Actually, it makes no sense at all to me and I would think that any young woman of child bearing age needs to be covered. I have never had employer coverage and always had to buy on the individual market – back in the day I used to buy separate individual policies for me and each of my kids because that was cheaper than a family policy, and I know that it cost more to cover my daughter than my son because I put her on a policy that covered maternity when she was fairly young, probably around age 14 – definitely as soon as she was dating in high school. It is not as if all pregnancies are planned – and there is probably a higher risk for someone who is just on the verge of becoming sexually active than someone older who has already had time to figure out the ins and outs of birth control. But a younger teen who is pregnant also has a higher risk pregnancy – all the more need for good prenatal care.
I’m sorry for my misinformed post in the other thread - it just was unthinkable for me that insurance companies would be allowed to exclude maternity coverage for dependents of any age. I mean – it’s clearly defined as an essential benefit – something that ACA makes me pay for now, despite the fact that I am in my 60’s and well past menopause – and I don’t mind, because I do understand that spreads the cost around and I have my own share of expensive old-person disease – but it just doesn’t make sense that there would be any sort of exemption for anyone.
My guess is that the doc has a sonogram machine in his office. They are very expensive machines so it is not uncommon for docs in this situation to offer more sonograms than other docs. Sad, but true.
If this will fly, it’s her best option now. She needs to call immediately – they’re open 24/7 – work schedule or no work schedule. With each passing day, “I couldn’t get through” sounds thinner and thinner. I called them on Wednesday or so, and had no wait.
I’d raise hell with the insurance company if it’s true that she told her prenatal care would be covered. And I’d raise hell with the doctor for not mentioning the fact that her insurance wasn’t paying for these unexplained ultrasounds. Oh, and I’d get a new doctor, as this one seems to have ethics challenges.
Patsam, you previously said.
“Is it true that a person can’t just call an insurer and buy coverage in any month of the year? She is not eligible for a subsidy, and even if she were, no subsidy is better than no coverage.”
She can call an insurer. If she earns too much for a subsidy, she doesn’t need the ACA “marketplace.” No need to keep calling them and trying to somehow fit there.
Start by picking a large insurer in your area and look online for plan options.
And ps. Ultrasounds can be legitimately used when the doc thinks there could be an underlying problem to identify or rule out. Since you describe this as the daughter of a friend, you may not know why the doc chose to run two.
Yep, it is misleading, @lookingforward . They won’t sell outside of open enrollment (except for qualifying events) because they can’t decline coverage based on medical history or condition. If people could buy coverage throughout the year, they’d wait until they get sick, and that would cause the death spiral that used to be so frequently predicted on this thread.
And apparently Anthem will let you jump through the hoops to get a quote, but notice the fine print on the quote page. Of course, it appears they haven’t updated the verbiage on this page since they 15th. Maybe eventually it will say “You can’t apply now except for qualifying events.”
LasMa, I agree with what you have said. I also had forgotten about the reasoning for not just selling insurance all the time. That does make sense, and I was all for that thinking, until I knew someone in the situation of not being able to get it…interesting how your viewpoint can change when you’re in a situation.
She is on the website now, for some reason the username she created Friday ight let her into the system today. I hope she gets through.
She couldn’t call the the ins company yesterday and now today they are closed! I guess due to the snow, or the guy I spoke to is working, but the switchboard is shut down? Here in south jersey the side roads were crappy, but even at 10 am medium and major roads were fine.
Just got a text, she just competed the app online now. What happens next? Do you have to wait? I hope it doesn’t decline her based on no qualifying event when the extension thru today exists.
As far as the shotgun, it might be on the table if falls through. The gamble of a complicated pregnancy is something to consider.
Good news. She just told me she applied, enrolled and paid the first month online, effective march 1. She even printed it out (at that age they often don’t)
What is Oscar Insurance? Ehealth offered that option, said they extended it until,February 28, but it’s not offered here.
I hope anybody with girls on their policy is checking their coverage and letting the girls know! I let my S and his gf know! Let your friends know too, though it is awkward to tell someone they should tell their D (and S!)
Now she can fight the dr and insurance. I will suggest she find a new dr, but it’s hard when you comfortable with a practice. At least now she has learned to ask the prices of tests etc. she is very happy she didn’t have all the blood work that is about to be due, that would have been $ out of her pocket.
Btw, my advice was to take a slightly higher premium and the lowest out of pocket. About $50 higher, but 1500 less OOP. She will cancel in sept and go on employer plan. I hope I was right.
Patsmom, Oscar is a new start up, NY-based insurance company – see http://fortune.com/2014/12/09/oscar-health-insurance/ – it looks like the company is more hype than substance. Lots of Yelp complaints about small network and difficulty getting claims paid.
$16 reimbursement for a primary care visit with a Medicaid patient (who is likely to have complex health issues anyway) is ridiculous. A minimum of four times that amount would still be low.
My PCP gets about $87for an office visit, and I think she’s underpaid vs. what the specialists get. The eye doc gets $122 from my most recent visit; the orthopedic surgeon’s PA (billed as the orthopod) got $125 + payment for an injection. Not at all clear why office visits to specialists should get much higher reimbursement than office visits to primary care doctors. My PCP is the one who gets (and reviews) findings from all of the other docs, handles the phone calls, and in general does more to help keep me healthy than any of the others do – and yet she’s paid the least.
When people talk about doctors being overpaid, they’re not talking about primary care docs. A doctor’s office should be paid more per visit than a nail salon, for crying out loud.
I was just doing my taxes, using Taxactonline, and I finally got to the ACA part where I enter the information from the 1095-A form. This is the tax credit info, where they look at how much tax credit I have been given over the course of the year and compare it to how much I deserve based on my income. My income was a little higher than my estimate, so I owe some of that tax credit back, like about $600. What has really thrown me for a loop was the calculation shown by the Taxactonline software. After it shows, "Excess advance payment of premium tax credit: ", which is the amount I owe, it shows, “Repayment limitation: $1,500” Does that mean I would not have to pay back more than $1,500 even if I owed more? That is nuts!
NJRes, there is a limit to the amount one has to repay, so yes, a sneaky person planning ahead could make a bit of money. That will likely be addressed in coming years.
@NJres – the repayment limit is based on your income tier – if your AGI is 400% of federal poverty, then there is no repayment limitation – but if it is less, there is a limit. That is there to protect lower income families, because otherwise people would be presented with huge tax bills that they could not possibly afford.
It’s very possible that the repayment limitation will work to a family’s benefit, but unlikely that it will end up being more than a few hundred dollars for individuals or small families simply because there is no limitation for those with more than moderate income – the 400% level is reached at about $45K for an individual, $62K for a couple. I suppose it could reach into pretty high income levels for very large families - and those are the ones who could also be getting a huge benefit from subsidies as well.
But bottom line: if you are seeing a limit on repayment, that is because your income is within the range that you qualify for a subsidy. So worst case for the government is that they end up giving deserving people a little more than they deserve – but a lot more people will end up like you – the $600 you owe is well within the limit. If your income was higher there would be no limit.
Or to put it another way: at your income level, $600 is affordable. If instead, you did your taxes and discovered that you owed $5000 — would you be able to pay that? The $1500 limit is because your AGI is under 300% of the FPL – it would bump up to $2500 if your income were between the 300%-400% mark, then unlimited for higher earners.
ok, nice to see the limit increases and disappears as income increases, but the tax credit (subsidy) also decreases and disappears as income increases so I don’t immediately see the need for the repayment limit. But that’s ok. I just hope it’s not an incentive to game the system.