Skip to main content

What does the ACA looks like to a pretty healthy 50-year old male in Seattle who's been in the individual market for a number of years and has an income above any subsidies? Not bad. And below are all the numbers showing why.

First, you need to understand where I am at now.  I have a high-deductible HSA-eligible PPO with a $3500 deductible and yearly out-of-pocket max of $5000 (includes deductible) and co-insurance of 50% between the deductible and OOP max. Until last year, the plan didn't include prescription coverage which was a huge potential liability for me. This year prescription coverage was added, but rates didn't go up to reflect that, so basically somehow I got a year of prescription coverage basically for free.  Not sure how that happened, but it was related to preparing closed plans for the ACA and needing to meet actuarial values.  It's an important point however when trying to compare apples-to-apples.  My current premiums are $200/month, but those are really below market and unsustainable.  For a better comparison, if I try to buy a comparable HSA PPO plan today with prescription coverage, with a $3500 deductible, and $5000 OOP max and 20% co-insurance (the closest comparison I can find), the rate would be $346. That $346 is more representative of what I should be paying for a plan with prescription drug coverage and in-line with numbers I've seen in past years when I've considered plans with drug coverage.

For 2014, I can find the rates on the Washington health exchange (still glitchy, but I've got the information from it...).  The HSA plans I'd look at from the exchange are:

Bronze: $5250 deductible, $5250 OOP Max, co-insurance: 0%,  Premium: $315
Silver: $2500 deductible, $4100 OOP Max, co-insurance: 20%, Premium: $395

So how to do an apples-to-apples comparison? Continue beyond the squiggle for all the numbers.

To compare plans, I like to look at the my total medical bills (at the insurance company negotiated rates, but excluding preventative care which is 100% covered) vs. what I actually pay out if I add up premiums, deductible and co-insurance costs up to the OOP max.  The results are shown in the table below. The left column is the total medical bills encountered in the year.  The other columns are the expenses based on the plan shown.  For each plan I show two numbers. The first number is my total expense for the medical bills.  The second number is how much more or less I pay over not having insurance at all.  So, for example, if I rack up $3000 in medical bills (roughly what I ended up with this year, mainly to be told I'm getting older), for the Bronze plan I'd have paid 315*12+3000=$6780 to cover $3000 in medical bills, a loss of $3780, shown as the second number. Of course, what I'm buying insurance for is the off-chance of needing a $40000 surgery, where I'd pay 315*12+5250=9030 to cover that 40000, meaning I'm ahead $30970.

Here are the numbers for the Bronze and Silver compared to a current plan with prescription coverage (sorry if the formatting is messed up in your browser, this works better in a spreadsheet):

Expenses             Bronze                        Silver                          Current
$0                $3,780,  ($3,780)        $4,740,  ($4,740)        $4,152,  ($4,152)
$1,000          $4,780,  ($3,780)        $5,740,  ($4,740)        $5,152,  ($4,152)
$2,000          $5,780,  ($3,780)        $6,740,  ($4,740)        $6,152,  ($4,152)
$3,000          $6,780,  ($3,780)        $7,340,  ($4,340)        $7,152,  ($4,152)
$4,000          $7,780,  ($3,780)        $7,540,  ($3,540)        $7,752,  ($3,752)
$5,000          $8,780,  ($3,780)        $7,740,  ($2,740)        $7,952,  ($2,952)
$6,000          $9,030,  ($3,030)        $7,940,  ($1,940)        $8,152,  ($2,152)
$7,000          $9,030,  ($2,030)        $8,140,  ($1,140)        $8,352,  ($1,352)
$8,000          $9,030,  ($1,030)        $8,340,    ($340)         $8,552,    ($552)
$9,000          $9,030,     ($30)          $8,540,      $460         $8,752,      $248
$10,000        $9,030,      $970          $8,740,    $1,260        $8,952,    $1,048
$12,000        $9,030,    $2,970         $8,840,    $3,160        $9,152,    $2,848
$14,000        $9,030,    $4,970         $8,840,    $5,160        $9,152,    $4,848
$20,000        $9,030,   $10,970        $8,840,   $11,160        $9,152,   $10,848
$40,000        $9,030,   $30,970        $8,840,   $31,160        $9,152,   $30,848
$60,000        $9,030,   $50,970        $8,840,   $51,160        $9,152,   $50,848
$100,000      $9,030,   $90,970        $8,840,   $91,160        $9,152,   $90,848

You can see that if I don't have very many medical expenses, the Bronze plan is the way to go.  For a medium to high range of expenses, I'd be better off with the Silver. The current plan is in-between at the low end of expense, and a worse plan at the higher end.

So what's the bottom line?

First, I could argue I'm being 'forced' to buy prescription coverage.  But I'm OK with that.  Although I'm not currently on any medications, I'm well aware a full course of some chemo drugs can easily run $50000 or more.  I know I should have the prescription coverage and prodding me to have it is a actually a good thing.

Second, I could argue that my premiums are rising 50%. But that's mostly due to the addition of the drug coverage.  Again, I'm OK with this because you don't get things for free.

Third, although my rates are going up 50%, the ACA rates are really saving me money over the current market rates for plans with drug coverage.

Fourth, I have guaranteed coverage in the future.  This is huge.  It scares me that if I do develop a pre-existing coverage under the current rules, it's almost impossible to change insurance plans from then on.  And make a mistake and miss a couple payments and your just out of luck.


1. I'm going with the Bronze since my $3000 in expenses this year was higher than usual for me and hopefully will be less next year.
2. Even if I'm wrong about my level of medical expense, my largest liability is $9030. That would hurt, but I could handle it.  Limiting that liability is why I have insurance.
3. ACA is a good thing.  I get guaranteed coverage and a prescription drug benefit to limit my total liability at a reasonable cost.
4. This is why the  ACA will succeed. When based on a true apples-to-apples comparison with real numbers, it just makes sense.

Originally posted to dobergo on Wed Oct 02, 2013 at 10:19 AM PDT.

Also republished by Community Spotlight.

Your Email has been sent.
You must add at least one tag to this diary before publishing it.

Add keywords that describe this diary. Separate multiple keywords with commas.
Tagging tips - Search For Tags - Browse For Tags


More Tagging tips:

A tag is a way to search for this diary. If someone is searching for "Barack Obama," is this a diary they'd be trying to find?

Use a person's full name, without any title. Senator Obama may become President Obama, and Michelle Obama might run for office.

If your diary covers an election or elected official, use election tags, which are generally the state abbreviation followed by the office. CA-01 is the first district House seat. CA-Sen covers both senate races. NY-GOV covers the New York governor's race.

Tags do not compound: that is, "education reform" is a completely different tag from "education". A tag like "reform" alone is probably not meaningful.

Consider if one or more of these tags fits your diary: Civil Rights, Community, Congress, Culture, Economy, Education, Elections, Energy, Environment, Health Care, International, Labor, Law, Media, Meta, National Security, Science, Transportation, or White House. If your diary is specific to a state, consider adding the state (California, Texas, etc). Keep in mind, though, that there are many wonderful and important diaries that don't fit in any of these tags. Don't worry if yours doesn't.

You can add a private note to this diary when hotlisting it:
Are you sure you want to remove this diary from your hotlist?
Are you sure you want to remove your recommendation? You can only recommend a diary once, so you will not be able to re-recommend it afterwards.
Rescue this diary, and add a note:
Are you sure you want to remove this diary from Rescue?
Choose where to republish this diary. The diary will be added to the queue for that group. Publish it from the queue to make it appear.

You must be a member of a group to use this feature.

Add a quick update to your diary without changing the diary itself:
Are you sure you want to remove this diary?
(The diary will be removed from the site and returned to your drafts for further editing.)
(The diary will be removed.)
Are you sure you want to save these changes to the published diary?

Comment Preferences

  •  Yeah. When I look at my employer-subsidized plan (14+ / 0-)

    The exchanges don't look that great.

    When I look at trying to have my plan with CORBA or god forbid, on the marketplace?

    The exchanges are quite good, even when I get no subsidy, and would be a godsend if my income suddenly dropped (because, you know, I'm no longer employed in my high paying job that provides the employer-subsidized health insurance)

    •  I'm 64, in very good health. (14+ / 0-)

      My current underwritten plan (which doesn't meet ACA standards and will go away) costs $255 for $5000 deductible/80% insurer copay/no first dollar or Rx coverage. Max Out of Pocket (OOP) $6250.

      So far, shopping just the BCBS-IL member site, a similar $5000 deductible/80% copay (I pay 20%), but with all the preventive care benefits first dollar will cost $356. Max OOP again $6250 but I get 100% coverage on the preventive.

      And I can get a $6000 deductible/100% insurer copay for 24 cents (yes cents) less that ends up with a slightly lower max out of pocket limit of $6000.

      So my gross costs, for much better preventive first dollar coverage, would be $100 higher. However, looks like I will qualify for about a $200 tax credit. That's math I can believe in.

      So someone my age won't save much, may pay more if they don't qualify for the tax credit, but I think it's worth it to know everyone can get in the game now, not just those of us blessed with good health.

      When the power of love overcomes the love of power, the world will know peace.

      by CoyoteMarti on Wed Oct 02, 2013 at 11:31:19 AM PDT

      [ Parent ]

    •  Beware New Very Thin Exchange Plans (WA) (4+ / 0-)
      Recommended by:
      Abelia, tofumagoo, peregrine kate, antooo

      Beware Thin Plans

      However, buried in the slimy underbelly of all of it is the new paradigm shift that has been defacto, if not purposefully engineered by the law. That is, the plans on the Exchanges offer *drastically* thin provider networks. I know Lambert has talked about this, but I am not sure that he understood how bad it really is. I know I didn’t, and I have a degree in cynicism (aka Political Science). People may see this in the abstract and think, oh well, a few doctors will be left out. But what is happening nationwide and in my Seattle area is that the highest quality and most major research, teaching and cancer hospitals, as well as a large portion of the top doctors in areas are being left out of the in-network provider list in Exchange plans. As I’ve said, this is a paradigm shift in how health insurance works in our country. People think they are getting the same kinds of plans on the Exchanges that they’ve always gotten through work or the individual markets. They. Are. Not.

      To bring the issue into sharp focus, here is a list of MOST of the hospitals in the Seattle area that are OUTSIDE OF the NETWORK on the Exchange plans offered by Premera, our only Washington Blue Cross affiliate:

      Swedish Hospital (major Seattle Hospital with branches all over town and in suburbia)
      University of Washington Medical Center (Our teaching hospital)
      Providence Hospital (another major hospital)
      Harborview Medical Center (Major trauma center affiliated with University of Washington. People all over the state are flown to this hospital for trauma treatment.)
      Seattle Cancer Care Alliance (our Fred Hutchinson Cancer Research Center hospital).
      Veterans Medical Center
      I do not have a grasp of how many doctors in private practice have been dis-included, but I do know that no doctors at Polyclinic are included either. Polyclinic is a large Seattle area clinic, known for its rock-star doctors.

      Print out the whole piece for reference and be sure to check which providers are included, and which ones are not!  See below:
      At first, I thought, well, if a person is desperate they can just go to an in-area, but out-of-network provider. However, there is a separate copay-coinsurance and deductible system for out-of-network providers. Out-of-network deductibles and copays are typically at least twice as high as their in-network counterparts, and they are not subject to cost sharing subsidies. In addition – and this is the greatest travesty – the law appears not to have regulated spending caps for out-of-network providers. Thus, the plans on Premera Blue Cross have an UNLIMITED out-of-pocket maximum for out-of-network providers. (Link to the Premera silver plan) Translated this means if you have emergency out-of-your-very-thin-network care needs, your cost burden is apparently UNLIMITED. And assuming that you can afford to pay an unlimited cost, none of what you paid applies to your deductible, coinsurance or out of pocket maximum once you get to your home network. This all flies in the face of Pelosi's justification that Obamacare would stop people from contracting medical emergencies they can’t pay for. And of course, Obamacare cut funding to subsidize emergency care for the poor.

      One of the issues this law was sold on was that it would eliminate medical bankruptcy for extreme care needs. However, in the Seattle area, none of the in-network Premera plans (and Regence/Bridgespan pending) have in-network hospitals offering bone marrow transplants. And as far as I can tell, only one of the hospitals offers organ transplants, but I haven’t gotten to researching if the doctors who do those transplants at that hospital are in-network providers. In-network providers exist for basic cancer or heart care treatment, however with the especially thin provider network, this care will likely be defacto rationed, as not enough providers are available to offer the care. I could go on, but you can fill in the blanks, I'm sure. People who need accelerated care may have no choice but to go to an out-of-very-thin-network hospital. If they do, because of the unlimited out-of-pocket maximums, I believe their cost exposure will be nearly as unlimited as if they had no insurance at all.

      This is not what most of us expected here in Washington!
      •  Wow! This is important (4+ / 0-)
        Recommended by:
        splashoil, tofumagoo, Aunt Pat, antooo

        When looking at the plans, I noticed the exchange kept telling me none of the providers I tried (like UW Physicians) was in the Premera network. They did all seem to be covered by BridgeSpan.  I assumed the exchange website was still glitchy. How could the UW related facilities not be the Premera network? I was going to re-check later.  Knowing that they were purposely left out will change my calculation a bit.  The numbers won't change that much, but I'd go with BridgeSpan over Premera (which I used for the tables above).  In addition, since I'm not getting subsidies, I can always go off-exchange. I'll also need to look into the OOP max of the out-of-network costs.  I know they have separate deductibles vs. in-network due to a ruling earlier this year.  I was unaware of the possibility they might not have an OOP max out-of-network.  Thanks again for pointing out this extremely important information.

        •  Moe info... (2+ / 0-)
          Recommended by:
          Aunt Pat, antooo

          The problem here is Premera, not some fatal flaw in the exchange.  Premera is providing a very limited network and has no OOP max on out-of-network providers. In addition, Premera provides no coverage for off-formulary prescriptions.  BridgeSpan on the other hand seems to have the same network as my current Regence plan. They have a separate out-of-network deductible/OOP limit. That's OK, as long as its not unlimited. I've never gone out-of-network before, but just in case I do, I want some type of limit.  BridgeSpan has a higher co-insurance on non-formulary drugs, but they're still covered.  All of these comparisons are easily seen on the Exchange website (when its working).  Competition is a good thing.  Premera is out. So it looks like I'll be on the BridgeSpan Bronze plan.

          •  Bridgespan IS Regence (1+ / 0-)
            Recommended by:

            Cambria is the umbrella.  Regence Blue Shield and Bridgespan are subsidiaries.

            There is a very good reason for these fractured corporate structures--the top execs hold the same job in each one and get a separate paycheck from each.  That sounds like a good reason to them....

            The CEO of Cambria makes over $1mil a year.  The CEO of Premera, a larger outfit, makes over $3mil from his multiple paychecks.

      •  Presumably the insurers are doing this (3+ / 0-)
        Recommended by:
        tofumagoo, Aunt Pat, figbash

        to keep exchange offered insurance as cheap as possible.  Providers who won't cut their rates to get in the network just don't get into the network.

        There's a lot of greed in the medical profession and the for-profit hospitals too.

        The whole system is monstrous.  The ACA only attacks a piece of it.

        "If there are no dogs in heaven, then when I die I want to go where they went." - Will Rogers

        by Kentucky DeanDemocrat on Wed Oct 02, 2013 at 08:20:03 PM PDT

        [ Parent ]

      •  The Article Linked To In You Comment Is Very (3+ / 0-)
        Recommended by:
        tofumagoo, mumtaznepal, Aunt Pat

        unclear.  "Teresa", the article author is very "thin" in her description of the problem and even more unclear in her subsequent comments.  When I look at the Bridgespan policy it indicates a deductible of $10,000 for in network and $12,000 for out of network, so it isn't unlimited as the article seem to claim.  Someone who knows the medical jargon needs to write more about this.  For example the terminology of in-network, out-of-network, extended network, contracted provider, non contract provider,  dual deductibles, etc.  The author even claims her insurance policy brochure explicitly says the out of network deductible is "unlimited".  I didn't see that on the website.

        "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

        by kerplunk on Wed Oct 02, 2013 at 08:34:23 PM PDT

        [ Parent ]

        •  We need the answers. (2+ / 0-)
          Recommended by:
          kerplunk, Aunt Pat

          The cost of the premiums is not the whole story.  I think it is useful to vet all the information and sort it out.  

        •  Bridgespan Link (From Correntewire Comments) (1+ / 0-)
          Recommended by:

          Trust, but verify by asking in writing!

          Only in network amounts shown on splash page.

          •  I Agree One Has To Call Customer Service To Verify (0+ / 0-)

            and then call 4 to 5 times again and talk to different customer reps and see how many different answers to the same question is given.

            This seems to indicate a limit on out-of-pocket for out-of-network.

            Is there an out-of-pocket limit on my expenses?
            Yes. In-network: $4,900 per insured / $9,800 per family per calendar year.
            Out-of-network: $12,500 per insured per calendar year.
            The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

            "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

            by kerplunk on Thu Oct 03, 2013 at 04:38:22 PM PDT

            [ Parent ]

            •  Silver Plan Information. (1+ / 0-)
              Recommended by:

              I thought everyone was talking about the bronze plan.  It's important to keep that straight too.

            •  A New Twist! Unregulated Balance Billing. (1+ / 0-)
              Recommended by:

              Obamacare does not have restrictions on balance billing.  Some states take it on.  What is it?  The practice of providers billing for the difference between the insurance payment and their bill.  Regulated Balance Billing
              Washington State does not regulate out of network balance billing!  So the stated limits don't really mean much.

              Heya, Lambert, I thought of one other issue that you haven't listed. That is "balance-billing". The term sounds like the love-child of humpty-dumpty and a duck, but actually it's the practice by providers of billing patients for the difference between insurance reimbursement and the actual billed amount.

              Balance billing is only sometimes legal for in-network providers. But for OUT-of-network providers it is typically legal. Or if illegal, it's typically only illegal for emergency services. And of course, this has big implications for insurance that has skinny networks.

              Here's a list of states and their laws regarding balance-billing:

              So the stated caps may not mean much.  Print out the linked article and refer to your State for the details.
      •  WA Unregulated Balance Billing Out of Network! (0+ / 0-)

        Out of network providers will bill you for the difference between what your insurance pays them and what they bill.  Obamacare does not regulate this!  Add very thin networks like being offered in the exchange and you have recipe for medical bankruptcy!
        I added a link in the comments downstream.

    •  COBRA for me was $1500, my premium (0+ / 0-)

      subsidized by my employer was $350 so the exchange has to be better than using COBRA!!

      "The poor can never be made to suffer enough." Jimmy Breslin

      by merrywidow on Thu Oct 03, 2013 at 09:09:33 AM PDT

      [ Parent ]

  •  Thanks for the detailed analysis... (5+ / 0-)

    A mind like a book, has to be open to function properly.

    by falconer520 on Wed Oct 02, 2013 at 10:59:14 AM PDT

  •  Excellent diary. (10+ / 0-)

    We need more people to actually sit down and do the math.  

    I appreciated that you were realistic about the plan you had and the realities of the market.

    Really, great diary!  We need more like this on this site.

  •  If you enlarge the page in your browser (1+ / 0-)
    Recommended by:
    Aunt Pat

    a couple of times (control or command +) all the columns line up very well.

    thanks for this — though I don't need it.

    I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

    by samddobermann on Wed Oct 02, 2013 at 11:39:37 AM PDT

  •  Prescription coverage is important (8+ / 0-)

    even for smaller things than Chemo.

    Suppose you get a bad case of bronchitis over the winter that you just can't kick. The first round of antibiotics (a Z pack for example) runs about $80. The inhaler runs about $54. Now if they put you on a stronger antibiotic (which is likely if the first doesn't work), you could be looking at an additional $200 for antibiotics. Plus prednisone (not too bad, ranging from $4 to $12).

    If that bronchitis happens to become the last straw for your lungs and you go into bronchial asthmatic, that inhaler cost can turn monthly, and you can add in the possibility of a nebulizer ($50 to $200 depending what kind you get), neb treatments at $20/month, and the possibility of something like advair ($200 + per month). This on top of co-pays for multiple doctor's visits, possible co-pays for an ER visit depending how hard it hits you, etc.

    "Madness! Total and complete madness! This never would've happened if the humans hadn't started fighting one another!" Londo Mollari

    by FloridaSNMOM on Wed Oct 02, 2013 at 01:41:01 PM PDT

  •  Thanks for doing this. (7+ / 0-)

    I have great insurance because of being retired civil service and also over 65, but I sure want to see this work in the worst way. I can't believe people in this country don't think other people should be able to afford the insurance that will allow them to get health care.   I don't get it.

  •  Single-payer health insurance would be cheaper. (5+ / 0-)

    How?  1. Insurance companies skim off ~30% for overhead. Hey, those CEO bonuses, lawyers to write contracts with confusing jargon, and claims departments to deny deny deny are expensive, y'know? Compare that to Medicare, which has ~3% overhead.
    2. Everybody would be in it, so everybody would pay into it.
    3. There is no '3'. It's surprisingly simple. Other countries don't "ration" care any more than insurance companies already do it to us.
    4. Really good diary, dobergo. T&R'd. Thank you.

    •  ACA now mandates (3+ / 0-)
      Recommended by:
      TopCat, Aunt Pat, JerryNA

      that insurance companies must 80 - 85% of their revenues toward the payment of actual health care services.

      In other words, their net revenues (before overhead) is limited now to 15 - 20%.

      That's going in the right direction.

      Would single payer be more cost effective, not to mention more efficient?  Hell yeah.  You're going to get little argument from anyone on this site.

      And single-payer was not going to happen - through the front door.

      But single-payer will now happen - through the back door.

      It'll take some time, but the day will come when we will have our single-payer.  If for no other reason than because there won't be enough profit in it to make the health insurance companies happy, and also because they don't like to be regulated.  They liked it when they could screw everyone at will.

  •  I, too, was going to make sure to call your (4+ / 0-)
    Recommended by:
    kerplunk, Aunt Pat, splashoil, SingleVoter

    attention to the network of providers in any plan you are considering.

    I have an individual plan now that costs about $9,450/year (for premiums -$608/mo - and deductible - $2,250) before first dollar of benefit (includes drugs and state and Fed. mandated preventive care) It's a PPO with some out of network benefits. After the deductible is met, I am covered at 100%.

    ALL of the Exchange offerings (all seven of them) in my Albany, NY area are very tight HMOs with narrower networks than I am used to. I remember tight HMOs from the 1980s - a bad idea that hasn't gotten any better with time, in my opinion. A really big HMO like Kaiser on the West Coast is one thing, but smaller, regionally-limited HMOs can leave you without an in-network provider, or much choice  in hospitals, etc..

    It's my impression that at least in NY, that if your entire network fails to have any facility or doc that can provide the needed care (let's say it's something quite specialized like a heart transplant) then you can appeal and force them to find a provider rather than leave you completely OON. But you might not have  much choice in the matter. You might want to ask about this sort of thing to make you understand what you're buying.

    This is a serious weakness in the ACA, at least in my area where all the insurers have chosen to only offer HMO plans this first year.  

    Another thing to keep in mind: insurers have more than just the plans on the HBX.  And they frequently have a different set of providers for different types of plans.  So don't just assume that just because your neighbor gets his health insurance from X company and sees Y doctor that you can, too.

    You need to look over the provider netwrok of the specific plans you are choosing.

    I used to be pretty clueless about this sort of thing. Four years ago Mr. A had a very serious heart attack and the first set of docs suggested he might need a heart transplant. I was terrified because I knew there wasn't a transplant hospital in the region.  When I contacted our insurance company (same one I still have today) they were clear that this wouldn't be a problem, at least as far as insurance.  In the end, Mr. A. recovered, but not before he needed - and got - out of network care in both Boston (MGH) and at the Mayo Clinic in Minnesota. Our local insurance had an extended PPO agreement with Beech Street which covered the costs of out of the area/OON in the same way as the costs in network.  And all under the same deductible.

    I am now quite wary of HMOs w/o OON benefits. I wish my current insurance plan was continuing, but I have already been warned that it may be dropped. At least with the HBX, I will be able to find some individual coverage for the part of the year that I have to get through before I can begin Medicare, where I will be covered for any doc, anywhere. Which is how it should be for everybody in the US.

    Make any plan you're seriously considering tell you about their network.  And be sure to ask about circumstances where none of their providers/facilities would be able to provide the right care for you.

    Good luck!


    •  I Was Referred To An Out Of Network Provider By (2+ / 0-)
      Recommended by:
      Aunt Pat, splashoil

      my HMO and they didn't even tell me.  I assumed it was an in network provider.  I guess they assumed that I would prefer an out of network provider since it was in my city rather than giving me a choice if I wanted to go to a different city to use an in network provider.  So my lesson is that I have to question everything.  Of course by using an out of network provider a bunch of different rules start applying that I had no idea about.  My new rule is if I am referred to someone, then I need to call my HMO customer service and start asking endless questions cause they aren't going to answer anything beyond what is explicitly asked them and if you don't get it then it's your fault and you pay.

      "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

      by kerplunk on Wed Oct 02, 2013 at 09:41:31 PM PDT

      [ Parent ]

    •  There should have been coupled mandates (1+ / 0-)
      Recommended by:


      The providers in a state (or multi-state metropolitan area) should have been allowed a majority vote on their being forced to accept insurance as payment in full less stated and legally permitted policy deductibles and co-pays in exchange for fines (or 120% of [subsidized] premium level income set-asides) for people not buying insurance.

  •  ACA chioces still tell me that single payer is the (2+ / 0-)
    Recommended by:
    Aunt Pat, splashoil

    best choice. Well I have Tricare and at 65 it becomes Tricare for Life joined with Medicare. My only quibble is I pay extra for dental and it is treated like cosmetic surgery. Oh sure biannual teeth cleanings and such but root canals and crowns? 2000$ plus. I have paid for the root canal but even retired and at my age I have to choose crown or brake job on my car. But at this time I can't complain. Despite my dental issues I understand that I have single payer, unless the republicans steal it from me. This is what everyone should have. Tricare/Medicare for all.

  •  Maybe Obamacare Will Help Further Expose (3+ / 0-)
    Recommended by:
    Aunt Pat, splashoil, JWK

    the horrible healthcare insurance industry practices with 40 million additional insured people telling their horror stories even with this improved Obamacare.

    "I think that gay marriage is something that should be between a man and a woman.” - Arnold Schwarzenegger 2003

    by kerplunk on Wed Oct 02, 2013 at 09:49:36 PM PDT

    •  I can hear the Republican strawmen now... (1+ / 0-)
      Recommended by:

      "because ACA isn't perfect, then it's a failed government intrusion."  When in fact, as you say, it is an improvement over what we had.

      "Those who can make you believe absurdities, can make you commit atrocities" Voltaire.

      by JWK on Thu Oct 03, 2013 at 08:14:22 AM PDT

      [ Parent ]

  •  Really helpful look at the reality of ACA. (1+ / 0-)
    Recommended by:
    Aunt Pat


    Fiat justitia ruat caelum "Let justice be done though the heavens fall."

    by bobdevo on Thu Oct 03, 2013 at 04:48:22 AM PDT

  •  Keep in mind (0+ / 0-)

    Keep in mind that there are more policies available off the exchange than on the exchange.  You said that you don't qualify for the subsidy, and you may not need all the ten essentials, especially maternity and pediatric coverages.  Check with any good insurance agent.

    In my rural Washington county the only companies on the exchange are Premera and their for-profit subsidiary Lifewise.  More Premera policies plus Cambria's...Regence & others are available off the exchange.

  •  I paid $57/month for COBRA coverage (2+ / 0-)
    Recommended by:
    SeekCa, splashoil

    in 1987.

    The hospitals had nurses and MRIs even back then.

  •  What percentage of young invincibles (1+ / 0-)
    Recommended by:

    and low-income folks using the ER as their primary care and are the most likely to buy bronze coverage happen to have the Bronze deductible of $5250 available?

  •  People with no assets (1+ / 0-)
    Recommended by:

    would generally be better off paying the annual non-deductible $750 fine ($60/month) and filing for bankruptcy.

    Bronze: $5250 deductible, $5250 OOP Max, co-insurance: 0%,  Premium: $315
    If they have cancer or an expensive disease not covered by the EMTALA they will have a 90 day wait to buy coverage and most of those 90 days will be taken up by waiting for an appointment in a thin provider network.
    •  About 45% of American adults (1+ / 0-)
      Recommended by:

      have little or negative net worth.

    •  Huh? (0+ / 0-)

      You're comparing my unsubsidized numbers for someone with no assets? (And I would assume low income).  That's why subsidies are provided. In addition, both deductible and OOP max limits can be reduced for some plans based on incomes.  My point was to make an apples-to-apples comparison of plans for someone who doesn't need a subsidy and compare it to my current plan.  ACA is an improvement. If someone wants to try the penalty/bankruptcy route, good luck.  I think I understand why they have no assets and probably never will.

  •  Another Seattle Report (0+ / 0-)

    Comment from Frugal Nurse:

    I completely agree! I just went on the healthplanfinder and discovered that none of the doctors my family uses is "in network" for Lifewise, Premera, Bridgespan or Molina. Neither is Swedish hospital, the hospital I have used my entire life. I wasn't expecting this, as these companies have been around for ages and have always had great provider networks. I don't understand, either. All these companies have off-exchange plans that are only slightly more expensive than their plans on the exchange. And they don't pay the subsidies, so why the narrow network on the exchange plans? I am really, really disappointed (in premiums, out-of-pocket costs and provider networks). My guess is these provide networks will get smaller, too, next year.
    Devil is in the details!
  •  WA by Numbers: Don't get Cancer! (0+ / 0-)

    Loopholes to skirt Treatment:  Cancer Edition

    The American Society has a full-color brochure about how great Obamacare is for cancer patients.

    The myth (from the brochure)

    Taylor Wilhite of Marblehead, Ohio, was diagnosed with acute myeloid leukemia in 2007 at the age of 8. She received three rounds of chemotherapy, had a bone marrow transplant, and at one point was taking 23 pills a day along with many IV medicines. Now age 12, Taylor is in remission. But the costs of her treatment quickly reached her insurance plan’s lifetime benefits cap, leaving her family struggling to pay for the care she needed for the side effects of her treatment.

    The Affordable Care Act does not allow health plans to place lifetime caps on coverage. The law restricts and soon will ban yearly limits. This will give people like Taylor and her family peace of mind that coverage will not suddenly end because of caps on benefits.

    The Reality Scenario:

    Yes! Affordable Care Act removes lifetime caps so my child can have their lifesaving bone marrow transplant! Yayyyyyy.

    Okay, here’s the national registry for locating bone marrow transplant centers. Let’s look them up and go see ‘em and save my baby’s life!

    Okay! So for my Washington state, the transplant centers are Seattle Cancer Care Alliance (SCCA) and VA Puget Sound Health Care System.

    Okay! Well, I’ve signed up for a Blue Cross/Blue Shield plan on the Exchange. BCBS brags of having the largest provider network in the country. And WOW, SCCA is local so we don’t even have to travel!

    Oh, SCCA is not on my provider list, and nor is the VA Hospital? Gee, did I choose the wrong insurance? Well, it’s open enrollment time. I can change. What? None of the insurance companies on my state Exchange have SCCA or VA Hospital in their provider list?

    OMFG!!!!! Well, I guess we’d better not cancel those bake sales and grocery store money collection jars after all.

    End scenario.

    Dobergo you just can't make this stuff up!  I hope you can respond with an action plan lol.
Click here for the mobile view of the site