Hospitals out of room!

[Hermit]

I have two friends with resent major medical. One had a brain tumor and had the best hospital in the state on cheapest Medicare policy (AARP) available. No issues with the results. The other had Medicare and I am sure he did not pay for the most expensive. He lives on SSDI. Had a plate put on the front of his spine and two rods down the back sides of his spine to support a crushed vertebrae. He is doing well three months after the surgery. I think that is pretty outstanding service and results for folks on the low end of the medical cost scale.

[Gumby]

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Originally Posted by Dogman ObamaCare is ACA everyone in the USA should or does know this, it has been on every TV station for the last 7 years. And yes my Cardiologist and my primary care physician said if I change from Cigna $16,700.00 per year to Obamacare/ACA they would have to drop me as a patient. I asked why, and they responded that it take ACA months to pay and they get paid much less regardless of whether it is a Bronze, Silver plan, etc.

Your original post (and some of the posts following yours, particularly Bingybear's and Irishgal's) got me thinking, so I called some people today and learned that, in Connecticut, the network for the Anthem plan provided through the ACA health exchange may indeed be narrower than the network for Anthem employer group health plans, primarily due to the fact that reimbursement rates to doctors are lower for the former. The people with whom I spoke said it was like that in some other states too. I did not know that, so I thank you for bringing it to my attention.

I still don't know if the network expands or contracts depending on whether the plan is gold or silver or bronze. Perhaps I'll follow up with my contacts again tomorrow and see if they know.

[rodi]

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Originally Posted by Dogman We/EMS had to take my 60 yr old BIL to the the hospital on 1/4/16 for a seizure from a stroke. The hospital was in Chandler,AZ (Phoenix area).

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Originally Posted by Dogman Thank you for asking, he is not OK because of the delay the clog ended up bursing the vein in his neck and he now has a dark spot (dead) brain cells the size of a baseball. He mostly says no to every statement asked. It has taken him 2 years to be able to stumble around walking instead of a wheelchair, he is only 59 it hard for his wife. Luckily he had disability insurance from work and a separate policy that provides $1,200.00 per month until age 64.

I sense a morphing story.

Is the brother in law 60 or 59. Did he go to the hospital last week, or 2 years ago?

This entire story seems to be playing loosely with the facts to try and make a rant.

[razztazz]

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Originally Posted by rodi I sense a morphing story. Is the brother in law 60 or 59. Did he go to the hospital last week, or 2 years ago? This entire story seems to be playing loosely with the facts to try and make a rant.

Hee hee. This is gonna be good.

[ziggy29]

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Originally Posted by Dogman We now have to pay $16'700.00 with 7500.00 deductible HSA to get our same doctors.

If a deductible is $7500 it is not eligible for an HSA, because that exceeds the maximum deductible allowed for an HSA-eligible HDHP. What am I missing?

[rodi]

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Originally Posted by ziggy29 If a deductible is $7500 it is not eligible for an HSA, because that exceeds the maximum deductible allowed for an HSA-eligible HDHP. What am I missing?

Just to be devil's advocate - if it's a family deductible it can be higher. Our exchange purchased plan has $4500 deductible/person, $9k deductible for family. OOP max's are even higher at 6500/person, 13k family.

[iac1003]

The private individual plans may have different doctors in network from the employer-run plans which in turn are different from the exchange plans which are eligible for a subsidy. Usually the plans that are subsidy-eligible are narrower and may pay a different rate to the physicians. Sometimes you can get lucky and the networks will be the same. Just because it is from the same insurance company, it does not make the plans equal.


Sent from my iPhone using Early Retirement Forum

[NW-Bound]

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Originally Posted by ziggy29 If a deductible is $7500 it is not eligible for an HSA, because that exceeds the maximum deductible allowed for an HSA-eligible HDHP. What am I missing?

Perhaps the law was changed recently. Pre-ACA, up to 2014, I had an HSA account with a $10K deductible policy.

[Texas Proud]

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Originally Posted by athena53 When Coventry said my policy would not be available in 2016 but sent me a link to one I "might like" I was furious when I found it had zero out-of-network coverage. I'm not concerned about routine doc visits; I'm concerned about what happens if some bozo runs me off the road when I'm bicycling or I develop a nightmarish disease. I don't want to choose a brain surgeon or oncologist based on who's in the network- I want the best doc for what I have.

I did not say that your plan was good or not good... I was saying that (at least where I live) there are options that include out of network coverage... but the cost of those plans are HIGH... the out of network deductible is twice as high and the premiums are about twice as high.... that is a LOT of costs to pick a doc...


BTW, if you are run off the road you will get whoever is there at the time or on call...

Also, since one of my sisters has been a nurse for over 30 years I doubt if you would know who is a good doc and who is not.... she has said a few times that there are some highly thought of docs who actually are not that great.... just got a reputation and have lived on it for years.... not saying you would or would not, but IMO it is kinda a crap shoot...

[AllDone]

If the uncle went to the ER in the first week of January in any year, pre- or post-ACA implementation, the place was packed from floor to ceiling and people were stranded in the ER for hours if not days waiting for beds. That has nothing to do with the ACA -- it's the season for COPD, flu, pneumonia, falls, and most of the other ills that beset the elderly.

[jim584672]

The ER is required to treat those who show up, even those with no insurance. So the uninsured and illegal aliens (who are not ACA eligible) flock there for care.

[bingybear]

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Originally Posted by timo2 Your post reminded me that technically every health care plan is an ACA plan, as every plan falls under the law. I'm thinking that when people use 'obamacare' they mean exchange plans. In Colorado next year we have a ballot issue for single payer for the State. But I don't see how that is going to fix the problems with the doctor networks.

I think you'll find most employer plans fall under the law too. Even grandfathered plans fall under it as it has provisions for accepting them. Exchange plans to fall under the law. Off exchange individual plans are covered under the law. I think you'll find most employer plans are compliant to the ACA law.

I think the difference is pretty much the difference that existed before, large employer plans have a well defined risk pool while individual plans don't as everyone is not complying with the law and signing up.

Also, some people are gaming the system by signing up for plans when they need care by claiming non-existent special enrollments (United Health Care news recently) and then cancelling them after getting care.

I don't know what to think of a single payer plan in the US. I had no issues when I lived in the UK with their single payer system.

[bingybear]

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Originally Posted by Gumby Your original post (and some of the posts following yours, particularly Bingybear's and Irishgal's) got me thinking, so I called some people today and learned that, in Connecticut, the network for the Anthem plan provided through the ACA health exchange may indeed be narrower than the network for Anthem employer group health plans, primarily due to the fact that reimbursement rates to doctors are lower for the former. The people with whom I spoke said it was like that in some other states too. I did not know that, so I thank you for bringing it to my attention. I still don't know if the network expands or contracts depending on whether the plan is gold or silver or bronze. Perhaps I'll follow up with my contacts again tomorrow and see if they know.

I agree with employer plans often (hard to say always) have broader networks. Mine does. What I have found in the few cases I checked was that individual on exchange and off exchange (direct through insurer) seemed to have the same network. For my present insurer and state, the individual plans on and off exchange seem to be the same.

[MichaelB]

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Originally Posted by Gumby Your original post (and some of the posts following yours, particularly Bingybear's and Irishgal's) got me thinking, so I called some people today and learned that, in Connecticut, the network for the Anthem plan provided through the ACA health exchange may indeed be narrower than the network for Anthem employer group health plans, primarily due to the fact that reimbursement rates to doctors are lower for the former. The people with whom I spoke said it was like that in some other states too. I did not know that, so I thank you for bringing it to my attention. I still don't know if the network expands or contracts depending on whether the plan is gold or silver or bronze. Perhaps I'll follow up with my contacts again tomorrow and see if they know.

My guess is that the only people that could accurately describe the differences among Anthem's networks in Ct would be Anthem employees. A quick check shows 19 networks for individuals and 34 for employer groups.

Networks for employer groups are designed the same way as for individual policies. Some are large and broad (and pricier), others are small and restricted (and less unaffordable). Mega corp and large public sector employers tend to offer the insurer's biggest networks as a benefit, such as BCBS Bluecard. Smaller companies are not so generous, and even larger employers are now offering policies with restricted networks as a way to reduce or contain benefit costs (as my daughters have found out )

There is no easy way to analyze or compare insurer networks, they do not share this information, so misunderstanding among consumers is common. The administrative cost of managing so many different provider networks is probably one reason why private insurers have so much more overhead than Medicare.

Across the country there are many individual plans that share the same nationwide insurer networks as the large group policies (such as BCBS Bluecard), so the report that some healthcare providers "do not take ACA policies" is impossible to prove, but most likely not factual. It would be more realistic to say

- The only providers that "don't take any ACA" policies probably don't take any insurance at all.
- Most providers accept some private insurance. They do not care if it is group or individual, the only thing that matters is the network, which determines how they are reimbursed.
- Most providers probably don't take most of the new policies. That is because they are so restrictive. This is not the doctors and providers choosing not to participate, the insurers are excluding them as they all compete for a bigger share of the healthcare spending.
- the ACA standardized how insurance must be offered and what a policy must cover. Insurers can no longer limit coverage as a way to artificially lower premiums, so they now design networks to achieve their cost objectives.
- Healthcare is very expensive, unaffordable for the average family. Insurers offer policies with restricted networks so they can have a lower premium.
- this whole debate is about individual policies because they are the only ones that are subject to public scrutiny. It's happening with employer group policies, just not visible to us or the media, so not subject to the same intense public debate.

[bingybear]

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Originally Posted by MichaelB My guess is that the only people that could accurately describe the differences among Anthem's networks in Ct would be Anthem employees. A quick check shows 19 networks for individuals and 34 for employer groups. Networks for employer groups are designed the same way as for individual policies. Some are large and broad (and pricier), others are small and restricted (and less unaffordable). Mega corp and large public sector employers tend to offer the insurer's biggest networks as a benefit, such as BCBS Bluecard. Smaller companies are not so generous, and even larger employers are now offering policies with restricted networks as a way to reduce or contain benefit costs (as my daughters have found out ) There is no easy way to analyze or compare insurer networks, they do not share this information, so misunderstanding among consumers is common. The administrative cost of managing so many different provider networks is probably one reason why private insurers have so much more overhead than Medicare. Across the country there are many individual plans that share the same nationwide insurer networks as the large group policies (such as BCBS Bluecard), so the report that some healthcare providers "do not take ACA policies" is impossible to prove, but most likely not factual. It would be more realistic to say - The only providers that "don't take any ACA" policies probably don't take any insurance at all. - Most providers accept some private insurance. They do not care if it is group or individual, the only thing that matters is the network, which determines how they are reimbursed. - Most providers probably don't take most of the new policies. That is because they are so restrictive. This is not the doctors and providers choosing not to participate, the insurers are excluding them as they all compete for a bigger share of the healthcare spending. - the ACA standardized how insurance must be offered and what a policy must cover. Insurers can no longer limit coverage as a way to artificially lower premiums, so they now design networks to achieve their cost objectives. - Healthcare is very expensive, unaffordable for the average family. Insurers offer policies with restricted networks so they can have a lower premium. - this whole debate is about individual policies because they are the only ones that are subject to public scrutiny. It's happening with employer group policies, just not visible to us or the media, so not subject to the same intense public debate.

+1
I did look up Anthem in my state. Two networks for direct individual plans that are not the same as on the exchange, but all the exchange networks were also there for direct purchases plans.
We likely need something more disruptive to get healthcare more affordable and with better outcomes.

[Dogman]

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Originally Posted by bingybear I'm lost. You replied to Gumby with the above where he admitted that ObamaCare was a colloquial name for the ACA (Patient Protection and Affordable Care Act (PPACA)) which is commonly called the ACA. There may some people who extend that to mean an exchange purchased health insurance plan. Later this year I will have to either go back to work or buy an individual plan as my COBRA will run out. I've looked at the exchange for my present insurers plans and also look at what they sell directly to individuals... guess what, they are the same plans! Thru the exchange you may get a subsidy, direct you won't. They have the same networks from what I could tell (both greatly reduced from my COBRA plan)). I also did not see any additional plans on their site for individuals. But this is a sample of one insurer in one state. I agree that the narrowing of networks on insurance policies (on or off exchange and especially for individuals) has caused many problems. I'll have to see how these plans work for me when I fall off COBRA. BTW... both my Cardiologist and PCP is in network for the exchange or direct plan I have been looking at. I'm just not sure which insurance plans you are referring to when you use ObamaCare or ACA. On exchange? Any individual plan? Any plan (including employer plans) the meet the ACA's (the law's ) requirements? ,,, or what? But I can sympathize with the frustrations with health insurance in general. I think we have a long way to go for it to be affordable.

Maybe some clarity will help. After reviewing all plans, talking to my doctors, and what hospitals they service I chose Cigna Access Plus HSA Bronze 6000 plan that was closest to my plan in 2015. The cost was increased by 1,500.00 in Phoenix AZ. I contacted my doctors and asked them directly what insurance plan works best at their office. I was told if you chose an ACA/ObamaCare plan will not accept you as a patient any longer. I could have gotten an ACA plan, but the price was not much different but it included only HMO plans to doctors that no one I know had heard of and most name were extremely foreign. I chose to pay more for confirmed coverage with the doctors and hospitals I know. If I have a heart attack I did not want to have the lower care afforded by the ACA.

[Dogman]

My friend told me he has had it with everything. He and his wife have decided to sell his business (small repair business) pull all his money from his bank and put it in a safe at home. He is 61 and going to apply for medicaid, food stamps, and anyother state/federal program. Wait until he can draw SS, and live frugally.
This is the state lower income middle American has gotten to, it is a shame. He has a neighbor who brought his mother over from China and within months she is now on SS earning as much as he will when he can draw.

[John Galt III]

Maybe this is urban myth, but I read somewhere that the first 3 letters of your insurance ID can (sometimes?) allow the provider to tell whether you are on an Obamacare policy or not.

[Dogman]

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Originally Posted by razztazz Hee hee. This is gonna be good.

The brother in law had a stroke two years ago in Feb., then cancer was discovered in his thyroid in May, then in August they discovered cancer in on his colon. In January the time I was referring to in my original post he was taken to the hospital for a seizure at which time there were people in the corridors in beds and the ER was packed. My brother in law was 59 at the time of his original stroke and will be 61 in Feb. His employer insurance had a 7,000.00 ded. but is now running out as of Feb. 2016 he will go on cobra until May of 2016 at which time he will be able to go on Medicare as he is fully disabled. He has had a hell of a time and lucky he is still with us. The first ER room did little and let the vein in his neck burst. His family is now sueing the hospital for their lack of service and who conveniently loss the important scans now that they are getting sued.
It is a mess but he has extensive damage that should not have occurred if the clot buster drug was administered timely. He was in the emergency room for 6 hours before the vein burst.

[MichaelB]

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Originally Posted by Dogman Maybe some clarity will help. After reviewing all plans, talking to my doctors, and what hospitals they service I chose Cigna Access Plus HSA Bronze 6000 plan that was closest to my plan in 2015. The cost was increased by 1,500.00 in Phoenix AZ. I contacted my doctors and asked them directly what insurance plan works best at their office. I was told if you chose an ACA/ObamaCare plan will not accept you as a patient any longer. I could have gotten an ACA plan, but the price was not much different but it included only HMO plans to doctors that no one I know had heard of and most name were extremely foreign. I chose to pay more for confirmed coverage with the doctors and hospitals I know. If I have a heart attack I did not want to have the lower care afforded by the ACA.

Reviewing the summary of benefits and coverage (here), the Cigna Access Plus HSA Bronze 6000 is an "ACA Plan" for individuals in Arizona. Looks like you snuck this one past your doctors.