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Hospitals out of room!
Old 01-09-2016, 12:55 PM   #1
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Hospitals out of room!

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). The hospital was over run with patients in the hallways and we were told there was were 200 people Waiting for rooms. My brother in law waited for 48 hrs in the emergency room, before getting a room. We were told this was the same situation in the other hospital in Chandler. What was interesting is that after the insurance card was run (Cigna), Attitudes seem to change and level of care. I also have been told by several doctors they won't take Obamacare! We now have to pay $16'700.00 with 7500.00 deductible HSA to get our same doctors.
As someone who is about to retire early how much more in health ins can one pay?


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Old 01-09-2016, 02:20 PM   #2
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I was unaware that Obamacare was some sort of insurance policy that doctors could accept for payment or not. I always thought it was just a colloquial name for the Patient Protection and Affordable Care Act (PPACA), a federal law. To the best of my knowledge, the PPACA required states to set up health insurance exchanges where you can obtain a private insurance policy from a variety of commercial insurance companies if you don't otherwise have insurance from Medicare/Medicaid or your employer. Perhaps you can clarify what you mean when you say "I also have been told by several doctors they won't take Obamacare."
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Old 01-09-2016, 02:35 PM   #3
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Docs are free to decline insurance plans with payment rates they consider inadequate. Some, for example, won't accept new Medicare or Medicaid patients. My own doc, when I told the staff I had Coventry, said they didn't take Coventry plans bought from the Exchange. (Mine was a private plan.)

I used to work for a UK-based boss. He and the other execs had a supplemental plan on top of the NHS. When his wife called a doc to get their son checked out because of some concerns, they offered her an appointment 2 weeks away. When she mentioned the supplemental policy, they gave get an appointment that day.

So, insurance doesn't guarantee the same level of access for everyone.
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Old 01-09-2016, 02:43 PM   #4
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I am aware of the problem with doctors and Medicare/Medicaid reimbursement rates.

But how would a doctor know if you got a commercial plan from Anthem through the state exchange established under Obamacare, through your employer or directly on your own? All they will know is that it is Anthem, and if the doctors are satisfied with Anthem's reimbursement rates, they should take it. Unless the reimbursement rates vary somehow by source, but I am not aware that they do.
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Old 01-09-2016, 02:50 PM   #5
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But how would a doctor know if you got a commercial plan from Anthem through the state exchange established under Obamacare, through your employer or directly on your own? All they will know is that it is Anthem, and if the doctors are satisfied with Anthem's reimbursement rates, they should take it. Unless the reimbursement rates vary somehow by source, but I am not aware that they do.
Not thought about that before. Does the insurance card you hand over indicate if it was bought through an exchange or not?
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Old 01-09-2016, 02:50 PM   #6
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Unless the reimbursement rates vary somehow by source, but I am not aware that they do.
I'm guessing that's how it works.
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Old 01-09-2016, 02:54 PM   #7
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Not thought about that before. Does the insurance card you hand over indicate if it was bought through an exchange or not?
my Healthspan aca plan does not have anything like that on it.
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Old 01-09-2016, 02:55 PM   #8
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I'm guessing that's how it works.
I just looked at my BCBS card which is not through an exchange but I expect that the Group Number and Plan number on the card is what lets the doctor know if it is a plan that he is part of.
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Old 01-09-2016, 02:55 PM   #9
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I have seen the impact of higher end insurance on level of care long before the ACA/Obamacare passed.

Not always to the patients benefit.
Case in point: DH's uncle had full-blown cadillac insurance. He was having some GI issues. When the doctor found out his insurance was super premium he started pushing for aggressive surgeries for a problem that didn't warrent them. Uncle ended up with an ostomy bag after an unnecessary surgery. He regretted consenting to the surgery. When he saw another doctor after the fact - this other doctor agreed the surgery was more about lining the doctors pocket - not quality of life for uncle.

HDHPs, in theory, make the insureds more careful about what they agree to pay for... after all - the insured is on the hook for the high deductible. HDHPs also were around before the ACA.
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Old 01-09-2016, 03:01 PM   #10
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I am aware of the problem with doctors and Medicare/Medicaid reimbursement rates.

But how would a doctor know if you got a commercial plan from Anthem through the state exchange established under Obamacare, through your employer or directly on your own? All they will know is that it is Anthem, and if the doctors are satisfied with Anthem's reimbursement rates, they should take it. Unless the reimbursement rates vary somehow by source, but I am not aware that they do.
I don't know if they know that you have a exchange plan or not, but they do know if you more than what insurer. I'm on COBRA from a past employer with AETNA. They have many different networks that are somewhat defined by plan name. Aetna may have 10 or more networks. The ACA (exchange) plan has a different network than my COBRA plan, but I believe is the same as the ACA like plan from the insurer directly.
The takeaway... don't assume insurer defines the network of doctors of agreed upon rates. Each plan (ACA or not) likely changes doctors willing to support and rates for doctors.
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Old 01-09-2016, 03:06 PM   #11
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Not thought about that before. Does the insurance card you hand over indicate if it was bought through an exchange or not?

When the admissions person enters the information into the computer what will appear is coverage limits, reimbursements, much more- along with data that shows if it an employer sponsored plan or an exchange plan.

So.. Yes.


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Old 01-09-2016, 03:13 PM   #12
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When the admissions person enters the information into the computer what will appear is coverage limits, reimbursements, much more- along with data that shows if it an employer sponsored plan or an exchange plan.

So.. Yes.


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Does it actually show that the plan was from exchange vs the insurer site? I now the card will show the network. With Aetna it seems to be somewhat plan dependent for what the network is. In my state the network is the same for exchange or insurer website. However, employer plans all seem to have different networks. I would expect all the employer based insurances that have different networks may have different reimbursement rates.
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Old 01-09-2016, 03:20 PM   #13
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I don't know if they know that you have a exchange plan or not, but they do know if you more than what insurer. I'm on COBRA from a past employer with AETNA. They have many different networks that are somewhat defined by plan name. Aetna may have 10 or more networks. The ACA (exchange) plan has a different network than my COBRA plan, but I believe is the same as the ACA like plan from the insurer directly.
The takeaway... don't assume insurer defines the network of doctors of agreed upon rates. Each plan (ACA or not) likely changes doctors willing to support and rates for doctors.
Thanks. That makes more sense to me. I am still on an employer group plan (which is take it or leave it) so I am not familiar with the details of obtaining individual insurance. I also live in CT. In our state measuring 50 miles by 100 miles, there are 32 hospitals, so the crowding issue is not such a problem.
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Old 01-09-2016, 03:28 PM   #14
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Does it actually show that the plan was from exchange vs the insurer site? I now the card will show the network. With Aetna it seems to be somewhat plan dependent for what the network is. In my state the network is the same for exchange or insurer website. However, employer plans all seem to have different networks. I would expect all the employer based insurances that have different networks may have different reimbursement rates.
You are correct that employer based insurances have different networks and different reimbursement rates. As an example, insurance A might have what is called the "premium" network that they "sell" to an employer, the "selling" point is that those providers have better outcomes (those providers have provided to the insurance company data to show their patient/treatment outcomes). Additionally, those providers are often paid more.

I understand your question to be "can they tell if I signed up via the insurer website versus the exchange website", I would say that if its a state exchange yes, they can tell, if it is a non state exchange then I have to admit I am not 100% confident I know the answer to that.

I have heard many people who went from an employee sponsored plan to an exchange plan (many meaning probably 8) being turned away at speciality doctors who they have seen for years, such as a dermatologist, being told that the doctor or more likely "group" does not take ACA plans.
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Old 01-09-2016, 03:32 PM   #15
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In our state measuring 50 miles by 100 miles, there are 32 hospitals, so the crowding issue is not such a problem.
Wow, CT must be a dangerous place to live if they need that many hospitals. So many sick and injured!

Or maybe a lot of people with very good insurance plans....
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Old 01-09-2016, 03:43 PM   #16
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You are correct that employer based insurances have different networks and different reimbursement rates. As an example, insurance A might have what is called the "premium" network that they "sell" to an employer, the "selling" point is that those providers have better outcomes (those providers have provided to the insurance company data to show their patient/treatment outcomes). Additionally, those providers are often paid more.

I understand your question to be "can they tell if I signed up via the insurer website versus the exchange website", I would say that if its a state exchange yes, they can tell, if it is a non state exchange then I have to admit I am not 100% confident I know the answer to that.

I have heard many people who went from an employee sponsored plan to an exchange plan (many meaning probably 8) being turned away at speciality doctors who they have seen for years, such as a dermatologist, being told that the doctor or more likely "group" does not take ACA plans.
I can absolutely agree with this. I think the comment earlier that they could tell if you got the insurance from that exchange or off exchange. From what I've seen employers insurance has bigger networks in general. My real point was that (at least in my case) the individual (non-employer) plans on and off the exchange seem the same. Many of them have somewhat limited network. I'm not going to question if the doctors are better or not, but they are fewer. I've had some less expensive medical personal that are better than some or the more expensive ones over the years.... and sometimes the other way around.
I think the narrowing of networks are not a positive for ACA being a success at its goal, especially the limiting it to one state.... no real coverage when travelling.
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Old 01-09-2016, 04:46 PM   #17
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I just looked at my BCBS card which is not through an exchange but I expect that the Group Number and Plan number on the card is what lets the doctor know if it is a plan that he is part of.

That's the critical part. If he's in network for a plan, he's in the network and doesn't get to refuse it if you reveal that it's an ACA compliant plan, or (horrors) you bought it on an exchange.

If he's not in the network, then expect to not get network coverage and payment terms. (Sort of obvious to at least some of us...)




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Old 01-09-2016, 05:37 PM   #18
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I've never heard of a hospital with 200 patients waiting for rooms without some kind of natural disaster--and the same situation at the other hospital in town. If I couldn't be promptly seen, my rear end would be in an air ambulance to some place for immediate treatment elsewhere.

There are a couple of Medicare situations in place. One is where the patient has Medicare and a private insurance supplement. Then you have people on the Medicare Advantage Plan. Hospitals can take Medicare and supplements and refuse to participate in the Medicare Advantage Plans.

For example: Vanderbilt Hospital has gone on a whirlwind purchase of physicians practices in Nashville, Middle Tennessee and Central Kentucky. So far, they call the shots for 1,700 physicians and nurse practitioners working for them. And they now refuse to accept Medicare Advantage Plans due to low payment rates.

This means 100's of thousands of patients are having to find new doctors and in many cases hospitals in other cities because there are no non-Vandy health providers available. And many patients' specific problems are not being addressed by capable physicians specializing in their health problems. It's just a serious problem for those that chose the Medicare Advantage plans.

I see the payments that my internists receive from Medicare and it's a travesty they're paid so little. And then you see Medicare payments made to nephrologists, cardiologists and other specialists that are substantial. Our local large hospital is also paid very little for hospitalizations vs. the big city hospitals of equal size 2 hours away. There are just so many inequities in the medical field.
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Old 01-09-2016, 06:36 PM   #19
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As someone who is about to retire early how much more in health ins can one pay?
I pay one half of what my former employers COBRA cost in '13. Better coverage, lower co-pays deductibles. I see the same DR. as before, but every hospital in KC is in network and I've yet to find a DR. that's out of network.
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Old 01-09-2016, 06:50 PM   #20
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As someone who is about to retire early how much more in health ins can one pay?
I retired in 2014. I was on Kaiser Permanente for my employer insurance. I did cobra for the rest of the year - then switched to an exchange plan.... With Kaiser Permanente.

I made the choice to go with a HDHP with HSA, but could have paid premiums similar to the COBRA premiums and had a similar copay/benefit. The doctors/facilities are exactly the same because Kaiser Permanente is a closed network - all the doctors/facilities are employees, rather than just "accepting" an insurance.

What the ACA offered me was
a) tax credits if my income is below a certain level.
b) the ability to get affordable insurance given my medical history and my husband's medical history. Pre-existing conditions might have prevented me to buy insurance except through the pre-ACA high risk pool - and even that meant going without insurance, being turned down by insurance for 18 months.

Health insurance has been an issue for many early retirees. No more subsidized employer provided insurance and the budget item has to be accounted for. This is/was true before and after the ACA.
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