The Individual Health Insurance Market vs PPACA

[AllDone]

Nothing prevents the insurance companies from raising the premiums on their underwritten insurance.

In 2006 one of my patients was diagnosed with multiple myeloma (10-15 year life expectancy, but uncurable). A year or two later the premiums for the small business she worked for were raised so high that they had to drop health insurance. She was unable to get insurance on her own. She had also had asthma since childhood -- no cigarettes ever -- and when she had an asthma attack, she refused to go to the ER. She knew that ER care was not free and she was a widow on a tight budget who always paid her bills. When her daughter stopped by the next morning to pick her up to bring her to my office, she was dead in her bed. Of. Asthma. I think of her whenever I hear poisonous things said about the ACA. She was born a citizen, took care of her health, tried hard to buy private insurance, worked full-time and paid her bills, so she was allowed to die of a treatable problem. Had she lived four years longer or become sick enough to be declared disabled, she would have qualified for Medicare.

I understand that some very lucky people (so far!) are loosing decent, cheap insurance and that some more people are loosing crappy, cheap insurance. However, the old system was broken. According to the Robert Woods Johnson Foundation at least 1/3 of people who are uninsured have not been allowed to buy insurance. Many of them, like my BIL, are completely healthy. As a result, people are forced to work for large corporations in order to maintain insurance for themselves or family members when they would rather change jobs, work for a small company, start a business of their own, or even, RETIRE. Others choose to take their chances and risk their financial futures by going without insurance. I know a lot of people who fall into all of those categories

There are those who claim that the uninsured are non-citizens, too lazy too work, too lazy or cheap to purchase insurance, and that anybody can get free care at an ER. I know plenty of people for whom none of that is true and so do you.

[ziggy29]

Quote:

Originally Posted by ERhoosier Most states will not escape this Exchange network shuffle unscathed. It appears Texas provider networks are NOT all going to be the same for Exchange vs non-Exchange Plans for same carrier (e.g. Texas Oncology, a major cancer group, NOT joining any Exchange Plans). Texas Doctors, Hospitals Don't Know If They're In Or Out Of Obamacare Plans - Kaiser Health News

Straight from the horse's mouth, Texas Oncology (in a later press release) says they have not decided:

Texas Oncology Addresses Misstatement by Sen. Ted Cruz

Quote:

We have made no decision regarding participation in the marketplace, because it is not clear how the new plans will cover cancer treatment, together with related care that our patients need. We also have concerns about parts of the law that could put patients at significant financial risk. We ... explained that we have not completed our assessment of the plans and no decision has been made.

As far as cancer treatment in Texas goes, it does appear that MD Anderson will be in network for the Exchange-based BCBS TX plans, which may not be a big consolation if you are too far from Houston.

[audreyh1]

Quote:

Originally Posted by ziggy29 As far as cancer treatment in Texas goes, it does appear that MD Anderson will be in network for the Exchange-based BCBS TX plans, which may not be a big consolation if you are too far from Houston.

People go to MD Anderson from all across the state. A neighbor was there recently even though we are far.

[travelover]

Quote:

Originally Posted by ziggy29 No, not as long as the group your individual plan is a part of remains in existence and as long as you keep making payments (and don't commit fraud in your claims)........

I think some of the abuse was defining that "fraud" as not reporting a pimple on your butt when you were 15 years old.

[aja8888]

Quote:

Originally Posted by ziggy29 As far as cancer treatment in Texas goes, it does appear that MD Anderson will be in network for the Exchange-based BCBS TX plans, which may not be a big consolation if you are too far from Houston.

My BIL from North Carolina is at M.D. Anderson today and will be all week. Who says people don't travel far to go to that excellent facility?

[nvestysly]

Quote:

Originally Posted by ERhoosier Most states will not escape this Exchange network shuffle unscathed. It appears Texas provider networks are NOT all going to be the same for Exchange vs non-Exchange Plans for same carrier (e.g. Texas Oncology, a major cancer group, NOT joining any Exchange Plans). Texas Doctors, Hospitals Don't Know If They're In Or Out Of Obamacare Plans - Kaiser Health News

I heard something on the national news that indicated Emory Health Care (Associated with Emory University) in Atlanta was not accepting some exchange plans. When I investigated further I found the following list -

http://www.emoryhealthcare.org/patie...ance-plans.pdf

There are probably many non-exchange plans they don't accept too. Based on this single data point it makes me wonder what the significant factors are in the "Nationwide" exchange plans. I see Emory accepts several Humana nationwide plans. Figuring out provider networks was always a struggle during open enrollment at mega-corp. It's no easier now that I'm FIREd.

[M Paquette]

It's pretty much up to the insurers as to whether or not they want to play this sort of fun and games with policies offered. I do know that the HMO I selected offers the exact same set of individual plans both inside and outside the state exchange.

Now that you can easily comparison shop for prices and coverage terms, I suppose that playing with provider networks on a policy by policy basis is the exciting new way to do information hiding. Oh, and don't forget to re-check the provider and services networks annually once you have bought a policy. Back when I was covered by a UHC policy, we lost doctors pretty regularly, and one year we had all labs within about 50 miles become 'out of network'.

[MichaelB]

Quote:

Originally Posted by M Paquette It's pretty much up to the insurers as to whether or not they want to play this sort of fun and games with policies offered. I do know that the HMO I selected offers the exact same set of individual plans both inside and outside the state exchange. Now that you can easily comparison shop for prices and coverage terms, I suppose that playing with provider networks on a policy by policy basis is the exciting new way to do information hiding. Oh, and don't forget to re-check the provider and services networks annually once you have bought a policy. Back when I was covered by a UHC policy, we lost doctors pretty regularly, and one year we had all labs within about 50 miles become 'out of network'.

Exactly. This is nothing new, but it is fashionably newsworthy. My first out of network experience occurred just after I left my job and continued as we were knocked around the NY individual insurance marketplace. Insurers use networks to negotiate prices with health care providers. My guess is this will become even more intense in the next couple of years, especially now that coverage is subject to standards and is much easier to compare.

[bamsphd]

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Originally Posted by ziggy29 No, not as long as the group your individual plan is a part of remains in existence and as long as you keep making payments (and don't commit fraud in your claims). As long as that is the case, existing law still prohibits insurers from selectively non-renewing "sick" people who develop expensive conditions. (Yes, if enough people in the group get too sick and expensive, the insurer can drop the entire group, but no one can be singled out for being sick.)

The two biggest ways you could lose coverage that I'm aware of are/were Rescissions and group replacement. (There may be a formal term for what I'm calling group replacement.)

For Rescissions see United Health Care's page Consumer Protections: Rescissions | Health Care Reform Provisions
and especially the four paragraph insurance section of Rescission - Wikipedia, the free encyclopedia

Basically, when a customer was diagnosed with an expensive condition, a health insurance company would use third party software to search the original application for any misstatement of fact whether intentional or inadvertent. If any misstatement was found, bye-bye insurance retroactive to the start of coverage with that company. Good luck getting insurance with a condition like breast cancer, much less retro-active insurance!

The group replacement game was to jack-up the premiums very significantly for everyone in an existing group, and to selectively offer the healthy people in the old group new coverage in a different group with low premiums. The old group then either becomes a defacto high-risk group, or the entire old group is terminated.

I don't think the PPACA has entirely solved these issues, but now that age, smoking, and location are pretty much the only material questions on an application Rescission should be far less of a problem than when insurance companies routinely asked for pages of medical information on their applications. The ability to get insurance through the potentially large groups on the exchanges regardless of health status should also help considerably with the group replacement problem.

[ERhoosier]

Quote:

Originally Posted by ziggy29 Straight from the horse's mouth, Texas Oncology (in a later press release) says they have not decided: Texas Oncology Addresses Misstatement by Sen. Ted Cruz

I wonder if Kaiser also misstated Texas Oncology's position in Oct?

"Texas Oncology, one of the largest cancer treatment groups in the state, has chosen not to participate in any health plans offered in the marketplace because “there are many unknowns related to how the Health Insurance Market Place will cover cancer treatment.”

Texas Doctors, Hospitals Don't Know If They're In Or Out Of Obamacare Plans - Kaiser Health News

And in Nov, KHOU of Houston reported that "thousands" of TO's patients had received a letter stating:
"Texas Oncology will not participate as an in-network provider for the HIMP (Health Insurance Market Place) ... We understand that these changes have a significant impact to our patients, both clinically and financially."
Later a TO rep said in an interview that it had made "no decision" regarding participation in Marketplace Plans.

Insurance loophole jeopardizes cancer treatment | khou.com Houston

Looks to me like TO had backpedaled its stance in the few days before Cruz's interview, and his camp had not caught it in time.
Ted Cruz: The Obamacare Mess Is Only Going to Get Worse - Garance Franke-Ruta - The Atlantic

If a US Senator's aides cannot keep up with these situations, it's gonna be tough (impossible?) for ordinary folks to make informed decisions on choosing Plans which include their desired providers.

[audreyh1]

Quote:

Originally Posted by M Paquette Now that you can easily comparison shop for prices and coverage terms, I suppose that playing with provider networks on a policy by policy basis is the exciting new way to do information hiding. Oh, and don't forget to re-check the provider and services networks annually once you have bought a policy. Back when I was covered by a UHC policy, we lost doctors pretty regularly, and one year we had all labs within about 50 miles become 'out of network'.

BCBS told me provider networks could change twice a year. And that it was up to the doctor whether he/she stayed in network.

[Mike10]

Quote:

Originally Posted by aja8888 My BIL from North Carolina is at M.D. Anderson today and will be all week. Who says people don't travel far to go to that excellent facility?

There is no question that people will go great distances if there is hope for a better outcome. What I have not seen discussed, and I may have missed it, is how does the ACA policies cover this gentleman from North Carolina in the future if he wants or needs treatment in Texas.

[ERhoosier]

Quote:

Originally Posted by audreyh1 BCBS told me provider networks could change twice a year. And that it was up to the doctor whether he/she stayed in network.

Can't speak to your local region, but in many cases it's not always doc's choice.

UnitedHealth drops thousands of doctors from insurance plans: WSJ - Yahoo Finance

More on this topic -
http://www.early-retirement.org/foru...pen-68872.html

[audreyh1]

Quote:

Originally Posted by Mike10 There is no question that people will go great distances if there is hope for a better outcome. What I have not seen discussed, and I may have missed it, is how does the ACA policies cover this gentleman from North Carolina in the future if he wants or needs treatment in Texas.

MD Anderson is a "Blue Distinction Center". Many BCBS plans may consider it in network.

[meierlde]

It should be noted that studies have shown for equivalent quality measures, in joint replacement surgeries the hospital charges vary by a factor of 3. So CalPers has set a maximum reimbursement at around 1.5 times the charge at the cheapest institution. Interestingly this is the insurance industry shopping for the most cost efficient results.
I suspect that a lot of the "name" providers charge more relative to the competition, and with the increasing availability of quality measures, may not provide that much better care. In a few cases schemes like that cited above forced the high cost providers to cut their charges. (The big variation was in institutional charges not in physician payments)

[AllDone]

Quote:

Originally Posted by MichaelB Exactly. This is nothing new, but it is fashionably newsworthy. My first out of network experience occurred just after I left my job and continued as we were knocked around the NY individual insurance marketplace. Insurers use networks to negotiate prices with health care providers. My guess is this will become even more intense in the next couple of years, especially now that coverage is subject to standards and is much easier to compare.

I always worked for mega-group practices and we played that game with at least one insurer every year, long before the ACA was being debated.

Just try having an emergency surgery. If you get that appendix whacked out in the middle of the night, you get whichever anesthesiologist is on-call. That anesthesiologist is probably not in-network. Big bill, so sorry.

[MichaelB]

Quote:

Originally Posted by audreyh1 BCBS told me provider networks could change twice a year. And that it was up to the doctor whether he/she stayed in network.

Twice a year? That means you could shop and compare, choose a policy in part based on network composition, only to find it changing mid-year to your disadvantage.

[audreyh1]

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Originally Posted by MichaelB Twice a year? That means you could shop and compare, choose a policy in part based on network composition, only to find it changing mid-year to your disadvantage.

Unfortunately, yes.

[M Paquette]

Quote:

Originally Posted by MichaelB Twice a year? That means you could shop and compare, choose a policy in part based on network composition, only to find it changing mid-year to your disadvantage.

Yup. And, this applies to all medical insurance, whether individual, small business, or group coverage.

One of the first things my old doctors offices did (pre-HMO) was to check the insurance coverage on checking in for a visit. They'd check the coverage and tell me the copay du jour. (Well, until the last visit, when they told me I wasn't covered any more. PPOs...)

This is one more reason why I am happy with our HMO, which runs it's own offices, clinics, labs, and hospitals. They'd have trouble declaring something in their facilities to be out of network...

[ziggy29]

Quote:

Originally Posted by MichaelB Twice a year? That means you could shop and compare, choose a policy in part based on network composition, only to find it changing mid-year to your disadvantage.

Perhaps the rules for allowing "special enrollment periods" for status changes should be changed to include having a doctor who is no longer in-network. Either that or the open enrollment frequency should change to be the same as the frequency in which providers can go in and out of network. If they want to promote and encourage use of in-network providers.....