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what is the worst that can happen under ACA
Old 08-06-2013, 11:04 AM   #1
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what is the worst that can happen under ACA

This may be a very naive question, but we are blessed with 4 healthy family members so far. DW and I plan to purchase ACA beginning maybe 2015.

My plan is to purchase Silver plan from CoveredCalifornia: Affordable Health Insurance | Covered California? for a family of 4.

Looks like the monthly premium will be $570 monthly ($6840 annually) with $8000 out of pocket. We therefore budget $15,000 HI cost moving forward.

Before ACA, you often hear stories for folks with insufficient insurance. After a major illness strikes with very high cost, they exhausted all their life time savings. Will ACA put a cap on that or this will still happen if a major illness strikes?
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Old 08-06-2013, 12:12 PM   #2
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I would think you need to ask the Administrators of the insurance you plan to get.
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Old 08-06-2013, 12:33 PM   #3
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Out of pocket minimums and essential benefits provisions will surely reduce the incidence of health problems driving people into poverty. However, it won't eliminate it. By the same token, the affordability and guaranteed issue provisions will at least ensure that those fewer incidences aren't veritable death sentences.
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Old 08-06-2013, 12:35 PM   #4
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The risk of an insurance company cancelling a policy or refusing to pay almost gone beginning this January, and the minimum essential health benefits cover most chronic illnesses. Looking forward, one thing that can go wrong is needing - or wanting - care out of network which isn't covered. Current regulations cover emergency care out of network but not any other kind, and some of the policies have small or geographically limited networks. Finding out you have a life-threatening illness and your policy won't pay for treatment at the best medical providers would be disconcerting.
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Old 08-06-2013, 01:04 PM   #5
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The risk of an insurance company cancelling a policy or refusing to pay almost gone beginning this January, and the minimum essential health benefits cover most chronic illnesses. Looking forward, one thing that can go wrong is needing - or wanting - care out of network which isn't covered. Current regulations cover emergency care out of network but not any other kind, and some of the policies have small or geographically limited networks. Finding out you have a life-threatening illness and your policy won't pay for treatment at the best medical providers would be disconcerting.
That is interesting. I didn't realize that there wouldn't be the option to see out of network providers at a higher deductible or co-insurance rate.

What I wonder is how that works for providers that don't join any networks. For example, around here, anesthesiologists don't join networks. Under some policies for anesthesiologists, radiologists, pathologists the policy will pay as if they were in network but they actually aren't in network since they don't join networks.
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Old 08-06-2013, 01:17 PM   #6
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That is interesting. I didn't realize that there wouldn't be the option to see out of network providers at a higher deductible or co-insurance rate.

What I wonder is how that works for providers that don't join any networks. For example, around here, anesthesiologists don't join networks. Under some policies for anesthesiologists, radiologists, pathologists the policy will pay as if they were in network but they actually aren't in network since they don't join networks.
It's complicated because there is no uniform way to deal with it. New PPACA regs do consider the case where an out of network specialist is involved by the hospital, as in the case of an anesthesiologists assisting a colonoscopy, and the patient has no say. In this case the OON specialist must agree to the same fee as the in network doc.

For HMO care, it all depends on the wording of the agreement. For PPOs there usually is a second deductible amount, which for us has been 2 x the in-network deductible. So, with our $5k, another $10k. Then, the insurer reimburses a %, not of the amount you paid, but instead of some reference cost they determine. That reference amount is subject to much controversy, because it is based on a data base managed by an insurance group. They have been sued in more than one state for conflict of interest but little has changed. Going out of network can be a very expensive proposition.
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Old 08-06-2013, 01:19 PM   #7
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Finding out you have a life-threatening illness and your policy won't pay for treatment at the best medical providers would be disconcerting.
Evidently Cedars-Sinai Medical Center, which I understand is one of the best hospitals in LA, is not part of any exchange networks.
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Old 08-06-2013, 05:49 PM   #8
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PPACA insures that people will be able to get coverage regardless of group membership or pre-existing conditions and sets minimum coverage and out-of-pocket limits. It is based on and relies on the existing private insurance marketplace so lots of complaints/issues concerning current insurance (e.g. in vs out of network) will continue.
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Old 09-17-2013, 04:42 PM   #9
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Not sure if this is the proper topic to ask this question but I didn't want to start another Obamacare topic....

Currently, when you have medical care and have insurance, there is a "retail" cost and then there is a negotiated rate or allowed amount. The allowed amount is what counts. You pay your portion of the allowed amount. This difference can be very significant. For example, a blood test has a retail price of $98 and your insurance allows only $10 and that's what you pay, the $88 difference is noted as the insurance discount.

Supposedly the $98 retail price is for people without insurance.

When Obamacare is fully implemented (and I hope it's running well) if everyone has to have insurance then will there be a retail rate and an allowed rate? Will different insurance carriers have different allowed rates?

The reason I'm asking this is that DH and I will be considering his retiree insurance (open enrollment 10/01/13 to 10/31/13) vs. ACA insurance and I want to create a few spreadsheets to show examples of our options using previous years medical bills. Some of the options will have higher deductibles instead of a co-pay. All I have to go by is what the allowed amount was on previous bills and I don't have any info about how this will all play out in 2014 or 2015.

How does this work in Massachusetts?
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