OT: Obamacare… Don’t say we didn’t warn you…

[bearishgurl]

[quote=SK in CV][quote=bearishgurl] Perhaps you are referring to some emergency rooms currently providing “charity” care to non-paying patients (which will supposedly cease come 2014, assuming everyone signs up for a plan). [/quote]

That’s not exactly true. There are, as of a few days ago, still 26 states that have not agreed to expand Medicaid coverage, with no current cost to those states. Three of those are leaning towards expansion. The majority of the rest have declined expansion, with seven states leaning towards not expanding Medicaid. Those currently uninsured, that would qualify under Medicaid expansion will not be eligible for credits under the state run exchanges. They are likely to remain uninsured, and will remain a burden to non-profit hospitals in those states.[/quote]

Yes, SK, I was aware that some states were not expanding their Medicaid programs. I was referring to CA but did not indicate it as such in my post. Thanks for the correction.

As far as I know, in CA, the current large Medi-Cal one-stop clinics will NOT be closing their doors come 2014. Examples:

http://www.chgsd.com/

http://www.syhc.org/

They will simply see more patients. How MANY more? We do not really know until enough outreach is done in several languages to get eligible people signed up who weren’t previously eligible for Medi-Cal.

As in 2013 and prior, providers in 2014 will have the choice on whether or not they want to take Medi-Cal patients.

[no_such_reality]

Citydweller, The deductible applies to the out of pocket maximum. The OOPM, is $8850, not $8850+$2950. For the bronze plan, the OOPM is $6350, a mere $1350 over the deductible. Basically, a catastrophic coverage plan where you pay most of your health bills until you get into big numbers.

One thing to look at is the non-provider coverage level on your current plan and compare when available to the other plans.

When you get closer, you’ll also want to verify that the doctors in the EPO. Compared to an employer plan, the number of doctors is about 1/2. Not sure how it compares to their previous individual plans.

[quote=citydweller]I’m looking at the benefits page of my current policy (Anthem/Blue Cross), it shows a deductible of $2,950 and then “Participating and Non-participating provider Copayment/Coinsurance Maximum” of $8,850. I take this to mean my annual max out of pocket is $11,800. My monthly premium is $752 (and yes, I’m a boomer, mid-50’s)

I’m again looking at the Bronze plans, the Anthem EPO is only $388 per month, which means I would save $4,368 per year just in premium costs and still be able to stay within the Anthem network.

The deductible for this bronze plan is $5,000, which is ok with me if I’m saving over $4,000 in premium payments per year, and would still have to hit my deductible of $2,950 (on my current plan) even after paying $9,024 annual premium.

Also, the bronze plan has an annual max out of pocket of $6,350. Am I missing something, or does it make sense to switch to this lower cost plan?

I really appreciate everyone’s comments. I very seldom have medical bills and so have very little knowledge of how this all works, but I would like the security of knowing I have good coverage if I need it.[/quote]

[bearishgurl]

This out this morning on Yahoo:

… Premium prices for marketplace plans will remain stable throughout each calendar year, but can be raised from year to year for everyone in your policy group—that is, everyone who bought the same kind of plan from the same insurer.

The first coverage period is Jan. 1 through Dec. 31, 2014. Insurers face many uncertainties with this new market, and they will likely adjust their prices once they have more information, experts say. For example, if a disproportionate number of older and sicker people sign up for marketplace coverage, it will increase insurers’ costs, and companies may pass along some of this increase to policyholders. Consumers will be informed of 2015 premium prices during open enrollment next fall, which will run Oct. 15 through Dec. 7, 2014, when they will have the option of switching plans …

The (future) stability of premium prices for an entire calendar year will be a godsend for people like me who have already had 2 rate hikes each calendar year from their carriers (abt 3 each year since March 2010, when the ACA became law).

Now, since insureds can freely move from one plan on the exchange to another during each annual open-enrollment period, each carrier on the exchange who is consideration raising their rates has to balance those considerations with a proportionate loss of policyholders to another plan if their proposed rate hikes will render them “not competitive” with the other plans to choose from in a given locale.

Oh, and this is all the more reason to sign up for a PPO with a larger deductible (plans which fewer “sick” people or people with chronic conditions will likely sign up for). Hopefully, the few PPOs on the exchanges will have less rate hikes and their longtime policyholders will get more value for their money.

… Each state will have a health-insurance marketplace, and people must sign up for insurance in the state of their primary residence. Plans will include coverage for any emergencies that happen when you’re traveling out-of-state…

http://www.marketwatch.com/story/6-things-boomers-need-to-know-about-obamacare-2013-09-18?link=MW_retirement_popular

These are fascinating “facts.” I’ll be chomping at the bit to find out more about how all these (cheap) “EPOs” (yes, featured on all states’ exchanges who allow them) are going to actually “cover” emergency services while traveling. So far, that’s not what I’ve seen on the exchange websites OR on the carriers’ own websites. I’m not convinced that the MSM is getting the “straight scoop” on this issue … sufficient as to make such a blanket statement.

And what if one gets in the middle of, say, KS, intending to spend a week or two in mid-June and finds out they are horribly allergic to the poppies that grow wild in every cornfield? Will seeing and ENT or allergist there and getting a prescription be considered an “emergency?”

My OWN kids’ experience with using Sharp Healthcare (“EPOs”) while going to college in another county of CA or needing care and even emergency surgery while traveling has borne out differently. They were forced to have mom process and monitor claims to their secondary carrier (Tricare Standard) for months on end and have mom and dad cover Tricare’s deductibles and hefty coinsurance payments (20-25%). Sharp Healthcare (both PPO and HMO) was virtually worthless outside of SD County. This is why my youngest will get on Tricare Prime (premium for age 18-26 currently set at $422 yr) before they ever set foot out of SD County..

Again, choose wisely, folks. The devil is in the details :=0

[no_such_reality]

[quote=bearishgurl]
And what if one gets in the middle of, say, KS, intending to spend a week or two in mid-June and finds out they are horribly allergic to the poppies that grow wild in every cornfield? Will seeing and ENT or allergist there and getting a prescription be considered an “emergency?”
[/quote]

First, it’s not an emergency, unless one is so allergic that we’re talking shock.

Second, why wouldn’t one just go to a minute clinic at CVS or Urgent Care or similar and pay the $80-$90/cash for services for a basic allergy or many other issues consultation?

[bearishgurl]

citydweller, the way I see it is that, at your age, you have no idea if you will incur a large unexpected medical bill tomorrow thru illness or accident. Spending just 24 hours or less as an inpatient admitted from a small regional hospital’s emergency room (ex: Scripps Chula Vista Med Cntr) can cost $8500 – $12,000 … that is AFTER their charges are reduced to your PPO rate. These charges can be MUCH higher in big city hospitals (ESP those with trauma centers). I don’t know if you live in or near dtn SD but a very high percentage of drivers (over 50%) living south of I-8 are inconsistently uninsured or under-insured as are an extremely high percentage of drivers residing south of Hwy 94 (over 75%). In any case, the medical payments on your auto policy covering YOU are likely very limited. If you get into an accident with one of these thousands of uninsured or underinsured drivers, you don’t want to have to worry about your quality or choice of care. You want your medical carrier to subrogate the auto carrier(s) involved for what they can get and then cover the rest without question, while they attempt to go after the responsible parties (if you are not at fault).

nsr is correct that you have to compare every single copay and covered item on your current policy to an exchange policy or plan, when the details are made available, in order to make an educated choice on what to do.

Keep in mind that if a proposed policy or plan on the exchange seems VERY reasonably priced, it is likely that the “sickest” masses who qualify for tax credits and who are on a tight budget will sign up for it. The way I understood the article I posted (above) is that the plans with the “sickest” planholders have the most propensity to increase their rates come 2015 or increase them the most.

We’ll know a whole lot more when the statistics by region are made public … hopefully sometime next year. That is, how many signed up for each plan available in a certain region, which metal-level of plan did they sign up for (if more than one was avail) and how many of those who signed up did so utilizing one of the four levels of tax credits.

I’m going to also recheck Blue of CA’s website:

https://www.blueshieldca.com/home?seorefer=https%3A//www.google.com/url%3Fsa%3Dt%26rct%3Dj%26q%3D%26esrc%3Ds%26source%3Dweb%26cd%3D1%26ved%3D0CDYQFjAA%26url%3Dhttps%253A%252F%252Fwww.blueshieldca.com%252F%26ei%3Dm945Ut7jH8iWyAH_0IGgAg%26usg%3DAFQjCNH7_JG7tgJBVoscobaoq0bdt0MEGA%26bvm%3Dbv.52288139%2Cd.aWc

… in October to find out if their indiv PPO plans are comparable to the ones they offer on the exchange for a lesser monthly premium than the ones they offer on CoveredCa if ordered off the exchange directly though them. This should be an apples-to-apples comparison and could very possibly cancel out any tax credits I might be eligible for if I sign up on the exchange.

I noticed that other states’ exchanges which I perused listed ALL their new indiv and small group (=<50 emps) plans in compliance with the ACA, whether offered ON or OFF their exchanges and discovered that comparable plans were up to $250 less per month for my age group than those same plans offered on the state’s exchange.

Because of this discovery, I believe it is entirely possible that carriers agreeing to offer plans on state exchanges have jacked up the price of those plans to account for the mass applications of currently uninsured “sick” or those with chronic conditions who are currently uninsured, nearly ALL of whom will use “tax credits” to pay most or all of their monthly premiums.

It will be interesting to see how this all fleshes out in the coming year and if the local provider groups (ex: Sharp Rees Stealy) who will accept most or all of the plans on the exchanges end up turning into the DMV for ALL their patients while attempting to serve many new patients who haven’t seen a doctor in decades.

[bearishgurl]

[quote=no_such_reality][quote=bearishgurl]
And what if one gets in the middle of, say, KS, intending to spend a week or two in mid-June and finds out they are horribly allergic to the poppies that grow wild in every cornfield? Will seeing and ENT or allergist there and getting a prescription be considered an “emergency?”
[/quote]

First, it’s not an emergency, unless one is so allergic that we’re talking shock.

Second, why wouldn’t one just go to a minute clinic at CVS or Urgent Care or similar and pay the $80-$90/cash for services for a basic allergy or many other issues consultation?[/quote]

nsr, if your eyes swelled shut, you had been holding icepacks on them for two days and and you still couldn’t see enough to drive, I would consider this an “emergency.”

And allergy medications aren’t “cheap” for an person without prescription coverage. They cost up to $200 for brand name antihistamines, etc, $45 and up for generics and $75 and up for corticosteriods.

nsr, you’ve spent way too much of your life in suburban SoCal. There aren’t any “CVS Minute Clinics” in the vast majority of towns in “rural flyover America.”

LOL :=D

[no_such_reality]

There aren’t a lot of Doctors either. If your eyes have swelled shut, I’d consider that a shock type scenario, that’s not a normal allergic reaction and I suspect doctors would agree. If your eyes have swelled shut, what else is going to swell shut.

Those expenses are just as expensive on a PPO non-preferred list. With coverage often around 50% and a typical doctor visit in the $150-$200 range.

Are for prescription coverage, the Rx is the Rx, where it was prescribed shouldn’t matter.

Good info about the plans being cheaper off the exchange in the other States. I hadn’t thought of that and in retrospect, it makes complete sense.

If you’re under 400% FPL, the plans on the exchange aren’t the plans, they’re enhanced plans and the enhanced silver quickly looks more like a Gold plan due to the lower co-pays etc.

Essentially, the plan Silver plan is based on an expected applicant pool that will really qualify for a “gold” plan service level on a “silver” plan, where as off list, the silver plan is the silver plan.

[bearishgurl]

[quote=no_such_reality]There aren’t a lot of Doctors either. If your eyes have swelled shut, I’d consider that a shock type scenario, that’s not a normal allergic reaction and I suspect doctors would agree. If your eyes have swelled shut, what else is going to swell shut.

Those expenses are just as expensive on a PPO non-preferred list. With coverage often around 50% and a typical doctor visit in the $150-$200 range.[/quote]

nsr, rates for a specialist in rural flyover America are closer to $75 per visit ($75-$90) or $50-75 for a PCP … that is, unless they have to make a house call … and some still DO. Again, you’re operating on your SoCal mindset … as would be expected :=0

[quote=no_such_reality]Are for prescription coverage, the Rx is the Rx, where it was prescribed shouldn’t matter.[/quote]

That’s true, as long as your PPO’s drug network is in all fifty states (check the fine print on those EPOs). My current carrier’s is, as is their physician network. You are correct in that a typical PPO’s coverage level is just 50% for an out-of-network provider or facility. But this is a whole lot better than a kick in the backside if one has no choice but to utilize out-of-network care.

[quote=no_such_reality]Good info about the plans being cheaper off the exchange in the other States. I hadn’t thought of that and in retrospect, it makes complete sense.

If you’re under 400% FPL, the plans on the exchange aren’t the plans, they’re enhanced plans and the enhanced silver quickly looks more like a Gold plan due to the lower co-pays etc.

Essentially, the plan Silver plan is based on an expected applicant pool that will really qualify for a “gold” plan service level on a “silver” plan, where as off list, the silver plan is the silver plan.[/quote]

Agree, but if given the choice, I would still try to pick a plan which the masses of longtime uninsured likely won’t pick, due to cost (over and above the tax credits) or deductibles or both (possibly shunning the “enhanced silver” plans?). Rate hikes can EASILY double a monthly premium in 18-24 months. At my age, that’s a LOT of $$.

[bearishgurl]

Even though I’ve come very close to needing it in the past but didn’t end up having to, I’m grateful for having coverage for HBOT:

Clinical Policy Bulletin:
Hyperbaric Oxygen Therapy (HBOT)

Number: 0172

Policy

Aetna considers systemic hyperbaric oxygen therapy (HBOT) medically necessary for any of the following conditions:

-snip-

Decompression illness (“the bends”)

-snip-

http://www.aetna.com/cpb/medical/data/100_199/0172.html

I am very careful now in ascending and descending very high altitudes but I am in hopes I can find a carrier who will cover it … just in case … as the treatment runs about $200 per hr.

The need for it among mountain enthusiasts, skydivers and SCUBA divers is an “emergency” but it is likely that most carriers don’t cover it.

[citydweller]

My plan now is to go with the Anthem/Blue Cross Plan Silver 70 EPO, with the monthly premium of $520. Before I sign up through the Marketplace though I will check to see if it’s cheaper to buy directly from Anthem. Does anyone know if plans purchased outside the Marketplace have the rates locked in for 1 year?

The Anthem Silver 70 EPO has a $2,000 deductible and $6,350 max out of pocket. Also, copays are not subject to meeting the deductible, so primary care visits are $45, Urgent care is $60. And 1 annual preventative care visit at no cost.

I appreciate everyone’s feedback here. I’ve had very little experience with medical issues and so have very little knowledge about how insurance works and what all the terms mean. I’ve learned quite a bit an the past few weeks.

[bearishgurl]

[quote=citydweller] . . . Does anyone know if plans purchased outside the Marketplace have the rates locked in for 1 year? . . . [/quote]

That’s a good question, citydweller. CoveredCA has been “hush-hush” on the details of any individual and group plans which were approved by the insurance commissioner to be sold after 10/1/13 OFF the exchange … and so has each carrier’s website.

We’ll have to wait until October 1 to recheck all the carriers’ sites (and possibly contact their employees and agents) to get these answers. I don’t think any of the carriers that are left in CA can e-mail an inquirer with individual quotes anymore because their rates now have to be standardized as to age and location … so it will be easy to show them on a table.

The carriers are all in kind of a “transition period” right now in preparation for the 10/1 rollout of enrollments for coverage beginning 1/1/14.

[bearishgurl]

This just in:

http://www.huffingtonpost.com/2013/09/20/obama-government-shutdown_n_3963138.html?utm_hp_ref=politics&icid=maing-grid7%7Chtmlws-main-bb%7Cdl1%7Csec1_lnk2%26pLid%3D378827

Republicans playing games at the 11th hr (close of the Federal fiscal year in conjunction with inception of Obamacare enrollment period).

Is anyone surprised?

[SK in CV]

[quote=bearishgurl]This just in:

http://www.huffingtonpost.com/2013/09/20/obama-government-shutdown_n_3963138.html?utm_hp_ref=politics&icid=maing-grid7%7Chtmlws-main-bb%7Cdl1%7Csec1_lnk2%26pLid%3D378827

Republicans playing games at the 11th hr (close of the Federal fiscal year in conjunction with inception of Obamacare enrollment period).

Is anyone surprised?[/quote]

Only peripherally related to this post, I think you mentioned that one of your concerns about exchange policies with small networks is the lack of coverage when traveling. One of the provisions of the law is that exchange plans can’t charge more for emergency room visits for out-of-network providers. If you have a $250 deductible for in-network, it’s the same for out-of-network providers.

And no, I’m not surprised. GOP legislators have figured out that the exchanges will function far beyond expectations. They’re panicking before it fully goes into effect.

[bearishgurl]

[quote=SK in CV][quote=bearishgurl]This just in:

http://www.huffingtonpost.com/2013/09/20/obama-government-shutdown_n_3963138.html?utm_hp_ref=politics&icid=maing-grid7%7Chtmlws-main-bb%7Cdl1%7Csec1_lnk2%26pLid%3D378827

Republicans playing games at the 11th hr (close of the Federal fiscal year in conjunction with inception of Obamacare enrollment period).

Is anyone surprised?[/quote]

Only peripherally related to this post, I think you mentioned that one of your concerns about exchange policies with small networks is the lack of coverage when traveling. One of the provisions of the law is that exchange plans can’t charge more for emergency room visits for out-of-network providers. If you have a $250 deductible for in-network, it’s the same for out-of-network providers.

And no, I’m not surprised. GOP legislators have figured out that the exchanges will function far beyond expectations. They’re panicking before it fully goes into effect.[/quote]

That’s good to know, SK. Thanks! If it applies to closed networks, such as most EPO’s, or exclusive-to-SD networks such as Sharp Healthcare, for example, I’ll consider them along with the Blue Shield PPO. Deductibles are less of a concern to me than carrier and network size/choice of providers.

Now, all we have to find out from CoveredCA is WHICH carriers/plans will be offered on WHICH metal level. This info has been available for months on other states’ exchange websites but not in CA yet.

[citydweller]

The carriers/plans info is available at Covered California.

Click on “Resources”, then click on “Calculating Potential Insurance Cost”, then click “Get Started”.

Next, enter info, # of people in household, income, zip code and age. At the bottom of that page click the yellow button “See my options”.

Next will open a pop-up window with general information, you need to close that pop-up window. Underneath you will see the Bronze/Silver plans available in your area.
Choose the plan you’re interested in and click the “view details” button, then scroll up and click on “view plan benefits”.

At the top of that page you can also click a button that will take you to the Gold/Platinum plans.

In San Diego it looks like the Silver Plans are Anthem Blue Cross EPO, and Health Net, Sharp or Kaiser HMO’s.

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