Here's a statement of the obvious: The opinions expressed here are those of the participants, not those of the Mutual Fund Observer. We cannot vouch for the accuracy or appropriateness of any of it, though we do encourage civility and good humor.
You asked about the dental plan I noted previous. The below will cover the majority of this area.
The individual providing this info stated that there is the consideration to forgo the $91/month for two, when factoring the plan limits and all other data and just do a pay as you go plan (out of pocket). As things go in life; the adult in this new dental plan developed a cracked molar 2 months into the plan that cost $1,566, out of pocket.
Now sure how the layout of info below will format. I will clean up the layout as much as possilbe for readabilty.
---6 month and 1 year wait period for some procedures from plan beginning ---Deductible per person/per 1 year plan period and resets each year; is $50 ---Max/year-limit, per individual that the plan will pay = $1,000
---The 3 below are available at the beginning of the plan Diagnostic Examinations 100% Preventive 100% Bitewing Radiographs 100%
All Other Radiographs 80% coverage after 6 months Brush Biopsy 100% cover immediate Sealants Not Covered N/A Not Covered N/A Minor Restorative 80% after 6 months Major Restorative 50% after 12 months Endodontics 50% after 12 months Periodontics 50% after 12 months Relines and Repairs 80% after 6 months Simple Extractions 50% after 12 months Other Oral Surgery 50% after 12 months TMD 50% after 12 months Other Basic Services 50% after 12 months Prosthodontics 50% after 12 months Implants Not Covered N/A Not Covered N/A Orthodontic Services Code Range 8000 - 8999 0%
Below are some of the basic exclusions and limitations that apply to the policy. Please refer to your policy packet for a more detailed list. ---Diagnostic Oral examinations are payable twice per benefit year.
---Preventive ---Prophylaxes (cleanings) are payable twice per benefit year. A third prophylaxis is payable per benefit year with a documented history of periodontal disease and a fourth prophylaxis is payable for two consecutive benefit years following periodontal surgery. ---Space maintainers are payable once per area in a lifetime, for missing posterior, primary teeth, up to age 14. ---Fluoride treatments are payable twice per benefit period up to age 19 ---Bitewing Radiographs ---Bitewing x-rays are payable once per benefit period.
---All Other Radiographs Full mouth x-rays (which include bitewing x-rays) or a panorex are payable once in a five-year period.
---Minor Restorative Composite resin (white) restorations on a posterior tooth is not covered and the Plan will pay only the applicable amount that it would have paid for an amalgam restoration. ---Major Restorative Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period.
---Inlays are not covered services and will be optioned to an amalgam or resin restoration. ---Periodontics An occlusal guard is payable once in a lifetime. ---Root planing and scaling is payable once per quadrant in 24 consecutive months. ---TMD Benefits for Temporomandibular Disorders (TMD) are limited to services that would normally be provided by a licensed dentist to diagnose, treat and relieve oral symptoms. Predetermination is strongly recommended. ---Prosthodontics Full and partial dentures are limited to once in a five year period. Bridgework and substructures are limited to once in a five year period. Payment will be made to replace a tooth that has been missing prior to the effective date of coverage.
Whelp, not surprising that folks feel strongly about the ACA - considering all the bs circulated by both sides of the issue. My main problem with the ACA is that it did not go nearly far enough and was a sell out to big pharm, the AMA and the hospitals and particularly the health insurance industry.
Whoever said that providing health care services should be a 'for profit' industry. Rubbish. Having to lose a leg or arm, or your sight, or even your life, because you can't afford it is obscene. Now, if you want a nose job - pay for it. Otherwise, we need a 'one pay system' to make this work and we need it yesterday.
Right now, there is no check on rising medical cost because it's a three party bargain - patient, provider, insurer. And none are providing a check on costs like when you negotiate with a provide one on one.
Oh, and if someone wants to call this socialized medicine -fine.
Back in the 40's the President of Costa Rica decided that they didn't need an army but they did need national health insurance. Today it's one of the finest places to live on the planet.
Practicing medicine is a "skill"..it there different levels of competence, I would think so! Find/use the best, takes a little research, asking people/professionals in the business, I always ask the nurses, esp. in a hospitals they always know...takes a little probing...
You asked about the dental plan I noted previous. The below will cover the majority of this area.
The individual providing this info stated that there is the consideration to forgo the $91/month for two, when factoring the plan limits and all other data and just do a pay as you go plan (out of pocket). As things go in life; the adult in this new dental plan developed a cracked molar 2 months into the plan that cost $1,566, out of pocket.
"---Max/year-limit, per individual that the plan will pay = $1,000"
To me, that severely compromises the plan. Most unfortunate that so many dental plans do this. There are some very expensive dental procedures out there.
Major Restorative 50% after 12 months Endodontics 50% after 12 months Periodontics 50% after 12 months Other Oral Surgery 50% after 12 months TMD 50% after 12 months Other Basic Services 50% after 12 months Prosthodontics 50% after 12 months Implants Not Covered N/A Not Covered N/A
Whelp, not surprising that folks feel strongly about the ACA - considering all the bs circulated by both sides of the issue. My main problem with the ACA is that it did not go nearly far enough and was a sell out to big pharm, the AMA and the hospitals and particularly the health insurance industry.
Whoever said that providing health care services should be a 'for profit' industry. Rubbish. Having to lose a leg or arm, or your sight, or even your life, because you can't afford it is obscene. Now, if you want a nose job - pay for it. Otherwise, we need a 'one pay system' to make this work and we need it yesterday.
Right now, there is no check on rising medical cost because it's a three party bargain - patient, provider, insurer. And none are providing a check on costs like when you negotiate with a provide one on one.
Oh, and if someone wants to call this socialized medicine -fine.
Back in the 40's the President of Costa Rica decided that they didn't need an army but they did need national health insurance. Today it's one of the finest places to live on the planet.
>> "to comply with federal law", as noted in the documentation from the plan provider."
\\\ Yep, the govt is dictating every angle it appears.
oh, it is, it is, whatever will become of us under this tyrant?
What lameass excuse did the insurance company give in years when it could not blame federal law for its rise in rates? You are quoting the voice of some marketing kid who got a bonus for that phrase alone. Oh, of course it is outrageous, to comply with federal law. Without that horrific law, what would happen then?
Mona, serious question, do you know in what way your splendid plan was ACA-noncompliant? Can you elaborate? Do you know, did they say, could you infer? If you have a real case here, it would be pretty much a first, so far as I have read, and you should get the press on it, seriously. Everyone who said what you said in the past year, and there sure were a lot, upon serious investigation it all turned out to be bogospeak and misunderstanding. But with you and from your posts, I would doubt that.
I haven't read the links here, and I may have only skimmed some of the posts, but I am nearing the end of my career, and I have been delivering primary medical care for almost 40 years. I was (am) a National Merit Scholar and I was in the top 2% of my medical school class, and I, as a child of the 60's, went into primary care, despite my conservative upbringing, as a means of serving my country. I wasn't going to Viet Nam, but I was willing to do my part. For my financial future, this was an unwise decision. It also hasn't done much for my retirement investments. I was not the doctor at the bottom of my class, but I have endured 40 years of second guessing on the part of my patients and consultants, who seemed to presume that they knew more than I did. I keep up with the pertinent medical literature, which has become easier with the internet and Journal Watch, and I think the medical-industrial complex is in control.
I don't have a solution for the current medical care problem, but you can not trust the drug companies, who were allowed at the table by Bush II, and the Republicans, with whom I identified for most of my life, do not have a plan. The Affordable Care Act is seriously flawed, because of the deals that had to be made to ensure its passage, but it is better than what we had before. I didn't vote for O, but he at least has a plan.
Probably, the best solution is similar to British plan, which seems to offer a base plan for all with a commercial plan superimposed, which allows those who can afford it to purchase coverage similar to current US plan. I doubt US politicians will support this, but you can't have everything unless you pay for it. That's not a bad plan (since it allows all of you who can afford it to buy the coverage), but it plays badly at elections. If the National Health Care Plan was unsatisfactory to the doctors, we should have seen an influx of Brits, but I haven't seen them yet.
Those of you who bemoan the loss of your previous plans probably weren't really paying for it, if you were in a plan with union input, although those of you working for government entities probably paid by taking lower salaries.
Suck it up. Look at the costs, if you can find them. Realize there is no free lunch. Appreciate the benefits you have enjoyed.
Pay for the benefits. It's only a harsh world until you consider a Chinese peasant walking behind a water buffalo. Then it looks pretty wonderful.
Thanks for a thought provoking and enlightening post. This healthcare issue has been racking my brains ever since the HillaryCare debacle. Which way is the best?
I am not a physician but worked in hospital pharmacy for over 35 years. As part of that experience I was able to work directly with nursing and doctors on the floors to provide good pharmacy care. I was not stuck in the basement.
I have heard many good things about the Australia plan which sounds similar to Britian's. Everyone gets general care and private insurance can be purchased for additional care. Australians like it a lot. I am also conservative and while plans like these might fly in the face of what I believe I think there is some good as long as misuse does not go rampant.
I have a friend who is a GP. he had his own office. These days that is a rarity in of itself. He finally had to retire. He could not make the practice go anymore as hospitals are forming groups which attract physicians (and patients) away from the single office operation. Even group offices are going away. Medicare became his primary payer and as you surely know, the time and energy to get any sort of payment out of them is long and expensive.
With insurance plans the public has not had to experience the full cost of medical. They complain about a antibiotic that costs $80 as they pay their small copay. The true idea of controlling costs by a direct relationship between patient and doctor never really happened. If a doctor were to prescribe me an expensive medication, I could ask if a cheaper one could work. Amoxicillin works just as well as many of the newer drugs in most cases as one example. But, people want the best care regardless of their capacity to pay for it. Insurance fills that need.
I don't know what the right answer is, but I do not want the govt to decide for me. That is not the America I knew.
@David Moran: Without drilling deeper, it's my understanding that a plan able to exclude those with preexisting conditions is, prima facie, noncompliant with the ACA.
@Catch22: With only a $1,000 annual benefit paid by the insurance co., it seems a challenge to justify paying the insurance. As teeth seem to break down more the longer they are around in your head, it may well pay to seek a different dental insurance plan (though that argument also speaks to keeping *some* form of dental insurance).
In my situation, as a self-insured person over many decades, I have been able to keep the BCBS Blue Value Advantage for my state, grandfathered, and apparently it is continuing into a second year post-ACA, with a 9% price increase on Jan 1 and a whopping ca. 25% increase on the anniversary date, by which time I will have squeaked into Medicare, with another set of issues to contend with.
The highest level of health exchange insurance I could afford (with federal subsidy) in my state was the Silver plan, which would have cost me more per month (even with a subsidy) and excluded (at least the Blues' Silver plan excluded) the premier medical institutions within a few minutes' walk or train ride from my home.
When did it become OK for health care insurance -- not care itself, but insurance -- to eat up 11% of Adjusted Gross Income? I can't get my brain around that at all.
Though VGHCX will fund a chunk of my retirement, the opportunity costs of self-paid insurance over all those decades just make me miserable to think about.
Pheh.
I'm with rono, and others who have raised different solutions.
You noted: "With only a $1,000 annual benefit paid by the insurance co., it seems a challenge to justify paying the insurance. As teeth seem to break down more the longer they are around in your head, it may well pay to seek a different dental insurance plan (though that argument also speaks to keeping *some* form of dental insurance)."
>>>A tough question and answer, indeed. I have discussed this with several folks I know well and the thoughts travel in various directions. 'Course, current income levels for these folks varies; so for some, they are not so concerned with the monthly premium which is about $47/month for an individual. Also, the existing "quality" of individual dental needs vary, too. Some seldom have had any dental problems with excellent tooth genes; while others have had nothing but problems for years. Further, there are others who have limited dental coverage during retirement (generally union plans) but have attempted to further reduce costs by having dental services that go beyond any coverage performed at the university dental schools available in our state; to help reduce out of pocket costs.
Everyone will have to make their own choices based upon all of the circumstanes suitable for their income status, eh?
I have mentioned this before but it fits in with the current conversation.
In my growing up years, (50's and 60's), very few kids had braces or any kind of that treatment. Crooked teeth became a disease that had to be treated. Now pretty much every kid gets some sort of orthodontics and it makes me wonder if the dental industry is behind this surge? I think it is. Perfect teeth and straight ones at that lead to good self esteem.
There are instances when braces are needed but I think the therapy is being way over-prescribed like many other medical issues. In the case of dental, the consumer pays the bill as insurance pays maybe half at most. Many pay less than that. Dental offices set up in house financing to help the budget which in turn helps the dentist even more. How many parents have had to juggle dental benefits in order to take care of their kids?
I have nothing against dentists. But just like many other professions, the over sale of product is benefiting only their pocket.
I was a candidate for braces but my folks didn't have the money. Later when I did, I had some teeth pulled and the rest went into alignment. Not perfect but my self esteem is fine and I can chew steak just as well. That is what really counts.
Government involvement in Healthcare is NOT the Answer (sorry Obama fans)! If you have to ask WHY? Look around for ANY program or business government is involved and get me a success Story. Please? Social Security might be an exception, but the current politicians are trying the best they can to dismantle this "Past" success story.
" you can not trust the drug companies, who were allowed at the table by Bush II"
The SJMercury had a multipage report in yesterday's paper entitled "The Rx Alliance That Drugs Our Kids", subtitled "The doctors get rewarded, the drug companies get rich and foster children get more meds". OJ is right - the Merc does good stuff.
@STB65 - People may not realize just how huge a financial hit it is for doctors to go into primary care. On my EOBs I'm seeing less paid to my PCP than to labs for processing routine tests.
My PCP may spend triple the time and effort that my specialist spends - who just tells me the results of that lab test and gets 4x the remuneration. I don't know how PCPs manage to cover their fixed costs. When people (the ones with coverage) say that we can't afford to provide care to everyone because we don't have enough doctors, I think this lack of remuneration (for PCPs) is a good part of the problem.
@catch22 - Dental "insurance" plans are largely prepayment plans. You come out a little better than your premium if you have problems with your teeth but not much, because of the caps. What you get with some dentists is a negotiated rate (like medical insurance). But you can "buy" that rate for around $70/year, vs. $50/mo for the prepayment ("insurance") plan. Yes, it's still something of a racket, but it seems to come out better if you're not needing much care, and because of the insurance caps, similar if you need a lot of work done.
@IE --- >> it's my understanding that a plan able to exclude those with preexisting conditions is, prima facie, noncompliant with the ACA.
oh, yes, of course, sorry to have forgotten that obvs parameter. Thanks and apologies.
I am waiting to hear Mona's analysis.
I am paying my own dental now on the advice of dentist in family, always offering cash for small discount. (All docs are small businessmen, reminds my s-i-l.)
@Tb, if you really think gov can do nothing well, you simply have not read enough of the data about SS, Medicare overhead vs insurance companies, and a great many mil suppliers. I worked in DoD-related industry the last decades and the comparative efficiencies and oversight and rigor of practice and delivery are a sight to behold. But Medicare overhead cost and price hammering are the famous success stories. Do the rudimentary research. I believe that even rightwingers do not (because cannot) write outraged reports about how much more expensive and inefficient Medicare is than private enterprise. There are other examples, but of course if your premise is that gov can do nothing right and is never the answer, then have at it. FEMA or the Coast Guard or the Park Service or the FAA (or even TSA) as a private enterprise, omg, too funny, in terms of either responsiveness or cost. Or your local police and fire and schoolteachers. But whatever.
Regarding "to comply with federal law" - if I read the original post correctly, this was given as a reason to raise the deductible from $12.7K to $13.2K.
There are (at least) three problems with this statement. One is that (outside of multi-state plans), it is the states that set the requirements for standard plan deductibles. And those standards vary by "metal". For example, California's bronze plan carries a $5K/$10K deductible (individual/family), no more, no less. (Insurers can also offer nonstandard plans; I believe the state must approve them.)
Second is that the figures quoted are for out of pocket maximums, not for deductibles.
Third is that these are the maximums allowed under ACA, they are not required in order to comply with federal law. The out of pocket max's may be lower - as you can see from the California page I linked to, where the max out of pocket for a family is $12.5K (i.e. less than the federal caps).
As the article notes, individual plans often carried high caps and lower premiums. But the article also noted that "Existing policy holders may be able to keep their current plans that fail to meet the new limits." I read that as saying this was not an automatic disqualifier for grandfathering.
@msf Thank you for your contributions. I was able to check the health plan document again, and the following is, as written, regarding the new plan year, 2015. This document was sent to current plan holders:
Changes we're making to your coverage
- Deductible - Your deductible and out of pocket max will increase from $6,350 to $6,600 for an individual plan or from $12,700 to $13,200 for a family plan to comply with federal law.
Thanks Catch. I'm having problems locating any Michigan plan with a deductible that high. Admittedly I'm not checking all the rate regions of Michigan - I just tried Ann Arbor. The highest deductible there is, yes, BC/BS of Michigan, at $12,700 for 2015. Here's the plan I found (MetroDetroit EPO Bronze). Note from the URL that it is a 2015 plan: http://www.bcbsm.com/content/dam/public/Consumer/Documents/find-plans/2015/blue-cross-metro-detroit-epo-bronze.pdf
Still checking on catastrophic plan rules, but the explanation of the raise may be legitimate. Mea culpa.
For this plan, the deductible is set to be as high as the out-of-pocket max. But AFAIK, there is no federal minimum requirement for plan deductibles, except for HDHPs (i.e. ones that qualify for HSAs), where the minimum for 2015 family plans is $2,600. Nowhere near $13,200.
BC/BS of Mich knows it is misleading you in saying the limit (even if we're talking about out-of-pocket limit) is being raised to comply with federal law. There is no minimum requirement.
Elsewhere (not on your bill, of course), BC/BS writes that the maximum out-of-pocket limit is raised to $13,200 for 2015. Nowhere in the law is a policy required to impose an oop limit that high - which is obvious from the fact that most policies have lower limits. (In case it isn't just as obvious, a deductible cannot possibly be higher than the oop max.)
It's bad enough that the complexity of the ACA system makes it difficult to know what all the pieces are. Being magnanimous and allowing that BC/BS may not understand what it is talking about (rather than saying it is deliberately deceiving you), it is still disheartening if not downright depressing that the companies charged with understanding and implementing these plans disseminate such misinformation.
I found this info from my original write on Nov. 20:
The adult plan is named: Premier Bronze and the minor child plan is named, Premier Value.
I am aware of "rate regions" for coverage pricing; but don't know the boundary lines. I suspect their major metro area to be between Ann Arbor and Flint, Michigan; for purposes used by BC/BS.
Well, just a few more trinkets of info above. Don't make yourself crazy with this.....
I actually did find the rate regions (probably on the Michigan state site) - didn't keep it around though. All I remember is that Ann Arbor is in some state beginning with W (long name) and it was just to the west of Wayne and another county that cover Detroit and the region just to Detroit's south.
(I may be pretty good with details, but I don't commit out-of-state names to memory most of the time ) I've gone far enough learning about Michigan, thank you.
>> "to comply with federal law", as noted in the documentation from the plan provider."
\\\ Yep, the govt is dictating every angle it appears.
oh, it is, it is, whatever will become of us under this tyrant?
What lameass excuse did the insurance company give in years when it could not blame federal law for its rise in rates? You are quoting the voice of some marketing kid who got a bonus for that phrase alone. Oh, of course it is outrageous, to comply with federal law. Without that horrific law, what would happen then?
Mona, serious question, do you know in what way your splendid plan was ACA-noncompliant? Can you elaborate? Do you know, did they say, could you infer? If you have a real case here, it would be pretty much a first, so far as I have read, and you should get the press on it, seriously. Everyone who said what you said in the past year, and there sure were a lot, upon serious investigation it all turned out to be bogospeak and misunderstanding. But with you and from your posts, I would doubt that.
It did not cover mental heath services and a yearly wellness visit. That said, I believe the reason the price was significantly lower, was because it was an underwritten plan and my health is very good. Under ACA, my understanding is underwritten plans are no longer legal, because there can be no price differentiation tied to your state of health, and the prices can only be based on age, sex, location, if you are a smoker, and of course, level of metallic.
Again, Mona, I have to ask: What does "underwritten" actually mean, in this context? The way that you use the word suggests that it is significant to the issue, but I don't understand how.
She means "medically underwritten", i.e. considers health in assessing risk to the insurer. Substitute "pricing based on health" for "[medically] underwritten", and you'll see that the writing is a tautology:
"Plans with pricing based on health are no longer legal because there can be no price differentiation tied to your state of health."
Though age and smoking are permissible factors, they are only permitted within limits that are likely narrower than older policies. I've already explained (with links) how limiting (but not prohibiting) the use of age would affect policy rates. (Over your lifetime, you'd pay more than your age would suggest at first, and then less than your age would imply as you got older - possibly a wash.)
Sex is not a permissible factor, period. Just as it isn't used in RMD calculations or pretty much anything the government does. There still is a fourth factor allowed in the ACA's modified community rating system - family size. The more people you insure, the higher the insurance cost. Duh.
But there are other factors that affect price that have nothing to do with who's insured. Such as benefits offered. Two bronze plans, each covering the same family, could charge very different rates based on what they provided (though being bronze they would both have to cover about 60% of the expected medical costs of that family under the plan).
A prime example of differing benefits is dental care for children. "When the [ACA] was approved in 2010, it listed pediatric dental care as an 'essential' benefit. But .. [HHS] issued a ruling allowing insurance companies in NJ and most other states to leave out pediatric coverage. ... Insurers are allowed to offer pediatric dental benefits embedded in their medical plans ..." http://www.njspotlight.com/stories/14/01/20/change-in-aca-rules-means-fewer-kids-will-have-dental-coverage/
Aside from the deficiencies Mona listed - lack of (modified) community rating, free preventive care services, and mental health care - there are lots of other ACA provisions that could have disqualified a plan. Few would have prevented grandfathering.
One that would have is more a practice than an explicit provision. Unfair rescission - this is the practice where an insurer finds some excuse (other than deliberate fraud) to void a policy. Insurers routinely did this (apparently starting about a decade ago) to people who dared to get sick. (When they said a policy was for healthy people, they weren't kidding.)
"WellPoint Inc., UnitedHealth Group and Assurant Inc. cancelled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million .. over a five year period." http://articles.latimes.com/2009/jun/17/business/fi-rescind17
"When questioned about these practices, insurance executives refused in the absence of mandatory laws or health reform to limit rescissions to cases of clear and intentional fraud. ... The companies who engage in these rescissions argue that they are entirely legal, and to a large extent they are. But that goes against the whole point of insurance." http://lawschool.unm.edu/nmlr/volumes/40/3/05-lindsey-why.pdf
So if one had an especially low cost policy, it's fair to ask whether that policy would really cover anything substantial, or was it an illusion that would vanish in a puff of smoke?
Mona, thanks very much for responding, honestly and frankly; and yes, I can see why your plan was noncompliant, as some would argue it certainly should be and have always been, with no mental health, no preventive, and with level-of-current-health pricing.
I am fully persuaded that there are all manner of things wrong or suboptimal with ACA. I sure would like to read about them impartially.
Iowa Senator Joni Ernst (the hog castrater) last month:
“We’re looking at Obamacare right now. Once we start with those benefits in January, how are we going to get people off of those? It’s exponentially harder to remove people once they’ve already been on those programs…we rely on government for absolutely everything. And in the years since I was a small girl up until now into my adulthood with children of my own, we have lost a reliance on not only our own families, but so much of what our churches and private organizations used to do. They used to have wonderful food pantries. They used to provide clothing for those that really needed it. But we have gotten away from that. Now we’re at a point where the government will just give away anything.”
[article] That’s the fundamental belief that motivates most, if not all, the conservative opposition: Health care should be a privilege rather than a right. If you can’t afford health insurance on your own, that is not the government’s problem.
Comments
I'll check this weekend to contact them about the dental portion.
I agree the opposition is strong and persistent. The midterm elections spoke volumes.
Mona
You asked about the dental plan I noted previous. The below will cover the majority of this area.
The individual providing this info stated that there is the consideration to forgo the $91/month for two, when factoring the plan limits and all other data and just do a pay as you go plan (out of pocket).
As things go in life; the adult in this new dental plan developed a cracked molar 2 months into the plan that cost $1,566, out of pocket.
Now sure how the layout of info below will format. I will clean up the layout as much as possilbe for readabilty.
---6 month and 1 year wait period for some procedures from plan beginning
---Deductible per person/per 1 year plan period and resets each year; is $50
---Max/year-limit, per individual that the plan will pay = $1,000
Take care,
Catch
Whelp, not surprising that folks feel strongly about the ACA - considering all the bs circulated by both sides of the issue. My main problem with the ACA is that it did not go nearly far enough and was a sell out to big pharm, the AMA and the hospitals and particularly the health insurance industry.
Whoever said that providing health care services should be a 'for profit' industry. Rubbish. Having to lose a leg or arm, or your sight, or even your life, because you can't afford it is obscene. Now, if you want a nose job - pay for it. Otherwise, we need a 'one pay system' to make this work and we need it yesterday.
Right now, there is no check on rising medical cost because it's a three party bargain - patient, provider, insurer. And none are providing a check on costs like when you negotiate with a provide one on one.
Oh, and if someone wants to call this socialized medicine -fine.
Back in the 40's the President of Costa Rica decided that they didn't need an army but they did need national health insurance. Today it's one of the finest places to live on the planet.
and so it goes,
peace,
rono
Find/use the best, takes a little research, asking people/professionals in the business, I always ask the nurses, esp. in a hospitals they always know...takes a little probing...
"---Max/year-limit, per individual that the plan will pay = $1,000"
To me, that severely compromises the plan. Most unfortunate that so many dental plans do this. There are some very expensive dental procedures out there.
Major Restorative 50% after 12 months
Endodontics 50% after 12 months
Periodontics 50% after 12 months
Other Oral Surgery 50% after 12 months
TMD 50% after 12 months
Other Basic Services 50% after 12 months
Prosthodontics 50% after 12 months
Implants Not Covered N/A Not Covered N/A
rono,
Spot on post!
Mona
\\\ Yep, the govt is dictating every angle it appears.
oh, it is, it is, whatever will become of us under this tyrant?
What lameass excuse did the insurance company give in years when it could not blame federal law for its rise in rates? You are quoting the voice of some marketing kid who got a bonus for that phrase alone. Oh, of course it is outrageous, to comply with federal law. Without that horrific law, what would happen then?
Mona, serious question, do you know in what way your splendid plan was ACA-noncompliant? Can you elaborate? Do you know, did they say, could you infer? If you have a real case here, it would be pretty much a first, so far as I have read, and you should get the press on it, seriously. Everyone who said what you said in the past year, and there sure were a lot, upon serious investigation it all turned out to be bogospeak and misunderstanding. But with you and from your posts, I would doubt that.
I don't have a solution for the current medical care problem, but you can not trust the drug companies, who were allowed at the table by Bush II, and the Republicans, with whom I identified for most of my life, do not have a plan. The Affordable Care Act is seriously flawed, because of the deals that had to be made to ensure its passage, but it is better than what we had before. I didn't vote for O, but he at least has a plan.
Probably, the best solution is similar to British plan, which seems to offer a base plan for all with a commercial plan superimposed, which allows those who can afford it to purchase coverage similar to current US plan. I doubt US politicians will support this, but you can't have everything unless you pay for it. That's not a bad plan (since it allows all of you who can afford it to buy the coverage), but it plays badly at elections. If the National Health Care Plan was unsatisfactory to the doctors, we should have seen an influx of Brits, but I haven't seen them yet.
Those of you who bemoan the loss of your previous plans probably weren't really paying for it, if you were in a plan with union input, although those of you working for government entities probably paid by taking lower salaries.
Suck it up. Look at the costs, if you can find them. Realize there is no free lunch. Appreciate the benefits you have enjoyed.
Pay for the benefits. It's only a harsh world until you consider a Chinese peasant walking behind a water buffalo. Then it looks pretty wonderful.
Cheers. Or "Tschuss.
Thanks for a thought provoking and enlightening post. This healthcare issue has been racking my brains ever since the HillaryCare debacle. Which way is the best?
I am not a physician but worked in hospital pharmacy for over 35 years. As part of that experience I was able to work directly with nursing and doctors on the floors to provide good pharmacy care. I was not stuck in the basement.
I have heard many good things about the Australia plan which sounds similar to Britian's. Everyone gets general care and private insurance can be purchased for additional care. Australians like it a lot. I am also conservative and while plans like these might fly in the face of what I believe I think there is some good as long as misuse does not go rampant.
I have a friend who is a GP. he had his own office. These days that is a rarity in of itself. He finally had to retire. He could not make the practice go anymore as hospitals are forming groups which attract physicians (and patients) away from the single office operation. Even group offices are going away. Medicare became his primary payer and as you surely know, the time and energy to get any sort of payment out of them is long and expensive.
With insurance plans the public has not had to experience the full cost of medical. They complain about a antibiotic that costs $80 as they pay their small copay. The true idea of controlling costs by a direct relationship between patient and doctor never really happened. If a doctor were to prescribe me an expensive medication, I could ask if a cheaper one could work. Amoxicillin works just as well as many of the newer drugs in most cases as one example. But, people want the best care regardless of their capacity to pay for it. Insurance fills that need.
I don't know what the right answer is, but I do not want the govt to decide for me. That is not the America I knew.
@Catch22: With only a $1,000 annual benefit paid by the insurance co., it seems a challenge to justify paying the insurance. As teeth seem to break down more the longer they are around in your head, it may well pay to seek a different dental insurance plan (though that argument also speaks to keeping *some* form of dental insurance).
In my situation, as a self-insured person over many decades, I have been able to keep the BCBS Blue Value Advantage for my state, grandfathered, and apparently it is continuing into a second year post-ACA, with a 9% price increase on Jan 1 and a whopping ca. 25% increase on the anniversary date, by which time I will have squeaked into Medicare, with another set of issues to contend with.
The highest level of health exchange insurance I could afford (with federal subsidy) in my state was the Silver plan, which would have cost me more per month (even with a subsidy) and excluded (at least the Blues' Silver plan excluded) the premier medical institutions within a few minutes' walk or train ride from my home.
When did it become OK for health care insurance -- not care itself, but insurance -- to eat up 11% of Adjusted Gross Income? I can't get my brain around that at all.
Though VGHCX will fund a chunk of my retirement, the opportunity costs of self-paid insurance over all those decades just make me miserable to think about.
Pheh.
I'm with rono, and others who have raised different solutions.
You noted: "With only a $1,000 annual benefit paid by the insurance co., it seems a challenge to justify paying the insurance. As teeth seem to break down more the longer they are around in your head, it may well pay to seek a different dental insurance plan (though that argument also speaks to keeping *some* form of dental insurance)."
>>>A tough question and answer, indeed. I have discussed this with several folks I know well and the thoughts travel in various directions. 'Course, current income levels for these folks varies; so for some, they are not so concerned with the monthly premium which is about $47/month for an individual. Also, the existing "quality" of individual dental needs vary, too. Some seldom have had any dental problems with excellent tooth genes; while others have had nothing but problems for years. Further, there are others who have limited dental coverage during retirement (generally union plans) but have attempted to further reduce costs by having dental services that go beyond any coverage performed at the university dental schools available in our state; to help reduce out of pocket costs.
Everyone will have to make their own choices based upon all of the circumstanes suitable for their income status, eh?
Thank you for your thoughts will all of this.
Catch
In my growing up years, (50's and 60's), very few kids had braces or any kind of that treatment. Crooked teeth became a disease that had to be treated. Now pretty much every kid gets some sort of orthodontics and it makes me wonder if the dental industry is behind this surge? I think it is. Perfect teeth and straight ones at that lead to good self esteem.
There are instances when braces are needed but I think the therapy is being way over-prescribed like many other medical issues. In the case of dental, the consumer pays the bill as insurance pays maybe half at most. Many pay less than that. Dental offices set up in house financing to help the budget which in turn helps the dentist even more. How many parents have had to juggle dental benefits in order to take care of their kids?
I have nothing against dentists. But just like many other professions, the over sale of product is benefiting only their pocket.
I was a candidate for braces but my folks didn't have the money. Later when I did, I had some teeth pulled and the rest went into alignment. Not perfect but my self esteem is fine and I can chew steak just as well. That is what really counts.
Look around for ANY program or business government is involved and get me a success Story. Please?
Social Security might be an exception, but the current politicians are trying the best they can to dismantle this "Past" success story.
The SJMercury had a multipage report in yesterday's paper entitled "The Rx Alliance That Drugs Our Kids", subtitled "The doctors get rewarded, the drug companies get rich and foster children get more meds". OJ is right - the Merc does good stuff.
@STB65 - People may not realize just how huge a financial hit it is for doctors to go into primary care. On my EOBs I'm seeing less paid to my PCP than to labs for processing routine tests.
My PCP may spend triple the time and effort that my specialist spends - who just tells me the results of that lab test and gets 4x the remuneration. I don't know how PCPs manage to cover their fixed costs. When people (the ones with coverage) say that we can't afford to provide care to everyone because we don't have enough doctors, I think this lack of remuneration (for PCPs) is a good part of the problem.
@catch22 - Dental "insurance" plans are largely prepayment plans. You come out a little better than your premium if you have problems with your teeth but not much, because of the caps. What you get with some dentists is a negotiated rate (like medical insurance). But you can "buy" that rate for around $70/year, vs. $50/mo for the prepayment ("insurance") plan. Yes, it's still something of a racket, but it seems to come out better if you're not needing much care, and because of the insurance caps, similar if you need a lot of work done.
oh, yes, of course, sorry to have forgotten that obvs parameter. Thanks and apologies.
I am waiting to hear Mona's analysis.
I am paying my own dental now on the advice of dentist in family, always offering cash for small discount. (All docs are small businessmen, reminds my s-i-l.)
@Tb, if you really think gov can do nothing well, you simply have not read enough of the data about SS, Medicare overhead vs insurance companies, and a great many mil suppliers. I worked in DoD-related industry the last decades and the comparative efficiencies and oversight and rigor of practice and delivery are a sight to behold. But Medicare overhead cost and price hammering are the famous success stories. Do the rudimentary research. I believe that even rightwingers do not (because cannot) write outraged reports about how much more expensive and inefficient Medicare is than private enterprise. There are other examples, but of course if your premise is that gov can do nothing right and is never the answer, then have at it. FEMA or the Coast Guard or the Park Service or the FAA (or even TSA) as a private enterprise, omg, too funny, in terms of either responsiveness or cost. Or your local police and fire and schoolteachers. But whatever.
There are (at least) three problems with this statement. One is that (outside of multi-state plans), it is the states that set the requirements for standard plan deductibles. And those standards vary by "metal". For example, California's bronze plan carries a $5K/$10K deductible (individual/family), no more, no less. (Insurers can also offer nonstandard plans; I believe the state must approve them.)
Second is that the figures quoted are for out of pocket maximums, not for deductibles.
Third is that these are the maximums allowed under ACA, they are not required in order to comply with federal law. The out of pocket max's may be lower - as you can see from the California page I linked to, where the max out of pocket for a family is $12.5K (i.e. less than the federal caps).
Speaking of caps, that is another reason why lots of plans were nonconforming. From Kaiser, 2013: "Study: One Third of Individual Plans Exceed Law's Out-Of-Pocket Cap"
As the article notes, individual plans often carried high caps and lower premiums. But the article also noted that "Existing policy holders may be able to keep their current plans that fail to meet the new limits." I read that as saying this was not an automatic disqualifier for grandfathering.
Thank you for your contributions. I was able to check the health plan document again, and the following is, as written, regarding the new plan year, 2015. This document was sent to current plan holders:
Changes we're making to your coverage
- Deductible - Your deductible and out of pocket max will increase from $6,350 to $6,600 for an individual plan or from $12,700 to $13,200 for a family plan to comply with federal law.
This is a BC/BS of Michigan health plan.
Take care,
Catch
Yup...........been stated many times here
http://www.bcbsm.com/content/dam/public/Consumer/Documents/find-plans/2015/blue-cross-metro-detroit-epo-bronze.pdf
Edit: BC/BS Mich's catastrophic plans do have a $13,200 deductible
http://www.bcbsm.com/index/plans/michigan-health-insurance/catastrophic.html
Still checking on catastrophic plan rules, but the explanation of the raise may be legitimate. Mea culpa.
For this plan, the deductible is set to be as high as the out-of-pocket max. But AFAIK, there is no federal minimum requirement for plan deductibles, except for HDHPs (i.e. ones that qualify for HSAs), where the minimum for 2015 family plans is $2,600. Nowhere near $13,200.
BC/BS of Mich knows it is misleading you in saying the limit (even if we're talking about out-of-pocket limit) is being raised to comply with federal law. There is no minimum requirement.
Elsewhere (not on your bill, of course), BC/BS writes that the maximum out-of-pocket limit is raised to $13,200 for 2015. Nowhere in the law is a policy required to impose an oop limit that high - which is obvious from the fact that most policies have lower limits. (In case it isn't just as obvious, a deductible cannot possibly be higher than the oop max.)
It's bad enough that the complexity of the ACA system makes it difficult to know what all the pieces are. Being magnanimous and allowing that BC/BS may not understand what it is talking about (rather than saying it is deliberately deceiving you), it is still disheartening if not downright depressing that the companies charged with understanding and implementing these plans disseminate such misinformation.
I found this info from my original write on Nov. 20:
The adult plan is named: Premier Bronze and the minor child plan is named, Premier Value.
I am aware of "rate regions" for coverage pricing; but don't know the boundary lines. I suspect their major metro area to be between Ann Arbor and Flint, Michigan; for purposes used by BC/BS.
Well, just a few more trinkets of info above. Don't make yourself crazy with this.....
Catch
(I may be pretty good with details, but I don't commit out-of-state names to memory most of the time
It did not cover mental heath services and a yearly wellness visit. That said, I believe the reason the price was significantly lower, was because it was an underwritten plan and my health is very good. Under ACA, my understanding is underwritten plans are no longer legal, because there can be no price differentiation tied to your state of health, and the prices can only be based on age, sex, location, if you are a smoker, and of course, level of metallic.
Mona
"Plans with pricing based on health are no longer legal because there can be no price differentiation tied to your state of health."
Though age and smoking are permissible factors, they are only permitted within limits that are likely narrower than older policies. I've already explained (with links) how limiting (but not prohibiting) the use of age would affect policy rates. (Over your lifetime, you'd pay more than your age would suggest at first, and then less than your age would imply as you got older - possibly a wash.)
Sex is not a permissible factor, period. Just as it isn't used in RMD calculations or pretty much anything the government does. There still is a fourth factor allowed in the ACA's modified community rating system - family size. The more people you insure, the higher the insurance cost. Duh.
But there are other factors that affect price that have nothing to do with who's insured. Such as benefits offered. Two bronze plans, each covering the same family, could charge very different rates based on what they provided (though being bronze they would both have to cover about 60% of the expected medical costs of that family under the plan).
A prime example of differing benefits is dental care for children. "When the [ACA] was approved in 2010, it listed pediatric dental care as an 'essential' benefit. But .. [HHS] issued a ruling allowing insurance companies in NJ and most other states to leave out pediatric coverage. ... Insurers are allowed to offer pediatric dental benefits embedded in their medical plans ..."
http://www.njspotlight.com/stories/14/01/20/change-in-aca-rules-means-fewer-kids-will-have-dental-coverage/
Aside from the deficiencies Mona listed - lack of (modified) community rating, free preventive care services, and mental health care - there are lots of other ACA provisions that could have disqualified a plan. Few would have prevented grandfathering.
One that would have is more a practice than an explicit provision. Unfair rescission - this is the practice where an insurer finds some excuse (other than deliberate fraud) to void a policy. Insurers routinely did this (apparently starting about a decade ago) to people who dared to get sick. (When they said a policy was for healthy people, they weren't kidding.)
"WellPoint Inc., UnitedHealth Group and Assurant Inc. cancelled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million .. over a five year period."
http://articles.latimes.com/2009/jun/17/business/fi-rescind17
"When questioned about these practices, insurance executives refused in the absence of mandatory laws or health reform to limit rescissions to cases of clear and intentional fraud. ... The companies who engage in these rescissions argue that they are entirely legal, and to a large extent they are. But that goes against the whole point of insurance."
http://lawschool.unm.edu/nmlr/volumes/40/3/05-lindsey-why.pdf
So if one had an especially low cost policy, it's fair to ask whether that policy would really cover anything substantial, or was it an illusion that would vanish in a puff of smoke?
I am fully persuaded that there are all manner of things wrong or suboptimal with ACA. I sure would like to read about them impartially.
This is droll but from last summer:
http://nymag.com/daily/intelligencer/2014/06/republicans-finally-admit-why-they-hate-the-aca.html
This makes one want to jump off a bridge:
http://www.gallup.com/poll/179426/new-enrollment-period-starts-aca-approval.aspx
more disconnect:
http://www.washingtonpost.com/blogs/plum-line/wp/2014/11/17/obamacares-year-two-is-off-to-a-good-start-but-the-politics-are-still-terrible/
Iowa Senator Joni Ernst (the hog castrater) last month:
“We’re looking at Obamacare right now. Once we start with those benefits in January, how are we going to get people off of those? It’s exponentially harder to remove people once they’ve already been on those programs…we rely on government for absolutely everything. And in the years since I was a small girl up until now into my adulthood with children of my own, we have lost a reliance on not only our own families, but so much of what our churches and private organizations used to do. They used to have wonderful food pantries. They used to provide clothing for those that really needed it. But we have gotten away from that. Now we’re at a point where the government will just give away anything.”
[article] That’s the fundamental belief that motivates most, if not all, the conservative opposition: Health care should be a privilege rather than a right. If you can’t afford health insurance on your own, that is not the government’s problem.