Obama Care
 

I 'thought' I was fortunate in that I have an individual health insurance plan that although $1,200 per month premium it provided 100% coverage no deductible, no lifetime max, etc with just $10 office visit co-pays and $7 Rx co-pay. Now thanks to Obama Care I am losing that plan...it ends 3/31/14 and I received letter yesterday that I MUST purchase a new plan through the Exchange. I glanced at the Exchange website and it did not instill any confidence that I am not really getting screwed here. Really provides little to no details about what you actually get

Seems to me Obama Care 'might be' good for underinsured/uninsured but not me! I am SHOCKED that this is affecting me and I am sure I am not the first/last to learn Obama Care is NOT a good thing for me. Seems there should have at least been a grandfather clause for those of us who have been paying rather than forcing me to now repurchase a new plan without even knowing what will wont be covered.

Take a bettler look at the plans. There are 4 levels and the highest one looks very comprehensive. You can also look at private insurance companies to see what plans they are offering that comply with the ACA. You can also contact an insurance agent for assistance.

All of the plans have out-of-pocket maximums.

Florida rejected Medicaid expansion and the federal funding that comes with it. The coverage for low income residents seems not as good as other states.

I am sorry Steph. I am worried I will be facing the same fate. I am thinking that very few plans will be willing to cover IVIG in the coming years.

so sorry!!!! I used to think maybe obama care would be a good thing with those, like me, with a chronic illness.. I pay SO much each month for my plan, and then have a 10k out of pocket maximum (which I hit the very first month- due to IVIG)... but then i'm covered the rest of the year.. so, its not cheap.. but at least i can get IVIG.. I too am worried, that insurance plans will start going broke, and therefore cracking down on their "expensive"" patients, like IVIG patients and try to deny IVIG... i'm terrified of this, as I don't think I can live without it.. terrifying.. I feel like Obama care will hurt me as a patient, and a tax payer.. all around.. hopefully i'm wrong!

That is exactly my concern...I read more and the plan details are not even all there (yet we are already supposed to choose?) and for those that do have plan details posted they ALL say experimental and investigational not covered and no details on how that is determined or even how decision might be appealed. Another thing appears that now all sorts of exclusions that were NOT things that were exclusions on my plan...home health care - meaning IF I get IVIG approved I will have to go to center for 10 hours for 2 days every three weeks, oh joy! :-)

..as patient who needs IVIG to function even 10-20 hours per week I too am terrified by this development. So the way I see it initially at least it does appear as if a loophole has been created for the insurance companies to get out of paying for these very expensive treatments we receive. I will continue researching though and share my findings as I learn more. Anyone else find out anything please do likewise.

I admit I havent read everything but I spent several hours reading (and Im a lawyer how is average person really expected to understand) and getting more concerned about the future quality of life under this new law.

PS re the plan levels...I only have first three offered...no platinum plans available for me.

*post removed*

Just a reminder that we have guidelines that limit political posting.

Discussing the AFCA in general is fine...becoming political in a partisan way is not.

We would like to allow this thread to stay open as this is an important topic of relevance to most here....but it will be closed if posting becomes directly political.

StephC;

I am curios who sent the letter you must purchase a new
plan through the Exchange? Your now insurance company?

It was my understanding that you would be able to keep your present insurance company if you wish. Not true? Just wondering.

scrubbs

Scrubbs,

I've heard about it happening to two other people as well. Just because you choose to keep your current policy does not mean that current policy will be available any more. It's a scary time for those of us with health issues.

Because I am self insured, I have only been able to get coverage from my state's high risk pool since my mg dx a few years ago.

Two weeks ago, the High Risk Pool notified me the State is ending all coverage effective 12/31/2013 at midnight since the Affordable Care Act will take effect Jan. 1, 2014.

So most, but not all folks, may be able to keep their insurance...my circumstance takes me out of the 'most' group!

There are 14 states that refused to set up state exchanges...so folks in those states have to go on the federally administered plan. Many of those same 14 states also refused federal funds to expand Medicare in their states -- so that will leave many folks that fall below the minimum income level for a federal subsidy uninsured.

The ACA requires insured individual plans and small group plans to provide coverage for the 10 categories of "essential health benefits" - ambulatory patient service; emergency service; hospitalization; maternity and newborn care; mental health and substance abuse disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services. It appears individual and small group plans that do not cover those 10 essential health benefits are being canceled. It's not a matter of changing insurance companies or not being able to keep your insurance company.

Within those 10 categories, what is covered will vary by state. HHS declined to issue regulations establishing a national definition. Instead, each state had to select an existing health plan as a base for determining what constitutes an "essential health benefit" within those 10 categories.

There are 27 states with federally-facilitated state exchanges, and another 7 states with "partnership" exchanges that are run by the federal and state governments together. The exchanges (including those that are federally facilitated) are just a place for you to go to get individual insurance - they aren't insurance plans themselves. Costs will vary and depend on the state in which you live.

In addition to reviewing the costs carefully, be sure to review the networks associated with the exchange-based plans. In order to keep costs low enough to have their plans approved to be offered on the exchanges, many of the plans come with much narrower networks of doctors that could further limit one's choice of doctors.

Hopefully some of that info is helpful.

How in the world would anyone believe that the "Obama Care" insurance takeover would benefit you when the plan is over 7,000 pages long and you have to "pass it to know what's in it". The congress that passed this mess didn't even read it.

The purpose of this plan is to make everyone dependent on the government. There is no way millions of people could be added to insurance coverage with pre-existing conditions and not have someone pay for it, hence the premiums for insurance that people currently have skyrocketed. Somebody has to foot the bill.

Although I'm on Medicare with an insurance supplement, my husband has an individual policy with a $10,000 deductible and his premiums are going through the roof.

Southern Bell
:grouphug:

??? for Souther Bell
 

Southern Bell - ?????

I too, am on Medicare with an insurance supplement.

I am under the age of 65.

Do you know how or if existing supplemental premiums will be affected?

Thanks in advance for any info.

:hug:

My son is a teacher for a charter school in California. He will keep the same coverage at a lesser cost. California is one of the states that accepted the Medicaid expansion. He does not any pre-existing conditions but it seems to me that in the states that took the federal funding would have an impact those states in a positive way. The funding would pick up the some costs that would have to be included in determining the price companies in the exchange have to charge.

I am not sure how Medicare works, and maybe Southern bell can respond.
Did the state you live in accept the federal funding?
If not, is it possible that your husband’s premiums are going up to cover your Medicare costs because the extra dollars are not there and he is picking up the slack for you?

In the states that accepted the federal dollars, lower income families may have access to expensive treatments, like infusions that would be not available to them otherwise.

The funding is only for the first 5 years, and if it works out like it is supposed to the free market will drive down prices for everyone because of more insurance companies will be vying for dollars. I personally think this will happen.

scrubbs

So what is the real world latest story on Obamacare? I am very interested in what is happening around the country. This is a complicated mix of individual needs, business, politics, law and is scary, especially if you have an illness like MG.

There's a lot of 'news' out there on Obamacare but some of it is contradictory and sounds like political spin. It's hard to know what the truth is. I thought I'd ask a few questions and also share what I thought was supposed to be happening. I may not have it right but I tried to ask questions below that go to the heart of the matter.

So who's deciding what we can buy? Is it true the feds are not the ones deciding the available insurance policies or prices but rather the insurance companies? I know the feds can set limits for what a minimum policy covers but that's not what we are talking about if the discussion is about IVIG coverage or coverage of 'off label' meds. In that case it was supposed to be free market competition without the need for a 'group'. Is that really happening? Is there real competition in different states?

I understand Obamacare operates on a state by state basis. That's the same as pre-Obamacare. So are the good plans offered in different states really that different? That would seem very unfair but I thought it would be decided by insurance companies, not the feds.

There seems to be at least five different cases to consider:
a) free care plans for low income people
b) partially fed subsidized plans for 'lowish' income people
c) plans offered (and typically partially subsidized) by employers
d) individual plans purchased by 'full paying' individuals
e) medicare supplemental coverage

a) I thought free care plans would stay about the same as pre-Obamacare. I thought nothing would change under Obamacare.

b) I thought that 'lowish income' people who could previously not have afforded insurance (like those whose employers did not offer a plan or kept work hours below 24 hrs) could now apply for a fed subsidy and purchase a reasonable plan. In the past, this would have been impossible because there would not be an employer subsidy and as an individual, the insurance company would charge very high rates and exclude people because of pre-existing conditions etc. Since the notion of being in a group is eliminated by the exchanges, the person could get reasonable coverage for a reasonable rate, partially subsidized if incomes were 'lowish'. The exchanges were supposed to provide competition to keep rates low. Many young people fall into this category. This is a new Obamacare category.

c) If your employer offers a plan it is likely subsidized at least 50% by the employer and it is in the employer's best interest to offer decent plans. Working people whose employers offer subsidized group plans will probably get a low rate because the employer pays a substantial portion of the cost. This is supposed to be the same with or without Obamacare.

d) People who don't have access to an employer plan but can afford coverage can buy through the exchanges and get 'group rates' as individuals. The exchanges would eliminate the need for a group and competition would keep rates low. I thought competition and the elimination of groups would make it easier for this category to get good plans at a lower rate. In this case, Obamacare was supposed to make it so individuals could get good rates despite not being part of a group.

e) I don't really know about supplemental plans. I have relatives who are very afraid right now. I thought these plans would be similar before and after Obamacare. In both cases they are purchased by individuals and I would think the free market would set pricing and coverage.

I know I've probably way over-simplified but that's the limit of my understanding. I personally fall in category C and I haven't seen a change except even employer based coverage seems to change from year to year. I've had to switch plans several times even with the same employer. My employer covers about 50% of my health insurance cost and to keep costs down, the plan has become leaner and leaner as time passes. My MG coverage has been good but I don't know what will happen down the road and that is a concern.

If I was an insurance company I would be very scared right now. I doubt I would offer my best deal to anyone because there is a lot of uncertainty. Obamacare hopes that hoards of young uninsured people will flock to purchase insurance and provide a larger 'pool' for everyone, but no one knows if that will happen. Supposedly, if that happens, we will all benefit but I doubt the insurance companies are willing to bet their profitability on anything right now. Wall Street doesn't reward CEOs that make bad bets and I think insurance company CEOs are not willing to make bets that can get them fired.

Because I have an employer based plan, I have a (perhaps misguided) sense of security right now but I do know what it's like to be scared of the uncertainty of MG and my heart goes out to those who now have to face the double uncertainty of Obamacare on top of MG. I'm very interested to hear what is happening to people in different states and in different situations because it could affect all of us. We don't have a lot of health insurance security in this country and a lost job or other misfortune can cause anyone to be in the shoes of another.

I hope I didn't step in some political pothole by writing this. I'm OK hearing people's opinions and it would be nice to also get some facts on the table. We've all heard a lot about what Obamacare will be and now is when we find out what it is. I hope whatever happens works out for all of us. We deserve good care.

Dear gr8ful,

I would love to respond to your post but I am afraid it may sound political no matter how hard I attempt to keep it out.

What I can say is that my primary care physician left his practice. I have paid for my own health insurance coverage, an individual policy for 40 years. I am NOT eligible for any subsidy unless I drop my insurance and go into an exchange. The cheapest exchange plan will only cover 60% of my incurred expenses. I would be responsible for 40% of everything. One short hospital stay could wipe me out completely and then some. I do not know what deductible would be involved. I would lose my drug benefit which would cost me over $1200 per month. No matter how high my current insurance will continue to climb, it will still be better than the alternative.

I have tried to state JUST my personal situation, NOT any "opinion" to avoid any issues to have my post removed.

You mentioned a lot of "suppose to's". Well, I am not sure things are turning out like they are "suppose" to. Good luck to everyone here with health care needs. Dealing with our illnesses is hard enough. I have several doctors and am thankful for them. I just hope I will not see any more loss of my docs.

the letter was sent by current insurance company and states
"The ACA will affect you health insurance plan. Your current policy will end on 3/31/2014. Therefore you will need to buy a new plan..."

It does state I can purchase an ACA plan from any insurer in the market, or on your state's Health Insurance Exchange.

my issue is not where I have to buy a plan but rather that the ACA is taking my plan from me! A plan I purchased in 1999 and for which I have always timely paid $1200 per month premiums for many years now which provided coverage at least covering the essential stuff then some...no annual deductible. A plan the coverage of which no longer is option for me at all.

PS the letter does say "We're here to help...call member services" which quite frankly is quite a joke as member services are the most incompetent, dismissive, condescending and unhelpful representatives I have ever dealt with!

Hopeless,
Are you saying there are no plans on the exchange that will cover more than 60% of your medical expenses? I believe you but why is that? If you are paying the full cost of your insurance and everything has been OK for years then what caused the situation to change? I thought you should be able to go on the exchange and buy a similar plan. You said the cheapest exchange plan will only cover 60%, what about the most expensive plan on the exchange? Aren't you able to buy a good plan through the exchange? Supposedly the exchanges are administered by the feds but the plans are whatever the insurance companies choose to offer. Your insurance company has been offered your plan for 40 years. Why aren't they offering the same plan on the exchange?

StephC,
I guess I have the same question. Are you able to get a similar plan on the exchange for a similar monthly cost? The exchanges are supposed to be a place where your insurance company offers various plans. The government doesn't offer plans, your insurance company does. Why wouldn't you be able to get a good plan at a cost similar to what you are paying now? Why wouldn't you be able to get the same plan you have now through the exchange?

The exchanges are supposed to just be a place where individuals can go as individuals and be treated as if they were part of a group. They would be offered the same plans as a group and pay the same cost as group member. It doesn't make sense that someone who is willing to pay the full cost of a comprehensive plan wouldn't be able to find a good plan on the exchange. Could it be that your current insurance company sells your current plan if you buy it through the exchange? Maybe you have to switch companies but there is a similar plan through the exchange?

I hope everyone finds a plan that works for their needs. It doesn't bode well for anyone if the insurance companies start denying coverage for things they've covered in the past.

As I said in a prior post my son is glad to see what is happening with his insurance.
Lower cost with better benefits but he works for a small company that owns 5 charter schools. He did not have to hassle with an insurance company. The company he works for assigned an administrator to walk the employees through the process.
He also lives in a state that accepted the Federal Medicaid money and that has to impact the cost of insurance for everybody living there.
On the other hand. he does not have any pre-existing conditions with high costs like we have to deal with.
scrubbs

my plan was originallly written in 1999. it is a good plan that can no longer be purchased directly or through group, regardless of enactment of ACA. There are NO plans offered which provide same coverage to I have now regardless of pricing. In fact, there are no platinum plans offered to 48 year woman in florida.

I'm sorry to hear your situation Steph. I looked at a Florida Blue Cross website and saw an individual platinum plan with an $800 deductible, 90% coverage and a $2500 yearly maximum out of pocket. On the bottom was the fine print, "Premium is based on age, gender, county, tobacco usage, etc.". I don't know what that means exactly. It doesn't sound as good as your current plan but hopefully you can find something that can work well enough. Perhaps more plans will be offered between now and 3/2014. Good luck. I hope the uncertainty ends quickly. No one with MG deserves that kind of stress.

Grandfathered plans
 

It appears there 'is a provision in the "Patient Protection and Affordable Care Act" section 1251 entitled "preservation of right to maintain existing coverage" and which states "nothing in the act shall be construed to require that an individual terminate coverage under a group health plan or health insurance coverage in which such individual was enrolled on the date of enactment of this Act. " There is also reference made to grandfathered plans...which I think would be something I want to do...

I need to read more - the Act is about 1,000 pages - but am hopeful there may be something in the Act which provides protection for situations like mine. It seems to me there be some sort of protection in it but based on the letter from my insurance company they make it seem as if the Act is terminating the coverage.

I am hopeful there might be a way to reject the termination letter and instead claim my right to continue with my current policy. I will post more as I learn more.

Did it provide any premiums for any group?

i figured my medical billings for last year, based on billings not payments by insurance company, since insurance only pays about 1/5 of the bill! if I didnt have insurance, I would have incurred about $600,000 worth of bills (IVIG billed at $35,000 per every three weeks is big majority of that)

Thank you for the research and the time, Steph. I think it will be invaluable to all of us with these expensive diseases. I am really getting worried about it all.

Hi Steph C,

I am grandfathered under my individual policy as long as I make NO change whatsoever. Any change of any kind terminates your grandfathered eligibility. A grandfathered policy is also NOT subject to the rules of ObamaCare. In other words, if you have a lifetime limit, it still exits under a grandfathered policy. Any of the mandatory provisions under the PPACA, like maternity coverge, etc. does NOT apply to grandfathered policies. A grandfathered policy must not be changed in any manner. If you had certain coverages under your grandfathered policy, you may not ADD nor Subtract any coverage, including items that are now mandatory coverage items of the PPACA. Grandfathered policies are not allowed to make any changes, even ones that are now required under the law. Grandfathered policies are EXEMPT from the new mandates of covered items. About the only thing that is allowed to change on a grandfathered policy is the cost for it.

Steph, I could not find any premium information for that Florida BlueCross plan because I would have to apply and I'm not a Florida resident.

Meanwhile, that letter you got from your insurance company seems like a booby-trap. If you signed up for a plan under ACA, you would lose your chance at keeping your grandfathered plan. It appears they forgot to mention that there was a grandfather provision in the ACA. Perfect, they send out a letter like that, make you afraid, prod you into making a decision in the midst of fear and they get out of having to cover you under the terms of your old policy.

I may be way, way over-thinking but it may be in the insurance company's financial interest to 'bump' people with good plans into the exchanges. I hope you have unlocked the secret to keeping coverage that works for you. I'll be happy for you if you can find security during this change.

I'll also comment that StephC's discovery of the grandfather provision of the ACA could be very, very helpful to a lot of people. As the information about that becomes clearer it probably deserves some type of 'sticky' status and not just on the MG forum.

Hi Gr8ful
 

I live in florida and you are right, it is awful. I am on medicaid/medicare. Most doctors have stopped taking patients with this kind of insurance. ginnie:grouphug:

ginnie;
Florida is one of states that rejected the Federal Medicaid money.
scrubbs

Yes, it should be on other forums as well.

Another thing to consider........

No matter what insurance you have, no matter how great the benefits, it is of no help if the providers (docs) will not accept it.

Even if you want to keep your current policy under the "grandfather" clause, there is no guarantee that your insurance company will continue to offer it. Insurance companies are not required to continue to offer all their plans. The grandfather clause allows you to not have the mandated benefits listed under PPACA. Example: If the policy that you have was in force before passage of the PPACA, and it had a lifetime maxiumum, that will remain. The grandfather clause does not force insurance companies to continue to offer plans in effect prior to PPACA. Just means if they do and you were under it before passage, you have those provisions, not the provisions of ObamaCare. And you can NOT make any changes to your poicy or you lose your grandfather status.

Hopeless you are exactly right. Doctors are either not accepting the insurance coverage or they are leaving the medical community because of the government involvement.

I have found that being covered by Medicare there are so many doctors that won't accept me. My supplemental coverage will cover anything that Medicare accepts. I have had two different doctors who are practicing within a group but there are only one or two doctors who will accept me in that practice. And it is mainly because Medicare dictates how much they will be paid for procedures. I actually have been to a Dermatologic Surgeon who accepts Medicare but you have to sign an agreement that you will be responsible to reinburse him for anything that Medicare reduces his charges.

Southern Bell
:grouphug:

Is this legal? I thought doctors have to agree to accept whatever Medicare pays when they agree to be a doctor who accepts Medicare. I'd check with the State you're in to verify that this is legal (for the doctor to do).

I'm pretty sure that the state does not get involved in the coverage a doctor decides to accept or the choice he makes to get the patient to pay the outstanding balance.

If I didn't want to pay the difference, I have the choice to shop doctors. But this physician is highly recommended by my dermatologist and since the surgery was on my face I wanted someone who would do a good job so that there wouldn't be any bad scars. It was my choice to pay the difference.

The state doesn't have the right to force doctors to accept insurance or Medicare coverage but with Obamacare the federal government will do that in the end, I have no doubt. The main purpose is to control the medical coverage Americans will or will not receive and hopefully end up with the "single payer system".

Southern Bell
:grouphug:

Hi Scrubbs
 

Is the lack of medicaid funding in this state the reason why no doctor will accept medicaid? I know they do not get paid that much with Medicare as well.
I never really understood all the ins and outs in this. ginnie

Ginnie;
26 states have refused Federal dollars and in those states anyone on Medicaid will suffer greatly. They are concerned about Federal spending and the aid to the states will be Federal tax payers’ dollars We all pay for that.

The 24 states that have accepted aid know it will reduce the costs for Medicaid in their states. The aid is only for the first 5 years of Obama Care and when that time expires the cost of insurance will be less for everybody and the costs to the Federal and local governments will be re deduced. They believe.
Tax payers’ dollars are being used right now to pay for the uninsured and under insured in emergency rooms. While a hospital visit for the flu that might cost only a few hundred dollars, a visit by someone in a Myasthenia crisis could cost the tax payers tens of thousands of dollars.

All 50 states feel their actions will save tax dollars.

ginnie, until we find out what will happen you may be forced to use the emergency room for your medical needs. I wish you well.

scrubbs

Hi Scrubbs
 

Thank you for the info. If my PCP stopped taking me, It would indeed be the emergency room. ginnie:grouphug:

Well, my husband brought home health insurance information from work last night. Indeed, we are able to keep our current policy next year. However, the cost of each month will go up a couple of hundred, to $1500 a month and there's now an out of pocket max of $22,500 before the policy covers us 100%. I don't have an extra $22.5K lying around for IVIG, so we get to choose from 3 "tempting" marketplace policies.

I don't have all the details on those yet, as the office will not open that information until Nov 4. However, when doing some checks on prescriptions, I was shocked to see that a medication my daughter has used since age 10 will suddenly be "banned" until she completes "step therapy" (trying less expensive alternative short acting meds vs the extended release one she uses now) before she can be approved to get the med. I am FURIOUS, as she is 16, a junior in high school, and is on a "streak of success" right now like she has never known in her life. Messing with her meds (for ADHD) at this point could really mess up her life and her future, in the worst case. I am going to be ALL OVER the folks in the marketplace, as well as writing my representatives, etc. Hell knows no fury like a ticked off Mama bear protecting her cub!

In summary, I am not happy!:mad: Has anyone else found out information on their plans for next year?

I don't know yet if this will work with the new plans but....

My husband's Cobra ended last September and I purchased an individual plan. When I went to renew a prescription he has used for years, it was denied and he was told to go through the Step process. I called Blue Shield about it. I told them that he had been using the prescription for years. They said that if he had been using the prescription and was stable on it on his previous plan, he did not have to go through the Step process. They needed my physician to indicate on the script that the precription has been used before.

I don't see any reason that this won't work on the new plans, but we shall see....