New Health Insurance Changes Take Effect

The first wave of health insurance changes take effect today. Which ones?

  • No denial of children based on pre-existing conditions
  • No more lifetime benefit limits
  • No canceling policies of very sick and benefit-needy peoplefor technical errors on their application
  • Coverage of kids up to age 26 on their parent policies
  • No co-pays on some preventive procedures, including colonoscopies, mammograms and immunizations
  • Allowing those on new plans to keep their own doctors and to appeal reimbursement decisions to a third party.

One area of immediate concern: In many states, insurance companies will stop offering child-only policies immeidately. "Anthem Blue Cross, Aetna Inc., UnitedHealth Group Inc., Cigna Corp., are among the companies that plan to halt all or part of their child-only policy sales." More here.

Here's the new White House website explaining the law, the changes and the benefits.

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    iirc (5.00 / 1) (#1)
    by nycstray on Thu Sep 23, 2010 at 01:59:23 AM EST
    In Ca there's a bill on the way to the Gov to stop the companies from dropping child health insure. my gut reaction . . . WTF?! how the h*ll can you even call yourself an insurance co if you drop off folks at the drop of a law . . . and to do it with children?! just makes me sick.

    It's all about the Benjamins. (none / 0) (#2)
    by caseyOR on Thu Sep 23, 2010 at 02:13:34 AM EST
    Health insurance companies are first and foremost profit-making businesses. Paying out claims is not good for the bottom line. This is one of the major fault-lines of a health care system dependent on the insurance companies.

    Insuring children is profitable because most kids do not require much in the way of health care. There is no money to be made off sick kids. If there is no money to be made there is no reason to offer the plans.

    This health insurance reform thing is a house of cards,a nd these are the first cards to fall.


    Huh? (none / 0) (#33)
    by squeaky on Thu Sep 23, 2010 at 11:22:17 AM EST
    Insuring children is profitable because most kids do not require much in the way of health care. There is no money to be made off sick kids. If there is no money to be made there is no reason to offer the plans.

    If insuring children is profitable because they are low risk, as you say, your logic as to why insurance cos are dropping child policies does not make sense.

    I must be missing something.


    yes, you are missing something. (5.00 / 1) (#41)
    by nyrias on Thu Sep 23, 2010 at 12:25:38 PM EST

    This article explains it.

    And i quote "Insurers said they were acting because the new federal requirement could create huge and unexpected costs for covering children. They said the rule might prompt parents to buy policies only after their kids became sick, producing a glut of ill youngsters to insure"

    This is called adverse selection.

    Moral or not, the rule does have the potential of making the business not profitable.


    Yeah (5.00 / 1) (#44)
    by hookfan on Thu Sep 23, 2010 at 12:51:09 PM EST
    Insurance companies compete by limiting exposure to risk, making themselves as profitable as possible. They do not operate on the biblical golden rule, but on "he who has the gold,rules." We shouldn't be surprised at that. It's their required nature, under the rules we allow. And the rules we allow promotes gaming to make them profitable.
      What ticks me off no end, is that our reps allow and promote these rules, rather than do what is necessary to change the system to get us the help we need.
      We had our shot and still have a Rube Goldberg system that allows gaming. Well that's not exactly fair to Mr. Goldberg. His systems actually worked as intended. . .

    What makes you think (5.00 / 2) (#48)
    by PatHat on Thu Sep 23, 2010 at 01:02:33 PM EST
    the health care system isn't working as intended (by the politicians and those who elect them)?

    Point taken (none / 0) (#49)
    by hookfan on Thu Sep 23, 2010 at 01:07:04 PM EST
     Guess I read our reps pr and took it as serious intent.

    OK (none / 0) (#45)
    by squeaky on Thu Sep 23, 2010 at 12:52:05 PM EST
    Then caseyOR's notion that children only policies are profitable, is false. According to the insurance company, child only policies are relatively rare.

    Of course if Schwarzenegger signs the bill disallowing Insurance Companies in CA to sell very lucrative individual policies for 5 years, if they do not also offer children only policies, the Ins Cos will change their tune.

    What stupid move for the insurance companies, very bad PR move.  This will blow up in their faces, imo.


    Who'll make the dynamite? (none / 0) (#47)
    by hookfan on Thu Sep 23, 2010 at 01:02:28 PM EST
    Not our reps on the national level, nor our president. They've already shown who their priority is. And don't you find it interesting that the Ins Cos are willing to take that in your face approach regardless of pr?
     Why are they so emboldened? Likely its because they have a pretty sure bet, they'll pay no price, or if they do they can pass it on to us. Hike, hike, hike those premiums,baby!! Yeah! We must keep the "legacy industries" profitable. . .

    Yeah (5.00 / 1) (#51)
    by squeaky on Thu Sep 23, 2010 at 01:16:59 PM EST
    I guess Politicians are going to have to do the math on this one.

    Amount of cash from insurance lobby compared to the political currency gained form speaking out about protecting our children, particularly those who are gravely ill.

    My guess is that they will still get the insurance $$$ but the political capital is too enticing for any sane politician to pass up the speeches about little jonnys and gillians who are being left to die by ruthless cold hearted Insurance companies.


    Not suprising .. (none / 0) (#66)
    by nyrias on Thu Sep 23, 2010 at 02:19:58 PM EST
    remember that bad PR is not a deterrent unless it is going to cost the company a lot of business.

    It is different than a car company making an unsafe car. People usually don't switch insurance company because their insurers stop a certain coverage.

    CA has the right approach. The only way to change behavior is to threaten the loss of a even a larger piece of the profit.


    I think caseyOR meant (none / 0) (#50)
    by Democratic Cat on Thu Sep 23, 2010 at 01:10:41 PM EST
    That under current rules the policies are profitable because most children don't get seriously sick, and insurance companies can deny coverage to those that are already sick. But if insurance companies can't deny coverage for a child's pre-existing conditions, then there would be an increase in the number of sick children who would be requesting these policies, and that might not be profitable. (Whether it would or not depends on the rates charged.)

    I haven't heard much about Schwartzenegger's proposal, but I think California has done the same thing in other areas.  If you want to sell home insurance there, for example, I think you have to offer earthquake coverage. Now, it's so expensive I think most people don't actually buy the earthquake rider. But the insurance companies have to offer it.


    Makes Sense (none / 0) (#52)
    by squeaky on Thu Sep 23, 2010 at 01:17:54 PM EST
    Yes, that is the issue (none / 0) (#65)
    by ruffian on Thu Sep 23, 2010 at 02:15:55 PM EST
    they were profitable when they could exclude kids with pre-existing conditions. Now that they can't, they apparently don't think they are worth offering. Or at least that is the 'blame HCR' excuse.

    I think it is a by-product of the mandate-for-all implementation schedule being out of sync with the no-pre-existing conditions for children schedule.


    Thank you, DemCat (none / 0) (#87)
    by caseyOR on Thu Sep 23, 2010 at 06:35:21 PM EST
    That is what I meant. Sorry I wasn't more clear.

    Its dumb (none / 0) (#79)
    by Socraticsilence on Thu Sep 23, 2010 at 04:20:53 PM EST
    but probably still profitable.

    I'm not sure point 3 is right (5.00 / 2) (#5)
    by BDB on Thu Sep 23, 2010 at 05:47:32 AM EST
    The proponents of the bill have always claimed it did that, but insurers can still cancel policies for fraud or misrepresentation on the application and that's how a lot of the policies got cancelled on those minor mistakes.  I had a case on this one - guy took one antidepressent pill and went to a few counseling sessions after he had to lay off his entire staff and lost his own job and insurer denied him coverage for his leg cancer claiming he'd lied on his application when he said he'd never had a mental illness.  They lost, but it was the fraud/misrepresentation analysis that they relied on to try to deny him his benefits.

    I think the terms for (none / 0) (#80)
    by Socraticsilence on Thu Sep 23, 2010 at 04:23:13 PM EST
    recission have been restricted a ton (essentially only allowing for outright fraud) but I could be wrong.

    The firm I work for is gearing up for (5.00 / 4) (#6)
    by Anne on Thu Sep 23, 2010 at 07:16:11 AM EST
    open enrollment for a plan that takes effect on 11/1; I don't participate - I have my own insurance - but the bad news is that even with changes to co-pays and deductibles - which means they are increasing - the costs are going up 17% for what is known as the "core" plan, which is the most basic and less expensive option, and 13% for what is known as the "buy-up" plan, which is the more expensive plan.

    The reason for the increase?  Claims history, apparently.

    In addition to higher co-pays and deductibles AND higher premiums, the core plan will only cover in-network care - if you go out of network, you're on your own.  It's the less expensive plan, but using it will limit you to coverage only from those providers in the plan.

    My favorite part of the news was this: "We have to be very careful consumers of health care services, while getting the care we need."

    The core plan's premiums are going up more than the other plan because it was - apparently - greatly underpriced.  Does that mean, "Waaaah!  We missed out on an opportunity to make more money, but we won't get fooled again!"

    Family coverage for the staff is only going up 9%...woo-hoo!

    And the kicker...we must do something to stop these constant increases in health care costs.  Hmmm...what could that be?  Well, the firm will be looking at other plans, but we should expect more changes.  Oh - here it is: we also need to work on our claims by getting healthier.  Stay tuned for "wellness initiatives," with incentives for adopting "healthier lifestyles."


    Last year, the firm offered $100 off the annual cost of the coverage if you submitted to some simple blood tests and "health profiling," and - call me paranoid - but I was suspicious of this kind of benevolent, we-just-want-to-help-you kind of initiative.

    I'm not suggesting people shouldn't try to be healthy and do what they can to stay that way - we all should - but this kind of pressure from employers to be "careful" consumers of health care, and the message that it's claims that drive the cost, make people feel that if they can be identified as the reason for the claims, perhaps they will be deemed too expensive to continue to employ - and makes them reluctant to actually use the coverage for actual care.

    But, hey - not to worry - with higher premiums, co-pays and deductibles, I'm sure fewer people will be using it, and - voila! - more money for the insurance company.

    Love the way that one works...

    I'm the opposite (none / 0) (#35)
    by waldenpond on Thu Sep 23, 2010 at 11:43:44 AM EST
    I like the incentive plans.  Our last insurance was offering over $1000 to hit ideal weight, participate in a nutrition program etc.  The corp offers weight watchers on site, yoga, gym memberships, gyms on site... paid for or heavily subsidized.

    Prevention is always a focus but it was after several employees had serious cancer issues in one year and Blue Cross was going to increase premiums $1 mill to hit their profit goal .. the health system became temporarily self-insured and prevention is the most cost efficient for longevity.


    Works great (none / 0) (#57)
    by TeresaInSnow2 on Thu Sep 23, 2010 at 01:44:10 PM EST
    When people don't have underlying genetic conditions that make them unhealthy....

    It's basic discrimination against those with bad genetics.


    I'm just surprised that (none / 0) (#62)
    by Zorba on Thu Sep 23, 2010 at 02:07:03 PM EST
    insurance companies never did require genetic testing before issuing a policy- certainly, testing for many genetic conditions has been available for quite awhile.  Although maybe they considered it, and decided that the sh!t they would get, not just from the public, but from lawmakers, would be so huge, they took a pass on it.

    Wrong in this case (none / 0) (#63)
    by waldenpond on Thu Sep 23, 2010 at 02:11:50 PM EST
    I'm beginning to hear quite a few Repub talking points about systems to improve health care and out comes.

    For this program, you are rewarded simply for participating.  It is a very simple program.  You sign up to a website, you save money (they are assuming you will read the wellness updates and recipes, participate in surveys where you win exercise equipment etc.)  If you sign up for the nutrition counseling program.. you save money.  Are you willing to actually make dietary or weight changes?  A counselor will call you quarterly to check up on progress, if you actually lose some weight you save more money.

    The largest savings come to those who make dietary changes and continue to lose weight.  There is no one who can not participate in this employee program.


    There's certainly nothing wrong with (none / 0) (#67)
    by Anne on Thu Sep 23, 2010 at 02:32:23 PM EST
    saving money - or getting healthier - but what is the effect of not enrolling in wellness programs, of not losing the weight or whatever it is?

    I have to tell you - one of the reasons I didn't elect to get my firm's insurance was that I didn't want them in my business.  I don't care how many times they assure us (I get the e-mails because they are distributed firm-wide, not just to participants) that the information and results of screenings is confidential, I don't trust that.

    The firm gets reports on what drugs are being taken, what procedures are being done, what types of providers are being utilized, and so on, and even if there is no identification of individual employees, it's just too close for comfort.

    Healthy is good, but the real money that is being saved is not on your end, but on the insurance company's end,  And, from what I've been told, it is quite likely that the firm is being rebated some of what it is paying in premiums, but to a greater extent than what is being offered to those who participate in these programs.

    It just would be so nice if we could all stop worrying about health care, wouldn't it?


    Couldn't disagree more (none / 0) (#76)
    by waldenpond on Thu Sep 23, 2010 at 04:01:12 PM EST
    with about everything you just wrote.  Cost is the effect of not participating.  For myself, the company, the hospital, the community.

    I worked at a hospital for years (still do part-time contract work) doing budgets and even negotiating insurance contracts so am very familiar with the (I'll be polite and call them) 'inefficiencies'.  I have experience with data systems and it unless a severe systems error has occurred, it should not be possible to include your personal data.  (Could anything be more basic than simply blocking the ability to download personal info?) My lab tests go to the doc and the hospital etc and my privacy has never been violated.  Also, health care data is really, really uninteresting.  Most of it's coding and it's just too boring to inspire most to look.

    I couldn't disagree more that I am not saving.  I save on insurance costs and by not having to pay co-pays.  Having worked for a non-profit, the goal is to provide the greatest care to the largest number of people .. the benefits of wellness programs in cost and longevity are indisputable for long-term community health.

    It would be great if we could stop worrying about health care but it seems there is an opportunity for continuing education.


    Mathwise it makes (none / 0) (#81)
    by Socraticsilence on Thu Sep 23, 2010 at 04:26:44 PM EST
    sense and is frankly appealing- doing this is one of the few things that has been consistently shown to lower the cost of healthcare across virtually every variable- simply by reducing a ton of preventable costs (obsetity related heart conditions and diabetes, smoking and cancer etc- none of these diseases is solely caused by behaviors but all are effected by them).

    Insurance Cos got their mandates (5.00 / 2) (#9)
    by ruffian on Thu Sep 23, 2010 at 08:39:30 AM EST
    even though they don't kick in until later. I guess the lawmakers thought that they would be grateful enough to keep the Child Only policies available until then, when the adults would have to have a policy too. Wrong.

    My eyeballs (5.00 / 4) (#25)
    by lentinel on Thu Sep 23, 2010 at 10:05:59 AM EST
    spun a bit when I read Obama's having said the other day," ..there is not a country in the world that would not want to change places with us."

    Besides being one of the most outdated, jingoistic cold war clichés in the history of the world, as well as being insulting to every other country in the world, I think to myself (screaming inside my head), "ARE YOU NUTS?!"

    Who in France, where you can visit a doctor of your choice for 22 bucks (partially reimbursed) or get a house call within a few hours notice (50 bucks - also partially reimbursed) would trade for the system we have?

    Which Scandinavian country would want to swap with us?

    Would Canada?

    I'll give him this - maybe the Philippines - or Haiti....

    And which country in the world would want to inherit a two billion dollar a week war?

    Anyway - I'm so tired of having to be told that we're the greatest.
    We are a great country among many great countries. What's wrong with that?

    But our health care system is way down the list - and will remain so as long as we are dependent on people who are out to make a profit.

    You hit the (5.00 / 1) (#27)
    by BWS on Thu Sep 23, 2010 at 10:22:08 AM EST
    nail on the head.

    He knows its not a perfect bill, and was disingenuous in suggesting so.

    Not having to get out of bed and take the subway in the dead of winter to make sure I don't have the super-flu of the season is not something I would be interested in trading.


    We ahve the best healthcare in the world (none / 0) (#83)
    by Socraticsilence on Thu Sep 23, 2010 at 04:30:19 PM EST
    but only for those who can afford it. Now, its true that even a straight adoption of say the french system would be a lot more expensive here due to the standard of care expected, malpractice liability, and the inherent expense of the technology used- but it would be a lot cheaper than it currently is.

    I am going to say something controversial, and (none / 0) (#3)
    by Gerald USN Ret on Thu Sep 23, 2010 at 02:57:39 AM EST
    I am going to say something controversial, and before I say it I would like to clarify a few things.

    First off I am for a universal health care for all citizens at some reasonable minimum level of coverage essentially provided by or at least controlled by the US Government.  If companies or people wish to add more to this minimum level, that should be their privilege.  This coverage should be paid for by taxes and that subject isn't for this discussion.

    Now once this comes into effect, the US annual budget would have a much bigger Medical Section covering everyone including people like me who already have a sliver of that pie because I retired from the Navy.  I would assume that in the long run, most everyone would be in the same program.  

    Now what will naturally follow from this new situation is that there would be budget fights and (pay heed especially here folks) limits on the spending for this Medical Budget.

    Sure we can expect cost overruns like occur elsewhere in the US budget, but still there will be limits and discussions of limits and many forces and pressures, not to mention watchdogs to keep those limits from getting too far out of hand.

    The costs for each  patient under this Medical Budget will be paid for by the US Government.

    Probably the above isn't so hard to accept by most people, but from now on it will get harder.

    On my TiVo tonight was a news segment on medical care.  There was a child who requires an intravenous treatment each and every day which costs in excess of $1,000 each time.  The simple sum of that one treatment per day is $365,000 per year. Probably other stuff is needed too so that is about $400,000 a year for 1 child.  In 5 years that is 2 Million.

    There was a woman who took a pill each day for about $60,000 a year.  She probably had other stuff too.

    Every year there are new more expensive treatments, machines, and medicines.  

    There are defacto budgets or limits on medical care now, but with the Government in charge there will be more exacting control and scrutiny by lawmakers and the public and decisions will be made that can be seen and discussed by everyone.

    The methods by which these decisions are made now, in some states, and in some countries, vary.  But basically a budget of a certain amount is decided on, and then one or more methods are chosen on how to distribute the funds.

    One method is to budget for everyone at a relatively low amount of say $2,000 to $10,000 and after that is paid out per individual (i.e. each individual is guaranteed at least that) what is left over goes to the people that need more on some kind of need basis that will be separated into two kinds of need.  One kind is non-recurring, like an accident or food poisoning and the second is recurring, like the lady with the $60,000 per year pill and the child with the $400,000 per year illness.) The $60,000 might  be ok, but the child needing $400,000 each and every year could run short.

    I have seen some people say that there will never be limits or shutoffs on medical care in the US, but as these costs grow along with other budget costs I believe there will be limits to health care as well.

    We have them now but they are all defacto because of the way the health system operates and are usually hidden from view.

    Anyway, as Jeralyn has shown above the Insurance Companies don't want to be obligated to pay for care that they haven't collected the money for.  It is that simple.  You can carry on all you want about CEO pay, but that is a pittance compared to the cost of care.

    The only sure thing about all this is that unless we can change our entire health care system, the doctors, the hospitals, the imaging services, etc. and cut out a whole lot of treatments that are marginal at best, the costs will just keep going up even faster than they have before because now more people will be getting treatments and people will be getting more treatments because it will be a "right" and it will appear to a lot of people to be "free."

    Wonder how much people in other (5.00 / 4) (#4)
    by MO Blue on Thu Sep 23, 2010 at 03:08:55 AM EST
    countries pay for that $60,000 a year pill or that $1,000 a day injection. Other countries control costs much better than we do.

    Personally I would rather divert the money (which never has a limit) we spend on endless wars to health care, rather than decide who should live or die based on how rich they are.


    The whole price structure is so distorted (5.00 / 1) (#8)
    by ruffian on Thu Sep 23, 2010 at 08:35:30 AM EST
    that it is impossible to figure out how much things should cost.

    I like the idea of an insurance strike for that reason - if no one had insurance, we might be able to get to a reasonable price structure.

    Plus, other countries don't accept it as a given that doctors are millionaires.


    was an arthritis treatment (who's efficacy is questioned) where every day you basically filter platelets out of the patient's entire blood supply, concentrate them, and then inject them back into the specific site of the arthritis in a very concentrated area.

    Surely many other countries will have a lower labor cost for such work, but it still sounds like a pretty pricey procedure.

    Could not find anything about a $60,000/year pill.


    Plenty Of Links (none / 0) (#58)
    by squeaky on Thu Sep 23, 2010 at 01:44:25 PM EST

    Duodopa, for instance, is expected to cost $60000 - $70000 a year. ... decreasing the "off" time between the action of each pill. .


    heh, your second link was the same (none / 0) (#59)
    by sarcastic unnamed one on Thu Sep 23, 2010 at 01:59:20 PM EST
    as my second link, this very thread on TL.

    Anyway, according to your link, Duodopia is not a "pill."

    In this technology, Duodopa, a form of levodopa/carbidopa that is concentrated into a gel, is pumped through a small tube that is placed through the stomach and into the duodenum.
    It is also not allowed/covered yet by Canada's HC so we can't compare its cost there vs ours.

    The yet there (none / 0) (#85)
    by Socraticsilence on Thu Sep 23, 2010 at 04:35:20 PM EST
    is a bit hopeful- Large scale health systems simply can't afford stuff like that in the long run its not cost effective when a older drug with slightly lower efficacy is cheaper.

    There was a segment on PBS' Newshour... (none / 0) (#68)
    by EL seattle on Thu Sep 23, 2010 at 02:39:30 PM EST
    ... yesterday that featured a kid with severe hemophilia who's on a $1,000/day treatment.

    Link: 9/22/2010 PBS VIDEO AND TRANSCRIPT

    The segment goes into the various parts of the Health Care plan that take effect this week, and there's more discussion of the ban on a lifetime caps on coverage than I've seen in other reports.


    in my car, I forgot all about it.

    Prophylactic treatment of hemophilia is prohibitively expensive here, on the order of several hundred thousand dollars per year.

    google showed a bunch of abstracts of studies from different European counties and Iran and Turkey doing cost/benefit analyses on the treatments which I guess means it's super expensive there too.

    I can't imagine the equivalent treatment's cost would be significantly less in these other countries, aside from presumably lower labor costs.


    In a lot of those (none / 0) (#84)
    by Socraticsilence on Thu Sep 23, 2010 at 04:33:23 PM EST
    countries they just wouldn't get the injection- check the NICE standards for high cost treatments and compare them to those in the US. Similarily, I don't think most Americans could take the waiting times of the Candadian system for non-emergency treatments (for critical care its almost the equal of the US).

    How much of that is profit? (5.00 / 1) (#7)
    by Realleft on Thu Sep 23, 2010 at 08:15:55 AM EST
    There are certainly fiscally unwise decisions made in healthcare, and will continue to be whether private or public.  No matter what, at some point highly expensive treatments/services will have to be reconsidered.

    In the meantime, though, should come a careful study of the actual costs of the treatments that are billed so highly for, tightening of not-for-profit rules, and a reconsideration of patent protections that allow medicines often supported by some public dollars in R&D to remain so expensive for so long.


    I'm a Navy brat. (5.00 / 6) (#23)
    by Chuck0 on Thu Sep 23, 2010 at 09:46:37 AM EST
    So I grew up with what was essentially "universal health care." No insurance companies, no claims, no medical bills. We just went to the local Navy dispensary or hospital, got treated, went home. Even picked up drugs from the pharmacy before leaving, without paying for ANYTHING. It was excellent government run health care and treatment. There is NO REASON, none, that a similar system cannot be created in this country. Expand the US Health Service. Run it like a military organization. Start a medical academy like Annapolis and West Point. You get a free medical education for 10 or years of public service. Take all the money we're feeding insurance companies and wars to pay for it. I personally could care less if the medical insurance companies fold up and go bankrupt. Push them all out of business. Health care should not be a for-profit commodity.

    Exactly (5.00 / 0) (#61)
    by glanton on Thu Sep 23, 2010 at 02:05:40 PM EST
    Putting them out of business was the only rational solution to this problem.  Health care should not not not be commodities like cars and plasma television screens.

    It's sickening (pun intended), this bill.  It's even more sickening to see Obama touting it like a major achievment.  

    Look how the GOP has responded to Obama.  It's the same level of hostility, the same charges of socialism, that he would have drawn, the same level of intense hatred, had he and the Dem Congress actually given us a health care bill.  

    The droolers on the Right are gonna hate you either way, Mr. President. In trying to mollify them you've done little beyond disgust independents and lose whatever enthusiasm you had earned with committed progressives.


    IMO the health insurance legislation (5.00 / 2) (#64)
    by MO Blue on Thu Sep 23, 2010 at 02:14:42 PM EST
    that was passed had less to do with placating the right and more to do with keeping the campaign contributions from the insurance and medical industries in the Dem coffers and out of the Republicans.

    I was (none / 0) (#70)
    by efm on Thu Sep 23, 2010 at 02:56:51 PM EST
    in the military and I'll take private insurance over that any day. They do use an insurance company for family members as well, Tricare. And Tricare does the exact same thing as all of the other insurance companies, the only difference is that the employer pays all of the premiums, except dental.

      And talk about denying coverage.  Every time I or any of the other lowly enlisted I knew had something wrong with them, you have to convince the doctor that your not lying to them to get out of doing some push-ups. It took me 9 months of going to the doctor every week, after I hurt my back, for them to authorize an x-ray, another 5 months after that for them to give me some muscle relaxers, and a couple more months after that for an MRI.
     I also broke my foot in the army. The army clinic said that their bone doctor was on vacation so I couldn't be seen at the clinic on post, so you'd think they would let you go off post and see a doctor, wrong.  I was told I had to wait 3 weeks for the doctor to return. I asked many times if I could go to the civilian hospital a 2 minute drive off post and was denied every time and told that the visit would be out of my own pocket.

    Now with my health insurance I get sick I go to a doctor that believes that I'm telling the truth, and gives me an antibiotic to cure the sickness, instead of just motrin to make pain of the sickness go away with out actually getting rid of it.  My daughter broke her arm a month ago, she got an xray and a cast the very same day as she fell. She didn't have to wait 3 weeks to see a doctor thats on vacation, and if the doctor would have been on vacation, I would have gone to a different one and that would have been covered as well.

    I know there are things wrong with our health care system, but based on my experience I'll take this jacked up system over what the military does any time.


    Not under Obamacare (none / 0) (#10)
    by Abdul Abulbul Amir on Thu Sep 23, 2010 at 08:42:44 AM EST

    There are defacto budgets or limits on medical care now, but with the Government in charge there will be more exacting control and scrutiny by lawmakers and the public and decisions will be made that can be seen and discussed by everyone.

    Lawmakers will not make these decisions, the law gives that power to administrative panels.


    unlike today (5.00 / 3) (#22)
    by CST on Thu Sep 23, 2010 at 09:44:01 AM EST
    where it is insurance company panels who make these decision based on profitability.  Which means they try to limit your coverage and care every single time.

    Not at all the same (none / 0) (#37)
    by Abdul Abulbul Amir on Thu Sep 23, 2010 at 12:15:10 PM EST

    You can sue the insurance company and win.  Decisions made be the health care administration cannot be sued.  

    only if (5.00 / 1) (#46)
    by CST on Thu Sep 23, 2010 at 01:01:51 PM EST
    they said they would provide a service and they don't provide it.  Not if they refuse to provide that service to begin with.  There are currently many plans with lifetime or annual limits on coverage - not to mention all the people that simply can't get coverage because they have a condition insurance companies don't feel like covering.  

    In order to fight insurance companies you generally need a huge amount of stamina and resources - and by the time you win or lose it might be too late, because chances are you are fighting them over something that's making you sick, quite possibly a life or death decision.

    The best part of that quote you linked to is this:

    "decisions will be made that can be seen and discussed by everyone."

    That's a much better alternative than what we have now.

    People today who have a disagreement over  coverage in existing government run plans can still fight it the same as any other insurance(ask Tracy).  There's no reason to believe this will change under the new law with respect to new plans.


    Exactly (none / 0) (#12)
    by vicndabx on Thu Sep 23, 2010 at 08:55:22 AM EST
    Insurance Companies don't want to be obligated to pay for care that they haven't collected the money for

    In a perfect world, this wouldn't be the case - no one would care about profits, stock price and 401K's.

    I understand it's kids, but generally there are alternatives, e.g. Child Health Plus for families who can't get coverage thru their employer.

    Wish it wasn't spun as a Scrooge and Tiny Tim story.


    Don't think this is right in the NYTimes piece: (none / 0) (#11)
    by vicndabx on Thu Sep 23, 2010 at 08:47:18 AM EST
    allows consumers who join a new plan to keep their own doctors

    You could do this already prior to today in many cases.  Simply use your out of network benefits.

    Here's what whitehouse.gov says on it:

    Guarantee enrollees their choice of primary care provider: Consumers will have their choice of provider within the plan's network of doctors, including OB-GYNs and pediatricians, without a referral, as well as out-of-network emergency care

    Finally, here's the language I found skimming the bill:

    ``(a) PROVIDERS.--A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

    I'm not seeing any change.  I wouldn't go to out of network docs w/o checking w/your plan first.  The article makes it seem as though you can go to any doc regardless of par status and there'd be no downside.  I'm not sure that's true.

    "Simply" go out of network? (5.00 / 3) (#16)
    by Anne on Thu Sep 23, 2010 at 09:12:57 AM EST
     My company is rolling out changes to its plan, one of which is that if you go out-of-network, none of the costs are covered.  Zip.  Zero.  All on the insured's dime.  This was in an effort to lower the increase in the premiums - which are still going up 17%.

    You can pay more and get the better plan that will allow you to go O-O-N, but co-pays and deductibles for that are also higher.

    The concern?  What are the criteria for providers to be in the network?  Is it that they have a history of delivering care at a low cost?  Or is it about the quality of their services?

    So, sure, people still have choices - if they can afford them.

    And I could have sworn one of the selling points of this health whatever reform was going to be more access, lower cost.


    That network vs. out-of-network (5.00 / 4) (#19)
    by Chuck0 on Thu Sep 23, 2010 at 09:40:46 AM EST
    is crap. It's a way for the insurance companies to deny claims. I had a health insurer in the past that denied EVERYTHING upon first submittal as "out-of-network." Now, I'm one of the anal people who researches, then double checks if a provider is in my network, so I knew the denials were BS. The insurer knew they were BS, but played the game hoping a certain percentage didn't call them on it. They paid every single claim I ever made, but every time, I had to call and make them do their job. A couple of items, I had to write two to three letters, threaten them with lawyers, but in the end, they paid. I don't fold too often. And never with POS insurance companies.

    What likely happened (none / 0) (#24)
    by vicndabx on Thu Sep 23, 2010 at 09:53:52 AM EST
    is your doctor was submitting claims using a provider number either not on file or not crosswalked to the in-network legacy provider number.  A few years back a law took effect that required every provider to obtain a unique identifier called an NPI (National Provider Identifier.)  These NPI's crosswalk or map to the old provider number used to process claims.  Problem is this mapping isn't always 1:1.  This has nothing to do with you or the insurer attempting to run a scam.  It's a system issue most if not all insurers have to deal with.  The gov't allowed providers to sign up for all kinds of NPI's instead of limiting them to one.  Ideally, there would be a single NPI only.

    So contrary to the popular theme, it's not personal.  Where do y'all get this stuff from?  I understand it can be frustrating to deal w/bureacracy sometimes but "played the game hoping a certain percentage?"  C'mon.


    You should get off your knees (5.00 / 3) (#26)
    by Chuck0 on Thu Sep 23, 2010 at 10:09:53 AM EST
    and stop orally copulating insurance companies. You don't know what you're talking about. This wasn't the case with ONE doctor. What I said was, EVERY claim was denied. From EVERY provider I and MY WIFE dealt with. Don't tell me they ALL used some wrong number. The insurance company was gaming their insured because they know that Americans are sheep who taught not to question authority. And they win at it because I'm certain many people are not as tenacious as I in calling them on their crap. Like I just called you, on your crap.

    You should learn to have a discussion (none / 0) (#30)
    by vicndabx on Thu Sep 23, 2010 at 10:43:51 AM EST
    like an adult.  Thanks for talking.

    And you should (none / 0) (#60)
    by gyrfalcon on Thu Sep 23, 2010 at 02:03:47 PM EST
    read more carefully and/or address the points the person is actually making, not just make stuff up to suit your own narrative.

    You should know by now I don't make stuff up (none / 0) (#69)
    by vicndabx on Thu Sep 23, 2010 at 02:52:45 PM EST
    it detracts from the debate.  Nor do I wish to misinform people.

    Info on the NPI: CMS Website

    Google: "NPI Crosswalk Issues" or "NPI Claim Rejection"  you'll see a bunch of links w/info on how to deal w/this supposedly made up issue.  Here's some info from a Dermatology Provider website:

    CMS recently announced that beginning Sept. 3, 2007 carriers will no longer correct billing or pay-to provider information submitted on Medicare claims submitted by dermatology group practices. This may lead to an increase in claims rejections when not using the correct National Provider Identifier (NPI) or NPI and legacy number combination. Group practices should be reporting the group NPI or group legacy number in combination with the group NPI in the billing or pay-to-provider identifier field.

    This was three years ago, and this was Medicare.  Is it possible private insurers may be doing the same thing?  Also, I can't really speak to the commenter's particular situation other that to say what I believed may have happened.  Seems odd the all his/her claims would get denied.  I wonder who the insurer was (is it small or large?)  Were other subscribers claims denied?  Were the doctors truly on the network?  Maybe the directory was out of synch w/the claim system?  Point is, there's a bunch of reasons why this persons claims could've denied as out of network that may or may not have had anything to do w/him/her but also wasn't the result of some malfeasance on the part of the insurer.

    Finally, please explain how a doctor will have any knowledge of the efficacy of doctors beyond the docs he already knows? (either in his group, or at partner locations)  The contention was the local doc knows best as to who may also be able to provide treatment.  How is it an insurer that has access to data at a macro level won't also have this info and make at worst, at least as good a recommendation, at best, an even better recommendation?

    I don't have a problem being on the "wrong" side here.  I can state facts and be comfortable with that.


    Oh, come on now... (5.00 / 1) (#73)
    by Anne on Thu Sep 23, 2010 at 03:23:53 PM EST
    How does an internist know who the best specialists are?  How does a pediatrician know which are the best pediatric oncologists, pediatric cardiologists?  How does a gynecologist know which docs are the best for breast cancer, or ovarian cancer, or fertility?  

    How?  Really?

    They MAKE IT THEIR BUSINESS to know in order to make sure their patients are receiving the best care.  Doctors are quite capable at researching, of networking a problem, just the same as any other professional in a general practice who depends on other professionals to handle the more specialized matters.

    Good docs know other good docs, and they don't send their patients to hacks - if they do, their patients don't come back - they find better care elsewhere.


    Little example:  last year, I needed a Virginia attorney to represent me in a guardianship/conservatorship proceeding for my elderly aunt.  I called someone in our DC office, and was referred to someone who did an excellent job for me.  When I needed an attorney to handle claims that needed to be filed against my aunt's husband's estate, the guardianship lawyer referred me to an estates and trusts lawyer who also did an excellent job for me.  

    Can you think of a reason why someone I work with would refer me to a bad lawyer, or why the lawyer I was referred to and who represented me in one capacity would send me to someone incompetent or marginally proficient to assist me on another matter?

    Their reputations are on the line; there is nothing good in it to make referrals based solely on the minimal qualifications you suggested.  "I know this guy" is probably not how it's done, just so you know.

    As to your info about coding - no one said the coding issue wasn't real or that you were making it up; what the poster said was that "coding" was not the likely reason that every claim for every member of his family, for whatever reason, regardless of provider, was denied.

    How was that not obvious?


    Who said it wasn't obvious? (none / 0) (#75)
    by vicndabx on Thu Sep 23, 2010 at 03:53:56 PM EST
    I did quite well in reading comprehension growing up.  I believe it's a trait I still have.

    As I noted, it was a possible explanation.  Since it could affect every claim.  How?  Well, not knowing where the poster lives, let's assume he and his wife go to two different docs in a small geographic area.  Let's assume these doctors both use the same software vendor (as is not uncommon.)  My personal experience is these software vendors aren't usually quick w/fixes.  So a problem w/the provider number sent in on a claim might not be fixed right away.  Heck, for all I know the doc could be sending in the provider number in the wrong format.  Or, staff in the doc's office isn't using the software correctly.  Maybe this poster has a direct-pay contract, and payments weren't up to date or hadn't been posted to his account.  I don't know.  Point is there's all kind of reasons.  Again, I was speculating on a possible explanation. While these may not seem feasible to you or other laypersons, they would be quite reasonable to someone who's does what I do.  Not everything is a conspiracy.

    Also, in your example, your first step was:

    I called someone in our DC office

    That seems in line w/what I stated about using friends and colleagues.  Nonetheless, that really wasn't what I was talking about.  The doc referring to friends and colleagues is not an issue.  There's nothing wrong w/that.  To go back, I was responding to this point:

    What if the specialist your internist wants to send to because he or she thinks that doc is be best one for your problem, is not in the plan

    My point was, that doc that's not in the plan is not your only recourse w/r/t care.  You should be able to stay in network and find a reputable, qualified, safe, effective doctor using the in network docs.   Your insurer does the same due diligence (if not more) you local doc does.  It's possible, that just maybe, the insurer also knows who's best to fix your problem.  Just because it's not who your doc knows doesn't mean he's not just as good or better.


    My insurer knows who's best? (5.00 / 0) (#77)
    by Anne on Thu Sep 23, 2010 at 04:06:51 PM EST
    Oh, sure they do - because they have my best interests at heart - even if they don't know me, don't have any relationship with me, and always have their eye on the bottom line, right?

    Pardon me for not buying that one.

    One should be able to take the recommendation of one's doctor, the person who knows him or her best, shouldn't they?  If the doc gives more than one name, then possibly, problem solved.  But if not, then what?

    You're missing the point on how docs know who's best, but that doesn't surprise me.


    I'm not missing the point at all (1.00 / 0) (#82)
    by vicndabx on Thu Sep 23, 2010 at 04:29:35 PM EST
    You believe you should be able to go to an out of network doc if you so choose and allow that doc to choose who to refer you to.  You trust your own doc more.  I don't disagree with that.  

    What I don't buy is an insurer will send you to some quack to save a few bucks which is what you are implying.


    Doctors pay to know others efficacy (none / 0) (#78)
    by waldenpond on Thu Sep 23, 2010 at 04:16:32 PM EST
    If a doctor has hospital privledges, efficacy is done by the hospital, but I don't think I have ever met a doc who doesn't pay to know efficacy rates.  Cost will depend on what/how often you feel like reporting and who and how often you want comparisons.  I am very surprised you are in the industry and are unaware their is a whole additional industry for outcome and productivity reporting.

    Also, it is not malfeasance that drives the industry to automatically deny payment.  It's cash flow.  The longer they hang onto the cash, the more money they make investing (actually losing) the money.  Docs don't have an incentive to improve this either.


    Now we are talking something totally different (none / 0) (#86)
    by vicndabx on Thu Sep 23, 2010 at 04:40:27 PM EST
    I know hospitals have this info and share w/docs in their groups - hence the reason they usually refer to other docs associated w/the hospital.

    I know there is all kinds of reporting that takes place, to state health agencies, to insurers, to the employer, etc.

    Does every doc use this info?  Do some refer to someone they've used in the past w/o any addt'l follow-up on their current performance?  Of course.  Professional courtesies and all that.  Again, there's nothing wrong w/that either.  My point is something different as noted in my earlier post.


    When there are well-documented cases (5.00 / 4) (#31)
    by Anne on Thu Sep 23, 2010 at 10:58:11 AM EST
    of insurance companies tasking their employees to find ways to rescind policies, routinely just deny claims until the claimants just gave up, and offer monetary rewards to those employees for doing so, please do not insult our intelligence by chalking up the poster's experience to bureaucratic snafus.

    Gaming the system is one way insurance companies make money for their investors; these are not charitable organizations, after all - they are stock-issuing, dividend-paying corporations for which the bottom line is the only line that really matters.


    Similar well-documented cases (5.00 / 0) (#54)
    by Dr Molly on Thu Sep 23, 2010 at 01:32:58 PM EST
    relative to the credit card companies and their 'mistaken fees', etc.

    As if it's a surprise that they play these tricks by now. Most of us have spent hours on the phone battling these phony charges and dismissals, knowing full well what the game is.


    Right, OK (1.00 / 0) (#36)
    by vicndabx on Thu Sep 23, 2010 at 11:46:25 AM EST
    Us folks who actually do the work are blind know-nothings.    

    You want to take isolated incidents and settled lawsuits as proof that things happen on a large scale throughout an industry that processes and pays millions of dollars in claims daily because it suits your agenda.  Go for it.  You want to repeat the same old talking points w/o any knowledge of the history of the health insurance industry.  Go for it.  You insult your own intelligence w/o any help from me.  I'm done.


    Isolated? (5.00 / 0) (#38)
    by Anne on Thu Sep 23, 2010 at 12:16:08 PM EST
    That it is going on at all, that it was not being done by rogue clerks, but on an institutional basis as part of a business plan makes scale irrelevant, don't you think?

    It certainly was irrelevant to people who were denied coverage when they got sick because they forgot to disclose a visit to a dermatologist, for example.  And it certainly was irrelevant to people who all of a sudden couldn't get claims approved for no apparent reason.  I know someone who worked for a large insurance company a while back, and he was told to "lose" the claims the first time they were filed, ignore them the second time, and if the claimant was persistent enough to keep filing, to deny them.  If they still came back, they would pay.  Most people just gave up - no claim paid, more money for the company.

    No one is accusing YOU of doing any of this.  And no one believes you to be an unethical person set on finding ways to keep people from having claims paid.  No one is even saying that claimants themselves don't try scamming the insurance companies, getting unethical providers to submit bogus claims and splitting the money.  It happens.

    But we've all read about the companies that looked for ways to deny and rescind coverage for people who developed chronic and/or costly conditions - regardless of how little these companies had paid out on the claimants' behalf up to that point.

    Look, I work in a law firm.  I constantly hear people ragging on "all the crooked lawyers."  I know that the majority of lawyers are ethical and honorable, but I don't deny that there are some bad ones out there taking advantage of people.  And I understand that if one lawyer screwed over one client, it is irrelevant to that client that the majority of clients are treated well.

    You may consider examples of insurance companies actively working to pull the rug out from under people who have paid them thousands of dollars every year to be nothing more than "talking points," but the people who have been on the receiving end of overzealous insurance company greed would probably consider that to be more a matter of life and death, both physical and financial.


    You too Anne? (5.00 / 1) (#43)
    by kdog on Thu Sep 23, 2010 at 12:46:16 PM EST
    For 3 straight years my outfit has downgraded our plan (higher co-pays, less choices, less coverage, etc.) in order to minimize the increase in price...but the price still went up every year.

    Selling points will get the sale, but they aren't always accurate.  In my business they just want you to sell it...if it gets returned ya whop 'em with a restock fee...you still made money.


    Merely pointing up an untruth in the article (1.00 / 0) (#18)
    by vicndabx on Thu Sep 23, 2010 at 09:35:26 AM EST

    Have you looked at a provider directory at the major health plan's websites lately?  D@mn near every doctor in a given area is in it.  It's been this way for the longest.  Docs being "out of network" are not the choice of the insurer, it's the doc.  I'm fairly certain those remain out of network aren't doing it for altruistic reasons.

    Point being, there are few justifiable reasons for going to out of network doctors.


    Says the person who works in the (5.00 / 1) (#29)
    by Anne on Thu Sep 23, 2010 at 10:24:53 AM EST
    insurance industry...no bias there, I'm sure.

    Even living in a geographical area where medical providers abound, when my firm has changed insurance companies and/or plans, many people I work with have found that the docs they utilize were not in the new plan.  Or that many of the ones in the plan were not taking new patients.  I think your sweeping statement about "almost everyone" being in these networks is just that - a sweeping statement that isn't backed up by anything that looks like an actual statistic.

    What if the specialist your internist wants to send to because he or she thinks that doc is be best one for your problem, is not in the plan?  Oh, just pay more, no problem.  Or worry that, because you chose to go out of network, and later decide to get additional treatment in network, that your claims could be denied because you originally went out of the network.  People do worry about that, I can tell you.

    So, my internist does not participate in any insurance plans; he and the other docs in the practice made the decision some years ago that the quality of the care they could provide would be compromised by having to increase the volume of patients they see in order to compensate for the low reimbursement rates being offered by the insurance companies - they didn't want an assembly-line practice, but one where each patient can have the time he or she needs with the doctor.  They will submit the paperwork, but I pay the doc and get whatever reimbursement I am entitled to from the insurer.  If I did not have my own insurance, and were insured through my employer, none of the "out of network" charges would be reimbursed to me - even though I was paying some $700/month for the privilege of having "coverage."  

    What a nice deal for them- collect some $8,400 a year, and pay nothing on my behalf.


    You make my points for me (1.00 / 0) (#32)
    by vicndabx on Thu Sep 23, 2010 at 11:16:41 AM EST
    and your docs are but one example of why gov't run insurance won't work in this country.  People want to be free to do things as they see fit when they see fit.  I have no problem w/that.  It seems others do and/or don't want to face the reality that is healthcare in this country.

    What if the specialist your internist wants to send to because he or she thinks that doc is be best one for your problem

    How can a lone doc or group of docs know this?  They don't have access to cure rates or stats on a large scale.  Be honest and admit this is largely referral to friends and colleagues.  If there are limited or no docs of a particular speciality in an area, that is a separate matter and should be addressed as such.

    Question.  If these docs are so great why wouldn't every one want to go to them?  How would they have a choice to refuse patients (which make no mistake is what they're doing) under gov't run insurance?

    Lastly, to this so-called "bias."  Yes, I work for a large insurer.  I'm not an idiot however and am honest enough to admit what works and what doesn't.  Might you be biased yourself?  Might there be perspectives you are not aware of that are equally valid?  Might your perspective be limited?

    Bottom line is these docs generally cost you more (as someone who is paying for insurance) and create an administrative burden (i.e. cost) for the insurer since YOU have to submit a claim (or a bill or receipt or whatever) vs. a provider who can do it cheaper electronically.


    Now, you're just making stuff up. (5.00 / 1) (#42)
    by Anne on Thu Sep 23, 2010 at 12:28:08 PM EST
    For one thing, we don't have government run insurance.  This stuff that is happening now has nothing to do with the government doing anything other than setting rules - rules which the insurance companies are working overtime to find ways around.

    And you once again make another sweeping statement that has no basis in fact: that doctors have no way of knowing who the best docs are, so their referrals must all be to friends and colleagues.  

    Seriously?  That's just ridiculous.  Whatever credibility I ever thought you had just evaporated.


    Kind of known from the beginning... (5.00 / 1) (#53)
    by Dr Molly on Thu Sep 23, 2010 at 01:31:37 PM EST
    by the use of the term "obamacare" IMO.

    That's just ridiculous.  Whatever credibility I ever thought you had just evaporated.

    How odd..... (5.00 / 0) (#34)
    by waldenpond on Thu Sep 23, 2010 at 11:26:39 AM EST
    It is just untrue that it is a doctors decision only.  It's also regional.  If you are a certain distance from a major metropolitan region, the insurer defines the area as out of network.

    Yes; if you live in one city, say (5.00 / 0) (#39)
    by Cream City on Thu Sep 23, 2010 at 12:21:44 PM EST
    but commute a distance to work in another city, and your insurance is through that employer, you are "out of network" where you live -- and imagine the complications and extra commuting that can be involved to see an "in network" doc, and imagine especially the problems in emergencies.

    Exactly the situation of one of my family members.  And the job involves working from home or traveling sometimes to yet other areas, so most days, said family member is not at the office "in network."


    But it has to do with contracts (5.00 / 1) (#40)
    by Democratic Cat on Thu Sep 23, 2010 at 12:24:05 PM EST
    Being in-network means that the doc, hospital, etc. has signed a contract with the insurance company to provide services at a discounted rate. The docs, hospitals, etc. who are out-of-network for a specific insurer are those that have not signed these discount contracts with that specific insurer. I was surprised to learn recently that there are substantial areas of the country where even the largest insurers have not signed up all or even any of the providers. If you are an insurance company, it pays to expend resources in an effort to sign up providers in the most densely populated areas. As with so many things, unfortunately, there is less bang for the buck in rural areas, and so essentially whole swaths of them get designated as out-of-network.

    The insurance companies drive volume to in-network providers by charging patients different reimbursement rates for in-network and out-of-network thereby encouraging them to stay in-network. By offering a provider higher volumes of patients, an insurance company can get better discounts from the provider. Some providers don't sign up because the insurer's patient volume is not worth it to them for the discounted rates the insurance company is asking for--and due to all the well-known problems associated with getting paid by an insurance company.  

    So, whether docs are in or out-of-network depends both on the insurance company's decision of where to focus its resources and how hard to bargain with providers, and the providers' weighing of patient volume versus discounted rates and other hassles.

    (Sorry for the extended lecture. I've studied the insurance industry enough to think that it's a pretty interesting industry -- and one that has no business being involved in health care!)


    I was stating a fact (none / 0) (#55)
    by waldenpond on Thu Sep 23, 2010 at 01:37:58 PM EST
    I'm not sure if you are responding to me. Were you disagreeing? [whether docs are in or out-of-network depends both on the insurance company's decision]  I couldn't quite tell as you were going on about simplistic revenue maximization theories of an individual physician or insurer versus my statement of fact that insurers define entire regions as out of network (and other insurers jump on board.)

    A simple example....  A health system of 13 hospitals has a 'contract' with an insurer.  The insurer defines 11 hospitals as in network and 2 rural hospitals as out of network.  The 2 hospitals pay a higher share and the individual employees at those two hospitals pay higher premiums.


    Never seen that situation (none / 0) (#74)
    by Democratic Cat on Thu Sep 23, 2010 at 03:52:17 PM EST
    I've seen a lot of insurer-provider contracts, but never one that designated some locations of a provider (under the same contract) as in-network and some as out-of-network. The provider has the incentive to demand in-network status if it's going to give the discounted rates to the insurer.

    But since your last sentence refers to the premiums paid by a hospital's employees to the insurance company (rather than the discounts negotiated between the insurer and the provider) maybe we are talking about two different things.


    Well of course there's always operating area (none / 0) (#71)
    by vicndabx on Thu Sep 23, 2010 at 03:05:32 PM EST
    That's a given as you point out.  I was speaking from the in-area perspective.  In-area docs not contracted can always reach out to the insurer and begin the credentialing process to become par.  Think new docs at a facility (added by the facility) or a doc starting his/her own practice.  The insurer won't know about these activities.

    Who buys child-only policies? (none / 0) (#13)
    by gyrfalcon on Thu Sep 23, 2010 at 08:56:58 AM EST
    I'm trying to figure out under what circumstances someone would buy one of these for a kid.  Presumably, if the parents had health insurance themselves, it would be cheaper to up that to a family policy than to have separate policies.  So I assume these child-only policies are bought by adults who don't themselves have health insurance, is that right?

    And if the parents don't have it, why don't they?  Presumably, because they can't afford it.  But then where does the CHIPS program fit into this?  If the parents' income is too low to afford insurance for themselves, shouldn't they be eligible for that for their kids?

    I don't have kids myself, so I don't understand how all of this works out.

    Can somebody enlighten me?

    Many employers provide health care for (5.00 / 2) (#15)
    by MO Blue on Thu Sep 23, 2010 at 09:12:35 AM EST
    the "employee only" at a really good price but their family policies are often very expensive. If one or both parents get insurance through their companies, it is often cheaper to get child only policies.



    The way I saw it explained (5.00 / 2) (#28)
    by ruffian on Thu Sep 23, 2010 at 10:24:13 AM EST
    in the Orlando Sentinel yesterday, it seems to be mostly people that are not covered at all, but wanted coverage at least for their kids. They can buy these policies a lot more affordably than a whole family policy on the open market.

    There was no mention of CHIP in the article I read. I don't know what the income requirements are for that. Maybe these people make too much money to qualify.


    Doesn't Matter... (none / 0) (#14)
    by ScottW714 on Thu Sep 23, 2010 at 09:03:20 AM EST
    ... if some insurers stop offer child only policies.

    They are throwing tantrums hoping people are so stupid they won't realize that their are plenty of fish in the sea.

    Someone will insure your child, just not the big boys in some states.  

    How about when all the rules go into effect? (none / 0) (#17)
    by Saul on Thu Sep 23, 2010 at 09:18:23 AM EST
    Down the road the new rules of not being able to deny coverage for preexisting conditions will apply to all not just children.

    So what happens then.  Will the insurance companies then decide not to write insurance to anyone who is sick and calls an insurance company that  they need insurance today. They either have to write it or not. If not then how will they stay in business?

    I feel this is what will happen down the road:

    1. Company will say ok you need insurance right now here is the price.  It will be an exuberant price in order for the customer to say I can't afford that.  The insurance company will then say we complied with the law, the customer refused to buy it.

    2. Company will have two prices those with no pre existing conditions and those with pre existing conditions as explained above.

    3.  The laws of each state would have to pass laws like the one being contemplated in CA, which would penalize an insurance company to write any health insurance in that state if you try to circumvent the Obama health care rules.

    4.  The Republicans get control of congress in Nov and will try to modify (if not eliminate Obamacare) the new law and will offer bills to amend Obama's health care law.  Unless the republicans get a veto proof majority in Nov, Obama will have to entertain the
    republican modifications or veto them.

    I'm pretty sure (none / 0) (#20)
    by CST on Thu Sep 23, 2010 at 09:42:08 AM EST
    #2 on your list is not allowed.  There are a very strict set of factors that they will be able to charge different prices for coverage.  Age, location, smoking, things like that.  But pre-existing conditions is not one of them.

    I agree (none / 0) (#21)
    by lentinel on Thu Sep 23, 2010 at 09:43:41 AM EST
    in particular with your point #1 above.

    I thought I must be crazy to have thought that the law would read that, yeah, a company has to accept you, but they can charge whatever the hell they want - but maybe it is the reality that is crazy.

    What you wrote makes me think that the latter it true - and we have been sold a real junkyard and told it was a rose garden.