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Old 08-18-2016, 10:43 AM   #41
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That's inevitable when there are a number of people who are deciding those things, and those people very explicitly disagree with each other about those things, and even about more fundamental aspects of the situation.
In the business world (where people's jobs are actually on the line) it's called "Product Ownership". The person in the trenches who owns this and is responsible for its success.

You put one person in charge at the detail level who calls the shots and who's career hangs on it; not a committee.

At roll out, AFAIK, there wasn't a single point person who was responsible for making this product succeed, no 'product readiness review', no effort to make the public aware of what it was, or what it wasn't.

Six years later most people still don't know what this is all about or how it works and sadly, through the lens of that lack of information people end up believing all sorts of things, as evidenced by this thread.
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Old 08-18-2016, 10:53 AM   #42
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Can health insurance be simplified?

There are so many qualifications, in terms of which procedures and drugs are covered and which are not, which providers are included and which are not, etc.

When I was choosing policies at open enrollment every year with my employer, it wasn't much easier. This was with various comparison tools and so forth.

I think the confusion and complexity of choosing insurance are just a reflection of our expensive, balkanized health care system.
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Old 08-18-2016, 01:05 PM   #43
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However... They refuse to divulge any info on the percentage breakout between exchange and off exchange. Evidently enough that they do not want the losses on their books.


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Your state insurance commissioner should have that info, as they need to provide to them for rate approval on the off-exchange plans.

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Old 08-18-2016, 01:18 PM   #44
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Your state insurance commissioner should have that info, as they need to provide to them for rate approval on the off-exchange plans.

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I would assume the Stl Post Dispatch would have tried that route as they specially mentioned in yesterdays article it would not be released to them, but who knows as I certainly do not. We haven't had much "insurance oversight" here and have totally dumped it on the Feds. Our state until at least this year has had no input or regulatory control. I have read state may get more oversight, though.


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Old 08-19-2016, 03:29 AM   #45
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In the business world (where people's jobs are actually on the line) it's called "Product Ownership". The person in the trenches who owns this and is responsible for its success. You put one person in charge at the detail level who calls the shots and who's career hangs on it; not a committee.
Precisely. That'll never happen in government. Even when you privatize public services, it is still a committee - no... worse... a Congress - that the private company has to satisfy (which was precisely the case with ACA - my spouse worked for the product owner for one of the exchanges).
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Old 08-19-2016, 04:14 AM   #46
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"Try not to worry about things that may, or may not happen in the future". I have told my kids that for years.

Much of the distress about who the players will be, and how much it will cost is premature. The real info will not be known until later in the fall (open enrollment).

Meanwhile, it's back to another day in paradise (semi-retirement)............
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Old 08-19-2016, 04:30 AM   #47
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There can be no market competition when the prices are kept secret. And when there is neither competition nor regulation of prices. With ACA, only part of the problem was partially solved. The other problem is combatting ridiculously high prices. Doctors and hospitals are regulated to death but they cheat anyway. My dad was billed for the highest level visit when the cardiologist spent 1 minute in the room and 10 seconds listening to his heart. My son was billed for critical care for a broken arm-yeah, I won that one. But he was also over billed for OR supplies. I couldn't fight that battle.

A patient is in no position to complain. One can get kicked out of the practice. Or worse.

We consumers need more robust representation.

The price of an Epipen just went from $100 to $400. This is a life saving emergency medication. It costs a few dollars to make. When asked why, the company gave gobbletygook for an answer.

We are caught in the middle of three very greedy systems, healthcare providers/hospitals, big insurance, and big Pharma. I'm one of them-a physician. In the lowest paid specialty.


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Old 08-19-2016, 06:44 AM   #48
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There can be no market competition when the prices are kept secret........
+1 Good post. Eventually the golden goose will be killed as a result of an angry backlash when the whole thing reaches a crisis point. Until then.........
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Old 08-19-2016, 07:43 AM   #49
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Aetna is also "Coventry" which is what I have. <snip>
Aetna is very big in MO.
I had Coventry last year and then they sent me an e-mail during Open Enrollment telling me they were discontinuing the off-exchange policy I had for 2016 but here was a link to another policy I "might like". It had zero coverage out-of-network. Ummm, no. Just no. I realize they're required to cover out-of-network in emergencies but I don't want to fight after the fact about whether something was an emergency. I especially don't want to get hit with whatever some specialist charges when they close a surgical wound while I'm under anaesthetic- or when they're supplying the anaesthetic.

I went with BCBS. So far it's been a pretty bad move on Aetna/Coventry's part; I've had only routine preventative exams, which is typical for me.
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Old 08-19-2016, 08:49 AM   #50
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I had Coventry last year and then they sent me an e-mail during Open Enrollment telling me they were discontinuing the off-exchange policy I had for 2016 but here was a link to another policy I "might like". It had zero coverage out-of-network. Ummm, no. Just no. I realize they're required to cover out-of-network in emergencies but I don't want to fight after the fact about whether something was an emergency. I especially don't want to get hit with whatever some specialist charges when they close a surgical wound while I'm under anaesthetic- or when they're supplying the anaesthetic.

I went with BCBS. So far it's been a pretty bad move on Aetna/Coventry's part; I've had only routine preventative exams, which is typical for me.


Yes, I had the same experience as you had. I don't even do the preventative exam waste of time though. But I do carry a sign around my neck in case of a medical emergency directing them to take me to 3 hospitals under in network. If unable to find them, let me die, as the bill would kill me anyways.


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Old 08-21-2016, 06:48 PM   #51
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I read some more articles in Sunday paper today about companies pulling out of exchange but still offering off exchange policies, with implication by articles they were ducking people with more claims that purchase through exchange. Interestingly I read something that I had not known before. Washington DC and Vermont are the only 2 areas in US that have mandated insurance companies cannot offer off exchange plans if they do not offer exchange programs also.


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Old 08-21-2016, 07:19 PM   #52
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I don't understand why exchange plans would draw more claims than off-exchange ones, unless the subsidies made it easier for people to use services since not only their premiums but their deductibles are subsidized.

Maybe that's what the insurers are seeing and they're cherry-picking, even though you'd think the exchange would have way more enrollees, not just because of the subsidies but all the publicity funnels people into signing up through the exchanges.
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Old 08-21-2016, 07:43 PM   #53
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Well we know one thing...Insurers have more than a few bean counters hired. And I will take a wild guess they have seen a strong pattern developing. We certainly are not seeing many articles about insurers pulling out of off exchange markets while staying in the exchange markets of that state, that is for sure... If they have, I have missed every article, ha!


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Old 08-21-2016, 07:58 PM   #54
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But it can't be just about collecting premiums and not paying out claims for the off-exchange plans vs. the exchange plans.

They have to pay out at least 85% of premiums in claims.

So does that mean on the exchanges they're paying out like 90 or 95% in claims?

Someone posted that the one leading exchange insurer in FL was doing well, paying out 87% but still making almost a $500 million profit.
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Old 08-21-2016, 08:10 PM   #55
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Are the premiums the same for the on-exchange and off-exchange policies (assuming it's the same policy coverage)?
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Old 08-21-2016, 08:13 PM   #56
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I don't understand why exchange plans would draw more claims than off-exchange ones...
On-exchange plans - attractive to people who qualify for subsidies (MAGI < cutoff; may or may not have high net worth)

Off-exchange plans - suitable (but not necessarily attractive) for people who don't qualify for subsidies (MAGI >= cutoff; may or may not have high net worth)

In general, are people with MAGI >= cutoff less likely to file claims than the others? An insurer who drops on-exchange plans but keeps identical off-exchange plans predicts YES. It would be interesting to look at the actuarial data that supports this prediction.
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Old 08-21-2016, 08:16 PM   #57
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Well there's no more underwriting right?

So you'd think insurers would gradually get rid of those well-paid actuaries.
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Old 08-21-2016, 09:43 PM   #58
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Actually studies have shown that more affluent folks tend to be healthier. Thus since no subsidy folks tend to be more affluent, it is at least possible that they make fewer claims in general.
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Old 08-22-2016, 05:22 AM   #59
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Here is a map indicating the number of 2017 on-exchange carriers by location based on current information. The small gray area in AZ represents no exchange carriers for Pinal County but the AZ DOI and HHS are working to get Blue Cross back in the county.

http://www.nytimes.com/2016/08/20/up...main.html?_r=0
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Old 08-22-2016, 07:52 AM   #60
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Actually studies have shown that more affluent folks tend to be healthier. Thus since no subsidy folks tend to be more affluent, it is at least possible that they make fewer claims in general.
And most likely have had continuing access to health care. So perhaps less likely to have long term untreated issues which can be very pricey. Also more likely to buy a plan a with higher deductible which is less exposure for the company. They just break it down to on exchange and off exchange and don't say what plans people are buying.
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