Affordable Care Act Scene 2 - Insurance Premiums

Parent Cafe
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<p>I was amazed by the magnitude of the mortality drop in Massachusetts after Romneycare was enacted. A 3% drop in mortality, all of it in adults 20-64, is huge. It’s extending the life expectancy in MA by something like two years.</p>

<p>All results like this can be challenged, but this one looks strong. Rather than sampling in Massachusetts, the researchers looked at all deaths, which makes a big study. If the death rate had been from something other than uninsured people getting insurance, then we might expect to see a drop in death rates for all ages, but the drop was only in the 20-64 age group that contained the newly insured people. The death rate drop was bigger in counties that have more poor people who would have become newly insured. They matched counties in Massachusetts with similar counties in other states, and the counties in other states did not see any death rate decrease. The mortality decrease might have been caused by something else, but there are not a lot of obvious candidates.</p>

<p>Some people might wonder why the Oregon Medicaid study didn’t show a similar mortality decrease. Turns out, it couldn’t; it was underpowered. If there had been a similar mortality drop in Oregon, the Medicaid study would not have been big enough to detect it.</p>

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<p>CF: Sutter/PAMF is gobbling up markets like a hungry swarm of locusts.</p>

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<p>“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>The difference between an EPO and a PPO is that one can go out of network if you are in a PPO. You just pay a higher rate when you go out of network. For example - if I go out-of network my plan becomes 80/20 and is subject to the deductible… In network, I only pay a co-pay and I am not subject to the deductible. EPO (Exclusive Provider Organization) allow no out of network coverage. </p>

<p>I’m sorry that your friend didn’t understand the difference but I don’t think the blame for that is on ACA. I do find it odd the plan she picked didn’t explain what was covered and what wasn’t - but since I haven’t looked to see - I have no idea how plans were presented. Probably the only thing she can realistically do now is wait for the next open enrollment and switch to a different plan. </p>

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<p>I heard a radio interview in NYC with a woman in charge of one of the largest group of healthcare navigators. Someone reported a situation like this and the woman advised that she contact the state exchange. I know someone who had signed up for a plan on the exchange in NY that the insurance company said did not exist. The exchange got them to honor it and re-create the plan. I don’t know how it works in CA, but I would start with the state exchange people and the state insurance commissioner’s office.</p>

<p>A navigator told me that my daughter going away to college will be a qualifying event.</p>

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<p>emilybee

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<p>Yes yes yes…this is the understood and clearly spelled out portion of the issue. What is NOT spelled out, and what a reasonable person who has been working with health insurance for the better part of their lives would NOT intuit (as indicated by this example) is the network is LIMITED TO THE GEOGRAPHIC COUNTY. So, a reasonable assumption would be that if your down the street Sutter doc is in the network, the Sutter doc in the next county - less than 10 miles away, would also be ‘in network’. That’s the whole point of frustration…the network is bounded by county lines. That is not clear anywhere in the top level of comparison charts.</p>

<p>Even Sutters own list of accepted insurances does not make this clear on the top level sheet. It is on sheet #2 where a line states - Santa Cruz County BS EPO is only accepted by our doctors located IN THAT COUNTY.</p>

<p>Imagine you are told Stanford is ‘in network’ but Stanford has a clinic in San Mateo County and also one in San Jose. Now, you can go to the San Mateo County office, but not to the San Jose county office. Sorry…that is beyond non-intuitive. It can get even better … what if Stanford doc A practices in both offices…the soonest appointment is now in the office officially ‘out of network’ …what happens? Not a clue…but I could easily see appointment 1 being covered and appointment 2 being out of network. Again…this type of stuff should be in big bold letters. </p>

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<p>But Isn’t “limited” the first keyword, which should raise the first questions? The uh-oh moment? I get that people are confused, but what do they think “exclusive” means? </p>

<p>You said your friends confirmed with the local docs. Did they do the same with the away doc? Not meaning to hound, it’s just that, if my kid were seeing a doc for 3 years, i would include that name or practice right up there with the others, to inquire about. Not assume. But, you get this, dietz. I hope they appeal</p>

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<p>"…is the network is LIMITED TO THE GEOGRAPHIC COUNTY. So, a reasonable assumption would be that if your down the street Sutter doc is in the network, the Sutter doc in the next county - less than 10 miles away, would also be ‘in network’. That’s the whole point of frustration…the network is bounded by county lines. That is not clear anywhere in the top level of comparison charts."</p>

<p>I do not see what difference it makes what page of the plan comparison chart the network boundaries are explained. I have a feeling your friend simply did not look beyond the “top level of comparison charts.” Not the fault of ACA, Covered CA, or the insurance company, imo. </p>

<p>It reminds me of people who get flooded and are shocked when the find out their homeowners will not cover the damage. They are shocked because they haven’t read their policy and don’t know what is covered and what isn’t. </p>

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<p>oh…changed my mind…need to go calm down ohm ohm ohm</p>

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<p>Actually, I spent about an hour online yesterday trying to find info on the Blue Shield web site that would confirm or explain the issue of a geographic boundary. I can’t find it. The only info I found about EPO’s are statements that it includes the ENTIRE (statewide) EPO network – but this is not in reference to the new Covered California plan, but rather to EPO’s under CALPERS- for example: </p>

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<p><a href=“Health insurance plans | Blue Shield of California”>Health insurance plans | Blue Shield of California;

<p>Absolutely nothing about zip codes or geographical restrictions. But again, that’s CalPers (insurance for state public employees) – not individual market issues.</p>

<p>So: 1) Either Dietz & friend are correct and there are undisclosed limits on plans being sold via Covered California - in which case I think that the issue is something to be addressed via Covered Cal, the state insurance commissionr, and possibly down the line via a class action law suit. </p>

<p>or</p>

<p>2) Dietz is mistaken, and the problem relayed by the friend is because the son was seen by out-of-network providers rather than in-network providers whose bills were rejected due to geographic limitations.</p>

<p>I don’t know the source of the info that Dietz is relating about geographical restrictions right now, so I have to chalk it up to rumor/hearsay at this point. No offense intended toward Dietz – but my lawyer brain likes to see written documentation. </p>

<p>But,on the other hand, the total absence of such documentation on the Blue Shield web site is equally troubling. I suppose it is possible that those who are insured under the EPO’s would see that information when they logged into their accounts, or that it may have been included with the initial packet that was sent to them when they first enrolled …but it seems to me that people would need to know this before they enrolled, not after. </p>

<p>I’ve got a PPO so I’m not dealing with this issue, and of course when I log into the insurance web site I only see info for my own policy, not for those in other counties.</p>

<p>(And yes, PAMF/Sutter does seem to be taking over everything-- I’ll probably be switching to PAMF for primary care later this year.)</p>

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<p>Calmom: I am 150% correct in my description of the problem. My friends H spent time with the CC help line and it was confirmed that this is the case. No out of area coverage. The only option open to them is to switch to the Health net PPO during next enrollment period. But, they are stuck with large large bills from specialist - who were in their previous BS network. Ugh.</p>

<p>I spoke with the insurance/coverage/brave new world guru at my down the street PAMF urgent care facility. After handing me a page which lists all the plans they do accept, she said…oh…but…the BS EPO is for in area only. The specific example, one can see the Santa Cruz based PAMF doc, but not the San Jose based doc. I was specifically asking about cardiologist. Bottom line, if a procedure is available in the area with an in network doc… that is where it must be done. No going to another PAMF location - their cardo specialized unit is in SF! </p>

<p>Believe me, my friend would like nothing other than to have this be wrong.</p>

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<p>here we go…<a href=“http://shargel.com/whats-new/”>http://shargel.com/whats-new/&lt;/a&gt;&lt;/p&gt;

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<p>and this…</p>

<p><a href=“https://www.blueshieldca.com/producer/ifp/products/networks.sp”>Blue Shield of California | California Health Insurance;

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Note is says the member must LIVE in the area but does not let the member know that all the providers must be in that area!!!</p>

<p>So, it seems these are new plans…and the details are not easily (if at all) to be found by the average buying consumer…</p>

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<p>More info <a href=“http://www.bizjournals.com/sanfrancisco/blog/2013/11/narrow-networks-obamacare-california.html”>http://www.bizjournals.com/sanfrancisco/blog/2013/11/narrow-networks-obamacare-california.html&lt;/a&gt;&lt;/p&gt;

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<p>It is one thing for companies to do this…and it’s not unreasonable or unexpected. More benefits are mandated (yes, I can now get a prostate exam and H can go for BC pills :)). However, one of the big big selling points of the exchange and the ACA in general was transparency. NOW we could finally compare plans with the full knowledge that they all had to provide a certain number of benefits. AND the format for comparison was such that one could line up the pretty graphs and simply compare across the board. The network issue was IMO intentionally hidden. Sorry guys GP gets the point on this one.</p>

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<p>But the map in the ifp link shows SF and Yolo counties are not in the EPO territory. ? “either PPO plans or EPO plans – never both. Where your client lives determines whether PPO or EPO plans are available to them.”</p>

<p>Isn’t the IFP info for brokers?</p>

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<p>Dietz,I don’t doubt you and appreciate the links-- but to me a statement on an insurance agency site doesn’t qualify as a reliable (cite-able) source. I found so much misinformation posted on insurance company web sites last fall - related to different issues - that I started my own web site to clarify those issues – my web site has specific citations and links to laws and regulations. (I can’t link to it here because it’s a blog).</p>

<p>And as you can see, the quote you found on the Blue Shield web site says nothing about the network being geographically limited – just that the plans are offered based on the regions where people live, which is true of all plans offered via Covered California. Note that it refers only to “the” EPO network – not multiple, separate EPO networks. </p>

<p>There’s got to be documentation somewhere, within the actual policies issued by Blue Shield and in paperwork the insurance company has filed with the state and/or Covered Cal to in the course of getting their plans approved – if there isn’t, it’s one helluva lawsuit.</p>

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<p>Back in Dec I asked a high level executive at Anthem if a subscriber in an Obamacare PPO plan could go to an in-network provider in an EPO region. The answer was yes, however, I never thought to ask if you could do the reverse. I remember how difficult it was to get straight answers from this guy, and he supposedly was the expert. I dare say very few people who signed up for these Obamacare plans have any idea who they can see or not see. </p>

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<p>EPO doesn’t include out of nwk.</p>

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<p>calmom: I am not a lawyer but an engineer/accountant our thought processes are probably similar. I am known as the ‘research it to death’ person in my group of associates/friends. I LOOK at stuff, way way beyond the glossy market brochures and talking heads hype. From my arguably limited source of information this EPO geography limitation is real, sneaky and in at least on instance very very costly. Some posters have suggested an applicant should have asked this specific question. However, given this is apparently a completely new type of plan structure…how would one even get the idea to ask??</p>

<p>Again, it’s like buying the car. Given our collective past experiences one would assume cars are sold with gas tanks and fuel systems. One would never THINK to ask whether or not such a thing was part of the package. The potential list of questions associated with a full and conclusive investigation would quickly become unmanageable. </p>

<p>It is incumbent upon a government system which promised to make a (supposedly) secretive, confusing and sly process easier to then actually make important and financially critical terms highly obvious. </p>

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<p>There are different EPOs- ultimate, preferred, enhanced, for HSA, etc, with different benefits. This links to the various benefits summaries. Obviously, I have no idea if all are offered in each EPO area. </p>

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<p>The networks shouldn’t be any different based on metal level – those are actuarial issues, not network issues. Th labels like “ultimate” “preferred” etc. simply are the labels for plans sold off-exchange that correspond to the identical policies at Covered Cal. Blue Shield of California is not selling any direct-to-customer IFP policies separate and apart from the identical metal level policies on exchange.</p>

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<p>Dietz, look at the map at <a href=“https://www.blueshieldca.com/producer/ifp/products/networks.sp”>https://www.blueshieldca.com/producer/ifp/products/networks.sp&lt;/a&gt;&lt;/p&gt;

<p>Light blue = EPO
Dark blue = PPO</p>

<p>Is the limitation as explained to you that you have to stay in-region (in your case, Santa Cruz county) – or that you have to stay within the EPO (light blue) network.</p>

<p>In other words, could an EPO customer in Santa Cruz see a doctor in San Benito County, even though San Mateo & Santa Clara (PPO counties) are off limits? Would your friends kid have coverage if he was attending college in Sonoma or Humboldt (EPO counties) – even though apparently the doctors in Davis (a PPO county) are off limits?</p>