<p>“Big companies are flirting with dumping high-cost employees off their private health plans onto Obamacare—legally.”</p>
<p>This is news to me. Apparently, a large employer can dump an ill employee on the exchange and save a good deal of money. Unfortunately, premiums will go up for everyone else in the individual market as well as taxpayers who will have to pay the subsidies.</p>
<p>LM, somewhere I saw it’s only non-payment (which some will have a field day with.) I didn’t find what I’d consider confirmation of that.
But my folks do keep sending me a letter that includes, “Failing to report changes can be a crime in certain circumstances.” Who knows what those circumstances are? A few lines later, they list the usual bullets- residence, marital status, access to other insurance, etc. It doesn’t seem to imply those would be criminal omissions. Just want to put the fear into me, I guess.</p>
<p>GP’s link outlined the process for how a company would be able to ‘dump’ a high cost employee onto the taxpayers lap. That part is not hypothetical, it is doable. There are so many unknowns and so many interesting and exploitable loopholes (some discovered, some as yet undiscovered) that we haven’t yet see the true behavior changes encouraged/induced by the ACA. It is reasonable to assume that a company - which has already seen and increase of 4% in the premiums due to the ACA tax on employeers - would try and see where it could recoup the additional costs.</p>
<p>Sounds like a dumb plan to me-- the employer deliberately reduces health care benefits for all employees to induce a few to drop their employer-provided care in favor of buying on the exchange. That’s going to make for a lot of unhappy employees. And I thought that the big grip against the exchange policies is that the networks are too limited – so the self-insured company restricts its own network even further? Makes no sense. </p>
<p>Can’t self-insured companies purchase reinsurance as a hedge against high end costs? </p>
<p>But the reinsurance will be more expensive if the expensive employee is included in the pool.</p>
<p>Offer crappy insurance and hope your employees don’t pick it up is a plan. But the company might as well just offer no insurance and pay the fine, if their objective is to save money.</p>
<p>Are we sure about that? Losing insurance because you lose employment is a qualifying event, but is losing insuance because you didn’t pay for it a qualifying event?</p>
<p>Tonight I received a phone call from the friend who chose the Covered California BS EPO option, she was crying because all of her son’s medical claims have been denied and they are now on the hook for the full cost.</p>
<p>To recap what I had previously posted…family was a H and W business. They chose not to bring on an employee inorder to maintain group coverage. The business has not been as profitable as in past years and they were eligible for subsidized insurance. They have been with BS for many many years. H spent hours on the phone with Covered CA and with BS. Finally made a well informed decision to enroll in the BS EPO plan. It took their out of pocket premium costs from $1400/ to $600/month. They checked with their local docs and these practitioners accepted the plan. Family has three kids, two in college outside of home town.</p>
<p>The S has had a number of expensive tests and procedures. These were performed in his college town - he’s been seeing these docs under the previous BS plan for the past 3.75 years. However, the EPO doesn’t cover him outside of his home county. My friend just kept saying …'you’d think someone would have mentioned this…why were we not told?" They are looking at many thousands of $$ !</p>
<p>These are well educated, well informed people who have run a business for many years. They ask questions, ask more questions and then make informed decisions. </p>
<p>So, I’m going to try and figure out a way for this family to have a ‘qualifying event’ so that they can drop the BS plan and go to Healthnet. I have a few ideas but am interested in what options come to the minds of any of the well informed people on this thread.</p>
<p>This sucks…it should not be…this was not and still is not transparent.</p>
<p>I would think since the son is not covered by the plan there should be some special circumstance which would allow them to change plans. I would call an experienced agent and see if he could help them. (Actually, I doubt if most agents would know the answer.)</p>
<p>If you are getting subsidies and you have a change of income, I think this would be considered a qualifying event. I read somewhere that in Ca you don’t need documentation to enroll in a plan outside of the enrollment period. They are supposedly going to rely upon the honor system.</p>
<p>I wonder how many people these days are finding themselves in this situation or other equally perplexing situations where they can’t get medical care. You knew once the govt was this heavily involved in our healthcare system, it was going to be a nightmare.</p>
<p>GP I was thinking along these lines. The fact that the S now resides in Davis could be viewed (by a logical person) as his having lost coverage. I hadn’t thought about the income angle.</p>
<p>Moving to a different coverage area is a qualifying event. </p>
<p>Do EPOs ever cover subscribers for treatment outside their home region? I thought the deal was clear: go to exactly the doctors on our list and we’ll pay, otherwise you pay.</p>
<p>Sorry, but since D2’s coverage in her college town was part of our decision making, I have to wonder if that was discussed with the carrier. After all, the family knew he had been seeing this doc for 3 years. And if BS misled the family- or if the doctor’s practice said they would accept the plan, then I see an immediate appeal.</p>
<p>We don’t have an EPO option- but BS clearly says it’s “exclusive.” no confuion in my mind that it is a limited list. I asked up front, when reviewing our plan options. When D2 needed a doc in her c-town, I asked how to id those covered, she asked/confirmed when she called for an appt. we didn’t assume anything based on the plan we had from summer to 12/31 or the one before. </p>
<p>I am sorry when people run into this. But it leaves me with questions. </p>
<p>CF: Given both mine and my friends complete misunderstanding of how an EPO functions I’m going to way way out on a fragile limb and say, no…it is not clear that one can only see docs in one’s home county. This is obviously one of the most important limiting factors in such a plan and IMO should be stated in an upfront in a clear manner. I’ll repeat myself…as a very informed health insurance buyer…I had no clue.</p>
<p>The family in question did call BS and ask about providers, they were told PAMF was in the network. They asked at their local PAMF office and were told…yes we take the insurance. The H spent hours on the phone with BS and with the exchange. He says once he was able to actually reach a person they were all very helpful. So, I am going to assume that this family made the same mistake I would have made…oh PAMF in network…that means all PAMF in network. Yes, that is how things used to be for as long as they/we have been asking that question. They did not know to dig down further and ask…is that ALL of PAMF or just the guys in my zip code.</p>
<p>LF: As to an EPO network being exclusive…so is a PPO network…I find a reasonable person who has been in this market for some time would assume the definition of ‘exclusive’ to be the same in both cases. Yes, I know where assumptions lead.</p>
<p>It reminds me of the situation when new cars stopped providing spare tires - of any kind. If you’ve purchased cars for the past several decades you’d never stop to ask…oh does it have a spare? Because that was industry standard. It was understood that this was part of a new vehicle. So the question is…when you got a flat and went to look for the spare only to not find one…where does the failure to understand lie? Should you as a consumer have to ask…does it have a tire…(since it was ALWAYS the standard)…should the dealer have been obligated to point this out? Then, next time you go to purchase a vehicle you can come armed with a check list of questions…does it include the tire, how about a radio, is a key provided or is that something I will need to find elsewhere, will there be gas in the tank, oil in the engine and wiper fluid in the container…should I bring my own brake fluid before picking up vehicle. Again, one assumes an industry standard…arguably…one should no longer do so.</p>
<p>The health insurance process was supposed to become transparent…make it easy to compare plans…so…it that system failed…or I (we) are just stupid…</p>
<p>It would be easy to make that mistake, I think. They say PAMF is in network, you go to a PAMF doctor, and then it’s not in network. (As an aside, they have Palo Alto Medical Foundation doctors in DAVIS now? PAMF is taking over northern California. I remember when it was just a little complex in residential Palo Alto.)</p>
<p>Neither. The system worked as economically as it could, as it HAD to, by restricting choice. (This was a no-brainer, and something I predicted years ago on cc, back when we had the political forum. Of course, then, as now, the cheerleaders were buried in the sand.)</p>
<p>Dietz, they should make a loud and very carefully strategic noise. Seems the rational point is: “we clarified PAMF is covered. Multiple times.” Pound it nicely, intelligently- and escalate. </p>
<p>I know we’re all trying to make the best sense we can out of all this. Most of this is info we never commonly thought about- and is complex. New lingo. Uncertain needs… Maybe the worst part is you have to have a mindset for all the what if’s and all their possible permutations. Best wishes to your friends. I’m also curious if you found an orthopedist.</p>
<p>Folks should quit the ‘cheerleader’ crap- it sure seems “from hunger.” Too easy a dismissal or putdown, a false sense of superiority, as if a small group alone understands. None of us who appreciate ACA are blind to the challenges. And I’m not the only one saying that, one way or another. </p>