documentation. If they want more than what you give them to start, they will ask for more – but again, they aren’t trying to penalize you, they just need to have something in their file to justify a decision. Obviously neither you nor anyone else can know what 2014 income will be-- maybe you’ll win the state lottery in March – all they can ask of anyone is the best estimate and an explanation of how you get that. The only thing they currently have to look at your 2012 return, so I think the letter/statement should focus on explaining why the difference.

lookingforward · December 30, 2013, 2:06am

Thanks, that’s reassuring. I thought I had covered it in my original application, under notes, because it passed muster in setting up the account and with the rep who enrolled me, in person. And, we discussed how I estimated; at that point, she had confirmed I was verified. But I do understand there has to be some process. Hoping this is just wanting some back-up. And, considering the looming 1/1, hate the anxiety of waiting to verify we’ll be covered without a break, without needing to pay my much higher cost to continue the independent plan, in the interim. The email does say I have till 3/20 to resolve this.

But, this snafu for me also underscores what several of us have said- it’s too easy to use the argument tactic that there are supporters and naysayers lined up on opposite sides, that it’s all so black and white. We’re all experiencing this for the first time.

calmom · December 30, 2013, 2:50am

I think the worst case scenario is that they tell you that can’t authorize the advance premium tax credit – and then you make a determination of whether to go ahead and pay full cost – knowing that you’ll get the balance back in the form of a tax refund in 2015 – or to change to a less costly ACA policy. (For example, shifting from a Silver to a Bronze). March 20 will still be within the open enrollment period, so you would be able to shift – I think that a negative decision would be grounds for a change outside the open enrollment period anyway.

That being said, I think they will tend to give you the benefit of the doubt. Obviously if you get a larger subsidy than you are entitled to, you’ll have to pay it back the next year – so there’s not much benefit to you to lie about your expectations unless you are truly desperate for the money. There are some wrinkles on that statement – for example, if you qualify for the cost-sharing reduction Silver plan, your copays would be lower and that couldn’t be recovered… but you’d lose that benefit in year #2.

Goldenpooch · December 30, 2013, 2:50am

Calmom, your post is incorrect in a few important areas. First, I would still stick with my current BS plan in a NY minute over the 2014 Anthem plans. All I am saying is that the 2014 Anthem network is far superior to BS. Anthem has all the UC hospitals, Cedar Sinai, City of Hope, Loma Linda, and many more. Is Anthem’s network as good as my current plan: absolutely not, but it is heck a lot better than BS.

My assessment of Anthem and BS has nothing to do with who I talked with over the phone. It’s based on objective data which I have been able to collect so far. Trust me, there is no way I could have started up a successful business and operated it for 25 years, if I could be easily persuaded by a salesman on the phone. I am going to take the high road and not respond to your personal characterizations of me.

somemom · December 30, 2013, 3:17am

In this example, with a pre-approved surgeon and a pre-approved facility, when you get the bill from the out of network anesthesiologist or physician’s assistant, you may get the insurance company to pay the entire thing by appealing in writing, noting that all pre-approvals were done and that you had no control over the out of network staff person. I see this happen surprisingly often and wonder if those people you never really meet and over whom you have no control deliberately stay out of network for bigger pay? I have gotten these bills covered for clients.

Surgeon paid network approved amount, hospital paid network approved amount, assistant paid full billed amount.

calmom · December 30, 2013, 4:09am

Well, the point I was trying to make is simply that the EPO has two tiers but -0- coverage for non-emergency out-of-network, whereas the PPO pays both in-network and out-of-network, but the out-of-network is generally at a lower rate and the out-of-network providers may balance bill.

I’m not trying to get into the nuances of when you might be able to negotiate something different – just trying to explain the difference in coverage.

Also, I haven’t been able to find documentation on what Anthem actually charges for copays for its tier 2 providers vs. tier 1. That just isn’t included in the plan benefit statements that I can find. So I don’t know how to factor in that price differential. (I am continually frustrated with the difficulty of getting information from Anthem - the lack of transparency drives me nuts.)

calmom · December 30, 2013, 4:11am

Not where I live.

All I am saying is that you should try to use your imagination to figure out that some people’s situations and circumstances are different than yours.

Goldenpooch · December 30, 2013, 6:05am

Which is your preferential Sutter Hospital?

Not sure of where you live, but I can safely say that if you live in San Diego, Orange County, Los Angeles, Santa Barbara and Central Ca., San Francisco and Sacramento, Anthem has a better network of hospitals.

Having said the above, it is highly problematic that Anthem’s provider directory is not working and their executives don’t seem to have many answers to some basic questions. Not of a big fan of Anthem, particularly their 2014 plans. But any insurance company that leaves out all the UC hospitals and some of the other hospitals I mentioned in my previous post is providing an inferior product. This is hardly unique to my circumstances or situation.

lookingforward · December 30, 2013, 8:40am

Calmom, “the exchange needs a piece of paper it can point to for their records” is pretty much what they told me, a few moments ago. We should be good because the system now shows a plan initiated, payment made, and all the expected details. I did learn that, despite the fact that an account summary I can see shows D2 is not a student, she is properly flagged where it matters.

My case is clearly different than some of the decisions for CA folks. But I think it’s important to accept, GP, that one person’s obsessive way of looking into all this is not the exact way the next person will weigh it, it doesn’t have to be and maybe “shouldn’t be.” We (you) can raise questions, eg, some detail about hospitals in different parts of the state, but we all have to respectfully assume the next person- especially highly detail-oriented folks like calmom, dstark, and CF- has similarly put on their thinking caps and come up with decisions that are initially successful, for them.

Now I mail copies of our back-up info and wait for our cards to come. No less vigilant. Still hoping all i’s are dotted and t’s crossed.

lvvcsf · December 30, 2013, 9:48am

I have an HSA I’m very happy with. I am grandfathered because I’ve made no changes to the plan since before 2010. The promise of lowering costs by an average of $2500 did not come to fruition for me however. The cost went up by 29% or about $2400/yr. The good news is I’m still in control of who my doctor is. I’m not sure I can afford much more “savings” though.

texaspg · December 30, 2013, 10:37am

I have posted about this doctor’s bill of $300 based on my discussion with some medical practices managers. They pick a ridiculous number that no would ever pay in order to be paid more in some plans which do and not shortchange themselves.

Here was their explanation.

Expected rate - $100

Reimbursement from insurance A - 70 + copay 20

Reimbursement from insurance B - 90 + copay 20

Reimbursement from insurance C - 110 + copay 10

If they billed a $100, they would lose out $10 from A because that is all they are going to pay but then also lose 10 and 20 from the other two who are willing to pay more for the same services.

Essentially, they are discounting 10$ voluntarily in the first case but don’t want to give up 10 and 20 with B and C just because they priced low since they will only get 100 in each case if their charge is 100 while they could have gotten 110 or 120 in total.

In order not to lose out due to variations but not having to keep up with schedule, they make the arbitrary charge up top.

They have told me that is the same with testing also where the bill says 3000, you pay 30, the insurance pays 200.

R

Cardinal_Fang · December 30, 2013, 11:17am

You have no idea whether costs were lowered ON AVERAGE. You have no idea whether your costs, averaged with everyone else’s, were $2500 less. So you have no idea whether the promise was fulfilled.

busdriver11 · December 30, 2013, 11:47am

Well in that case, I’d love to hear from someone whose costs were lowered significantly for similar benefits…and not by subsidy. Most everyone seems to be talking about large increases, and an occasional small decrease. Anyone paying a lot less? I leave out subsidies, because obviously that isn’t something that decreases the price, it just changes who pays.

Affordable Care Act Scene 2 - Insurance Premiums

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