ACA Federal Marketplace updates

[Sue J]

I asked this in another ACA insurance topic and never got a response so I'll try it here.

Not sure if this is the proper topic to ask this question but I didn't want to start another Obamacare topic....

Currently, when you have medical care and have insurance, there is a "retail" cost and then there is a negotiated rate or allowed amount. The allowed amount is what counts. You pay your portion of the allowed amount. This difference can be very significant. For example, a blood test has a retail price of $98 and your insurance allows only $10 and that's what you pay, the $88 difference is noted as the insurance discount.

Supposedly the $98 retail price is for people without insurance.

When Obamacare is fully implemented (and I hope it's running well) if everyone has to have insurance then will there be a retail rate and an allowed rate? Will different insurance carriers have different allowed rates?

The reason I'm asking this is that DH and I will be considering his retiree insurance (open enrollment 10/01/13 to 10/31/13) vs. ACA insurance and I want to create a few spreadsheets to show examples of our options using previous years medical bills. Some of the options will have higher deductibles instead of a co-pay. All I have to go by is what the allowed amount was on previous bills and I don't have any info about how this will all play out in 2014 or 2015.

How does this work in Massachusetts?

 

[samclem]

IMO, if you can't afford to pay for your health care if you were to have an illness and you refuse to buy insurance because it is too expensive you are not self insuring, you are avoiding an unfortunate reality of life.

"Avoiding" or else making the decision to pass the burden of providing your medical care on to others if a really bad event happens.

This decision to make health insurance "affordable" for everyone should come with real penalties for those who act irresponsibly despite all that is being done. For example, I'm not sure why emergency rooms and other providers should be under any obligation to provide care to those who have made a conscious decision not to purchase (affordable, often subsidized) health care coverage. These uncovered costs then get passed along to other people who are buying insurance (and taxpayers who are paying for the subsidies). We're not talking about the indigent, we're talking about the willfully negligent. At what point do we finally say "enough! You are an adult!"?

 

[2B]

I asked this in another ACA insurance topic and never got a response so I'll try it here.

Not sure if this is the proper topic to ask this question but I didn't want to start another Obamacare topic....

Currently, when you have medical care and have insurance, there is a "retail" cost and then there is a negotiated rate or allowed amount. The allowed amount is what counts. You pay your portion of the allowed amount. This difference can be very significant. For example, a blood test has a retail price of $98 and your insurance allows only $10 and that's what you pay, the $88 difference is noted as the insurance discount.

Supposedly the $98 retail price is for people without insurance.

When Obamacare is fully implemented (and I hope it's running well) if everyone has to have insurance then will there be a retail rate and an allowed rate? Will different insurance carriers have different allowed rates?

The reason I'm asking this is that DH and I will be considering his retiree insurance (open enrollment 10/01/13 to 10/31/13) vs. ACA insurance and I want to create a few spreadsheets to show examples of our options using previous years medical bills. Some of the options will have higher deductibles instead of a co-pay. All I have to go by is what the allowed amount was on previous bills and I don't have any info about how this will all play out in 2014 or 2015.

How does this work in Massachusetts?

You may not have gotten any replies because of your last line asking about how it works in Massachusetts. There are many differences between what I have heard about Massachusetts and what is rolling out as the ACA.

It is my understanding that the different insurance companies will not have standardized insurance coverages for different procedures except in a few cases where they are "free." What is being mandated are the items covered, deductibles and out-of-pocket maximums for the bronze, silver,etc. The insurance cost for different items can vary widely and I suspect there will be no way to determine what the cost of every specific item is until you see the bill. I also don't believe that copays are standardized. Someone may jump in and correct me.

One of the things people don't always realize is that copays typically continue to be required even if the OOP maximum is met and they don't count towards meeting the OOP max. That is true with the non-high deductible plan where I work now and it was true for my previous employer's plan.

 

[daylatedollarshort]

" At what point do we finally say "enough! You are an adult!"?

The point where chemistry teachers have to resort to cooking crystal meth to pay for their cancer treatments?

On a related note, what if Breaking Bad were set in the UK?

http://www.buzzfeed.com/lukelewis/if-breaking-bad-had-been-set-in-the-uk

 

[pb4uski]

"Avoiding" or else making the decision to pass the burden of providing your medical care on to others if a really bad event happens.

This decision to make health insurance "affordable" for everyone should come with real penalties for those who act irresponsibly despite all that is being done. For example, I'm not sure why emergency rooms and other providers should be under any obligation to provide care to those who have made a conscious decision not to purchase (affordable, often subsidized) health care coverage. These uncovered costs then get passed along to other people who are buying insurance (and taxpayers who are paying for the subsidies). We're not talking about the indigent, we're talking about the willfully negligent. At what point do we finally say "enough! You are an adult!"?

I totally agree with you that the only way our "voluntary" health care system can work is if there are dramatic consequences for poor decisions. I have for years thought that unless as a society we are willing to require those who refuse to buy health insurance like the rest of us to be turned away from the system or rely on charity care that our "voluntary" health care system isn't viable. The real poor are covered by Medicaid (warts and all). Those of lower means had a plausible excuse that health insurance was too expensive. That excuse is eroded by Obamacare subsidies.

 

[pb4uski]

You are certainly correct, but I wonder what a 27 year old with only a $100 left over each month is going to think. Do I use this to buy insurance and sit at home, or do I have a little fun and go chase some tail this weekend. Nothing is going to happen to me anyways so it's a waste of money. And even if something did, I couldn't pay the deductible anyways. Let them try to get blood from a turnip! I am certainly not advocating this position, but we have all become old foggies if we do not believe more than a few won't think this.

My DS. (he's only 25 though)

In part because I am encouraging him to buy health insurance. It is really as much for my protection as his in that if he had a critical illness and a big hospital bill that I would ultimately ante up rather than have him go without the care he needs. Between you and me, because I have the means, I would pay for his health insurance if it came to that for my own protection (but don't tell him that).

 

[Mulligan]

The point where chemistry teachers have to resort to cooking crystal meth to pay for their cancer treatments?

On a related note, what if Breaking Bad were set in the UK?

http://www.buzzfeed.com/lukelewis/if-breaking-bad-had-been-set-in-the-uk

The unfortunate thing about coming down with a long term health issue is two fold. You can have all the health insurance in the world, but if you are not working the bills will pile up and possibly bankrupt you anyways if you do not also have disability insurance. That is the one advantage us retirees have is we got the time to heal without income producing pressures, provided the insurance is adequate.

 

[Mulligan]

My DS. (he's only 25 though)

In part because I am encouraging him to buy health insurance. It is really as much for my protection as his in that if he had a critical illness and a big hospital bill that I would ultimately ante up rather than have him go without the care he needs. Between you and me, because I have the means, I would pay for his health insurance if it came to that for my own protection (but don't tell him that).

I concur 100%, PB. I am off the hook until 26, because my ex wife's husband has a good benefit provided health insurance plan. But once she is off it, no way could I let her go without. As you say, the bills would pile up then the parental tugs of obligation to help would then come. Better to pay cheap now for them, than owe and have a big mess.

 

[meierlde]

Of course the other attitude to take in the age range of 25-35 is if your net worth is negative or close to zero (excluding retirement accounts which are exempt) then bankruptcy is a good option if you have a lot of medical bills. Bk makes them go away, and if you have a one time serious problem, chances are your income by the time you get to bk will be under the median allowing Bk to wipe the medical bills out. In addition in at least some states equity on your primary home is protected. Not that I recommend it, but it is a possiblity. Of course you can only do this every 7 years.

 

[explanade]

"Avoiding" or else making the decision to pass the burden of providing your medical care on to others if a really bad event happens.

This decision to make health insurance "affordable" for everyone should come with real penalties for those who act irresponsibly despite all that is being done. For example, I'm not sure why emergency rooms and other providers should be under any obligation to provide care to those who have made a conscious decision not to purchase (affordable, often subsidized) health care coverage. These uncovered costs then get passed along to other people who are buying insurance (and taxpayers who are paying for the subsidies). We're not talking about the indigent, we're talking about the willfully negligent. At what point do we finally say "enough! You are an adult!"?

Well you can't refuse treatment at emergency rooms but haven't certain hospitals routed some people to emergency rooms at county hospitals when it found the patients didn't have insurance?

Maybe that's the punishment, to end up at a substandard facility and/or end up with a big bill.

 

[M Paquette]

Well you can't refuse treatment at emergency rooms but haven't certain hospitals routed some people to emergency rooms at county hospitals when it found the patients didn't have insurance? Maybe that's the punishment, to end up at a substandard facility and/or end up with a big bill.

Any hospitals which handle Medicare patients are prohibited from "dumping", the practice of diverting patients who might not be able to pay, under the Emergency Medical Treatment & Labor Act (EMTALA).

http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/emtala/

I've never heard of a private hospital, not taking Medicare patients, which also had an emergency room.

 

[ERhoosier]

There is a big difference between having resources and making a conscious decision to take a risk and self insure (for example, by deciding that dental insurance isn't worth the cost and accepting the risk of some dental bills) and not buying insurance because you don't want to spend the money and believe that society will step up for you should something bad happen.

The cost of health care in the event of an accident or critical illness are so expensive it is not practical for most people to self insure (other than the very, very wealthy). IMO, if you can't afford to pay for your health care if you were to have an illness and you refuse to buy insurance because it is too expensive you are not self insuring, you are avoiding an unfortunate reality of life.

Agree 100% most unissured are not that way by choice. But the financial consequences of catastrophic illness/injury fall upon the uninsured regardless of the reason for their lack of HI.
Whether HI is "affordable" or not for given individual or family is often clear but sometimes murky. I know more than a few decently employed 'young invincibles' who claim they cannot afford employer's HI copays yet maintain a hefty new car payment &/or 3-figure monthly 4G data service plan with latest smartphone. Somehow I doubt that gov't advertising alone will get these folks to change their fiscal priorities & sign up under the Marketplace.

 

[MRG]

Agree 100% most unissured are not that way by choice. But the financial consequences of catastrophic illness/injury fall upon the uninsured regardless of the reason for their lack of HI.
Whether HI is "affordable" or not for given individual or family is often clear but sometimes murky. I know more than a few decently employed 'young invincibles' who claim they cannot afford employer's HI copays yet maintain a hefty new car payment &/or 3-figure monthly 4G data service plan with latest smartphone. Somehow I doubt that gov't advertising alone will get these folks to change their fiscal priorities & sign up under the Marketplace.

When it became mandatory for everyone that drove to have a basic level of car insurance, what happened? Sure some people didn't, and continue to work around the system. Over time folks eventually get the message.

I haven't been worried about an uninsured motorist causing me harm for a long time.
I hope this change becomes a positive for all of us.

MRG

 

[samclem]

When it became mandatory for everyone that drove to have a basic level of car insurance, what happened? Sure some people didn't, and continue to work around the system. Over time folks eventually get the message.

I haven't been worried about an uninsured motorist causing me harm for a long time.
I hope this change becomes a positive for all of us.

Nationwide, about 1 in 7 drivers is uninsured. And I'm guessing they may not be the most responsible, conscientious of those with whom we share the road.

 

[meierlde]

Nationwide, about 1 in 7 drivers is uninsured. And I'm guessing they may not be the most responsible, conscientious of those with whom we share the road.

Agreed that there are a lot of folks who don't have auto insurance, starting with folks such as illegals who can't get licenses in at least some states. This is why you buy uninsured motorist coverage to cover at least some of your losses if you are in an accident with an uninsured motorist.

 

[MRG]

Nationwide, about 1 in 7 drivers is uninsured. And I'm guessing they may not be the most responsible, conscientious of those with whom we share the road.

Wouldn't disagree, what was the percentage before mandatory insurance?

I've witnessed folks, working accident issues on their own. One guy chopped up another guys car, with a double bitted axe while the owner watched!

No problem, unless you were the uninsured motorist. Well the guy with the axe, the state said maybe he has anger issues, no charges filed!

Maybe its good that folks need to have insurance, maybe it's not. Just MHO.

MRG

 

[bUU]

EMTALA only requires that ER stabilize patients, not provide any treatment beyond that. Hospitals do so of their own accord, effectively providing indigent treatment paid for by patients with insurance or personal financial resources in the form of overhead that is factored into reimbursement rates and the rates individual patients are charged.

 

[marko]

Not sure if this is the right thread for this tid-bit but:

Mom (age 84) went to pick up her prescription yesterday at CVS. For the past 9 years her Medicare cost was $50. Yesterday she was told it was now $116.

She pushed back, talked to the manager and was told that it's part of the new ACA's Medicare "adjustments"/cuts (or something along those lines). Is it possible that these changes are already taking place?

Meanwhile, DW's multinational Megacorp announced a new HC provider plan for 2014, cancelling our old BCBS. Guess what? Yep, my Dr of 15 years doesn't accept them.

 

[travelover]

Not sure if this is the right thread for this tid-bit but:

Mom (age 84) went to pick up her prescription yesterday at CVS. For the past 9 years her Medicare cost was $50. Yesterday she was told it was now $116.

She pushed back, talked to the manager and was told that it's part of the new ACA's Medicare "adjustments"/cuts (or something along those lines). Is it possible that these changes are already taking place?

Meanwhile, DW's multinational Megacorp announced a new HC provider plan for 2014, cancelling our old BCBS. Guess what? Yep, my Dr of 15 years doesn't accept them.

Interesting, but you have not provided enough information to show that these changes are really an effect of the ACA or just a result of ongoing health care cost increases. Maybe you can do a little digging and report back with more facts.

 

[MichaelB]

When Obamacare is fully implemented (and I hope it's running well) if everyone has to have insurance then will there be a retail rate and an allowed rate? Will different insurance carriers have different allowed rates?

./.

How does this work in Massachusetts?

Sue, no expert here, but I'll give it a shot. This would make a good topic for a new thread.

The ACA does not cover how providers set prices, so hospitals, physicians and labs will probably continue to charge different prices to users, as best they can. Each insurance company negotiates with each provider, so all the rates are different and will continue to be so. The rates are also private, so there is no way to know how much a particular procedure will cost you in advance.

If a medical provider has a "retail rate" and a negotiated rate with your insurance company, but the provider is not part of the network of your individual policy, you might also be liable for the retail price.

If you have a PPO plan with out of network coverage and use a medical provider not part of your network, a separate deductible will apply, but only the "usual and customary price" will be considered. In other words, using your example of $98 retail vs $10 plan, if that charge were out of network, you would be liable for the entire $98, but your PPO plan would only cover you for the amount they consider "average", which is probably very close to their reimbursement rate of $10.

Edit to change the bolded above from "will" to "might"

 

[rbmrtn]

I think he was just trying to spin your mom. I don't see any changes impacting medicare drugs. In fact the "donought hole" was closed in 2010. Depending on what it was the drug itself may have increased in price. I would ask for proof if he said something like that. Mine is 92 years old and they tell her all kinds of BS I later have to go back and straighten out.

ObamaCare by the Numbers

Key Features of the Affordable Care Act By Year | HHS.gov/healthcare

Switching HC plans isn't unusual. I know some small group users that have switched to 5 different plans in the last five years, trying to save a buck.

 

[ERhoosier]

When Obamacare is fully implemented (and I hope it's running well) if everyone has to have insurance then will there be a retail rate and an allowed rate? Will different insurance carriers have different allowed rates?

How does this work in Massachusetts?

Do not know how this works in MA specifically, but generally HI carriers have network of contracted providers (docs, hospitals, etc). Covered care from those providers is at the contracted (allowed) rate, subject to your policy's co-pay, deductibles, & annual OOP max. If you seek non-emergency care from providers outside the carrier's network, you typically pay MUCH higher co-pays, deductibles, &/or OOP max up to the full cost depending on your specific policy. AFAIK this will be similar under ACA.
https://www.healthcare.gov/what-are-the-different-types-of-health-insurance/

https://www.healthcare.gov/glossary/cost-sharing/

 

[MooreBonds]

When it became mandatory for everyone that drove to have a basic level of car insurance, what happened? Sure some people didn't, and continue to work around the system. Over time folks eventually get the message.

I haven't been worried about an uninsured motorist causing me harm for a long time.
I hope this change becomes a positive for all of us.

MRG

A "major" car accident might be $10,000 in repairs. Also, for a smaller fender bender, the uninsured can simply drive around with the damage and live with it. And I don't think too many of the uninsured are driving around town in brand new $70,000 luxury vehicles, so it wouldn't take much for a big accident to make them simply scrap the vehicle.

Compare that to even a "minor" healthcare service that can easily be several thousand dollars (even at the insurance negotiated rate). Major? don't even bother estimating. And you can't really just "scrap" your body and get a new one, or "just live with" an appendix that needs to come out and is ready to burst, or an infection that needs to be treated.

It's a lot easier to go without car insurance than health insurance because of the potential dollars involved in the event you need the insurance. Plus, while there can be ways to drive responsibly and avoid many accidents, it can be more difficult for healthcare, as the human body is unbelievably complex and still well beyond our grasp of what effects what, and your body can be susceptible to so many factors beyond your control and knowledge (genetics, tiny bacteria/virus you can't see, the effect of mixing different chemicals in your body that it has stored over the years that no one knows the effects of, etc.) Also, ultimately, we ALL will have some healthcare issue which ultimately puts us 6 ft under. Many of us will have various health issues long before that point, so in some ways, it's guaranteed to come at some point.

 

[sailor]

If a medical provider has a "retail rate" and a negotiated rate with your insurance company, but the provider is not part of the network of your individual policy, you will be liable for the retail price.

Not in my experience (unless you are talking outside of US medical care).
Your insurance will use some third party medical re-billers which has the contract with the provider and they will still get the negotiated rate (although probably not as good as their own negotiated rates).
This happened to us with different insurers (I can confirm that at least Kaiser and BCBS use this practice).

 

[MichaelB]

Not in my experience (unless you are talking outside of US medical care).
Your insurance will use some third party medical re-billers which has the contract with the provider and they will still get the negotiated rate (although probably not as good as their own negotiated rates).
This happened to us with different insurers (I can confirm that at least Kaiser and BCBS use this practice).

Very well could be different practices among insurers, as this has happened to us in the US (UHC, NY State).