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/a-pro-single-payer-doctor’s-concerns-about-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]

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]

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]

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]

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/health/as-hospital-costs-soar-single-stitch-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]

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]

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]

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

He will no more be the Gov.

 

[aja8888]

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]

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]

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/health/as-hospital-costs-soar-single-stitch-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]

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]

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]

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

 

[brewer12345]

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

Personally, I think the intentional misinformation campaign is nothing short of criminal. The sore losers should be ashamed of themselves.

 

[daylatedollarshort]

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.http://www.americanprogress.org/iss...tly-asked-questions-about-medicaid-expansion/

And that is the low information crowd with access to computers and the Internet. Many in the U.S. that are uninsured are also likely to be those on the losing end of the digital divide -

https://www.census.gov/hhes/computer/files/2012/Computer_Use_Infographic_FINAL.pdf

 

[Katsmeow]

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 do feel that high deductibles discourage people from getting medical care. In some cases, it may have been for something that was real but would have gotten better on its own ("every little sniffle"), but in other cases it may be something that gets worse without prompt treatment.

We have a $3000 deductible on our non-ACA policy. Early in the year before the deductible is met I do hate to have go appointments where I have to pay it all myself (discounted of course). But, I do it as necessary.

I did just have an experience where I delayed. I had a minor knee problem about 2 months and then a few weeks later I had a pain behind my knee. I thought about going to see the orthopedic surgeon that my daughter has seen but it would be a couple of hundred bucks that I would have to pay for since the deductible wasn't met. Had the deductible been met I probably would have just made the appointment.

Instead I waited a few weeks to see if it would get better on its on. It didn't. So I finally decided to go to the Urgent Care center (which would have been $140). I got there and they immediately sent me to the ER because it might have been a blood clot in my leg.

I ended up going to the ER to have an ultrasound to see if I had a blood clot. I sort of hated doing it because I knew I still had about $1500 left on my deductible and was about to blow through it. But, we have $1500 so it wasn't a big issue I guess.

As it turned out 6 hours later, I had no blood clot (I know do have an appointment with the orthopedic surgeon for a probably hamstring injury). I am starting to see the EOBs. The hospital charged about $2500 which the in network discount knocked down to a little over a $1000.

The one that irritates me is that it turns out the ER doctor who charged $500 was out of network. It irritates me as he didn't even lay eyes on my until after I had the ultrasound. The order for the ultrasound was written by a doctor I never saw based upon my reported symptoms. The doctor I did see wasn't the one to read the ultrasound (there is a bill from him too) and he showed up only after I had the ultrasound to basically tell me that the report was the ultrasound was negative. So he charges $500 out of network (like I had any choice in the matter). The insurer says that there is a multi-plan discount for him as an out of network doctor and he has agreed to accept $450. This is irritating since we had zero choice of doctor in this situation and we were in an in network hospital.

Well, I've digressed but we've now blown through the deductible. But, if the deductible had been met earlier I probably would have gone in sooner rather than waiting. As it turns out, waiting was probably fine for a hamstring injury but it wouldn't have been great if I had had a blood clot.

 

[jowi]

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.

This change was made quite awhile ago - long before anyone signed up. In fact, I had never even heard of it (as someone who is just under 400%, I'd have loved the idea of lower max OOP). I'm guessing that's why it wasn't 'newsworthy'. Had they just made this change last month, it would have been front page.

 

[2B]

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

It's nice to see a post from a self described "progressive" group explaining the issue. I'd post a similar summary from a less so group but that would undoubtedly be declared "political." All I'll say is that the massive Medicaid expansion has many landmines waiting for states that have and have not signed on. "Free" doesn't exist.