<p>Bay, as of Jan 1, 2013, insurers were no longer allowed to decline applicants due to pre-existing conditions. I don’t know if that’s how romani got her insurance last April – could also have been employer-sponsored – but ACA did help others who’d been shut out forever.</p>
<p>What LasMa said. </p>
<p>No, I’ve never had employer coverage available to me. Even when I worked for the state full time, I was a “student employee” and not eligible for benefits. I lost my coverage initially when my mom lost her job. </p>
<p>Ok. I don’t think one would have been eligible for the high-risk pool if other coverage (like through your university) had been available to you, even if you felt it was unaffordable. Not that this is relevant anymore.</p>
<p>Bay, according to how it was written, I was eligible. I had to become familiar with our law for a patron. That was the only reason I had ever heard of it.
You’re right, it’s now irrelevant. </p>
<p>Our personal experience with new obamacare has cost us $$$$$ of dollars for a surgery our child had to have out of network because not ONE doctor was qualified in network, to do the surgery. Prior to obamacare it would have cost us 9,000K out of network, post obama care 44K, yeah we are on the hook for 44K dollars in a year we have two in college. So be forewarned check the doctors of your plan in network, and pray to the heavens you do not require a specialist. We will all have bandaid care now, stay healthy.</p>
<p>Sam, was the surgery THIS year? If not, you’re going to have a heck of a time pinning on the ACA but I’m all ears. </p>
<p>Yes it was this year. Our plan gives you the option of out of network, but will only pay medicare rates if you chose to go out of network. We didn’t choose we had no choice but use an out of network surgeon. So for a 8 hour surgery, the doctor received 4,000 and that included the assistants reimbursement. The plan stated it would cover if already in treatment, if it was cancer. nothing else. so we are out of luck. Our child had been in treatment for 2 years with this doctor.</p>
<p>That is terrible, samiamy, just terrible.</p>
<p>I’m hoping you won’t now get a litany of responses about how you much have chosen the wrong medical plan, or how you had it so good before, or how it’s purely your doctors fault, or a list of reasons why this just fine for you to pay these kinds of costs.</p>
<p>It’s not. It’s awful.</p>
<p>I am sorry to hear your plight, samiamy. Hopefully your child is in the mend. Have you tried calling to see if they will reduce your bill? It is a longshot. </p>
<p>The surgeon will work with us on cos.He said the changes that have occurred to insurance plans will prohibit him from doing any hardship care going forward. He would do about 3 pro bono cases a month for medicaid children. I’m sure he won’t be the only surgeon affected this way. </p>
<p>We figured the surgeon was paid less than $60 an hour for his two years of work. </p>
<p>This is an employer sponsored “gold” plan, we did not have any say in the choice of plans. </p>
<p>Have you talked to your HR person at work? If no help there, personally, I’d get my US congressman or senator involved. The whole point of ACA is to avoid this type of thing.</p>
<p>You did go through the out of network referral process, right? And your insurer denied- AND you don’t have a maximum out of pocket- $6350/12.7 ? Trying to understand.</p>
<p>Do out of pocket maxes apply to out of network charges? </p>
<p>I agree with the suggestion of involving the HR person at work. It’s their job to work out situations like that.</p>
<p>I’m trying to understand the insurer’s position here. There are no surgeons in network that are qualified to do this type of surgery. Yet, if this is a normal accepted treatment, the insurer has to cover it-- that’s required by law. So how is the insurer covering it, if they can’t provide a doctor that does it? What is their story? I’m trying to understand how the insurer thinks it is legal to deny the child this treatment.</p>
<p>CF, seems they can, depending on the plan. Think we need a bit more info from that poster.</p>
<p>Samiamy - I’m sorry for whatever problems you are encountering, but the problem is the insurance company or the particular plan you have, NOT the law. </p>
<p>I have a Bronze plan in California with Blue Shield of California, bought of the state exchange, and my local doctor has not signed up for the new network. (There are no MD’s in my town on the new networks – don’t know if they plan to sign up or if I’m going to have to drive 20-30 minutes over to the clinics near the hospital in order to get in-network coverage.)</p>
<p>I managed to get sick on New Year’s eve and when I was still running a fever after 3 days I made an appointment with the in-town, out-of-network doctor. I wasn’t in any mood to shop for a new physician. I saw the doctor twice – once for the initial visit, and once about a week later for a followup up. The doctor billed $110 for one visit and $150 for the other. </p>
<p>The insurance “allowed” $83 for the $110 visit, and $122 for the $150 visit. That seems pretty reasonable to me - it’s almost 80% of what the doctor billed, and I assume doctors tend to bill more than they anticipate the insurance companies will pay in order to maximize their income. I’m pretty sure that is as good or better than what my doctor would have been paid under my old, pre-ACA plan, where she was a member of the network. </p>
<p>Because I haven’t met my deductible I will have to pay the full amount, but the “allowed” amount will be applied toward my deductible. My out-of-pocket max is +$9350 rather than $6350 when I use out-of-network providers, which would seem like a lot of money if I was managing to run that up for routine out patient care, but if I needed hospitalization or surgery that cost $50K, I think that $3000 extra would seem like pocket change. (In any case, it is an improvement over the out-of-network limits on my old policy with the same company).</p>
<p>Of course this doesn’t address the balance-billing issue – I plan to negotiate with my doctor if necessary and ask her to waive the balance (if her billing person doesn’t do automatically when billing me) – but my point is:</p>
<p>I have an ACA-compliant, exchange-purchased PPO that allows me reasonable leeway to go out of network without courting economic disaster. The balance-billing issue is a decision by the health care provider, not the insurer – and that ISSUE existed before ACA. While it is true that networks were generally broader in the past, it was often the case that specialists with particularized expertise were not in network – I have personal experience within my family going back 20 years or more where someone has had an unusual condition, seeing multiple doctors, and not getting a firm diagnosis until finally seeing a medical expert who was out of network. (Sometimes these experts are med school professors who don’t maintain much of a private practice – they only see the unusual cases that are sent to them by way of referral – so they don’t want to bother with the paper work required for the various insurances.)</p>
<p>So again – I’m sorry for whatever problems you are experiencing – but the point is, ACA doesn’t dictate the terms that insurance companies set for out-of-network care, or for in-network payments. The insurance companies decide that. Your employer-provided group coverage is still serving the same risk pool as before, so the law shouldn’t have had much of an impact on payment rates or network – though rising medical costs certainly would. </p>
<p>Maybe “covering it” just means paying Medicare rates for the surgery, which can be far below what the provider will accept. Non network providers don’t have to give bargain basement rates.</p>
<p>So this is employer-supplied insurance, correct? I’d like to understand why an employer would choose an insurance policy with a narrow network because of the ACA. Employers have been gravitating to narrow networks to save money for a while now, so what relevant issues tie this employer’s choice to the ACA?</p>
<p>We’ve had long discussions here about how private insurers for individual insurance under the ACA are now having to cover sick people, which costs substantially more, and they are trying to bring rates down by having narrow networks. These narrow networks for individual insuarnce are clearly the result of the ACA.</p>
<p>But-- that doesn’t apply to employer-supplied insurance. Employers already had to cover sick people like Samiamy’s daughter. She was covered last year. They’re not having an influx of sick people; they already had sick people. And most employers already covered most of the required benefits like maternity. So what is new under the ACA, that would be relevant here?</p>
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<p>As far as I can tell, no – ACA doesn’t address out-of-pocket maxes for non-network coverage, but does require the insurance companies to provide adequate networks. In other words, under ACA, an insurance company could theoretically have no limit at all on out-of-network costs, but the insurance company IS obligated to provide a doctor that is capable of providing the surgery that the patient needs.</p>
<p>Now it is very possible that the insurance company and patient will disagree on the qualifications and ability of the surgeon or the type of surgery that is needed - in which case the patient may choose to go out of network.</p>
<p>As I’ve noted, MY insurance company does have an out-of-pocket max set for out-of-network costs, which is $3000 above the out-of-pocket max for in-network (leaving aside the balance billing issue) – I think that’s pretty reasonable, and sets a reasonable balance between my right to choose and the insurance company’s interest in holding costs down, so I’m happy – at least in theory, especially as my unplanned test-run looks like the UCR the insurance company is attaching to the services I am receiving is generous enough to pay a substantial chunk of the medical bill. </p>
<p>But I know that different insurers will have different numbers – and that is something that is not always easy to ascertain.</p>
<p>So here it starts. Nothing is the fault of the ACA, it’s all good. It’s the insurance companies, your employer, never the possibility that the law has changed anything for the worse or that employers and insurers are taking actions because of the law. Certainly it is inconceivable that a single thing has changed yet for those with employer based insurance.</p>
<p>Had the law not been in effect, certainly samiamy’s family would be in the exact same situation, holding the bag for most of the cost. Is that really what some of you are saying?</p>
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<p>Exactly, and this is the question I have. If the network doesn’t have even one doctor who can do the treatment, then the network is not adequate. This story has the feel of a sleazy insurance company trying to get out of paying for something they are required to pay for. Alas, sleazy insurance companies trying to evade payment is not something new that happens with the ACA.</p>