<p>Not discriminatory if you have access to competent care. Aiui, that’s what the courts would look at. And the fact that, if the only doctor who could perform that procedure was at Cedars- and the procedure can be justified- the insurance already includes a process to review paying as in-net. You’d have to make a case- and the case isn’t, Doc X is the only one “I want” to do this. Nor that your neighbor has access to him or her, via a different scenario. Plus, you still have the option of going to the doc/facility of your choice- and paying on your own. </p>
<p>Calmom: Who said anything about wanting to go to SHOP? That comes with a whole other set of issues. And frankly, I trust my broker reading and interpreting skills. And, it is no less circumventing the system or using a loophole than is the suggestion to overestimate income in order to get subsidies which are miscalculated but then protected by ‘claw-back’. </p>
<p>kcmom: We are an LLC, we consist of and H and W, we pull K1 distributions now W2 wages. We have been a group for about 10 years. IIRC a C corp was treated differently - which is one of the reasons ‘we ain’t one’.</p>
<p>Dietz199, you need to rewatch your video. ;)</p>
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I remember someone suggesting that, and at the time I was kind of surprised. </p>
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<p>100% agree. We are talking about routine annual exams. In each case, it will have been a year and a few days since my last routine annual exam. I know how far ahead I need to call to get the appointment I want. </p>
<p>More importantly for this discussion, my wait times are NOT affected by ACA. They are the same, or even a bit less for the primary, as they’ve been for years and years, since long before anyone ever heard of ACA. </p>
<p>My wait times have been substantially reduced since ACA- partly because I changed doctors. It was at least 2 months to get an appointment for a routine physical with the old doctor, though very easy to get an appointment for sick care. But I was offered a next-day appointment when I called to schedule a physical with my new doctor, though I declined that offer and opted for an appointment two or 3 days later. </p>
<p>Obviously this has more to do with the individual practices than the type of insurance – I mean, I probably could easily find any number of in-network doctors who would have had more difficulty or delay in scheduling me. </p>
<p>I’d think that the greater impact of ACA on appointment scheduling would relate to specialist care in any case. Newly insured people aren’t rushing to get their physicals, but people who have been deferring needed treatment or surgery for years due to lack of insurance probably would have been in a hurry to get the care they need as soon as their insurance was activated. So I’d think that is where a backlog would have been more likely. </p>
<p>dstark: I’m doing it one better…I’m re-reading the whole book ;)</p>
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As far as I can tell, there’s nothing in ACA that restricts what insurers may offer as group plans outside of SHOP. The H/W restriction is a SHOP rule. Current regulations define a “group” as:</p>
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<p>and it defines “employment relationship” as:
<a href=“2”>quote</a> Employment relationship. In the case of a group health plan, the term employer also includes the partnership in relation to any bona fide partner. In addition, the term employee also includes any bona fide partner. Whether or not an individual is a bona fide partner is determined based on all the relevant facts and circumstances, including whether the individual performs services on behalf of the partnership.
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<p>Link: <a href=“45 CFR § 146.145 - Special rules relating to group health plans. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Institute”>http://www.law.cornell.edu/cfr/text/45/146.145</a></p>
<p>I think you are confusing the ACA SHOP restrictions with the fact that there is no longer any financial or market benefit to insurers to offer “group” insurance to individual families. As I have posted before, the market for that sort of insurance was created because of the law requiring that group policies be guaranteed issue. (No exclusions for pre-existing conditions). </p>
<p>Now ALL policies are guaranteed issue. </p>
<p>So you tell me: what financial benefit does a private insurer get from offering to sell a married couple who happen to be self-employed a policy that has a wider network, at lower premium cost, than the policies they are offering on the individual market? </p>
<p>Our small group is added to other small groups which are then a mega group of a number of H and W businesses, sole proprietors and other business entities which could be considered ‘group’. At one point we were a part of a much larger group which was the sum of many smaller groups - the common element was the type of business (rental housing). When this group was dropped it was picked up by another similar existing group. The benefit for the insurer was the same benefit as for all group coverages. If it had not been beneficial then why would any insurer ever have offered this type of plan? I am not aware of any legal mandate requiring HS companies to have issued group coverage for the above scenario.</p>
<p>So, in answer to your question…the financial benefit for bunching a bunch of small groups into a big group is the same financial benefit as having any group. So, either group coverages work for the insurance industry, or they don’t. Disallowing this specific type of grouping makes no sense other than topics which may not be addressed here.</p>
<p>Are you saying that ACA does not REQUIRE insurers to drop small H and W groups but gives them permission to do so? And, subsequently not require the insurer to issue any more group policies with that type of structure? That would explain the whole …well they may keep your current status unless you are among the 10% audited each year. </p>
<p>Answering the audit questions is a travel through legal speak. “Is this a H and W owned business?”. Well, no, it’s an LLC - H and W do not own the business, they own shares of the LLC which owns the business - so no H and W do not ‘own’ the business. (The same as if I own stock in Ebay - it’s just that - I own the stock, not the company). It is a strange strange world this legal speak.</p>
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Well, the idea that they are blessed because they don’t have to pay what they owe isn’t very reassuring and neither is the idea that I, or someone like me, picking up their tab makes everything peachy keen, calmom. Possibly, we simply differ as to the distinction between legal and moral.</p>
<p>Hard to imagine that this unintended push toward increased subsidization is going bend the cost curve down.</p>
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Beside the fact a lawyer would sue a three-legged dog if it: a) had a fat bank account and b) he didn’t like the way it walked, I’d suggest the insurers that are offering those narrow little networks because they’re being squeezed into doing so.</p>
<p>What would be hilarious to watch would be the plaintiffs trying to stack a jury with people that had to drive across the county for the one or two specialist they need, while the defense holds out for, oh, government employees.</p>
<p>Catahoula, despite the example I gave, with made-up numbers, it is highly unlikely that very many individuals will end up with significant overpayments based on the scenario described. You have to hypothesize a whole series of relatively unlikely events. </p>
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<p>Something like that. It has to do with a combination of factors related to the interplay between PPACA, HIPAA, and ERISA. The language which specifies that a spouse is not an employee seems to come from an ERISA regulation promulgated in 1975- <a href=“29 CFR § 2510.3-3 - Employee benefit plan. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Institute”>http://www.law.cornell.edu/cfr/text/29/2510.3-3</a> (“An individual and his or her spouse shall not be deemed to be employees with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse,”) </p>
<p>Oh my, not a clue about what happened in 1975. But as it stands H and I are not ‘employees’ we are share holders. The company provides it’s shareholders with group coverage. </p>
<p>Another issue with funding of the new system…</p>
<p><a href=“Millions of uninsured Americans exempt from ObamaCare penalties in 2016, report finds | Fox News”>http://www.foxnews.com/politics/2014/08/07/millions-uninsured-americans-exempt-from-obamacare-penalties-in-2016-watchdog/</a></p>
<p>And it seems that there is another big issue which will raise it’s head at some point…</p>
<p><a href=“https://www.wisconsinmedicalsociety.org/publications/archives/medigram-archives/2012-archive/medigram-july-5-2012/aca-upheld-but-federal-government-cant-withhold-medicaid-funds-supreme-court-says/”>https://www.wisconsinmedicalsociety.org/publications/archives/medigram-archives/2012-archive/medigram-july-5-2012/aca-upheld-but-federal-government-cant-withhold-medicaid-funds-supreme-court-says/</a></p>
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<p>Seems that the feds can not legally withhold medicaid funding from non-expansions States. So, no coercion allowed? And, another increase in the projected cost?</p>
<p>Cannot withhold existing Medicaid funding. Non-expansion states do not get the additional funding which expansion states get.</p>
<p>I just found out that I could save money by buying my student health insurance from the school my D attends. I will change my family plan to an individual plan - but it looks like it is about $400 less than keeping my D on my plan. Has anyone had a similar experience? What do you think of your school health plans in terms of quality?</p>
<p>Oh, that makes sense. </p>
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The thing about gov’t workers is that they often have an entitlement attitude. Most see nothing wrong with their outrageous health & benefit packages. And they even have the gall to wail 'n whine sometimes because their measly contributions to extraordinary health or retirement plans are increased. </p>
<p>People with certain dread diseases may, in fact, need to travel to, eg, a major cancer center. That’s entirely different than having qualified (yes) doctors available and dismissing them because you “want” someone else. Or going to doc X for legit, defensible reasons and not asking your insurer to review you for in-net coverage. </p>
<p>Maybe you should sue a doc for not having an office closer to your home. After all, the patients closer to that office have it so much easier. You feel discriminated against. </p>
<p>Or maybe they couldn’t “stack” the jury because the number of people who drove so far is so small. ?</p>