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Old 11-15-2013, 12:30 PM   #141
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They get added together according to both my state website and Blue Cross's own website.
You should call them - I'm pretty sure that is not right - certainly not the way my BCBS policy works.
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Old 11-15-2013, 12:33 PM   #142
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+1 to everything anethum wrote. I've never know it to be different. Do agree that Medicare is so much better in this respect, something I'm looking forward to. While it doesn't have a $ OOP limit, it does limit specific coverage, such as hospital stays.
We didn't see limits on some of the cancer treatments. I just remember they were facing up to $36K a year in copays - mainly for chemotherapy drugs.

Anyway - it was resolved for them by one of those dubious "foundation grants" that pretty much look like kickbacks to me - to cover the copays while Medicare gets to pay the drug company's outrageous price for the rest.
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Old 11-15-2013, 12:38 PM   #143
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There was a story in the news about a San Diegan woman who lamented the loss of her pre-ACA plan with United Healthcare who got completely out of California individual HI market. She was kept alive with Stage 4 cancer for 7 years, at a total cost of $1.2M.

Her new ACA plan will not be accepted at the places that have been treating her.
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Old 11-15-2013, 12:42 PM   #144
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There was a story in the news about a San Diegan woman who lamented the loss of her pre-ACA plan with United Healthcare who got completely out of California individual HI market. She was kept alive with Stage 4 cancer for 7 years, at a total cost of $1.2M.

Her new ACA plan will not be accepted at the places that have been treating her.
The same thing could have happened pre-ACA. Carriers routinely abandoned unprofitable markets. I'm not saying it would have, just acknowledging that it could have.

I wonder if she checked on networks before signing up for an ACA plan. If there are ACA plans that her provider accepts it may not be too late for her to make a change, but it won't be easy to change.
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Old 11-15-2013, 01:11 PM   #145
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The patient is Edie Sundby, a Stage-4 gallbladder cancer, in case anybody is curious to check on the Web for any follow-up story. I read her story again, and the problem seems to be that there's no ACA plan that has access to both places that are treating her.

The cost of $1.2M, and on going at that, is high. I wonder if other countries would spare no expenses to keep a terminal patient alive.

We would like to say that a human life is invaluable, but the fact is that if you are a victim of an fatal accident, such as a car crash, a freak accident in a public building, an airplane crash, the amount of compensation is only going to be about that much, I think. And that could be for a person in perfect health, with a long productive life in front of him, and who may have a young family to support.

It's a tough dilemma.
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Old 11-15-2013, 01:19 PM   #146
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NW-Bound,

I agree, especially when we see how some cancer(or other serious illness) respond to modern medicine. Hopefully this and similar issues get resolved quickly.

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Old 11-15-2013, 01:31 PM   #147
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You should call them - I'm pretty sure that is not right - certainly not the way my BCBS policy works.
I did call Blue Cross and they confirmed my understanding. I also discussed it today with a retired M.D. friend in my zip code who already signed up directly with Blue Cross for a PPO policy beginning 1/1/14, and his understanding was the same as mine.
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Old 11-15-2013, 01:37 PM   #148
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I did call Blue Cross and they confirmed my understanding. I also discussed it today with a retired M.D. friend in my zip code who already signed up directly with Blue Cross for a PPO policy beginning 1/1/14, and his understanding was the same as mine.
This might vary by state, as I have never seen this language in our policies. I'll add it to my list of questions to ask over the phone. BCBS is not the same across states.
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Old 11-15-2013, 02:05 PM   #149
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I don't know how representative we are here in Missouri, but there are some plans in my metro area that might be reasonable. For example, the lowest cost Silver plan ($16000 MAGI, age 57 male) from Coventry One has a premium of $45/mo, and a zero deductible! No charge for PCP OV's, and $5 generics. But you may be right, that some people are sufficiently satisfied with the low or no cost clinic/public hospital option instead. Having worked in those environments, that is not my impression -- but I encountered a lot of unhappy patients in the elite suburban hospitals, too! I guess we'll see...
I just looked on my web sit again, and the lowest deductible for the lower cost plans $4750 Deductible. If you move up to a platinum plan on there, they have a plan with a $100 Deductible from a Nevada Insurance Co, and if you move into BCBS gold plan, they have one that has a $750 deductible, but cost $355 a month and which would cost the individual making $16,000 a yr. $144 a month (according to Kaiser Calculator) I used the age 34

So hopefully other states offer something better.
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Old 11-15-2013, 02:07 PM   #150
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You should call them - I'm pretty sure that is not right - certainly not the way my BCBS policy works.
I'm looking at the BCBS TX plans available here, and one of the Bronze PPO plans shows a $6,000 deductible, AND a $6000 out of pocket maximum. Since it says "no copayments" for anything after the deductible is met, I'm pretty sure that the $6000 OOP max isn't an additional $6000 over the deductible. Different insurers and/or different states may do it differently; I'm not sure.
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Old 11-15-2013, 04:06 PM   #151
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I am not saying I'm against or for universal access to healthcare but I thought anyone can walk into any emergency room and receive heathcare. That sounds pretty universal to me.
I'm not getting into the issue of whether or not universal access is to be desired or not or as to the best way to do it if it is to exist. But I think when people talk about whether universal access exists and about providing coverage to previously uninsured people there are some points that get missed.

I think the above point is a good one for people who have either (1) acute problems or (2) minor illnesses/injuries that don't require much follow up. If you are uninsured and have appendicitis you can indeed get treatment at the ER and you don't have to pay a $6000 deductible (they might try to collect from you but probably unsuccessfully).

Where the ER does not provide universal access, though, is people who have chronic conditions that require ongoing medications or other materials (think diabetes - my mother is diabetic and takes daily prescriptions for it as well as having to check her blood sugar every day). Going to the ER isn't much help with this. You might get prescription from the ER and maybe a few pills but you won't get your daily medication from it. If you go into a diabetic coma, then the ER may provide treatment but it won't give you treatment to help you manage and treat your diabetes on an ongoing basis.

Also, the ER is not really an effective place of treatment for serious, even fatal, illnesses that require ongoing non-emergency treatment. Think of the person with cancer who needs chemotherapy or radiation. The ER doesn't provide much access for that.

There is another point that I think gets missed. I agree that for the average person who is above Medicaid level but is low income, the ACA premiums plus a deductible may be beyond what that person is able or willing to pay. So, it could be argued that person doesn't get a lot of benefit from a policy with a high deductible (yes, I know there can be cost sharing provisions). But, the sick person isn't the only player in this. That is, you have to look at it is also from the hospital point of view and the taxpayer point of view.

Let's say someone uninsured comes to the ER and requires surgery that costs $50,000. Under the current situation, the hospital eats that cost and tries to get it back from what they charge to the patients who are insured and, if a public hospital, what they get back from the county or whoever funds them (i.e. from the taxpayers).

On the other hand, imagine that person is insured but has no money and comes in and can't pay the $5,000 deductible. However, the person's insurance pays $45,000. So the hospital only has to eat the cost of $5,000 and only has to try to get $5,000 back from others or from the public. The patient is only a little better off - he owes $5,000 not $50,000 but this probably doesn't matter if he can't pay either one. But the hospital,other insureds and probably the public (if a public hospital) is really glad this patient had insurance to pick up $45,000 of the cost.
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Old 11-15-2013, 04:15 PM   #152
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I believe that those figures are for in-network only. Looking at a bronze Blue Cross PPO in my area, for example, although the maximum in-network out of pocket is $6,350 as you said, there is also an additional maximum out-of-network out of pocket of $12,700 (individual), so the potential total individual maximum out of pocket is $6,350 + $12,700 = $19,050. That's what the website is showing. Is this your understanding, as well?
That is interesting. It is certainly not the case in my current group policy. That is the in-network out of pocket max does go toward meeting the out of network out of pocket max. Likewise, in-network expenditures go to meeting the out-of-network deductible. I'm sure of this as we have an out of network provider that my kids see.

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Complicating things further, I believe that for out-of-network expenses, Blue Cross only counts toward out of pocket the amount which they consider "usual and customary", which can be substantially lower than the actual bill.
This is one of my big disappointments with the ACA. One of the big areas of problem is people being balanced billed for out of network costs. It is easy to say don't go to someone out of network. However, as has been discussed here, it is sometimes not possible to even know (such as ancillary providers when you have surgery). Around here, some ancillary providers such as anesthesiologists simply do not join any networks. It is literally impossible to find any in network as they don't join networks. The other problem is when there are limited providers in network but there is a far, far superior provider/hospital for treatment of a specific life-threatening condition. I might be entirely willing to go out of network even with the higher deductible and the lower percentage paid by my carrier, but I would be scared of the balance billing.

Not only does ACA not solve this problem, it makes it worse. It is worse because in an effort to control costs, exchange policies sometimes have a much smaller network than people are used to. So there are more people out of network. I would much rather see NO networks so this wasn't an issue (i.e. do it more like Medicare).
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Old 11-15-2013, 05:17 PM   #153
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That is interesting. It is certainly not the case in my current group policy. That is the in-network out of pocket max does go toward meeting the out of network out of pocket max. Likewise, in-network expenditures go to meeting the out-of-network deductible. I'm sure of this as we have an out of network provider that my kids see. This is one of my big disappointments with the ACA. One of the big areas of problem is people being balanced billed for out of network costs. It is easy to say don't go to someone out of network. However, as has been discussed here, it is sometimes not possible to even know (such as ancillary providers when you have surgery). Around here, some ancillary providers such as anesthesiologists simply do not join any networks. It is literally impossible to find any in network as they don't join networks. The other problem is when there are limited providers in network but there is a far, far superior provider/hospital for treatment of a specific life-threatening condition. I might be entirely willing to go out of network even with the higher deductible and the lower percentage paid by my carrier, but I would be scared of the balance billing. Not only does ACA not solve this problem, it makes it worse. It is worse because in an effort to control costs, exchange policies sometimes have a much smaller network than people are used to. So there are more people out of network. I would much rather see NO networks so this wasn't an issue (i.e. do it more like Medicare).

I couldn't agree more Kat. I can see it now since I am worried about getting screwed over, laying on the gurney asking anyone who tries to touch me if they are part of my network. If nothing else, our obligation should end when we go to the correct in-network hospital. Then it's their responsibility to get it correct from then on.
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Old 11-15-2013, 05:23 PM   #154
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I'm looking at the BCBS TX plans available here, and one of the Bronze PPO plans shows a $6,000 deductible, AND a $6000 out of pocket maximum. Since it says "no copayments" for anything after the deductible is met, I'm pretty sure that the $6000 OOP max isn't an additional $6000 over the deductible. Different insurers and/or different states may do it differently; I'm not sure.
Your interpretation is correct.

But pb4uski et al are talking about the out-of-network max OOP and whether it is added to the in-network max OOP to result in a total max OOP if you max out care in both.
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