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Old 09-25-2013, 07:57 PM   #341
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Taking the Texas average rate in the Dallas area, of 230 or so and mulitplying by 3 gets one about $700 a month. Now looking at the existing high risk pool (which does vary its rates by where one lives in Tx), Dallas along with Houston is in the highest cost area, so that is area 6 on the pool's tables. With a 2500 deductable the cost for 60-64 is 1164 (averaged men and womens rate) or with a 5000 deductable at 924. Stepping to the 55 to 59 age range its 998 for a 2500 deductable and 793 for a 5000 deductable. Note that the plan has a $3000 in network co insurance limit and a $10k out of network co-insurance limit. As a result the 2500 deductable is likely a bit closer with a 5.5k max out of pocket to the 5000 with an 8k out of pocket max.
Of course the pool is going out of business on Jan 1, 2014
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Old 09-25-2013, 09:15 PM   #342
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After downloading the Marketplace .xls SS for premiums, agree with Harry that there are some curious pricing issues. Could these be to differences in level of coverage (beyond ACA minimums) between Bronze plans? From what I understand, catastrophic plans for >30yo crowd are restricted to limited circumstances in mainly low income folks (e.g. homeless, QHP would otherwise be >8% MAGI, etc.). Not sure why these folks would opt for catastrophic plan since these are not eligible for subsidy and usu cost almost as much as Bronze.
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Old 09-25-2013, 09:21 PM   #343
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Agree COBRA cost is company ave, but COBRA is NOT always cheaper for comparable coverage (inc OOP max) than indiv market even at some arbitrary older age. HI premiums for employers (inc COBRA) depend largely on the specific population mix for specific employer, inc ave age, prevalences of diseases & smoking, usage pattern (e.g. ave freq of provider/hosp visits, expensive testing, etc), etc. Specific COBRA policy may include coverage individuals may not want or need (e.g. maternity, lower deductibles, etc.). And there are still a few employers who simply pick grossly overpriced HI for their market (i.e. poor negotiating skills with the carrier). FWIW- HR folks at my prev employer openly encouraged exiting workers, inc ER's, to shop around for HI before going COBRA. More than a few folks find COBRA is not their best option for HI.

In my case I was comparing a pre-ACA individual policy meeting my needs (HSA-qualifying plan) offered to self-employed (which I still am) for my state of health & completely healthy DW. It is (was?) being offered by an established major carrier which has apparently chosen NOT to offer coverage under the Exchange in my state.
From published info- Under ACA DW & I would/will be paying $14+k/yr for HI premiums (2nd lowest Silver, no subsidy) PLUS facing much higher OOP max of $12,700/yr. So annual HC costs could be >$27,000 per year. Might be better off going uninsured (self-insured) and paying the uninsured tax (official SCOTUS term for it)- or letting IRS try to collect it from my non-existent income tax refund. I could literally pay OOP for ave cost coronary bypass surgery about every 2 yrs and still break even under ACA !!!
Coronary Bypass Surgery Pricing by Healthcare Blue Book

As always YMMV, but my state's high-risk pool (pre-ACA) would have been a MUCH better deal than what ACA has turned out to be.
I don't blame you for thinking this ER. I am going to get burned percentage wise in a bad way too, triple digits plus. But at a lower price point. If it got to where I thought enough was enough, I wouldn't pay the tax, come and get it if you think you can. And right now the means to collect is very thin, as I would make darn sure no refund was coming my way. Of course there are probably millions of twenty something "invincibles" thinking the same thing. As long as I stay healthy and can collect an HSA deduction, I won't complain too much.
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Old 09-25-2013, 11:26 PM   #344
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Where is this Excel spreadsheet?
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Old 09-26-2013, 05:16 AM   #345
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Where is this Excel spreadsheet?
Here: http://aspe.hhs.gov/health/reports/2...book_2014.xlsx

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Notes about this File:

1) This analysis uses data pulled on 9/17/2013 at 1:00 AM. It excludes plans that are "Off-Exchange Only" and/or "Child-Only." It also excludes plans that were withdrawn or denied certification.
2) There are 36 states contained in this file. These states are either FFM, SPM, or SSBM states. Each of these 36 states has its own tab and the tabs are sorted alphabetically by state abbreviation.
3) The default age used to calculate ratings is 21. This default can be changed by selecting the drop down in cell H2 of each state tab. All the relevant rate information will update based on the selected age.
4) Each state tab has one row for every rating area in that state. The number of rating areas varies by state.
5) To look up the rating area for a corresponding zip code, navigate to the "Zip Code-Rating Area Lookup" tab.
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Old 09-26-2013, 06:49 AM   #346
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As always YMMV, but my state's high-risk pool (pre-ACA) would have been a MUCH better deal than what ACA has turned out to be.
I find that surprising but I probably shouldn't be. Insurance (all types) are shrouded in a cloak of mystery and the rates are determined by means that mediveal alchemists would find arcane.

Insurance is something for people that can not withstand the risk of the event it covers. Insurance companies build those wonderful buildings, hire lots of well paid people and spread dividends to their shareholders by charging the average person more than their share of the pooled risk.

Some people are in a postion to fully self-insure for their medical care. I'll use as an example Mitt Romney. He gets medicare now (if he bothers to use it) but why would our government feel compelled to force a centi-millionaire (if not higher) to buy HI. However, our ACA does just that.

For your case (and mine), paying for $50,000 in occasional episodes of medical treatment would probably be cost effective over paying for $27,000 in annual insurance costs. I'm estimating my actual insurance cost at less than $15,000/yr with the OOP simply what I would have paid anyway. Even at that lower rate, either DW or I would still need to undergo very high dollar cancer treatments to make the HI cost effective. Normal things (like bypass surgeries?) would not trip the wire to make them cost effective.

The same sort of argument gets used on LTC insurance. At a certain point there is no need to enrich an insurance company. The only insurance I think I really need at this point is liability insurance which forces the purchase of an umbrella over my home owners and auto insurance.
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Old 09-26-2013, 06:53 AM   #347
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Taking the Texas average rate in the Dallas area, of 230 or so and mulitplying by 3 gets one about $700 a month. Now looking at the existing high risk pool (which does vary its rates by where one lives in Tx), Dallas along with Houston is in the highest cost area, so that is area 6 on the pool's tables. With a 2500 deductable the cost for 60-64 is 1164 (averaged men and womens rate) or with a 5000 deductable at 924. Stepping to the 55 to 59 age range its 998 for a 2500 deductable and 793 for a 5000 deductable. Note that the plan has a $3000 in network co insurance limit and a $10k out of network co-insurance limit. As a result the 2500 deductable is likely a bit closer with a 5.5k max out of pocket to the 5000 with an 8k out of pocket max.
Of course the pool is going out of business on Jan 1, 2014
You can adjust the spread sheet for the ACA to your actual age. Multiplying by 3 is not needed.
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Old 09-26-2013, 06:58 AM   #348
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Originally Posted by ERhoosier View Post
After downloading the Marketplace .xls SS for premiums, agree with Harry that there are some curious pricing issues. Could these be to differences in level of coverage (beyond ACA minimums) between Bronze plans? From what I understand, catastrophic plans for >30yo crowd are restricted to limited circumstances in mainly low income folks (e.g. homeless, QHP would otherwise be >8% MAGI, etc.). Not sure why these folks would opt for catastrophic plan since these are not eligible for subsidy and usu cost almost as much as Bronze.
All we have available on the federal exchange is very limited information. We really won't be able to compare choices until they are all listed side-by-side. Summaries and "lowest" don't mean much with out the ability to look at their networks of hospitals and doctors. Without much trouble I could be the lowest cost insurance provider by offering a plan to Houston residents where their only doctor and hospital available are in Amarillo. Cynical me does not doubt there will be some plans that play off limited availability of care providers to achieve a lower "headline" cost.
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Old 09-26-2013, 07:32 AM   #349
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Without additional detail I don't think we can draw any meaningful any conclusions from the excel data.
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Old 09-26-2013, 12:49 PM   #350
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Updating an earlier post, it seems the DC exchange will stumble out of the starting blocks. Computer snags delay parts of Obamacare in some U.S. states - baltimoresun.com
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The "DC Health Link" web-based marketplace, where residents of the nation's capital who do not have other coverage will be able to purchase policies, will lack the ability to calculate whether someone is eligible for Medicaid. It will also be unable to calculate the size of federal subsidies, if any, that a customer qualifies for.
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Old 09-26-2013, 01:07 PM   #351
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Updating an earlier post, it seems the DC exchange will stumble out of the starting blocks. Computer snags delay parts of Obamacare in some U.S. states - baltimoresun.com
DC is a sate run and not a FED. In some ways I'm thinking it might be good my state backed out of running its own and defaulted to the Feds. I guess why we need 50 individual exchanges to do the same thing is another topic.
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Old 09-26-2013, 01:14 PM   #352
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Updating an earlier post, it seems the DC exchange will stumble out of the starting blocks. Computer snags delay parts of Obamacare in some U.S. states - baltimoresun.com

Unfortunate, but since coverage does not start until 1/1/14 it does seem like a few glitches at the start are that big a deal.
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Old 09-26-2013, 01:48 PM   #353
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To be precise, it's all about affordable health coverage for those who otherwise could not afford healthcare. That does include folks with preexisting conditions who were either simply barred from the system before ACA or charged such excessively large surcharges that they literally could not afford the coverage, i.e., it would force people to make decisions between health and food, etc.
Very true... If you had and could afford healthcare before your prices will probably go up; if you could not afford it or could not get it before, you will probably have an affordable option.
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Old 09-26-2013, 01:51 PM   #354
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I find that surprising but I probably shouldn't be. Insurance (all types) are shrouded in a cloak of mystery and the rates are determined by means that mediveal alchemists would find arcane.
Is insurance the root cause? Seems fitting with the "arcane, shrouded in a cloak of mystery" rates that our current private health care "system" produces - remember reading the Time article Bitter Pill? Why medical bills are killing us.

How do you underwrite discrepancies like these (and there are thousands more examples).
Quote:
A hospital in Livingston, N.J., charged $70,712 on average to implant a pacemaker, while a hospital in nearby Rahway, N.J., charged $101,945.


In Saint Augustine, Fla., one hospital typically billed nearly $40,000 to remove a gallbladder using minimally invasive surgery, while one in Orange Park, Fla., charged $91,000.

In one hospital in Dallas, the average bill for treating simple pneumonia was $14,610, while another there charged over $38,000.
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Old 09-26-2013, 02:01 PM   #355
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For your case (and mine), paying for $50,000 in occasional episodes of medical treatment would probably be cost effective over paying for $27,000 in annual insurance costs. I'm estimating my actual insurance cost at less than $15,000/yr with the OOP simply what I would have paid anyway. Even at that lower rate, either DW or I would still need to undergo very high dollar cancer treatments to make the HI cost effective. Normal things (like bypass surgeries?) would not trip the wire to make them cost effective.
The thing is that I think you are underestimating the cost of something like bypass surgery if one was uninsured. If you are uninsured you don't get those negotiated rates that your insurer pays. You get the chargemaster rates which are often several times higher. I've looked at some of the EOBs we've received over the years and have dumbfounded by how high the charge would have been if uninsured. If uninsured I think it would be very, very easy for any significant hospitalization to easily go over $100k, not even including ongoing care after being released.
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Old 09-26-2013, 02:09 PM   #356
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The thing is that I think you are underestimating the cost of something like bypass surgery if one was uninsured. If you are uninsured you don't get those negotiated rates that your insurer pays. You get the chargemaster rates which are often several times higher. I've looked at some of the EOBs we've received over the years and have dumbfounded by how high the charge would have been if uninsured. If uninsured I think it would be very, very easy for any significant hospitalization to easily go over $100k, not even including ongoing care after being released.
I am not advocating going uninsured in anyway. But recently our newspaper had a series on healthcare costs and one of the parts was the myriad of pricing schemes including why uninsured pay more. The hospital said if they are uninsured they immediately take 50% off the list price and go from there. She basically was implying we cut it in half and see how negotiations go from there. Of course that begs the unanswered question of why do you implement such a crazy pricing scheme in the first place. I consider myself a poor negotiator with cars, Lord knows how poorly I would be over hospital charges!
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Old 09-26-2013, 03:22 PM   #357
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The thing is that I think you are underestimating the cost of something like bypass surgery if one was uninsured. If you are uninsured you don't get those negotiated rates that your insurer pays.
In addition, without insurance you probably will not even get admitted for those expensive procedures. They'll get some money from an insurance company, getting a $100k from working Joe for some procedure is not worth it. Even the local PCP wants the $75 office visit up front if you don't have an insurance card.
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Old 09-26-2013, 03:50 PM   #358
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Here is a link to and angrybear post that provides more examples:
Angry Bear Maggie Mahar Healthbeat Blog: Reverse “Sticker Shock” Part 2 –Subsidies Mean Enormous Saving for Older Americans
Hartford Ct Bronze 423, for a 60 year old, silver Souix City $561 (All are before any subsidies) The article also provides subsidy example for the same folks.
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Old 09-26-2013, 04:56 PM   #359
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Is insurance the root cause? Seems fitting with the "arcane, shrouded in a cloak of mystery" rates that our current private health care "system" produces - remember reading the Time article Bitter Pill? Why medical bills are killing us.

How do you underwrite discrepancies like these (and there are thousands more examples).
Time article is no longer available their site without paid subscription, but IIRC it contained some rather significant misrepresentations/errors. I did not keep a copy, particularly since the "cloak of mystery" of medical billing is already being lifted.

Regarding examples of charging, most carriers have a set rate which they will pay for specific individual services, and many complex procedures are now being negotiated for global fees (e.g. preset charge for typical gall bladder removal). HC providers & facilities agree to these payments (or not) when they join a carrier's network (or not). This is a way of trying to contain HC costs and why some carriers have different (smaller) networks than others.
IMHO- While no 2 independent providers can agree to exactly same price structure for given service (anti-trust), most big inter-institutional charge/payment differences cited in lay press are due to differences in complexity of patient population undergoing the same procedures and how hospitals break down their charges. The proportion of seriously ill/complex folks in a specific population can obviously be a major issue in underwriting. But some of these cost differences are certainly due to varying efficiencies & negotiating 'skills' of the providers, facilities, and carriers. As HHS points out in its most recent report, more competition between carriers in a given market tends to mean lower costs. Hopefully under the Marketplace inefficient HC institutions & carriers will be under increasing pressure to improve lest they be forced into mergers or bankruptcy.

BTW- Providers in many US markets are MUCH more open to up-front price negotiation with cash-paying folks than they let on. Lots of HC in US is delivered under such arrangements, inc. "medical tourism" by non-US citizens, self-insured religious sects, etc. Trick may be finding the right business officer to speak with, and then presenting evidence of ability to pay (inc. business/banking references, perhaps cash bond, proposed payment schedule, etc.). Business managers are generally much more open to folks willing to pay something vs those who just ignore their bills. Particularly at institutions not running at 100% capacity. How this cash-business side of US HC will ultimately be affected by ACA (inc. how HHS regulates it) is anyone's guess.
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Old 09-26-2013, 05:05 PM   #360
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The thing is that I think you are underestimating the cost of something like bypass surgery if one was uninsured. If you are uninsured you don't get those negotiated rates that your insurer pays. You get the chargemaster rates which are often several times higher.
+1.

Here's the lengthy horror story of a man who decided to forgo insurance, then had the bad luck of being seriously injured in an accident.

Getting Stuck: Uninsured Patients Slammed with Lawsuits by Not-for-Profit Hospital - Page 1 - News - Houston - Houston Press
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...The total bill was issued in September 2012 and came in at $444,518.11. Malone and Alaniz didn't know what to do with it, so Malone put it in the small brown accordion file she'd placed the other notices in and kept trying to reach Ramon.

On January 5, 2013, Alaniz was served papers informing him that [the hospital] was suing him for $456,675.23 the sum of his bill plus interest and $2,500 in legal fees...

...People like Alaniz face a difficult situation when they need emergency care, because it can often cost almost double what it would cost an insured person by the time the patient is left holding the final bill...
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