Help! My health Ins is about to double!

[ziggy29]

Quote:

Originally Posted by audreyh1 I guess he had a grandfathered plan, but it is still going away? So the grandfathering did not last?

A plan can remain grandfathered indefinitely if it doesn't substantially change the coverages or the cost sharing.

https://www.healthcare.gov/health-ca...athered-plans/

Quote:

Can a plan lose its grandfathered status? Yes. Plans can lose their grandfathered status if they make certain changes that lower your benefits or increase your costs. In order to keep their grandfathered status, plans can't: Significantly cut or lower coverage Raise coinsurance of the allowed amount for the service Significantly raise copayment charges Significantly raise deductibles Significantly lower employer contributions Add or tighten a yearly limit on what the health plan pays

So we're seeing more and more grandfathered plans just going away, because they can't meet the criteria above in any way that keeps it remotely affordable.

[NW-Bound]

Quote:

Originally Posted by ziggy29 ... So we're seeing more and more grandfathered plans just going away, because they can't meet the criteria above in any way that keeps it remotely affordable.

In addition, grandfathered plans for individuals cannot enroll new people. Having its pool of the insured shrinking due to attrition is another reason for a grandfathered plan to be shut down by the insurer.

[Ian S]

Quote:

Originally Posted by NW-Bound In addition, grandfathered plans for individuals cannot enroll new people. Having its pool of the insured shrinking due to attrition is another reason for a grandfathered plan to be shut down by the insurer.

I think that last part is key: grandfathered simply means that the plan can continue to be offered; it doesn't mean it HAS to be offered. The insurer is free to terminate it if it wishes.

[GTFan]

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Originally Posted by athena53 Let's say I'm traveling and have a closed fracture (no bone sticking out). Life-threatening? Probably not. Resetting it after I've gotten to an in- network facility after it's started to grow back together crooked would be expensive and risky. So what would the insurer say if I got immediate treatment out of network?

We are in this exact boat now - while vacationing in DC last month my wife fell and broke her femur (closed fracture). Luckily the ambulance sent us to a hospital in-network for Humana, unluckily the surgeon that fixed it next day was out-of-network. So Humana paid the net $50k hospital bill for a 5 day visit (we pay the $6300 in-network deductible) and is not paying the reasonable $5800 bill for the surgeon.

Needless to say we immediately appealed the OON decision since the surgery was medically necessary and she could not have traveled, and the hospital made the decision to keep her and assigned the doc to do the work. So even if Humana denies appeal we are going to call the hospital and ask them to work it out between insurance and doc since it was entirely their call. Fortunately we have a letter from the surgeon backing our appeal claim about medical necessity (he's a great guy) but we'll see how it goes.

[ziggy29]

Quote:

Originally Posted by Ian S I think that last part is key: grandfathered simply means that the plan can continue to be offered; it doesn't mean it HAS to be offered. The insurer is free to terminate it if it wishes.

Precisely. And as a group ages (remember, you can't add new members to a grandfathered plans, so the group gets older every year), the insurer will eventually want to drop it because they can no longer offer it at a price anyone will pay, especially with the ACA eliminating medical underwriting and preexisting condition exclusions.

[Mulligan]

Quote:

Originally Posted by ziggy29 Precisely. And as a group ages (remember, you can't add new members to a grandfathered plans, so the group gets older every year), the insurer will eventually want to drop it because they can no longer offer it at a price anyone will pay, especially with the ACA eliminating medical underwriting and preexisting condition exclusions.

That was one of the "tricks" insurance companies used in underwriting days to get around the "you cant drop them after you accept them". Close off an existing group of individuals, and assign incoming ones to a "new group". Let attrition and maladies force the existing group to pay considerably more, or attempt to undergo underwriting again to catch on with the lowest rate.


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[ivinsfan]

Quote:

Originally Posted by GTFan We are in this exact boat now - while vacationing in DC last month my wife fell and broke her femur (closed fracture). Luckily the ambulance sent us to a hospital in-network for Humana, unluckily the surgeon that fixed it next day was out-of-network. So Humana paid the net $50k hospital bill for a 5 day visit (we pay the $6300 in-network deductible) and is not paying the reasonable $5800 bill for the surgeon. Needless to say we immediately appealed the OON decision since the surgery was medically necessary and she could not have traveled, and the hospital made the decision to keep her and assigned the doc to do the work. So even if Humana denies appeal we are going to call the hospital and ask them to work it out between insurance and doc since it was entirely their call. Fortunately we have a letter from the surgeon backing our appeal claim about medical necessity (he's a great guy) but we'll see how it goes.

Since you just got this bill, I have a question is the 5800 the doctors rack rate, or was that number knocked down by Humana before they denied the claim? This is the scary part about out of network, you might end up getting billed for rack rate prices. If it's rack rate you SHOULD be able to lower that number with a little effort. But how can this go on, even if you had been at home you might have gotten caught with an out of network doctor. So you have the cost of your yearly premium+6300+5800...how with people come up with this kind of money. Heck while you are talking to the hospital you might as well ask them to lower the 6300 bill as well.

[pb4uski]

One observation. I know that at one point in time if your plan was canceled and other plans available to you were unaffordable that would allow you to buy catastrophic coverage even if you are over 30. Not sure if this exemption still exists but I think it does.

Sent from my SAMSUNG-SGH-I777 using Early Retirement Forum mobile app

[NW-Bound]

Whenever we talk about healthcare in the US, inevitably the comparison with other countries pops up. This is a good thing, but we need to look at all aspects.

To an American who longs for other countries' "free" healthcare, I will ask if they have looked to see how much their citizens pay in taxes. To a foreigner who says that their system is superior, I will ask if they know how much lower in taxes an American pays? There's never anything "free".

It is true that we spend a lot more on healthcare per capita compared to other countries. But how does shifting the cost to the government fix the problem if it turns around and taxes us more? We cannot fix a problem until we identify its source. Reducing the cost is not done by shifting it around, just to have it come back on our shoulders.

[DEC-1982]

Quote:

Originally Posted by NW-Bound Whenever we talk about healthcare in the US, inevitably the comparison with other countries pops up. This is a good thing, but we need to look at all aspects. To an American who longs for other countries' "free" healthcare, I will ask if they have looked to see how much their citizens pay in taxes. To a foreigner who says that their system is superior, I will ask if they know how much lower in taxes an American pays? There's never anything "free". It is true that we spend a lot more on healthcare per capita compared to other countries. But how does shifting the cost to the government fix the problem if it turns around and taxes us more? We cannot fix a problem until we identify its source. Reducing the cost is not done by shifting it around, just to have it come back on our shoulders.

You are absolutely right talking about tax differences but I still don't see why a pharma company might charge a drug $50 here and $10 in Europe (I made up these numbers but drugs are a lot costlier here). European taxes don't pay for that difference. Just across the border, Canadian drugs are cheaper than our drugs, which is why we have the (possibly illegal) drug mail-order business. It's almost as though we are paying the R&D costs and others in the world get the R&D benefit free.

Does anybody think Europe would allow Martin Shkrelly (sp?) to charge $750 for what was a $13 drug for 50 or more years?

Sorry, I am not helping OP with his premium cost doubling issue.

[bingybear]

Quote:

Originally Posted by NW-Bound Whenever we talk about healthcare in the US, inevitably the comparison with other countries pops up. This is a good thing, but we need to look at all aspects. To an American who longs for other countries' "free" healthcare, I will ask if they have looked to see how much their citizens pay in taxes. To a foreigner who says that their system is superior, I will ask if they know how much lower in taxes an American pays? There's never anything "free". It is true that we spend a lot more on healthcare per capita compared to other countries. But how does shifting the cost to the government fix the problem if it turns around and taxes us more? We cannot fix a problem until we identify its source. Reducing the cost is not done by shifting it around, just to have it come back on our shoulders.

I think the cost of healthcare in some of those countries with universal healthcare includes the portion of tax used for healthcare. Thus they are not shifting it in a way at to hide it from being included in the cost of healthcare calculation. Before ACA we spend a lot more per capita, but many were not covered.
One of our problems is that most of the health coverage was covered by employer plans where the insured had no idea of what it really costs. So people did not understand to cost of insurance or healthcare. I have a friend who works for an insurance company (in IT) who is over 60 and covers his wife and self with a great health plan and thinks is really costs less than $200 per month. He refuses to believe that his company is paying any more for the insurance. So many of us still don't know what it costs.
I agree with you on realizing the added cost (taxes) and that we have not figured out why we are not running an efficient system (have not figured out why we cost so much more).
In my mind I think the bigger question is when we will finally get to affordable healthcare. With all the lobbyists I wonder if we will ever figure it out.

[bingybear]

Quote:

Originally Posted by DEC-1982 You are absolutely right talking about tax differences but I still don't see why a pharma company might charge a drug $50 here and $10 in Europe (I made up these numbers but drugs are a lot costlier here). European taxes don't pay for that difference. Just across the border, Canadian drugs are cheaper than our drugs, which is why we have the (possibly illegal) drug mail-order business. It's almost as though we are paying the R&D costs and others in the world get the R&D benefit free. Does anybody think Europe would allow Martin Shkrelly (sp?) to charge $750 for what was a $13 drug for 50 or more years? Sorry, I am not helping OP with his premium cost doubling issue.

When I lived in England a prescribed drug was 5 pounds 80, about $10 at the time. This was true for a cheap generic drug or an expensive drug. So I think there was cost sharing there too. I doubt you could determine what the health system was paying for a specific drug based on the cost at the chemist. But then, drugs like Viagra were not covered at that time. They saw this as not medically necessary.

[audreyh1]

Quote:

Originally Posted by NW-Bound Whenever we talk about healthcare in the US, inevitably the comparison with other countries pops up. This is a good thing, but we need to look at all aspects. To an American who longs for other countries' "free" healthcare, I will ask if they have looked to see how much their citizens pay in taxes. To a foreigner who says that their system is superior, I will ask if they know how much lower in taxes an American pays? There's never anything "free". It is true that we spend a lot more on healthcare per capita compared to other countries. But how does shifting the cost to the government fix the problem if it turns around and taxes us more? We cannot fix a problem until we identify its source. Reducing the cost is not done by shifting it around, just to have it come back on our shoulders.

You can talk about increased taxes to cover health care. But considering what is paid in insurance premiums, deductibles, max OOPs, and exposure to out-of-network higher deductibles/max or unlimited OOPs, and balanced billing, individuals are already paying a lot of money.

I guess for many people employed this insurance premium "tax" is invisible.

[travelover]

Quote:

Originally Posted by audreyh1 You can talk about increased taxes to cover health care. But considering what is paid in insurance premiums, deductibles, max OOPs, and exposure to out-of-network higher deductibles/max or unlimited OOPs, and balanced billing, individuals are already paying a lot of money. I guess for many people employed this insurance premium "tax" is invisible.

And ironically, this "free" employer provided health care insurance is government subsidized, as it is provided tax free. The guy that buys his own insurance (with no subsidy), does so with after tax dollars.

[audreyh1]

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Originally Posted by travelover And ironically, this "free" employer provided health care insurance is government subsidized, as it is provided tax free. The guy that buys his own insurance (with no subsidy), does so with after tax dollars.

That too.

[GTFan]

Not breaking ties that bind employees to heavily subsidized corporate health insurance is one of the biggest failings of reform, IMO. We're not going to get what we need until this is done, but I don't see it happening for the forseeable future. Everyone needs to eat the same dogfood on a level field before any of this gets fixed for good (and no I'm not implying single payer here).

My fear at this point is that ACA plans are going to get worse and worse every year (limited networks, excessive price increases, insurers pulling out of markets and/or merging to limit options etc.) and nothing will be done due to entrenched political BS so we'll essentially be right back where we were in a few years. Aetna merging with Humana is a prime example - Humana is the only insurer with all of the westside ATL providers (WellStar) in only one of their plans and Aetna is not in the GA market. So all Aetna has to do after merger is pull out of GA or remove that one plan and then we have to switch to Kaiser docs or something else because no exchange plan will cover our docs and hospitals. Couple that with a state insurance commissioner that hates the ACA and does everything he can to discredit it and the future is bleak, I doubt he's going to step in and ensure that the main provider network here is covered. We'd have to rely on WellStar getting something done.

And oh BTW, our Humana plan premiums went up almost 25% for 2016 (National Open Access point-of-service plan). They went from second-lowest to second-most expensive in each tier. Fortunately I'm going from an unsubsidized Bronze to a heavily cost-shared and subsidized Silver next year, but others with Humana will have a cow and drop the plans giving Aetna/Humana even more incentive to leave the market.

[NW-Bound]

Quote:

Originally Posted by DEC-1982 You are absolutely right talking about tax differences but I still don't see why a pharma company might charge a drug $50 here and $10 in Europe (I made up these numbers but drugs are a lot costlier here). European taxes don't pay for that difference. Just across the border, Canadian drugs are cheaper than our drugs, which is why we have the (possibly illegal) drug mail-order business. It's almost as though we are paying the R&D costs and others in the world get the R&D benefit free...

That's exactly why we need to address the cost at the source. Instead of talking about who's paying, let's talk about what is being paid for.

[Alan]

Quote:

Originally Posted by NW-Bound Whenever we talk about healthcare in the US, inevitably the comparison with other countries pops up. This is a good thing, but we need to look at all aspects. To an American who longs for other countries' "free" healthcare, I will ask if they have looked to see how much their citizens pay in taxes. To a foreigner who says that their system is superior, I will ask if they know how much lower in taxes an American pays? There's never anything "free". It is true that we spend a lot more on healthcare per capita compared to other countries. But how does shifting the cost to the government fix the problem if it turns around and taxes us more? We cannot fix a problem until we identify its source. Reducing the cost is not done by shifting it around, just to have it come back on our shoulders.

We relocate to the UK next year* and I have already done a detailed tax estimate for what we will pay for our circumstances.

We have a mixture of pensions, interest, qualified dividends and capital gains. Like the US, the UK taxes its residents on their worldwide income. Roth distributions are free of UK tax which is why I have been so aggressive in conversions this past 5 years.

We will pay ~$3k more in income taxes than in the US ($9k instead of $6k). (We live in Texas so no State income tax).

Cost of a prescription for 2016 will be ~$12.50, although seniors get free prescriptions regardless of income, as do minors, pregnant women and various other groups. Seniors also get free bus passes, free eye tests, discount rail fares etc.

Quote:

Originally Posted by bingybear When I lived in England a prescribed drug was 5 pounds 80, about $10 at the time. This was true for a cheap generic drug or an expensive drug. So I think there was cost sharing there too. I doubt you could determine what the health system was paying for a specific drug based on the cost at the chemist. But then, drugs like Viagra were not covered at that time. They saw this as not medically necessary.

My BIL has been on Viagara for quite a number of years now and that is a prescription. I doubt that it is free as he and his wife have good paying jobs.

Year to date we have spent $11.3k on HI, deductibles and copays. Last year it was $7.8k, 2013 it was $8.1k. The previous 3 years we only spent between $3k and $4k per year but in those years the premiums were only $80/mo and we were much fitter. 2016 we'll be paying $697/mo

Only after we have experienced it first hand instead of through our friends and relatives will I be able to say whether it is better or worse, but it is certainly going to be a lot less expensive.


We have already done a trial run of living in the town we will be moving back to (7 months in a rented unfurnished 3 bedroom detached house) so I know house prices, property taxes etc. For the size of house we will look to buy it will cost ~$380k and the property taxes will be ~$2.5k/year. Overall living costs look to be similar to what we have here in Texas, some things are much cheaper like bread, internet and cell phones, other things, like gas and diesel, are much more expensive.

*We are moving back for emotional reasons (family and friends) , not financial or because 1 country is somehow better than the other.

[marko]

I've mentioned before that my PCP doctor dropped out of all insurance networks.

He now charges a flat $1,000 per year fee that allows you 12 office visits, home visits ($35) and a few other things. He can now spend upwards of an hour with you if need be instead of the 'insurance mandatory max' 15 minutes.

He was able to drastically drop his overhead (something like 6 office people just to handle insurance) and also dropped his patient count from 2500 to 700. He claims he's ahead financially and feels like he's now really helping people and has just added another doctor to his team.

I had a PSA test last year from my urologist and my OOP was $175. This year I decided to have my PCP do my PSA and I was charged $6 (yes, six dollars).

[travelover]

Quote:

Originally Posted by marko I've mentioned before that my PCP doctor dropped out of all insurance networks. He now charges a flat $1,000 per year fee that allows you 12 office visits, home visits ($35) and a few other things. He can now spend upwards of an hour with you if need be instead of the 'insurance mandatory max' 15 minutes. He was able to drastically drop his overhead (something like 6 office people just to handle insurance) and also dropped his patient count from 2500 to 700. He claims he's ahead financially and feels like he's now really helping people and has just added another doctor to his team. I had a PSA test last year from my urologist and my OOP was $175. This year I decided to have my PCP do my PSA and I was charged $6 (yes, six dollars).

Interesting. What happens if you are admitted to a hospital?