Out-of-pocket costs could be higher than you plan

[kevink]

For those who've signed up for ACA and are in a position to exercise some control over their taxable income in order to maximize subsidies this article may be of some interest:

http://www.pnhp.org/news/2014/april/...bout-obamacare

The focus of the piece is on those with both relatively low incomes and minimal assets, but it seems to me that the same issues apply to many ER's. The changes reported here have not been widely reported in the press, as best I can tell.

[MichaelB]

I don't see any useful advice, it looks like an ACA opinion and advocacy piece. Cost sharing is very high, barely or not at all affordable for many. There have been good forum discussions along those lines.

[travelover]

Quote:

Originally Posted by MichaelB I don't see any useful advice, it looks like an ACA opinion and advocacy piece. Cost sharing is very high, barely or not at all affordable for many. There have been good forum discussions along those lines.

+1

[kevink]

I was referring especially to this section, whose content I have not seen either widely reported or discussed on these forums:

"In what seems to have gone essentially if not entirely unreported, a densely written rule issued by the Department of Health and Human Services in March 2013 eliminated the reduced out-of-pocket maximum for those making above 250% of the federal poverty level. Additionally, for those making between 200 – 250% of poverty, the limit was raised from one-half to four-fifths of the $12,700 maximum (i.e. $6,350 to $10,160). These limits were then rounded up a bit more to account for “any potential inaccuracies” in estimates, to give us today’s actual limits:

To summarize: everyone who makes between 200% and 400% of the federal poverty level (i.e. a good portion of the middle class) quietly had their Obamacare out-of-pocket liability raised substantially: for a family of four with an income of $60,000, it suddenly doubled to $12,700.

[rbmrtn]

They are required to adjust the CSR ( Cost Sharing Reduction ) based on the actuarial values. Probably will change again.

42 U.S. Code § 18071 - Reduced cost-sharing for individuals enrolling in qualified health plans | LII / Legal Information Institute

(ii) Adjustment The Secretary shall adjust the out-of pocket [1] limits under paragraph (1) if necessary to ensure that such limits do not cause the respective actuarial values to exceed the levels specified in clause (i).

One thing the article seemed to skip was that you must purchase a silver plan to participate in the CSR.

[modhatter]

I was not aware of the change. I was frequenting another board dealing with health insurance and of course much discussion on ACA. The moderator works in the insurance business.

My position on the High Deductible plans was that it may work OK for people who earn a good income, it fails lower income people, as it discourages them from seeking medical help when perhaps it is needed.

Her position is, it lowers overall costs as it stops people from running to the doctor for every little sniffle. My position was that though I am sure there is a small percentage of such people, that I felt that by and large people are not to eager to go to the doctor unnecessarily. Personally, even with insurance coverage without large deductible (such as Medicare, which I am now on) I am more apt not to go to the doctor when perhaps I should.

She was of the opinion that the opposite was the norm. I have no statistics on this other than my own personal experience and that of my sister who has had a high deductible plan, and will not pursue a foot problem, as she would have to pay for the MRI herself because of her high deductible, so she lives with the pain as she doesn't have the money for the scan.

Though the article centered more on the Out of Pocket Max on the silver plan, when income is low enough, such deductibles are preventing care in many cases, and I can see a doctor's concern over this.

[daylatedollarshort]

Our family out of pocket max with an ACA plan is still less than our previous policy and our premiums are 2K a month less. I am not complaining.

For many families with pre-existing conditions an ACA high out of pocket max policy is still better than no insurance at all. There were 47 million uninsured people in the U.S. in 2012 according to the Kaiser Foundation. That is the equivalent of more people than the entire populations of Greece and Canada combined.

[aja8888]

Quote:

Originally Posted by daylatedollarshort Our family out of pocket max with an ACA plan is still less than our previous policy and our premiums are 2K a month less. I am not complaining. For many families with pre-existing conditions an ACA high out of pocket max policy is still better than no insurance at all. There were 47 million uninsured people in the U.S. in 2012 according to the Kaiser Foundation. That is the equivalent of more people than the entire populations of Greece and Canada combined.

A high percentage of those 47 million, probably 40 million, still have no insurance because of the following:

1. They can't afford the deductibles and out of pocket maximums, (many can't even afford the premiums).
2. They can go to the ER in lieu of paying for this insurance.

[brewer12345]

Quote:

Originally Posted by aja8888 A high percentage of those 47 million, probably 40 million, still have no insurance because of the following: 1. They can't afford the deductibles and out of pocket maximums, (many can't even afford the premiums). 2. They can go to the ER in lieu of paying for this insurance.

I believe a fair fraction of those folks simply qualified for Medicare under the expanded eligibility many of the states accepted.

[M Paquette]

Quote:

Originally Posted by aja8888 2. They can go to the ER in lieu of paying for this insurance.

The bill for this may be slightly higher than the insurance premiums plus deductibles plus copayments. For many years of insurance.

Without insurance they'll pay the “Saudi sheikh problem” rate.

http://www.nytimes.com/2013/12/03/he...-tops-500.html



"You don't really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who's going to pay full charges." -- California Pacific Medical Center CEO Warren Browner

[modhatter]

I don't think anyone is arguing that it is not better now than before, but the reality is that budgeting becomes much harder when the income is very low. There's just not a lot of cutting back you can do. I mean how much room is there in the budget for someone making $18/$20,000 a year. For these people having a $1,500 deductible is a big deal.

I'm concerned that raising those deductibles and Out of Pocket Max numbers will discourage poor people from getting insurance, and they will continue to use the emergency rooms. The deductible is the deterrent for poor people considering insurance. In my state the Silver brought the deductible down from $5,500 to $1,500. (someone making $18,000) But I saw in another state (one of the Southern states) where one plan brought it down to about $300 or $500 as I recall. So I guess it really all depends on what county and state you live in.

But when you really think about it. Someone earning minimum wage or close to it, paying even $50 a month, along with a co-pay and having to spend $500 first before it kicks in is probably not all that anxious to purchase a policy themselves, if they got whatever care they needed before for nothing. Of course these same people probably think nothing bad is going to happen either. I don't see any solution to this problem as long as emergency rooms continue to treat people for non-emergency issues. Seems like there just can't be a choice involved.

[aja8888]

Quote:

Originally Posted by brewer12345 I believe a fair fraction of those folks simply qualified for Medicare under the expanded eligibility many of the states accepted.

I think you mean Medicaid, not Medicare. Many states did not expand; Texas, where I am, being one of them. So we have a "few" million folks in this state with no insurance, but they still can go to the ER (and choose not to pay, BTW).

[brewer12345]

Quote:

Originally Posted by aja8888 I think you mean Medicaid, not Medicare. Many states did not expand; Texas, where I am, being one of them. So we have a "few" million folks in this state with no insurance, but they still can go to the ER (and choose not to pay, BTW).

You are right, I meant Medicaid. Thank your governor for that decision at the next election...

[aja8888]

Quote:

Originally Posted by brewer12345 You are right, I meant Medicaid. Thank your governor for that decision at the next election...

He will no more be the Gov.

[aja8888]

Quote:

Originally Posted by brewer12345 You are right, I meant Medicaid. Thank your governor for that decision at the next election...

He will no more be the Gov. He's cashing out this term....

[brewer12345]

Quote:

Originally Posted by aja8888 He will no more be the Gov. He's cashing out this term....

Dopey question: if a state opted out of Medicaid expansion, can they change their mind at a later date and opt in?

[modhatter]

Quote:

Originally Posted by M Paquette The bill for this may be slightly higher than the insurance premiums plus deductibles plus copayments. For many years of insurance. Without insurance they'll pay the “Saudi sheikh problem” rate. http://www.nytimes.com/2013/12/03/he...-tops-500.html "You don't really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who's going to pay full charges." -- California Pacific Medical Center CEO Warren Browner

Wow, that is a long article. Really bugs me not being able to know the financial facts. That article said that the uninsured charity cases represented only 1.2% of their billing. With other hospitals in the 2-5% catagory.

That doesn't sound very high to me. Where are these hospitals that are being forced to shut down? Are they located in poor areas?

I have read about the "consolidation problems" with the hospitals. Same applies to health insurance companies. This is leading to higher and higher costs. Buy out the competition, then raise rates even higher.

Seems like our health care industry is just one big run away train, and no one can catch it (or won't even try)

Brewer12345 There is no cut off date set as to when they can opt to participate.

[aja8888]

Quote:

Originally Posted by brewer12345 Dopey question: if a state opted out of Medicaid expansion, can they change their mind at a later date and opt in?

I don't know the answer to that. But, being the government, I would guess they could do whatever they want. Maybe someone more knowledgeable here could answer that with accuracy.

I think "opting in" originally meant the federal government would pay the cost of the new Medicaid entries for two years, then the state would be obligated to pick up that cost going forward.

[daylatedollarshort]

Quote:

Originally Posted by aja8888 A high percentage of those 47 million, probably 40 million, still have no insurance because of the following: 1. They can't afford the deductibles and out of pocket maximums, (many can't even afford the premiums). 2. They can go to the ER in lieu of paying for this insurance.

And surely for many it is an issue with a lack of knowledge about how to sign up. Jimmy Kimmel did man on the street interviews last fall on "What do you think is a better plan, Obamacare or the Affordable Care Act" and got some pretty crazy answers from otherwise normal middle class looking people -

Jimmy Kimmel asks people which they prefer: Affordable Care Act or Obamacare? - ABC15 Arizona

Besides many states not expanding Medicaid, laws restricting health care navigators and college beer parties encouraging young people to opt out are not helping to get the uninsured understand their options. On this forum most people know their insurance options in great detail but on other forums a lot of the posters are as informed about the ACA as Jimmy Kimmel's man on the street skit.

[modhatter]

Quote:

Originally Posted by daylatedollarshort And surely for many it is an issue with a lack of knowledge about how to sign up. Jimmy Kimmel did man on the street interviews last fall on "What do you think is a better plan, Obamacare or the Affordable Care Act" and got some pretty crazy answers from otherwise normal middle class looking people - Jimmy Kimmel asks people which they prefer: Affordable Care Act or Obamacare? - ABC15 Arizona Besides many states not expanding Medicaid, laws restricting health care navigators and college beer parties encouraging young people to opt out are not helping to get the uninsured understand their options. On this forum most people know their insurance options in great detail but on other forums a lot of the posters are as informed about the ACA as Jimmy Kimmel's man on the street skit.

That's a good point. I have spent considerable time on a health insurance forum in the last six months, and also in talking with people about it, I am amazed at how little people know. Many are downright clueless about it, and say some crazy stuff about what they have heard or what they think it is. It is difficult for most people on here to understand how this could be as they are a "high information" crowd, as opposed to a "low information" crowd.

With reference to the medicaid question. The government pays for it up until 2017, and then reduces it down to paying 90% by 2020. It explains it here:

10 Frequently Asked Questions About Medicaid Expansion | Center for American Progress