the OP has an UPDATE // New health insurance rule caps 'surprise' billing (out-of-network charges at in-network places)

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UPDATE :  I have come across another reputable source that appears to mention this new regulation, and unfortunately the situation as described by the second article I found does not seem to be nearly as rosy as the first article made it sound. 

...I guess the first article said, "in certain circumstances" --
and the first article focused on emergency room billing,
so maybe the emergency room setting is the only circumstance where customers have won some decent protections against this practice.

(Meaning that it doesn't cover surprise billing in planned-ahead/scheduled treatments, which is the situation in which I received some surprise/"balance" bills from not-in-network medical personnel at an in-network hospital doing an in-network, pre-authorized procedure. 
Because the regulation appears to say that all the insurance company has to do to be let off the hook entirely is to inform the customer right before an in-network, pre-planned treatment that he/she might receive some surprise/"balance" bills from it.)

--
The second source says:

"Notice Of Potential Out-Of-Network Billing

The preface to the final rule reaffirms the requirement in the 2017 payment notice that QHP insurers must as of 2018 notify enrollees at least 48 hours before the provision of a service at an in-network facility that the enrollee might receive a service from an out-of-network ancillary provider who might balance bill and whose charges are not subject to the in-network cost sharing limit.
If the insurer fails to do so, and the enrollee is charged for out-of-network cost sharing by the ancillary provider, the insurer must count the cost-sharing against the enrollee’s annual out-of-pocket limit.

This provision does not apply to balance billing as such—billing for the difference between the provider’s charge and the amount the insurer is willing to pay. The insurer is not responsible for balance bills (although the balance bills may not be legally enforceable against the consumer). The rule does apply to QHPs both on and off the exchange and regardless of whether the QHP covers out-of-network services. It also does not preempt state laws that are more protective of the consumer."

from:  http://healthaffairs.org/blog/2016/12/18/the-final-2018-notice-of-benefit-and-payment-parameters-part-2/ 

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

MY ORIGINAL POST:

=======================================================================
A small step forward on surprise billing.
by Nicholas Bagley (assistant professor of law at University of Michigan)
December 20, 2016

"Per a rule released last week, CMS [Centers for Medicare and Medicaid Services, which oversees healthcare.gov according to Wikipedia] will now require qualified health plans 'to count the cost sharing paid by the enrollee for an essential health benefit provided by an out-of-network ancillary provider at an in-network setting towards the enrollee’s in-network annual limitation on cost sharing for QHPs [qualified health plans] in certain circumstances'.

Let’s say you go to an emergency room at an in-network hospital, but the ER doctor who treats you isn’t part of your insurer’s network. Because she hasn’t agreed to the insurer’s negotiated rates, the doctor can send you a bill for an extravagant sum.

These sorts of “surprise bills” have become common; one recent study estimated that one in five of all ER inpatient admissions involved a surprise bill.

CMS’s rule won’t end the unfair practice. Out-of-network doctors can still send you a huge bill.

But, starting in 2018, you only have to pay up to the amount of your annual limit on cost sharing. For 2018, that’ll be $7,350 for an individual and $14,700 for a family. Your insurer has to cover the rest.

In other words, the rule will relieve you of the very harshest financial consequences associated with surprise bills. But it won’t stop ER doctors from charging exorbitant fees, which will drive up premiums for everyone.
Some states—including California and New York—have limited surprise bills to a percentage of Medicare rates. CMS doesn’t go that far.
In addition, CMS’s rule applies only to qualified health plans, not to employer-based coverage.

...The need to tackle surprise bills could be one of those rare areas of bipartisan consensus on health care. No one who’s got insurance should suffer bankruptcy for seeking care from an in-network hospital."

http://theincidentaleconomist.com/wordpress/a-small-step-forward... 

============================================================================

I presume this rule affects "marketplace" and other individual plans.

And that it's for all out-of-network bills that emerge from an in-network situation, and which the patient had no choice over -- not just emergency room bills, which the brief article I quoted here focuses on.

If so, that would be great news... I am surprised that there hasn't been more press about it in the last week.

------
To learn about some Fatwallet readers' recent experiences with surprise-billing/balance-billing, see this recent thread:  https://www.fatwallet.com/forums/finance/1539048 

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Something is missing from this article
Even though you receive a huge bill you are still capped at Out of Pocket Maximum. Article does not talk about that but it should.

For instance my OPM is $4K per person and $8K per family. Even though I receive a $10K bill I am capped at $4K.

or am I missing something here?

fleetwoodmac said:   Something is missing from this article
Even though you receive a huge bill you are still capped at Out of Pocket Maximum.
Article does not talk about that but it should.
For instance my OPM is $4K per person and $8K per family. Even though I receive a $10K bill I am capped at $4K.
or am I missing something here?


The article does talk about the annual limit on cost sharing (the highest out of pocket maximum the person has to pay).

If you get a bill from an out-of-network doctor -- even though you had made sure to go all in-network as much as you could -- 
in the past, and still currently
(until this rule takes effect in 2018 -- unless the new administration drastically changes everything about our health insurance system in 2017, which it might!)
your out of pocket maximum does NOT apply to out-of-network charges.

If you have not heard of this before, and you want to see descriptions of situations when this happens, please see the recent Fatwallet thread about it here:  https://www.fatwallet.com/forums/finance/1539048 
[Update:  I later noticed that you were actually the person who had STARTED that recent thread about what to do about bills from out-of-network providers in in-network healthcare situations, so I'm quite surprised that you are still confused about this kind of unfair billing!]

It has happened to me, it has happened to many people. 
It causes some families to go bankrupt.  It has been a problem for a number of years now.

==========
In fact, it happens at 22% of all emergency room visits, according to the New England Journal of Medicine:

Surprise out-of-network doctor bills are much more common than we thought
Dr. Aaron Carroll (a medical doctor and a professor at I.U. School of Medicine)
December 5, 2016

"...the news periodically covers people who have gone to in-network facilities for care, but wound up experiencing huge bills because they were cared for by out-of-network physicians in those hospitals....

People try to do the right thing, and play by the rules, and still they get hit with extremely high, and surprising, bills....

A recent [article] published in the New England Journal of Medicine looked at data from emergency rooms across the country....

Patients, of course, may be able to tell what [hospitals] are in-network....
But there's almost no way they would know who is staffing the [in-network hospital's emergency room] when they need care.
...It's somewhat ridiculous to think that [in an emergency] they could check and see who's working, and whether they are in-network....

The research... showed that of the... emergency department visits which occurred at in-network facilities, [an average of] 22% wound up involving an out-of-network physician.

There was also a lot of variation. In some of the highest areas, upwards of 89% of in-network [emergency room] visits could involve out-of-network doctors....

We want to use cost sharing to help drive people to make better decisions about where and when they get care. Surprising them with bills they didn't expect and couldn't avoid serves no one."

http://www.academyhealth.org/blog/2016-12/surprise-out-network-d... 

Balance billing like this should be flat out illegal, unless the patient very explicitly agrees to servicefrom an out of network provider. And totally outlawed in emergency situations.

If you are a doctor who wants to work in a facility that's within a network, you must agree to get reimbursed at those rates. Don't like it? Go setup your own facility and charge whatever you want.

I think a lot of blame, however, goes to the hospitals. They are fully aware they are allowing independent contractors to operate within their facility.

By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.

belgique said:    If you voted for him...you voted for the insurance companies to run wild.
 

  Is that anything like "girls gone wild".  I loved those tapes.

belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
Please let's try to keep on-topic while not making it a political opinion thread. This is one of those topics that currently affects many patients out of the blue. It's good news, but a little too late for all those who have already suffered because of this.

It would be nice if this stuck, but I doubt it. On Jan 21, the ACA will likely be repealed in its entirety, and this will go with it.

Its hard not to draw this into the political realm, when it really IS simply politics. One tribe is against the ACA because the other tribe is for it. First chance they get, they will destroy it, regardless of whether parts of it are good or not. The worst part is that there's no replacement, so in 2-3 years, the individual healthcare market may literally collapse from the Congressional feuding.


BTW: it shouldn't be the insurer picking up the bill, it should be the hospital that advertises itself as "in-network", but allows out-of-network physicians to practice there.
A hospital that is "in-network" should simply be limited to "in-network" rates for any services provided within its walls. 

belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
  You can't really expect insurance companies to pay whatever bill some unknown physician provides. It's not their fault. They have no contract with that person.

The responsibility rests squarely on the facility providing the service.

The insurer needs a contract with that facitlity, and the facility must agree to charge only in-network rates, or use only in-network physicians.

canoeguy1 said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
  You can't really expect insurance companies to pay whatever bill some unknown physician provides. It's not their fault. They have no contract with that person.

The responsibility rests squarely on the facility providing the service.

The insurer needs a contract with that facitlity, and the facility must agree to charge only in-network rates, or use only in-network physicians.

  
or allow pts to ignore out of network charges from in network facilities . Watch how quickly that fixes the problem.

rascott said:   Balance billing like this should be flat out illegal, unless the patient very explicitly agrees to servicefrom an out of network provider. And totally outlawed in emergency situations.

If you are a doctor who wants to work in a facility that's within a network, you must agree to get reimbursed at those rates. Don't like it? Go setup your own facility and charge whatever you want.

I think a lot of blame, however, goes to the hospitals. They are fully aware they are allowing independent contractors to operate within their facility.

  
Most of the times the "out-of-network" doctor is in-network for insurance A, B and C but not for X, Y and Z. It is usual for the doctor with that specialty to be the only one available for visit with the patient at that time. You want the doctors to do what they are best at...to save lives and not to look at if they are covered in-network or not.

Now let's say that a patient explicitly agreed to not be serviced by an out-of-network provider and there was no in-network doc available at that time. The patient's test results came back from the lab and waiting for the in-network doc to review which could be another 12 hours. The patient is not in an emergency situation right now. After 10 hours the patient enters an emergency situation and the medical intervention (with/without in-network docs) did not help since it was not timely and the patient dies, which could have been prevented if a doc with a specific specialty had reviewed the results and prescribed an intervention. Would the hospital bear liability for the death? 

 

canoeguy1 said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
  You can't really expect insurance companies to pay whatever bill some unknown physician provides. It's not their fault. They have no contract with that person.

The responsibility rests squarely on the facility providing the service.

The insurer needs a contract with that facitlity, and the facility must agree to charge only in-network rates, or use only in-network physicians.

  
Actually you can.  And it would be quite simple. 

Insurance Providers negotiate big contracts with the in-network rendering Facility (aka Hospital).  This change will drive the Insurance Providers to contractually obligate rendering facilities to only allow rendering providers in their facility that accept the 'reasonable rate' as payment in full. 

Can't obligate a third party under such contract?  Of course not, but the Insurance Provider/Rendering Facility contract can also have an indemnity clause to shift the financial burden back to the rendering facility.

So, such a rule if enforced, could actually have a rippling effect that benefits everyone.  Of course time will tell how it really plays out.

rascott said:   Balance billing like this should be flat out illegal, unless the patient very explicitly agrees to servicefrom an out of network provider. And totally outlawed in emergency situations.

If you are a doctor who wants to work in a facility that's within a network, you must agree to get reimbursed at those rates. Don't like it? Go setup your own facility and charge whatever you want.

I think a lot of blame, however, goes to the hospitals. They are fully aware they are allowing independent contractors to operate within their facility.

"setup their own facility' - they do have their own practices, surprise, because they are highly qualified stress-prone high skill individuals in super high demand, not your regular physicians.
I work for a major hospital and go to ER on weekends a lot. You realize that the hospitals are forced to staff ERs not with what they want but with what they can so you still get help you need, and by "what they can" I mean very small number of MDs who have skills to be ER doctors? If doctors have a choice what to be - ER doctor or non-ER doctor, what do you think 99% of them are going to be? You probably do not want to work on weekends, deal with gang members with gunshot wounds and their families, homeless people with TB, AIDS etc (unknown to you), drug addicts etc don't you? The same applies to doctors. They have families, kids, money. And instead of traveling, dining out, spending Christmas with their loves ones they agree to spend their precious time with sick people dying in front of them. So. Hospitals bring whoever they can find who is qualified and who is willing to cover those ugly overloaded shifts and pay them extra just to be there. At most of the major hospitals you spend 4-5 hrs in ER just to get a chance see a doctor. You can force, make law, petition, make illegal whatever you want but not be surprised then that the next time you go to ER there will be 24 hrs waiting time or a nurse practitioner, not a doctor, who will serve you and will refer you to a doctor next business day.
So the insurance companies will swallow whatever they bill them or the insurance companies are very welcome to setup their own hospitals with ER and charge whatever rate they want.
======================================
Boring facts https://www.emra.org/uploadedfiles/emra/resources/advocacy/powerpoints/physicianshortages.ppt.:
~~By the year 2020, there will be a shortage of between 85,000 and 96,000 physicians.
Population factors will aggravate this problem over the next 12 years:
U.S. population to grow by 50 million people (18% growth)
Geriatric population to grow from 35 million to 54 million people
~~Lack of ER Physicians
Lack of board certified and residency trained
38% of currently practicing ER docs are neither
~~Currently, 38% of the physician workforce practice primary care medicine
Patients turn to ERs when they cannot get access
Fewer U.S. medical school graduates choosing primary care
~~Disparity in incomes
Lower total reimbursement
Medicare’s reimbursement guidelines are not as favorable to primary care
Other factors
Burden of numerous patients
On-call obligations are more onerous~~Rural areas have a smaller ratio of doctors to people
Metropolitan ratio of 262 physicians per 100,000 people
Rural areas (<50,000 people) is 92.5 physicians per 100,000
Areas with less than 10,000, is 72 physicians per 100,000
21% of U.S. population lives in rural areas
Only 12% of ER physicians choose to practice there
Uneven distribution primarily due to location of residencies
Most practice where their residency program trained them
Most residency programs are located in urban areas

belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
If by BushCare you mean affordable insurance that has reasonable deductibles that can actually be used, by all means bring it back.

The single, young(er), healthy, male, self employed who make over $47k/year ended up with the shaft.  

I'll give you one guess how I made out with ACA. 

quaters said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
If by BushCare you mean affordable insurance that has reasonable deductibles that can actually be used, by all means bring it back.

The single, young(er), healthy, male, self employed who make over $47k/year ended up with the shaft.  

I'll give you one guess how I made out with ACA. 

  This is wrong

Bushcare means existing condition rule applies so basically you are left on the street and die and rot if you have cancer because no insurance company will sell you a coverage. (Oh that's why health insurance was way cheaper back then woow I did not know that) bingo!!!!

And also, Bushcare means there is a $1MM limit per year for insurance companies to spend for you. Obamacare cancelled that $1MM and now there is no limit.
(Oh that's why health insurance was way cheaper back then woow I did not know that) bingo!!!!


The name itself Bush should scare you anyway.
Where is the weapons of mass destruction? Oh I know.

quaters said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
If by BushCare you mean affordable insurance that has reasonable deductibles that can actually be used, by all means bring it back.

The single, young(er), healthy, male, self employed who make over $47k/year ended up with the shaft.  

I'll give you one guess how I made out with ACA. 

  Bushcare?

No pre existing condition rule. That means if you have cancer you can not get coverage (With obamacare there is no preexisting condition rule)
Also there is a $1MM spending limit by insurance companies per year. (With obamacare there is no limit)

(Oh I see why Bushcare was sooo cheap back then but wait this is not fair)

Bingo!!!

fleetwoodmac said:   
quaters said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
If by BushCare you mean affordable insurance that has reasonable deductibles that can actually be used, by all means bring it back.

The single, young(er), healthy, male, self employed who make over $47k/year ended up with the shaft.  

I'll give you one guess how I made out with ACA. 

  This is wrong

Bushcare means existing condition rule applies so basically you are left on the street and die and rot if you have cancer because no insurance company will sell you a coverage. (Oh that's why health insurance was way cheaper back then woow I did not know that) bingo!!!!

And also, Bushcare means there is a $1MM limit per year for insurance companies to spend for you. Obamacare cancelled that $1MM and now there is no limit.
(Oh that's why health insurance was way cheaper back then woow I did not know that) bingo!!!!


The name itself Bush should scare you anyway.
Where is the weapons of mass destruction? Oh I know.

I wasn't saying there were not improvements to the system with ACA, but just pointing out who had to pay for them.

I assure you, I am not wrong about that.

I went from:

  • $110/month premium, $1,500 Deductible, $25/$50 co-pay Doctor Visit, $15 generic prescription, Dental, $2M lifetime cap
  • TO
  • $375/month premium, $7,100 Deductible, Full Price Doctor & Full Price Prescription until Deductible, No Dental, No lifetime cap & BONUS 1 FREE Wellness visit

This year my market went from 3 insurers (Aetna, United and Blues Cross) to ONE!  Blue Cross, which is the worst.

So if you are single and make over $47k you pay $11,600 out of pocket before the insurance pays one dollar.  Oh and by the way, by law you have to buy the one plan that is available.

Please tell me I'm wrong, I would love to be.





 

quaters said:   
fleetwoodmac said:   
quaters said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
If by BushCare you mean affordable insurance that has reasonable deductibles that can actually be used, by all means bring it back.

The single, young(er), healthy, male, self employed who make over $47k/year ended up with the shaft.  

I'll give you one guess how I made out with ACA. 

  This is wrong

Bushcare means existing condition rule applies so basically you are left on the street and die and rot if you have cancer because no insurance company will sell you a coverage. (Oh that's why health insurance was way cheaper back then woow I did not know that) bingo!!!!

And also, Bushcare means there is a $1MM limit per year for insurance companies to spend for you. Obamacare cancelled that $1MM and now there is no limit.
(Oh that's why health insurance was way cheaper back then woow I did not know that) bingo!!!!


The name itself Bush should scare you anyway.
Where is the weapons of mass destruction? Oh I know.

I wasn't saying there were not improvements to the system with ACA, but just pointing out who had to pay for them.

I assure you, I am not wrong about that.

I went from:

  • $110/month premium, $1,500 Deductible, $25/$50 co-pay Doctor Visit, $15 generic prescription, Dental, $2M lifetime cap
  • TO
  • $375/month premium, $7,100 Deductible, Full Price Doctor & Full Price Prescription until Deductible, No Dental, No lifetime cap & BONUS 1 FREE Wellness visit

This year my market went from 3 insurers (Aetna, United and Blues Cross) to ONE!  Blue Cross, which is the worst.

So if you are single and make over $47k you pay $11,600 out of pocket before the insurance pays one dollar.  Oh and by the way, by law you have to buy the one plan that is available.

Please tell me I'm wrong, I would love to be.





 

 I live in Houston and there are more than 10 options to pick in obamacare.
You can not live in the middle of nowhere and expect obamacare to offer you 10 different plans from hospitals which does not exist.

move to a big city and understand the rules of capitalism. Big cities have better and more choices

Fleetwoodmac said: I live in Houston and there are more than 10 options to pick in obamacare.
You can not live in the middle of nowhere and expect obamacare to offer you 10 different plans from hospitals which does not exist.

move to a big city and understand the rules of capitalism. Big cities have better and more choices


Okay, I'll stop responding to you now, ha.

Defending the poor implementation of a federal govt. program with me not understanding "the rules of capitalism", good belly laugh here.

Last time I checked Philadelphia was not in the middle of nowhere, but I know everything is "bigger" in the Texas.   
 

quaters said:   
Fleetwoodmac said: I live in Houston and there are more than 10 options to pick in obamacare.
You can not live in the middle of nowhere and expect obamacare to offer you 10 different plans from hospitals which does not exist.

move to a big city and understand the rules of capitalism. Big cities have better and more choices


Okay, I'll stop responding to you now, ha.

Defending the poor implementation of a federal govt. program with me not understanding "the rules of capitalism", good belly laugh here.

Last time I checked Philadelphia was not in the middle of nowhere, but I know everything is "bigger" in the Texas.   
 

  Let me clarify

So you live in Philadelphia and you are only given 1 option to choose in Obamacare?

Did I understand correctly?

fleetwoodmac said:   
quaters said:   
Fleetwoodmac said: I live in Houston and there are more than 10 options to pick in obamacare.
You can not live in the middle of nowhere and expect obamacare to offer you 10 different plans from hospitals which does not exist.

move to a big city and understand the rules of capitalism. Big cities have better and more choices


Okay, I'll stop responding to you now, ha.

Defending the poor implementation of a federal govt. program with me not understanding "the rules of capitalism", good belly laugh here.

Last time I checked Philadelphia was not in the middle of nowhere, but I know everything is "bigger" in the Texas.   

  Let me clarify

So you live in Philadelphia and you are only given 1 option to choose in Obamacare?

Did I understand correctly?

Yes, Chester County PA.
One Insurance Choice: IBX (Independent Blue Cross)
Last Year: 3 Choices (Aetna, United, IBX)

 

quaters said:   
fleetwoodmac said:   
quaters said:   
Fleetwoodmac said: I live in Houston and there are more than 10 options to pick in obamacare.
You can not live in the middle of nowhere and expect obamacare to offer you 10 different plans from hospitals which does not exist.

move to a big city and understand the rules of capitalism. Big cities have better and more choices


Okay, I'll stop responding to you now, ha.

Defending the poor implementation of a federal govt. program with me not understanding "the rules of capitalism", good belly laugh here.

Last time I checked Philadelphia was not in the middle of nowhere, but I know everything is "bigger" in the Texas.   

  Let me clarify

So you live in Philadelphia and you are only given 1 option to choose in Obamacare?

Did I understand correctly?

Yes, Chester County PA.
One Insurance Choice: IBX (Independent Blue Cross)
Last Year: 3 Choices (Aetna, United, IBX)

 

  Well, technically, that's NEAR Philadelphia.

You've only got one insurer, but 11 plans to choose from.  The $375 premium/$7500 deductible is a bit off, though - for $403/month, you can get a $2500 deductible.

No doubt, though, someone in your position (young, healthy, earn too much for subsidies) got hurt by the ACA, since insurers are no longer able to cherry pick the risk pool to only get people like you.  

cestmoi123 said:   
quaters said:   
fleetwoodmac said:   
quaters said:   
Fleetwoodmac said: I live in Houston and there are more than 10 options to pick in obamacare.
You can not live in the middle of nowhere and expect obamacare to offer you 10 different plans from hospitals which does not exist.

move to a big city and understand the rules of capitalism. Big cities have better and more choices


Okay, I'll stop responding to you now, ha.

Defending the poor implementation of a federal govt. program with me not understanding "the rules of capitalism", good belly laugh here.

Last time I checked Philadelphia was not in the middle of nowhere, but I know everything is "bigger" in the Texas.   

  Let me clarify

So you live in Philadelphia and you are only given 1 option to choose in Obamacare?

Did I understand correctly?

Yes, Chester County PA.
One Insurance Choice: IBX (Independent Blue Cross)
Last Year: 3 Choices (Aetna, United, IBX)

 

  Well, technically, that's NEAR Philadelphia.

You've only got one insurer, but 11 plans to choose from.  The $375 premium/$7500 deductible is a bit off, though - for $403/month, you can get a $2500 deductible.

No doubt, though, someone in your position (young, healthy, earn too much for subsidies) got hurt by the ACA, since insurers are no longer able to cherry pick the risk pool to only get people like you.  

  This person has 11 options to choose from and complaining?

I don't know what to say

fleetwoodmac said:     This person has 11 options to choose from and complaining?

I don't know what to say

I don't think you understand.  The 11 options are from 1 company = no competition = 40% premium increase this year.
You don't have to say anything.  Just understand there were losers in the ACA who make as little $47k a year.  

I remember the promises of no new taxes on anyone under $250k/year.  ACA was a big tax for me.

quaters said:   
fleetwoodmac said:     This person has 11 options to choose from and complaining?

I don't know what to say

I don't think you understand.  The 11 options are from 1 company = no competition = 40% premium increase this year.
You don't have to say anything.  Just understand there were losers in the ACA who make as little $47k a year.  

I remember the promises of no new taxes on anyone under $250k/year.  ACA was a big tax for me.

  You are unlucky to be just above 40K threshold I understand

But then such a big metropolitan area is served by only 1 company? What is the reason for this anomaly?

Here is a news article in Colorado with an ER physician group charging ridiculous out of network charges.

http://www.9news.com/news/investigations/buyer-beware/buyer-bewa...

quaters said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
If by BushCare you mean affordable insurance that has reasonable deductibles that can actually be used, by all means bring it back.

The single, young(er), healthy, male, self employed who make over $47k/year ended up with the shaft.  

I'll give you one guess how I made out with ACA. 

  
I'm older and not in good health. Before the ACA, I was able to obtain PPO insurance from my State's High Risk Pool, which had to take anyone as long as you had prior coverage for the preceding 18 months. Not cheap at all, but cheaper than the limited network HMO policies that are my only options under ACA for 2017, and at a higher price.  I can no longer keep ANY of my doctors because none of them are in any HMO's. I'm self-employed, so I don't have the option of "employer provided" healthcare.

I am also an actuary, and I will tell you with all certainty that anybody who doesn't qualify for the high subsidies for low income people all got screwed by the ACA.  Oh, it started out looking nice, but now it's a useless POS program.  The infamous 20 million previously uninsured who are getting their very high deductible plan for under $100 a month are balanced against the 20 million self-employed single entrepreneurs whose options have become all crap. 

As an actuary, I predicted when this passed that those previously uninsureds would eventually end up with nothing but an insurance card that they can't use because they can't afford the initial high deductible before coverage kicks in.  As a result, they are still going to the ER's for medical care. I was recently in an ER with a family member and they have a big sign that everyone will be treated regardless of their ability to pay.  So much for these folks "insurance" paying for their care.

The ACA destroyed a market that worked for 300 million people to provide useless coverage to 20 million, at an extremely high cost to the taxpayers.  Socialism at its finest, with the usual result.

quaters said:   fleetwoodmac said:     This person has 11 options to choose from and complaining?

I don't know what to say
I don't think you understand.  The 11 options are from 1 company = no competition = 40% premium increase this year.
You don't have to say anything.  Just understand there were losers in the ACA who make as little $47k a year.  

I remember the promises of no new taxes on anyone under $250k/year.  ACA was a big tax for me.
  You are unlucky to be just above 40K threshold I understand

But then such a big metropolitan area is served by only 1 company? What is the reason for this anomaly? 

===================

It's not an anomaly. It's the way the Democrats designed it to work. It was designed to fail and they expected to be in a position to come back and put their cherished single payer socialism on our backs. All over the nation, companies are pulling out of the exchanges and those remaining are offering in many cases only very limited HMO networks.  The "options" are which limited network you want to have to be forced into.  And they provided NO coverage for out of network providers.  I am in North Texas and we only have narrow network HMO options.  Period.

fleetwoodmac said:   
quaters said:   
fleetwoodmac said:     This person has 11 options to choose from and complaining?

I don't know what to say

I don't think you understand.  The 11 options are from 1 company = no competition = 40% premium increase this year.
You don't have to say anything.  Just understand there were losers in the ACA who make as little $47k a year.  

I remember the promises of no new taxes on anyone under $250k/year.  ACA was a big tax for me.

  You are unlucky to be just above 40K threshold I understand

But then such a big metropolitan area is served by only 1 company? What is the reason for this anomaly?

The ACA.  The law & regulations forced the insurance companies out of the market.

The exact opposite of Capitalism.

fleetwoodmac said:    I live in Houston and there are more than 10 options to pick in obamacare.
You can not live in the middle of nowhere and expect obamacare to offer you 10 different plans from hospitals which does not exist.

move to a big city and understand the rules of capitalism. Big cities have better and more choices

  about 1/3 of counties are projected to have a single insurance carrier for their ACA individual market in 2017.  This is by no means an exceptional case.  There is even one county in AZ that has none (although maybe they fixed that by now).  

http://www.nytimes.com/2016/08/20/upshot/obamacare-options-in-ma...

HSimpson101 said:   
quaters said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
If by BushCare you mean affordable insurance that has reasonable deductibles that can actually be used, by all means bring it back.

The single, young(er), healthy, male, self employed who make over $47k/year ended up with the shaft.  

I'll give you one guess how I made out with ACA. 

  
I'm older and not in good health. Before the ACA, I was able to obtain PPO insurance from my State's High Risk Pool, which had to take anyone as long as you had prior coverage for the preceding 18 months. Not cheap at all, but cheaper than the limited network HMO policies that are my only options under ACA for 2017, and at a higher price.  I can no longer keep ANY of my doctors because none of them are in any HMO's. I'm self-employed, so I don't have the option of "employer provided" healthcare.

I am also an actuary, and I will tell you with all certainty that anybody who doesn't qualify for the high subsidies for low income people all got screwed by the ACA.  Oh, it started out looking nice, but now it's a useless POS program.  The infamous 20 million previously uninsured who are getting their very high deductible plan for under $100 a month are balanced against the 20 million self-employed single entrepreneurs whose options have become all crap. 

As an actuary, I predicted when this passed that those previously uninsureds would eventually end up with nothing but an insurance card that they can't use because they can't afford the initial high deductible before coverage kicks in.  As a result, they are still going to the ER's for medical care. I was recently in an ER with a family member and they have a big sign that everyone will be treated regardless of their ability to pay.  So much for these folks "insurance" paying for their care.

The ACA destroyed a market that worked for 300 million people to provide useless coverage to 20 million, at an extremely high cost to the taxpayers.  Socialism at its finest, with the usual result.

  I don't agree

Before Obamacare and if you were poor say you make less than 40K you did not have health insurance, what happened to these people when they got a serious disease like cancer?

They die without care. Why without care? Because even though they wanted to have insurance, nobody would sell them insurance.

We passed that and we have Obamacare which is the best thing that could happen to USA.

No more personal bankruptcies due to 200K hospital bills.

No more dying people on the streets (shame on us), no more denials for coverage due to being cancer or some other disease (shame on us), no more denial of care because you hit $1MM spending limit (shame on us)

Whoever supports Bush and/or life before Obamacare has to be ashamed.

I've removed a couple posts from this thread. It's okay to disagree - after all, we are on a discussion board - but please refrain from accusations and name-calling.

Quarters, YES your insurance went up because Obamacare.

But it would have gone up without Obamacare too. A lot.

Your insurance also went up because you got older. About 20% more expensive for a 45 year old vs a 35 year old.
Your insurance also went up because health care costs go up every year. Costs are up ~50% in the past 10 years.

If you paid $200 /month back in 2006 and Obamacare didn't happen you'd probably be paying $360 a month today because of increased costs and your increased age.

Without Obamacare you'd have still had to pay more today versus previous years.

But as I said Obamacare did increase reates for you. Young men saw more increases than others. But I doubt you're particuarly young given your rates.

On the other hand older people have seen decreases in rates under Obamacare. Before Obamacare a healthy 25 year old guy could get insurance for $50-100 a month and a 60 year old guy might pay $800-1200 a month. But one element in Obamacare made it so that the difference in premiums due to age could only be up to 3x. In other words the most expensive premium for an older person can only be 3x the cost of the cheapest premium for a young person. So the $100 /mo for a young guy and $1200/mo for an older guy would be changed into $350 and $1050.

HSimpson101 said:   
quaters said:   
belgique said:   By 2018...we will be back to BushCare, expect it will be called TrumpCare...and it will take all regulations off insurance companies as Trump promised. If you voted for him...you voted for the insurance companies to run wild.
If by BushCare you mean affordable insurance that has reasonable deductibles that can actually be used, by all means bring it back.

The single, young(er), healthy, male, self employed who make over $47k/year ended up with the shaft.  

I'll give you one guess how I made out with ACA. 

  
I'm older and not in good health. Before the ACA, I was able to obtain PPO insurance from my State's High Risk Pool, which had to take anyone as long as you had prior coverage for the preceding 18 months. Not cheap at all, but cheaper than the limited network HMO policies that are my only options under ACA for 2017, and at a higher price.  I can no longer keep ANY of my doctors because none of them are in any HMO's. I'm self-employed, so I don't have the option of "employer provided" healthcare.

I am also an actuary, and I will tell you with all certainty that anybody who doesn't qualify for the high subsidies for low income people all got screwed by the ACA.  Oh, it started out looking nice, but now it's a useless POS program.  The infamous 20 million previously uninsured who are getting their very high deductible plan for under $100 a month are balanced against the 20 million self-employed single entrepreneurs whose options have become all crap. 

As an actuary, I predicted when this passed that those previously uninsureds would eventually end up with nothing but an insurance card that they can't use because they can't afford the initial high deductible before coverage kicks in.  As a result, they are still going to the ER's for medical care. I was recently in an ER with a family member and they have a big sign that everyone will be treated regardless of their ability to pay.  So much for these folks "insurance" paying for their care.

The ACA destroyed a market that worked for 300 million people to provide useless coverage to 20 million, at an extremely high cost to the taxpayers.  Socialism at its finest, with the usual result.

  

Just one point here:   I'm pretty sure that has been the law of the land for a long time and nothing to do with Obamacare.

https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Ac...

 

quaters said:   The exact opposite of Capitalism.
  

The entire health care and health insurance industry hasn't been very close to a valid functional capitalist system for decades.

The government pays ~50% of healthcare between medicare, medicaid and VA.
Companies give most people insurance which has a tax benefit and its expected then the company pays 50-100% of the cost.   The consumers don't see the real insurance cost.
Theres no price transparency.   How does capitalism function when the consumers don't know the prices??
The US government legally barred itself from negotiating drug prices for medicare for no good real capitalist reason.   That sure ain't capitalism.
Hospitals often write off ~5% of their services as charity for those who can't  pay.

etc.

 

If I have a beef with the ACA it is that most people, including virtually all doctors, think the well-publicized rules affect all plans. I don't know how many times I have had to tell the Dr. that preventative care isn't covered under our plan, just diagnostic. So routine colonoscopies, flu shots, immunizations aren't covered with our plan. The rules seemed to have been made to stick it to insurance companies, but not union health funds which seem to be grandfathered on all these popular rules. Oh, and our plan isn't a Cadillac either.

jerosen said:   Quarters, YES your insurance went up because Obamacare.

But it would have gone up without Obamacare too. A lot.

Your insurance also went up because you got older. About 20% more expensive for a 45 year old vs a 35 year old.
Your insurance also went up because health care costs go up every year. Costs are up ~50% in the past 10 years.

If you paid $200 /month back in 2006 and Obamacare didn't happen you'd probably be paying $360 a month today because of increased costs and your increased age.

Without Obamacare you'd have still had to pay more today versus previous years.

But as I said Obamacare did increase reates for you. Young men saw more increases than others. But I doubt you're particuarly young given your rates.

On the other hand older people have seen decreases in rates under Obamacare. Before Obamacare a healthy 25 year old guy could get insurance for $50-100 a month and a 60 year old guy might pay $800-1200 a month. But one element in Obamacare made it so that the difference in premiums due to age could only be up to 3x. In other words the most expensive premium for an older person can only be 3x the cost of the cheapest premium for a young person. So the $100 /mo for a young guy and $1200/mo for an older guy would be changed into $350 and $1050.

I'm okay with the premium increases with age and my pre-ACA plan was grandfathered for 2 years before Aetna killed it and it did double in that time to $200/month.

But the premium increase is *nothing* compared to the HUGE deductibles and lack of co-pays.  The last two years I haven't gone to the doctor when ill, because I'm scared of what 100% of a visit bill would look like.   

In essence, I'm paying a federal catastrophic insurance that will not be used (unless of car accident or cancer).  

Whereas someone else who is receiving a subsidized plan with subsidized deductibles gets to go the doctor without worrying about the bill.  Not very fair.

jerosen said:   
quaters said:   The exact opposite of Capitalism.
  

The entire health care and health insurance industry hasn't been very close to a valid functional capitalist system for decades.

The government pays ~50% of healthcare between medicare, medicaid and VA.
Companies give most people insurance which has a tax benefit and its expected then the company pays 50-100% of the cost.   The consumers don't see the real insurance cost.
Theres no price transparency.   How does capitalism function when the consumers don't know the prices??
The US government legally barred itself from negotiating drug prices for medicare for no good real capitalist reason.   That sure ain't capitalism.
Hospitals often write off ~5% of their services as charity for those who can't  pay.

etc.

 

That line was a play off of Fleetwoodmac's quote from above.

Not arguing the pre-ACA socialist state of our healthcare system, but the ACA wasn't a step towards the free market, it was a leap away from it.

quaters said:   
That line was a play off of Fleetwoodmac's quote from above.


 


 Ah, ok, I missed that.
 

Skipping 57 Messages...
fleetwoodmac said:   Here is my doctor's response

---------------------------------------------

The Shouldice repair is not very commonly performed here in the US anymore.  I did perform this operation in my training in the 1990s but only rarely with older surgeons that adopted this technique in the years prior.  The reason for this is that around the earlier 1980s the concept of a tension free repair was adopted by most surgeons.  The reason for this is that patient recovery was associated with much less pain (hence the concept of a tension free repair) and the recurrence rates were much less with mesh repairs.  No general surgeon in the US trains to do inguinal hernia surgery without mesh in the year 2016.  In Canada, cost is more of an issues.  Laparoscopy and robotic surgery is associated with higher hospital costs and this may be the reason that this is more commonly performed technique in that country.  As a matter of fact even in the US, only about 25% of inguinal hernias repairs are performed laparoscopically but this is because it is a difficult technique to learn and most surgeons that run a busy practice don’t want to take the time to get over the learning curve to adopt this technique.  In my opinion most inguinal hernias should be performed laparoscopically or robotically.  That is how I would like my own hernia repaired if I ever need it.  One thing I will say is that surgery is ever evolving/changing.  I feel that in our practice we pride ourselves in being dynamic and changing our techniques based on patient outcomes rather than by cost or historical dogma. I hope this puts your mind at ease.   


  Maybe ask him about failure rates and complications. Ask him how many of these surgeries he does each year.  Google some studies on it.
The surgeon I consulted here in the US quoted me a 10% failure rate for tension-free mesh. That's huge.

There's a reason why people come from literally all over the world to the Canadian center. (I met people from Australia and the UK while I was there). It's not because it's cheap. They could have gone to the US instead.

He's right that US surgeons don't train in the Shouldice technique. You can't just do a few each year, since it's complicated and requires constant practice. The doctors at the Canadian center do NOTHING BUT these surgeries, the entire year. They each do approx 4 a day, so hundreds a year. Unless the surgeon works in a dedicated hernia center, that's impossible to do in the US, so they do mesh instead. It's an easy procedure to learn and do.

He's also right that Laproscopic surgery results in less (initial) pain. Recovery is faster. However, the tradeoff is the possibility of long-term pain.



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