Can anyone explain the new insurance system to me?
I've been extremely grateful to have had good coverage through treatment, but I'm afraid that we will be losing our coverage soon. I'm trying to understand what our options are. What I've learned so far has been extremely depressing. I live in one county, and have primary drs here, however I chose a better healthcare system for my cancer care - which is in a different county. We were given a couple of options for coverage and neither included the facility that I've been using. Are these HMO kind of policies all that are available to self employed people? We are lower income and would qualify for help with premiums, but if you can get "private" insurance, can you still receive this subsidy? I don't even know if what I'm asking makes sense... Can anyone help? I'm so afraid of losing my drs.
Comments
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If you can get a subsidy, it has to be used on the exchanges. The policies offered on the exchanges have several different 'levels' - and you can apply your subsidy to differing levels (since you have BC, it's likely that you would want to pay higher premiums and have a lower deductible). There also have to be at least 5 'options' for you to choose from (different companies offering plans), so I am unsure as to why you were given only two. I would call your cancer center and find out what insurance they will be accepting next year - they should have a financial aid person who can help you out. Then I would call the number on the healthcare exchange & tell that person that you are looking for that specific company (i.e. medical mutual).
You can also call your current policy holder and ask them whether your plan is renewable for next year, although you would have to continue to pay for it as you have in the past.
Here's a link to a subsidy calculator that will let you see how much you qualify for. http://kff.org/interactive/subsidy-calculator/
See what you find out - I ended up much better off than I was even without a subsidy & then got a subsidy on top of that, I hope you do too. -
dh went to a seminar at the local hospital today and he said they were given 3 options - dean, mercy, and group health. Then the different levels within them. He asked about my cancer center but they weren't too helpful. They basically said I'd probably have to fight to get them to cover me at the cancer center.
So, we can still go with private insurance, but then no subsidies? Or we go with one of the options and hope for a nice subsidy. Can private insurance ask about preexisting conditions?
Right now we have state aid - so incredibly grateful for that. However we expect to be losing it sometime this next year - before I can have reconstruction, which I am set on having with a particular surgeon at this center. Plus if I do have a recurrence, I definitely want my team!! -
Yes, I've been told that effective Jan 1, 2014, we can no longer be denied health insurance based on pre-existing conditions. So we should have the option to buy private "individual family" plans outside the Affordable Healthcare Act "exchange." The ACA plans may be cheaper since they represent a larger pool of customers. Do you have anyone you can call, like an health insurance agent? (or your contact from your previous health insurance plan? I contacted a local agent. He couldn't answer all my questions but gave me the number of a state agency that should be able to). -
Hey Sophia -
1) Call the cancer center and ask them what types of insurance they will be accepting next year & if they can tell you whether they will accept any of the plans offered on the exchanges.
2) No insurance provider (OF ANY KIND) can refuse to cover you or jack up your rates because you have a pre-existing condition.The only reasons your rates can be higher than somebody elsess because you are older or a smoker.
3) Go to the link I provided and see what your subsidy would be on the exchange (were you to chose that as an option)
4) It might be that you want to just stick with the insurance that you have this year (if your cancer center isn't accepting the exchange plans) and then switch next year onto the exchange plans when you are not needing the services of the cancer center. -
Every state has different insurance companies willing to write there, and different options, whether through the exchange or not.
For example, in NY, you can ONLY purchase EPO's, which are similar to HMO's. You cannot, for any amount of money, purchase either indemnity or PPO plans.
Other states have different rules, and do allow those purchases.
The metal colors of the plans has to do with % covered and out of pocket maximums, not the coverage itself. If your income is lower and you want a subsidy to help you pay for your insurance, you have to go through the exchange available to you in your state - be it run by the state or through healthcare.gov. From the way I was reading the information, if you take the "silver" plan, you will receive help with not only your monthly premiums, but also with your copays and maximum out of pocket expenses.
Start with healthcare.gov - it will tell you whether your state is part of that system, or direct you to your state exchange.
Good luck with this - I know I am looking into moving now, because I am not comfortable with the thought of an HMO with no safety net...I like PPO's much better.
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thank you for this information! It still has my head swimming, but little by little I'm trying to sort through it. I wasn't even aware of PPO's - there is one that covers all of WI, but I haven't checked the premiums yet - and I'm thinking that there are no subsidies for these? Otherwise the HMOs don't cover both my county and where I need to go. Oh I hate this!! If I did have to chose a local plan because of affordability, I wonder what the chances would be of them letting me continue there since I'm established.... -
itsjustme10, interesting that in NY you can only buy an EPO. I've run into a similar block here in California. Of the ACA plans, my cancer docs only take the BlueShield. In my county, BlueShield only sells an EPO. I chose docs who work in the next county over. If I lived in that county, I could buy an PPO. One thing that's confusing is that this limitation is not spelled out clearly on the CoveredCA (California) website. I suspect that many consumers don't realize the limitation of the EPO. (the text is identical for EPO and PPO plans, saying if you go out-of-network you'll be reimbursed at a lower rate. It does not say you'll pay out-of-pocket 100%) -
Peggy... None of my doctors are accepting any of the ACA plans as of now. It's insane - they can't decide whether to accept a plan or not until they get reimbursement rates from the carriers, so they all said "no" until they see what happens. So I picked a silver plan, instead of the platinum I was willing to pay for, since I'm going to have to cross my fingers and pay out-of-pocket for my checkups anyway.
From what I've read, in NY, it doesn't matter what county you're in - the only plans offered are EPO's - and the few carriers we have willing to write plans in the downstate area surrounding NYC, 2 are known entities, the rest are completely sketchy.
It bothers me that Memorial Sloan Kettering is not accepting BCBS anymore. I don't want to sign up for a plan they will accept, as the origins of those plans are scary - we actually have one plan that was created by 3 MBA students who didn't like their health care premiums - maybe MSK will accept it, but I don't think they actually have a network of doctors yet. Another was the public option, which supposedly according to its website, is run by members (seriously???) - again, no doctors I know on there. The third one is not accepted by any of my doctors either.
I am not happy...I loved my plan that was cancelled. This is not good.
And I fear that you are completely correct - there will be a lot of people who are horribly surprised that this new insurance specifically says there is 0% reimbursement for out-of-network care, and end up with huge uncovered bills because of it. -
itsjustme, wow, what a mess. In our area, Blue Cross is still in negotiations, trying to decide if they will sign on or not. What are consumers supposed to do? I think we have until 12/23 to sign up for a Jan 1 coverage date. (and that some of the canceled plans delayed cancellation by a couple months). I wonder if you can upgrade from a silver to platinum plan if the providers eventually sign up. What a mess. Hope this works out for you. I have to say, it seems heartbreaking that you live close enough to consider going to MSK (a world-class cancer treatment center) and are not be able to go due to this insurance fiasco.
FWIW, a reporter at one of the major newspapers here wrote about the "doc shock" (consumer learning that they'll have to switch doctors). I've emailed back and forth with her about my situation, including a screen snapshot of the EPO description. At a minimum, maybe they'll fix their website so consumers gain a clearer picture of the limitations. (and maybe maybe....pressure their elected officials to improve the system? We can dream). When I asked the reporter who she thought I might contact who could fix things, her suggestion was to contact our Senators and Congressional Representatives. Seems like a long shot but I faxed letters this morning. Maybe if we all contact our elected reps they'll fix the problems. Seems like politicians respond to personal stories. (plus I think we cancer patients are the canaries in the coal mine. We are dealing with these issues today but in 6 months it could be anyone). -
Hi Sophia Marie!
Maybe you can call your state insurance commissioner and ask them which insurance company has the largest physician PPO network in your state/county.
Unless you think you will qualify for a subsidy, you don't have to buy through healthcare.gov. And if the subsidy offset isn't worth the sacrifice in your doctor choice (only you will know the answer to that), then you may want to opt for private individual insurance so you can pick from more options. So for all the PPO variety you need, go to http://www.ehealthinsurance.com and you can sign up for any 2014 insurance plan available in your state regardless of preexisting conditions. Pick a PPO that has your docs in the network. On the left hand navigation you can sort by deductible, coinsurance, premiums, etc. You'll need to review every plans summary of benefits to know how it will affect your price/selection for hospitals, doctors, etc. Don't sign anything without seeing the detailed summary of benefits from the broker.
You really have to think through where the financial risk is -- I put my priority on no coinsurance for hospitalization, specialists, and the ER, as well as a low deductible. You can also opt to buy insurance to cover you just for cancer as a separate benefit. ehealthinsurance.com calls it Critical Illness Insurance. A Critical Illness Plan pays you directly in the event that you are diagnosed with a covered critical illness. -
warmsmartcookie, thanks for that info. I went on http://www.ehealthinsurance.com and it only lists the exact same plans on our ACA website--there are no other plans listed at all. Maybe it varies by state. -
ehealthinsurance.com has the same plans available through the government exchanges. Not every state offers PPO's. Some only offer EPO's. The plans available in certain states are the same plans available under that state's exchange, minus access to a subsidy. It all depends on your local state's insurance laws, and cost of healthcare, which affects insurers choices as to whether to offer insurance in a particular area or not, and what type of plan to offer at all.
As a matter of fact, if you go directly to my state's BCBS signup page, and try to research plans, they are sorted by metal colors - same plans even direct from the insurer. -
In Texas, I get more diverse BCBS plans for individuals on the BCBS web site as well as multi state plans (not on the healthcare.gov site). I find the multi state plans have better benefits. You can ask a broker if they have multi state plans, which might help you get better options...here's hoping anyway. -
A big concern for us though is price. I'm sure we will have to have a subsidized plan - and it's not super clear to me if only the 3 HMOs here are subsidized. Nothing I read seems clear. I was talking with dh about seeing an insurance person here to see if we can get some more answers.
I see my ro tomorrow - yesterday my occupational therapist said I should see if she could get me in for a consult with the plastic surgeon right away - then I would already be an established patient of his and maybe that would help give me an edge for going out of network. But then she said that the HMO that covers our local hospital system won't allow out of network. It's just making me crazy! We have our primary, my surgeon, and gyno here - this system is 5 min from our house and we are happy with these drs. But for cancer - no, please!! -
This whole insurance issue gives me a headache This administration is causing this country to go to hell in a handbag.
Oceana
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SophiaMaria - if you believe you are eligible for a subsidy, the ONLY place you get that subsidy is if you purchase the insurance though your state (or the federal) exchange. So, be aware, as you speak to a broker, that your application must go through whichever governmental entity is running the excange in your state.
Yes, it is awful that you may be forced to change doctors at such a horrible time (and believe me, I'm so grateful to be 2 years out, and not in active treatment), but this is what we are left with - you only have so many options to choose from, and you may have to make some sacrifices.
I wish I could give you better news, but this is how it works. For now. -
I agree Oceana,
I am new to this BC thing....but I am without ins and do not want Obamacare. My docs are not taking it and if we do sign up for it we will be paying 374 a month, just for me, and a 12,000 deductible.......and still have to pay co pays with very limited choices for covered chemo.....who can afford that. At the same time we will have to pay upfront for my out- patient surgery coming up in the next couple of weeks. My surgeon is only charging me 899 for a triple lumpectomy......the surgical center...10,000. ouch!
what to do....what to do. -
momaton, if you think health insurance is expensive, try having cancer treatment without it. yikes. I believe most cancer treatment runs well over $100,000. I had a lumpectomy and rads (no chemo). At first, I tracked how much was actually billed, but stopped when it hit six figures. I've read stories in newspapers where other patients have had bills that exceed $300,000. So the $12,000 deductible may be a drop in the bucket.
Before writing off Obamacare, you might want to sit down and "run the numbers" for your treatment. Do you have a friend or family member who is good with numbers? Maybe they can help. Maybe the oncology department's social worker can help you find the right person in their billing department to give you an estimate of the entire cost of treatment. I was surprised that there were so many different charges. For my lumpectomy, the bills also included one from the anesthesiologist, an ultrasound (they inserted a little "flag" so the surgeon could easily find the tumor), and to have a dye injected around my nipple to aid in the sentinel node biopsy. Then there was the bill from the pathology lab etc etc. You get the idea.
That's kind of your surgeon to offer a discount on his/her services. Going forward, your medical team may not be able to do that, either because of fixed costs (like their costs for the chemo drugs) or....because they assume you'll buy Obamacare when it's available. Likewise, the nonprofits that offer aid may not be able to pay for the entire cost, especially when insurance is available.
FWIW, I know two families who had to declare bankruptcy due to huge bills from medical treatment. You may hate Obamacare (and I agree that it stinks to not have your choice of doctors.) But from my view, having no insurance at all feels much scarier. Sorry to be such a Debbie Downer here, but navigating cancer treatment without any health insurance feels very scary to me. Treatment itself is hard enough, without all the extra stress of the costs. I hope you can get financial help to ease that burden. Take care. -
momaton - If you are getting a lumpectomy done for $899, it is being subsided by somebody either a charity organization or the state or both. If you are being subsidized by a charity organization or the state, then it is highly likely that you had to prove low income status (charity organizations give charity to people who actually need it - if you accepting it without needing then you're taking money out of the hands of people who do). These organizations negotiate lower prices with the hospital which make everybody else's costs go up. If you are low income, then you will be eligible for subsidies on the exchanges and this 'evens out' the cost of insurance. Not only that, but it should be apparent to you that you can get sick with an unexpected and costly illness other than BC. While there is a large amount of charity available to BC patients, it is less the case with other things. I don't know how anybody can justify not paying for insurance when it is being offered to them on a sliding income scale. It just drives up the cost for everybody else. Since you are currently getting help from presumably a charity - perhaps you should talk to them about help with the costs for your deductible since you don't want to switch your insurance to one offered on the exchanges. -
Women at increased risk of breast cancer can receive so-called
chemoprevention drugs, including tamoxifen and raloxifene, without a
co-pay or other out-of-pocket expense. -
OMG!!!!
Now I am really upset!
Yes peggyj I happen to have people in my family that "are good with numbers" sheesh...did I sound stupid...so sorry.
What part of "my doctors are not participating in Obmacare" didn't you understand. I am paying CASH. Yes it is expensive....
you have insurance...congrats...but make no mistake YOU are also getting a break because healthy people are paying for your very expensive care. ask an actuarial.
ziggypop....my breast oncologist surgeon gave me that price. no freaking charity there....that is her price because someone without insurance is not creating the paperwork ....her price is reflected in what medicare is reimbursing doctors.....that medicare reimbursement is the standard of what insurance companies will pay so if you asked your doctors their "REAL" costs are you would be surprised.
I am actually now going to have to have a double mastectomy...yeah! on the 17th.
all I can say is thanks a lot ladies for your ideas on having ins....don't you think if I could afford it I would have it? And getting Obamacare is just another way to take from the haves....I am not willing to do that. I will pay for my treatment.
AND ziggypop...I am soooooooo not getting help from any charity!!! wow...I am so upset!!! how dare you judge me!!!
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momaton - I was not meaning to 'judge you' - personally I don't think that it is insulting for somebody to be subsidized or get charity so I certainly didn't mean it to be an insult. I hope that your mastectomy goes well and that you are able to have the doctors you want perform it. My apologies for not being sympathetic or understanding of your situation.
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ok, the more I find out, the more depressed I'm getting. It looks like we have only two providers to chose from and neither have great cancer centers. And I'm sure that neither will have plastic surgeons that will fix my lumpectomied and radiated breast like I could have done where I currently go. So what do we do?! We can only afford the subsidized coverage. Do we give up our self-employment and work for someone else to get coverage?! Or do I just hope I don't have a recurrence and accept the fact that I will look like this forever?? I am so desperately sad....
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I feel awful for those without insurance coverage - I have two adult kids in that boat and only pray they stay healthy. Obamacare was shoved down our throats and even those idiots in congress admitted they hadn't read the 22,000 page bill. I think it was that brilliant Nancy Pelosi who said, "we have to pass it in order to read it". What the hell?
I sure wish I had a better answer for all the ladies without insurance or those who are forced to change doctors because their new plan doesn't include their old doctor. Geez - if you like your doctor, you can keep your doctor comes to mind. Such a crock of sh*t.
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I don't know what I would have done without insurance! Fortunately it is through my spouse's employer as I lost my job d/t breast cancer and treatment. I stopped keeping tabs when I went over 1.5 million, about a year and a half in. We have an HMO that I have never had a problem with and my portion was $3,000, not including premiums (about 600 per month). The loss of a doctors group can happen anytime, so not unique to 'Obamacare'. I have had that happen several times. I can say that I sure wouldn't have wanted to have been paying this out of pocket. And while Dr's have discretion to discount their fees, other things are not negotiable. Many surprises can come about!
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I had to switch to a healthcare exchange plan and it's actually worked out better for me. I am self employed and had a private plan that cost $980/mo in premiums for myself and spouse. They wanted to raise my premiums to $1374. It had a limited pool of docs, no prescription plan. Also, so late in paying even in- network docs, I had several bills go to collections. Despite proximity to MSK, private insurance also not accepted there. So, the reality is, it's not only the exchange plans that didn't have access to a cancer center. A lot of the few affordable, full coverage plans didn't either and this was when we had to shop for it back in 2010, well before ACA. Hate to burst anyone's bubble but no matter what insurance plan you had before ACA, to pay the least for care you had to stay in-network or pay considerably more for out of network. When my husband changed jobs years before that and had to get new insurance, we had to change docs. This is not a new problem. I don't think that my private insurance was such an awesome deal.
With ACA, I found a new gold plan for $960 that actually has a prescription plan and I'm getting a subsidy that brings it down to $660. All my docs are on it except my PCP and with all the cancer crap, I rarely see her anymore. At the time we signed up, that plan was the only one with all my docs but when I was in the billing office last Tuesday, I saw the new list with more ACA plans and a list of the ones that are in negotiations with my docs and hospital. I assume that I'll have more choice in the future if I want to switch. All things considered, it took a lot of homework and number crunching on my part, but we are better off now than before.
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Bosumblues, what a dilemna! I can't answer your questions, but am also concerned. My current Aetna plan is non-compliant and is cancelling my policy at the end of Sept 2014...I am hoping something will be implemented where the insurance companies cannot cancel.
I can't sign up for the ACA until open enrollment this November which does not kick in until Jan 2015, I believe...
I cannot afford to sign up for ACA at the end of March and pay another huge deductible. I am still paying on last yrs' and had another one this January. $11k for both of them. My financial counselor at the cancer center is trying to get my deductible for this yr covered through a grant. I will not have insurance Oct-Dec if I can't find a solution. What a mess. I am single and self-employed. Trying not to stress about it, but I am! I know I will have on-going tests, etc for the next several yrs. I looked on the healthcare website and the policies and premiums are not any better than what I have now, even with the subsidy, unless I go with an HMO and lose my Dr's..... Just waiting it out, hoping the powers that be will get their heads out of their butts and help those of us that are struggling. End of rant.
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Insurance, though I have always had it through work, has never been easy. When I had a PPO, more than once, a medical practice I was using dropped out of the plan, forcing me to switch doctors. Sometimes, my employers totally switched entire plans, say from Cigna to Blue Cross/Blue Shield. Additionally, the HMO's that were offered were considerably less expensive in terms of what I paid. ACA has not effected my current medical coverage (Kaiser Permanente HMO) but who knows if it will in the future. I have been lucky enough to have medical insurance, but I know that many haven't. If ACA allows all of us to have medical insurance and not be denied due to preexisting conditions, I'm all for it, even if it is not perfect and even if, at some point in time, I can't have exactly what I want. Not a popular POV here, but I'd like to give it a chance. An undertaking this massive is bound to have more than a few kinks.
Caryn
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Hi Sophia. To my knowledge, the only way to receive the subsidy is to apply for one of the exchange plans through the healthcare.gov website. I can sympathize. Where I live the covered facilities and included physicians choice is abominable. I just got notice that my premium for crummy coverage is going to $835 a month, with a $3000 deductible & $6500 out of pocket.
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