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Thread: Obamacare ... the Unintended Consequences

  1. #71
    Senior Member Gerry Clinchy's Avatar
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    More on the cancer patient in that WSJ article. I got into it by following a link from another article
    http://online.wsj.com/news/articles/...71710423780446

    Since March 2007 United Healthcare has paid $1.2 million to help keep me alive, and it has never once questioned any treatment or procedure recommended by my medical team. The company pays a fair price to the doctors and hospitals, on time, and is responsive to the emergency treatment requirements of late-stage cancer. Its caring people in the claims office have been readily available to talk to me and my providers.


    But in January, United Healthcare sent me a letter announcing that they were pulling out of the individual California market. The company suggested I look to Covered California starting in October.


    You would think it would be simple to find a health-exchange plan that allows me, living in San Diego, to continue to see my primary oncologist at Stanford University and my primary care doctors at the University of California, San Diego. Not so. UCSD has agreed to accept only one Covered California plan—a very restrictive Anthem EPO Plan. EPO stands for exclusive provider organization, which means the plan has a small network of doctors and facilities and no out-of-network coverage (as in a preferred-provider organization plan) except for emergencies. Stanford accepts an Anthem PPO plan but it is not available for purchase in San Diego (only Anthem HMO and EPO plans are available in San Diego).


    So if I go with a health-exchange plan, I must choose between Stanford and UCSD. Stanford has kept me alive—but UCSD has provided emergency and local treatment support during wretched periods of this disease, and it is where my primary-care doctors are.


    Before the Affordable Care Act, health-insurance policies could not be sold across state lines; now policies sold on the Affordable Care Act exchanges may not be offered across county lines.


    What happened to the president's promise, "You can keep your health plan"? Or to the promise that "You can keep your doctor"? Thanks to the law, I have been forced to give up a world-class health plan. The exchange would force me to give up a world-class physician.
    I found that "Exclusive Provider Network" kind of an interesting sidenote to the overall story.
    G.Clinchy@gmail.com
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  2. #72
    Senior Member luvmylabs23139's Avatar
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    Quote Originally Posted by Gerry Clinchy View Post
    But what happens if the 40% is more than the cap? Then the policy will actually cover more than the 60%?
    Yes, it covers 100% after those caps are met. Most policies have been that way for years, they have a total out of pocket max. Let me rephrase, reputable policies. The other issue of course is annual and lifetime caps on how much the insurer will pay.
    Other factors though figure in like what is counted towards deductables and caps. Often co-pays on office visits and drus do not count. It all depends on the policy.
    Hihope Hiland Heathen of Perth CD, RE, CGC, TDI

  3. #73
    Senior Member Gerry Clinchy's Avatar
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    First place I found this concisely stated (Seattle Times)
    10 essential benefits

    The Affordable Care Act requires health-insurance plans to meet certain minimum criteria, including a prohibition against denying coverage to those with pre-existing conditions. It also limits a subscriber’s out-of-pocket medical costs. For 2014 that amount is $6,350 for individuals and $12,700 for families (the amount includes deductibles and co-payments, but not premiums). In addition, all plans must include services for the so-called 10 essential benefits:
    • Preventive and wellness services and chronic-disease management.
    • Prescription drugs.
    • Emergency services.
    • Hospitalization.
    • Ambulatory patient services.
    • Rehabilitative services and devices.
    • Laboratory services.
    • Mental-health and substance-use-disorder services, including behavioral-health treatment.
    • Maternity and newborn care.
    • Pediatric services, including dental and vision care.
    Dental and vision care is apparently only required for children. Aside from that, every health insurance plan I've ever had covered all those other things, although I was able to drop off the maternity/newborn care a long while ago The mental health benefit was pretty skimpy though. Maybe it's a good thing that this law includes the mental health provisions since we might all need more of that coverage as this law progresses.
    G.Clinchy@gmail.com
    "Know in your heart that all things are possible. We couldn't conceive of a miracle if none ever happened." -Libby Fudim

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  4. #74
    Senior Member luvmylabs23139's Avatar
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    The healthy who do not get subsidies are the ones with sticker shock. They won't tell the truth. It is not about junk policies for many. It is because of the change from policies being medically underwritten to a community rating pricing scheme.
    Hihope Hiland Heathen of Perth CD, RE, CGC, TDI

  5. #75
    Senior Member Gerry Clinchy's Avatar
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    Was wondering when we'd begin to see how this would affect Medicare, since a big chunk of $ was taken away from Medicare to put into O-care.
    Due to reductions in funding under the law, the Medicare Advantage programs, in which Medicare provides money for private insurers to cover seniors, have quietly started to cancel the contracts of providers to save money.

    Read more: http://www.americanthinker.com/blog/...#ixzz2jk64lgYV

    Medicare Advantage plans are less expensive than "traditional" Medicare. And they must be lucrative for the insurance companies, because there are always tons of ads for them all over the place.

    If these notices are also going out now, seniors could be frothing at the mouth by Nov. 2012.



    G.Clinchy@gmail.com
    "Know in your heart that all things are possible. We couldn't conceive of a miracle if none ever happened." -Libby Fudim

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  6. #76
    Senior Member Buzz's Avatar
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    Quote Originally Posted by Gerry Clinchy View Post
    First place I found this concisely stated (Seattle Times)

    The mental health benefit was pretty skimpy though. Maybe it's a good thing that this law includes the mental health provisions since we might all need more of that coverage as this law progresses.

    After mass shootings there is much lip service given to the dismal state of mental healthcare. Imagine actually doing something about it...
    "For everyone to whom much is given, of him shall much be required." -- Luke 12:48

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  7. #77
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    Quote Originally Posted by Gerry Clinchy View Post
    Was wondering when we'd begin to see how this would affect Medicare, since a big chunk of $ was taken away from Medicare to put into O-care.

    Read more: http://www.americanthinker.com/blog/...#ixzz2jk64lgYV

    Medicare Advantage plans are less expensive than "traditional" Medicare. And they must be lucrative for the insurance companies, because there are always tons of ads for them all over the place.

    If these notices are also going out now, seniors could be frothing at the mouth by Nov. 2012.


    Most plans restrict coverage to the immediate area - traditional plans do not, that's why people keep them.
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  8. #78
    Senior Member Gerry Clinchy's Avatar
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    A relatively new provision in the Affordable Care Act that requires states to accept temporary eligibility determinations from Medicaid-enrolled hospitals is opening up the Medicaid program to even more fraud, which in turn creates additional opportunities to raid the pockets of taxpayers, sources say.


    A former Medicaid director also is questioning Section 2202 of the ACA because he says it’s inconsistent with the whole premise of Obamacare and gives non-government entities access to public funds.


    Under the regulation, hospitals have the authority to use presumptive eligibility to provide temporary care for the uninsured who fall into the Medicaid categories that their respective state already covers, Medicaid spokeswoman Emma Sandoe said.


    But if it’s later found that a patient does not qualify for public assistance, the state is on the hook for those costs.
    What seems unclear is whether the Fed govt will reimburse for these payments that are made for those who do not qualify. While O-care is supposed to pay 100% for the first 3 years for the expansion of Medicaid in (in those states that elected to establish their own state exchanges), the article is not clear if these kinds of payments made by a state would be included in that "grant".

    In states with large populations like NY and CA, this could be a huge amount of $ each year. And after the Fed starts paying only 90% it would be an even larger burden on those states. Some of the states that elected not to set up a state exchange had already expressed concern that the expansion of Medicaid could be a large burden even at 10%; even before this additional cost might be considered.
    G.Clinchy@gmail.com
    "Know in your heart that all things are possible. We couldn't conceive of a miracle if none ever happened." -Libby Fudim

    ​I don't use the PM feature, so just email me direct at the address shown above.

  9. #79
    Senior Member luvmylabs23139's Avatar
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    Here are a few facts that cute little list does not fully explain. Deductables and total out of pocket expenses amounts are only if you are 100% within the network.
    We currently have a high deductable plan but it is a nation plan but unlimited doctor visits are covered for $25 per visit in network(very large network) and out of network at 40% specialist$50 out of network 40%
    Obamma's in network the same out of network copays increase to 60%

    OUr out of nework deductables go way up.
    YOur out of network out of pocket limits go way up. Remember this is "better"
    Our worst case senario which is what we base things on increases by $3000. That would be if we had an insane year and we both maxed out all limits, but remember somehow according to Obamma we should be happy to pay $6000 more per year for that.
    I do not follow. The math does not add up!
    A few more
    prescription drugs. Both had a $200 dedcutable before any coverage.

    OLD NEW
    GENERIC 10 NOT COVERED!
    prefered brand 45 50


    ER old $150 per visit
    New $150 first visit $500 any additional

    Urgent care old $50 new $75
    All out of network flips from me paying 40% to me paying 60%
    Both covered child eye exams with $25 copay.
    Hihope Hiland Heathen of Perth CD, RE, CGC, TDI

  10. #80
    Senior Member Buzz's Avatar
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    Quote Originally Posted by Gerry Clinchy View Post
    What seems unclear is whether the Fed govt will reimburse for these payments that are made for those who do not qualify. While O-care is supposed to pay 100% for the first 3 years for the expansion of Medicaid in (in those states that elected to establish their own state exchanges), the article is not clear if these kinds of payments made by a state would be included in that "grant".

    In states with large populations like NY and CA, this could be a huge amount of $ each year. And after the Fed starts paying only 90% it would be an even larger burden on those states. Some of the states that elected not to set up a state exchange had already expressed concern that the expansion of Medicaid could be a large burden even at 10%; even before this additional cost might be considered.
    Under the regulation, hospitals have the authority to use presumptive eligibility to provide temporary care for the uninsured who fall into the Medicaid categories that their respective state already covers, Medicaid spokeswoman Emma Sandoe said.


    But if it’s later found that a patient does not qualify for public assistance, the state is on the hook for those costs.
    It has always been a fact that when the uninsured get care, taxpayers and those who have insurance through work and those who take personal responsibility for themselves and their families by getting coverage in the individual market end up footing the bill. Otherwise doctors and hospitals would be unable to stay in business.

    While I was disappointed with the direction that healthcare reform took right from the start, one of the things it tries to address is these back door costs. Those who cannot afford to cover themselves are subsidized but at least now they will pay a portion of the costs. And those who cannot even afford to pay a portion will be covered through expanded medicaid in states where the governors and legislatures were not arsehats enough to refuse the expansion. Hopefully those people will go to the doctor before things like cancer go to stage 4, or before high cholesterol or high blood pressure results in a heart attack or stroke.
    Last edited by Buzz; 11-06-2013 at 03:32 PM.
    "For everyone to whom much is given, of him shall much be required." -- Luke 12:48

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