Jym, I did wonder if anyone would ask. Seems many prefer Emergency Dept over Emergency Room. use either, fine by me.
In our case, the doc gives his staff the procedure code. Even a colonoscopy can have a few potential codes- eg, if they do a biopsy.
@deb922 my son has Crohn’s and has Remicade infusions every two months. The drug company reimburses us for the copay and out of pocket up to $10,000/year. I assume because many patients would forego the drug because they can’t afford the out of pocket and the drug company would lose all those insurance payments. You might see if something like that is available.
Guess its regional, LF. Its typically ER where I am
That’s a 3x range in price. If you have a high deductible plan that is huge. But most of the time you can’t get this information.
Have you looked at the manufacturer’s website. For many expensive drugs, there are copay assistance programs. Legally, the max out of pocket for an individual is about $6500 for non-medicare plans. For Medicare, there is no max out of pocket.
People who say Medicare is cheap has never dealt with it as a provider. You have to go through so much to be an improved provider. Then there are a bunch of tricks they can use to try and recoup their money.
The cost of drugs vary greatly. Most medications are not that expensive. The issue is with new drugs and biologics. You can try and take a cheap generic before an expensive brand. With regards to biologics, their use is increasing. However, we should be seeing generic versions of them starting next year. Prescribers need to remember to prescribe old, cheap drugs first.
When husband was laid off and our benefits went away two years ago I did the right thing by purchasing insurance on the exchange. We qualified for zero subsidies. We paid $1200 a month for a family of three!! We made it happen and I am super thankful, but man…that’s not an easy amount when your income has been cut in half! Probably could’ve gotten by with a cheaper HMO but as a healthcare provider I think those are the WORST plans so we went with the PPO.
As mentioned above, there are parts of the ACA that are a good thing. Taking away the pre-existing conditons clause was a great thing and beneficial for so many people. Covering kids until age 26 was probably a good move since so many first jobs don’t offer benefits. I also think your health insurance should not be tied exclusively to your job…but it is definitely not a plan that is affordable for all!
Thanks for the tip. I will have my H take this up when he sees his rheumatologist next.
“She’d switched insurance as small business owners tended to do after a few years with a company (low rates for the first 2-3 years, then major hike.”
Not just small business owners did/do this. Big companies also did/do this. I was in charge of negotiating insurance for my father’s company (approx 10k employees) in the 80’s. We switched every few years. Most employees are/ were just unaware and paid very little attention because by switching we kept premiums/deductibles about the same cost with very little change in coverage.
LF: the out of network docs issue examples I have heard were things like an anesthesiologist or a second surgeon) brought into a surgery. The main surgeon and the hospital are in-network, but these are not. The patient is billed for the out-of-network medical care. This has nothing to do with the ACA, so sorry if that was unclear. It has to do with health care costs and insurance rules.
That sounds really cheap to me, if two of those three people are parents and the other their child. The cheapest policies available for me and Mr. Fang next year are around $1200.
When DH retired from a previous employer, I insisted he take the healthcare plan at the time. We kept it for over 2 years. It was ridiculously expensive (something like 1450/mo for family) but it was an old classic indemnity plan, 90/10 with. $250 deductible. Came in handy when DH needed surgery.
“We paid $1200 a month for a family of three!!” I haven’t looked at the rates on the health exchange, but for my companies group plan between what I pay and my company, for a family of three plan, it is 1800 a month…and in our area several years ago, before ACA, an individual trying to buy a family plan werre paying, then, close to 2000 a month.
Not saying that is cheap, just saying that ACA may have actually made that plan cheaper, one of the reasons for the ACA and the mandate to have insurance is that rates are cheaper in a group plan, so when you go into the health care exchanges you are from what I understand in a group plan, even though buying for yourself.
As far as getting hit with out of network costs without knowing, I don’t think ACA has changed that. Around 8 years ago I had a gallbladder attack and one of the doctors the hospital (which was in my network) had me see was not, so when his bill came I was paying the out of network rate. It wasn’t that bad, it cost me like an additional 250, but it could be expensive. Some doctors are sneaky, friend of mine had one where he went to a doctor in the network, but the doctor had multiple business id’s and filed the claim under the one that wasn’t in the network and my friend ended up getting billed out of network (which makes the doctor a lot more money, since they can bill you for the difference), and when my friend claimed to the insurance company, their basic answer was to complain to the doctor, they had nothing to do with it. I wish the law prevented crap like this, like if you go to a doctor in the network they can’t pull this kind of crap, or if you go to a hospital in network they have to make sure the doctors you see are in network, and if they absolutely need a doctor out of network for unique skills, the insurance company and hospital should be required to bill that as in network.
ACA isn’t perfect, but a lot of the claims that it is responsible for soaring medical insurance rates aren’t true, when we did our benefits last year, the head of HR said ACA was responsible for 5% of the increase in costs, 95% was the insurance company simply raising rates). The people I have heard complaining about the cost of the ACA plan were people who had substandard plans to start with, or were people who had an employer or union plan, lost that, and were comparing the cost of the ACA plan to their share of the old plan (not understanding they paid only a percentage of the premiums back then), or were people outright lying who simply don’t like the idea that maybe, just maybe, the free market didn’t work all that well with health care…
I think ACA is basically a stopgap, another bandaid personally, it isn’t addressing the real issues that make the system so inefficient and costly IMO, a large part of which is that a lot of shell games are being played with the data to try and hide where the money really is going and shed a reality on our health care system, where it often spends a lot of money on health care that quite frankly isn’t needed or wasted and the real choices we need to make.
IIRC, part of the ACA is that insurance companies must pay at least 85% of the premium dollars back out as payments or they have to refund the excess back to subscribers, so it seems like there is a builtin limit on much much the insurance companies can arbitrarily raise prices.
Right. A small correction, though: it’s 85% for group/employer-based insurance, 80% for individual insurance. And if the insurers got it wrong and paid out less than 85%/80%, they have to give the extra back to the subscribers.
“Right. A small correction, though: it’s 85% for group/employer-based insurance, 80% for individual insurance. And if the insurers got it wrong and paid out less than 85%/80%, they have to give the extra back to the subscribers.”
Didn’t know that one, my cynical side makes me wonder how much they play around with the numbers so that when end of year comes, they always spend 85%…or what I would bet, that they don’t make their 15%, so then have justification to raise rates the next year, claiming they aren’t making what they should. I wouldn’t be surprised years down the road if they don’t conduct an investigation into the books of the health insurers and find out the interesting things reported as costs to the plan that ‘surprisingly’ weren’t caught by the auditors.
What we experienced on the mega ACA thread was that many had heard of various scary issues, somehow or other, but not actually run into them and didn’t know how their policy would work (or not.). My feeling is we have to ask the right questions, real and hypothetical and learn about our specific plans. Maybe your plan won’t cover an out of net doc. But mine did cover an OON anesthesiologist, when the hospital and doc are in-net and it was not my call to use him.
And it helps to read about ACA directly, not rely on someone else who may not be accurate or even a media article, though some specialist firms do have solid info and detail on their web sites.
Folks,remember the exchange pricing is based on MAGI and family details. A high earning family will likely see no benefits on the exchange. It’s discounted for those who fall within its guidelines or tiers.
And you have to distinguish between exchange and private, which IS dependent on the individuals and their ages.
In the past couple of years, CC members have reported getting refund checks from their insurers for this provision.
Regarding the MLR Rebate $…there are very specific HHS rules regarding what insurers can count as part of the 85%/80%. You can’t really monkey around with your medical costs to change your %.
(I’m an accountant in a large insurance company)
So, here we go again, researching plans. Some plans charge a known co-pay for a doctor visit. I don’t care if it’s $25, $50 or even $80 because I don’t go that often, and it is waived for my annual physical, but most important, it is KNOWN. But now I see other plans where a doctor visit is full pay until deductible is met, then no charge. That’s great, but if the deductible is $5,000, I am most likely going to pay for each doctor visit, So do I call every doctor and specialist that I might go to and tell them I am in the process of selecting insurance, please tell me what you charge for a visit? I wonder if they will even tell me… or will they say, “Oh, that depends, we really can’t give you a number now.” ?
HealthSherpa has a very useful feature where you type in the name of your doctor(s) and they filter plans for you that are accepted by your doctor. Why cant Healthcare.gov do that? But this year it appears that my primary care physician and my dermatologist do not share one single freaking insurance plan!
NJRes, in my experience, the total charge is still subject to the negotiated max. My kid went in for a procedure and first I talked to the billing rep. She said, look, we’d like to charge you $$, but the cap with your insurer is ___. My experience is that even when you need to fill your deductible first, there are these controls.
In another case, one kid needed a diagnostic, we had not met deductible. I looked it up in healthcarebluebook.com and saw the local fair price is $850. We paid about 200, which I believe was our percentage of the negotiated price. These are things you talk to the insurer about, odd little parts of how they practice.
No, not easy, especially in some parts of the country, where you can’t get through. Honestly, I don’t understand it all.
When I choose, it’s not the difference between an $80 OV charge and a $140 charge (or the set costs some plans have.) I run some what-ifs. I worried more about whether a condition would flare up, I’d be back and forth to the specialist, maybe needing a procedure that, even at an outpatient place could run 3-4k. Or the different levels of in-inpatient coverage. I wanted to balance a reasonable deductible against higher monthly costs and possibly a higher max out of pocket. In 2014, I met my deductible (3k?) In 2015, the physical, one routine specialist visit, nothing more. For 2016, I’ll go through the same thing again.
There are other examples IRL where we expect to make these sorts of calculated decisions.