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ACA - state exchange policies reimbursement rates
Old 05-23-2013, 07:52 PM   #1
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ACA - state exchange policies reimbursement rates

Over the last few weeks several states have started to publish more info about the ACA exchange policies that will be offered as of Jan 1, 2014.

I haven't heard discussed how generous (or not) the provider reimbursement rates will be on these policies? Many on this forum have mentioned the difficulty of actually finding Docs that will take Medicare patients. How do we know that the exchange-sold policies will offer reimbursement rates which are sufficient that Docs will want to take patients with that insurance? Or will the reimbursement rates be similar/identical to group policies sold to companies for their employees?
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Old 05-24-2013, 04:24 AM   #2
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Hopefully, if practitioners start holding their services hostage, then the government will step in and pass laws prohibiting that practice, since healthcare is so essential.
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Old 05-24-2013, 04:52 AM   #3
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I haven't heard discussed how generous (or not) the provider reimbursement rates will be on these policies? Many on this forum have mentioned the difficulty of actually finding Docs that will take Medicare patients. How do we know that the exchange-sold policies will offer reimbursement rates which are sufficient that Docs will want to take patients with that insurance? Or will the reimbursement rates be similar/identical to group policies sold to companies for their employees?
My guess is the insurance companies will negotiate rates with providers as they currently do and then offer that policy on the exchange. They will be able to charge more on the exchanges since the policies there are subsidized. If you think about it, PPACA is great for the insurance companies.

Think about Medicare Supplimental (Medigap) insurance. The government does all the "negotiating" of the rates paid to providers, and the insurance company sells a supplimental policy to cover 20% of the low Medicare-negotiated rates. This is why insurance companies who have totally left the individual market (e.g. Mutual Of Omaha) continue to be big players in the Medigap market. It's a very profitable business for them.
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Old 05-24-2013, 05:27 AM   #4
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The insurance companies already operate in the states and have agreed on reimbursement rates with all the health service providers in their respective networks. The PPACA does not change this.
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Old 05-24-2013, 06:54 AM   #5
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I'm keeping my fingers crossed that rates and services may be satisfactory as compared to current small employer plans. California's plan, that MichaelB started a thread on, shows promise although the rate information is still sketchy. There are bound to be a lot of implementation problems with the exchange IT systems and other aspects of the program but, regardless of individual opinions on the pros and cons of the ACA, we should all hope that it succeeds. As bUU said above, "healthcare is so essential," and we are not going to get a comprehensive substitute for many years if the ACA massively fails.
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Old 05-24-2013, 12:21 PM   #6
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Anyone have info on how the state exchanges may work when there are two adults in the family but only one needs to purchase health insureance on the exchange. As far as I can tell all the calculators use the total family income and provide insurance quote both both. What if one has VA health coverage so does not need to purchase insurance to comply with the PPACA. Will they still use the total family income even if ony one member needs insurance?
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Old 05-24-2013, 12:24 PM   #7
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Yes.
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Old 05-24-2013, 12:33 PM   #8
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If true, then I quess I will save the VA some money by keeping a non VA plan so they can recover some of the cost. Thanks
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Old 05-24-2013, 12:36 PM   #9
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If true, then I quess I will save the VA some money by keeping a non VA plan so they can recover some of the cost. Thanks
How so?
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Old 05-24-2013, 02:02 PM   #10
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How so? not sure what you mean. VA bills your private insurance for cost that they can recover from them, but does not bill me for the difference, if that's what you mean. Thats what happens with my private Insurance now.

EDIT - after more research it seems you can still buy ins on the exchange if you have VA coverage but you will not be eligible for premium tax credits. Which brings me back to my original question since I only need to get insurance for my spouse. I am confused on whether or not she will will be able to buy insurance on the exchange and get the premium tax credit, and if so, will our combined income be used to figure this credit (under 30,000). Seems unfair to be punished because I have VA coverage for service to our nation, which is in effect what will happen if we use our combined income to figure the credit she is eligible for when only she needs it. Paying same price for two people when only one needs it. Maybe I am still confused. That is why I am posting the question and hoping more informed minds can help me.
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Old 05-24-2013, 03:35 PM   #11
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Agree with MichaelB that ACA does not appear to directly change provider/network relationships. Providers will (apparently) continue to negotiate rates and participate (or not) in the various HI plans (inc Medicare & Medicaid). Most folks will still need to check which docs & facilities are "in network" for their specific HI plans.
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