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Thread: Professional Woodworkers and The Affordable Care Act

  1. #16
    Join Date
    Jan 2008
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    Montgomery Creek, CA
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    315
    I think one of the key things for small employers is to find an agent that understands the ACA and the various state exchanges. It can be really confusing and a lot of brokers are not up to speed and see it as a threat to their business.
    Tom

  2. #17
    Join Date
    Mar 2013
    Location
    Central NJ
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    Paul, thanks for posting that article. I wouldn't have seen it and will be going back for his followup. I appreciate reading about one small business owner navigating through the new landscape. It sure beats all the posturing one way or another. I've been getting my insurance through my employer and still paying quite a bit. Haven't checked out the exchange yet but am inspired to try - site willing.

  3. #18
    Join Date
    Jul 2007
    Location
    CT
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    734
    One of the "rules" of the ACA is that all insurance companies offering medical insurance must now pay out $.80 of each $1.00 charged in premiums back to the insured as benefit payments. If the insurance company does not meet this goal they must refund the difference to the insured leaving $.20 of each dollar for admin, claims processing, commissions and profit. This "capping" has been in effect since 2012 (I believe) and that is partially the reason that some plans chose to cancel policies rather than compete. Also, each policy now offered for 2014 must meet a minimum "basket" of standard medical treatments, services, conditions and must offer policies to people regardless of prior existing conditions. There can be no annual limits or lifetime caps on the insurance company's obligation to pay a claim(s). Think major illness (cancer, back problems, etc).

  4. #19
    I'm one of those "unlucky" people whose rates jump considerably. (I quote unlucky because I make enough so that I don't get a subsidy.) I got a notice that I'll be paying over 1/3 more. The reason I'm not happy is not the money per se but the reason for the rate increase. My rates go up because those of us that were on individual plans or who couldn't afford insurance now are treated as a "group". The overall health of the group has declined because there are more sicker people in that group thus rates increase.

    I see the ACA as a small step in the right direction but I'd also show up in the polls as someone who doesn't like it. I wanted a single payer system ("medicare for all") which would have evened the risk out across the whole population.

  5. #20
    Join Date
    Jan 2004
    Location
    Lewiston, Idaho
    Posts
    28,504
    I would like to thank the participants so far for keeping to information and not allowing this to become political!

    It's nice to see some restraint to keep the thread and posts within the guidelines of the TOSs!

    Thanks again!
    Ken

    So much to learn, so little time.....

  6. #21
    Join Date
    Sep 2007
    Location
    Upstate NY
    Posts
    3,789
    Quote Originally Posted by Jim Barstow View Post
    I see the ACA as a small step in the right direction but I'd also show up in the polls as someone who doesn't like it. I wanted a single payer system ("medicare for all") which would have evened the risk out across the whole population.
    I am sure about half the population agrees with you, but the other half want nothing at all; so this is a compromise. You know the joke about a camel being a horse designed by a committee.

  7. #22
    Quote Originally Posted by Paul Wunder View Post
    One of the "rules" of the ACA is that all insurance companies offering medical insurance must now pay out $.80 of each $1.00 charged in premiums back to the insured as benefit payments. If the insurance company does not meet this goal they must refund the difference to the insured leaving $.20 of each dollar for admin, claims processing, commissions and profit. This "capping" has been in effect since 2012 (I believe) and that is partially the reason that some plans chose to cancel policies rather than compete. Also, each policy now offered for 2014 must meet a minimum "basket" of standard medical treatments, services, conditions and must offer policies to people regardless of prior existing conditions. There can be no annual limits or lifetime caps on the insurance company's obligation to pay a claim(s). Think major illness (cancer, back problems, etc).
    Or renal failure. The biggest claims I've ever seen in annual data are related to renal failure.

    It's not necessarily good that individuals who can afford to have major medical insurance only and pay out of pocket for all routine services can no longer do that, but the system needs the healthy financially secure individuals to buy coverage (and the younger ones, too, now that there's an age rating limitation) or the whole thing just won't work. The flip side of it is that groups that are very old with high claims experience will be able to afford coverage easier. There's no free lunch, but there is a case where your lunch is bigger than mine and you give me some food, at least that's how I'd describe it.

    I'd imagine a lot of people who had better coverage will end up with bronze coverage once they can do drop down box shopping. It'll just be too tempting to choose the lowest premium when the annual increases are double digit year after year, and the incentivization for which individuals pick up coverage on exchanges vs. which pay the excise tax for skipping coverage will encourage the average policy age to increase, which will drive up premiums more.

    For some reason, it sticks in my head that the minimum loss ratio was 85% and not 80%, but I haven't seen anything about those aspects for a while.
    Last edited by David Weaver; 11-07-2013 at 5:31 PM.

  8. #23
    Join Date
    Jul 2007
    Location
    CT
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    David,

    It appears that large groups require an 85% ratio and perhaps smaller groups are OK with 80%. I am not smart enough to figure it ou. But I copied the following from Healthcare.gov. I think that either ratio is an improvement toward protecting against future rate increases.

    80/20 Rule

    The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in on premiums on your health care and quality improvement activities instead of administrative, overhead, and marketing costs.
    The 80/20 rule is sometimes known as Medical Loss Ratio, or MLR. If an insurance company uses 80 cents out of every premium dollar to pay for your medical claims and activities that improve the quality of care, the company has a Medical Loss Ratio of 80%.
    Insurance companies selling to large groups (usually more than 50 employees) must spend at least 85% of premiums on care and quality improvement.
    If your insurance company doesn’t meet these requirements, you’ll get a rebate from your premiums.

  9. #24
    Join Date
    Dec 2007
    Location
    Gilbert, AZ
    Posts
    239
    I've got individual coverage, don't qualify for subsidies, but I will be saving $300/mo on the new exchange plans for similar coverage to what I am receiving now for my family of four. I also can get maternity coverage before, which was impossible to get previously.

    I also received a check last year from Aetna due to the 80/20 rule, so at least I know that is in effect and working.

    I would've preferred single-payer, but I'll live with this compromise for now.

  10. #25
    Personally, I hope we figure out how to repair DNAand genese before there's single payer. Who knows, though, once we learn to do that, we'll want to learn to do something else. As far as the loss ratio requirements, I'd imagine that 80-85 percent is pretty much where groups are before the act (though I don't know). You can't find out from insured groups what their claims are unless they decide for some odd reason to tell you. I've seen groups (because we use experience to model cash flows) that have had renewals where there has been almost no increase (you'd have to figure that's because the groups experience was favorable, but their rate wasn't doing enough to reflect it), and groups that have had increases like 35% (you know they have no loss ratio issues). I have seen some also where the claims are greater than the premiums. Those leave you scratching your head, you'd think the insurer would figure that out pretty quickly when the group has several hundred individuals in it.

    Whether they were at 84% on average or 79%, or whatever else, only individuals outside of the norm for one reason or another will see much of a discount or rate cut because of the rule. The groups on the other side of it will probably see bigger increases than they otherwise would have because the groups who were more profitable will do less subsidizing of the groups that were less - especially in non profit insurers.

    There's not much real cost control in the bill. There are goals and dictates, but not a lot of "how" to go along with the "what", so unless a group is a beneficiary of specific things (like older pre-medicare individuals or folks with pre-existing conditions), cost increases will continue and the overall average per capital will do the same. (There's nothing really at this point to keep health care as a share of GDP from increasing until we just don't like the price).

    When you think about why rates are where they are, a lot of it is utilization and demand. Can you imagine what demand will be if DNA repair and adjustment becomes commercially viable? Or repair to genes? I am predisposed to melanoma. I'd be all over a gene fix to genes that would otherwise regulate cell division if they weren't troubled.
    Last edited by David Weaver; 11-07-2013 at 8:18 PM.

  11. #26
    Join Date
    Dec 2006
    Location
    Toronto Ontario
    Posts
    11,248
    Thanks Guys, this is very interesting even to an outsider like me................Rod.

  12. #27
    Quote Originally Posted by David Weaver View Post
    (There's nothing really at this point to keep health care as a share of GDP from increasing until we just don't like the price).
    I guess that is the crux of the matter. Everything else is a shell game, I suppose.

    So as I said earlier, I am current on HIRSP (Heath Insurance Risk Sharing Pool) in the state of Wisconsin. I am on HIRSP because of my bad back, conventional insurers turned me down.

    HIRSP has (I believe) an 80% cap, and a couple of years ago, I got a refund to the tune of $700 at the end of the year. I was a bit floored because I had assumed the pool was subsidized by the state, and those insurance companies licensed to sell health insurance within the state. I had always figured the premiums were a fraction of the claims.

    So when I got that check I realized that this wasn't necessarily so. And then I started asking some of my friends what they were paying for insurance and realized some of them were paying as much as I was.

    It seemed kind of odd to me that here I was, lumped in with the guys with MS, ALS, heart/lung issues, various forms of cancer, AIDS, etc., and we (as a group) hadn't exhausted our premiums, and the premiums seemed quite reasonable.

    Maybe that year was a fluke.

    Maybe there are a lot of people like me (I don't make claims, if I'm lucky I'll never undergo back surgery). So us healthy but risky members of the pool are subsidizing the larger consumers?

    Don't know, but it was a SHOCK to get a $700 check. Of course, my wife ripped that check out of my hands so fast I got a paper cut deep enough to nearly require stiches. I'd have loved explaining that to the claims people.
    Last edited by Phil Thien; 11-07-2013 at 8:41 PM.

  13. #28
    Quote Originally Posted by Phil Thien View Post
    Don't know, but it was a SHOCK to get a $700 check. Of course, my wife ripped that check out of my hands so fast I got a paper cut deep enough to nearly require stiches. I'd have loved explaining that to the claims people.
    I don't know much about state pools. Health care is extremely regional. The average coverage here is probably gold level, and a lot of the insurance is from non-profits. further south and west, I understand that's not so much the case.

    I know the check scenario well, though! Happens to me, too (though it's usually me cashing something out on paypal or selling a guitar or something). "you'd better not spend any of that on tools!!" is what I usually get.

  14. #29
    Join Date
    Jul 2007
    Location
    CT
    Posts
    734
    There are programs under the auspices of Medicare to reduce the annual percentage rate of growth of per-capita cost of Medicare. Some of these programs seem to be working. The per capita growth rate of Medicare costs has been either flat or well below the cost growth rate in the Commercial market in the last few years. Some of these efforts are:

    Cutting costs in Durable Medical Equipment (scooters, power wheelchairs, etc) by putting these programs out to bid on a nationwide basis to selected vendors. The Federal government has been chasing fraud. The "Scooter Store" a nationwide firm advertising "free Medicare paid scooters" was raided last year and shut down. This was a big catch; unfortunately several thousand employees lost their jobs.

    Providing Diabetes supplies through mail order was a cash cow for hundreds of companies charging Medicare exorbitant fees. Medicare put these supplies out to bid to 17 national vendors who are providing the supplies at 50-60% lower prices than before.

    Medicare has been challenging Hospitals to prevent seniors from returning to the hospital within 30 days of original discharge by improving the discharge process and requiring hospitals to follow up seniors: Are you taking your medicine? Did you have a follow-up appointment?

    Medicare has started refusing to pay hospitals for extra costs due to their error: catheter infections, hospital acquired infections. Just two examples. Interestingly, most hospitals, rather than fighting this effort have seen this as a way to provide better patient care. Medicare is providing financial incentives to hospitals who surpass national norms in quality.

    Medicare started a pilot program, complete with seed money to the participants. Last year 17 medical practices across the country became "Accountable Care Organizations" My family Physicians are one of those groups. I notice better follow through from my doctors regarding tests, recommendations and treatments. Their staff calls to remind us to take tests or to make an appointment with a specialist. Medicare is seeding the cost of additional staff, but holding the "ACO" to a higher standard of care. The ACO's will split any savings with Medicare that are achieved without compromising quality care. We receive regular independent surveys regarding recent doctor visits and encounters.

    Electronic Health Records (now required by Medicare) seem to be helping doctors prevent duplicate testing. Each of the medical practices that we go to is now connected to each other so my health status is available to all.

    Prescriptions are being written electronically to reduce errors.

    My physicians and hospitals automatically give us printouts of each visit detailing: diagnosis, other relevant conditions, ongoing meds, recommended care plans and follow-ups.
    Last edited by Paul Wunder; 11-07-2013 at 9:30 PM. Reason: spelling

  15. #30
    Those are all fairly minor changes, though. And they are one-timers. The bigger cost savings from what I understood from the original bill were just flat out cuts in reimbursement rates. There was definitely a problem with lack of care items, like bed sores and wounds, etc (my wife worked in wound care, still does to some extent, I guess). There is also a cut in Part D participant drug prices, a "discount", but I don't know how that will play out (aside from the fact that it will be 50% off of retail, and the discount is not available to MAPD), it may just shift the cost of drugs non-medicare payers.

    The commercials for products before where folks were always saying "don't worry, we'll bill medicare and it'll be no cost to you" did bother me quite a bit. If they can get rid of that stuff, I'd be pleased. I don't know how the ACO information will go for staffing, though, as medicare reimbursement rates haven't kept up with general medical inflation over the last 15 years, not remotely close, and planned freezes in the rates are going to cause decreased staffing or decreased staff pay, and not more. i had a discussion with someone not long ago who works in a physician practice and who said their reimbursements have been cut 27%, and they've had a pay freeze because of it. I don't know where they got 27%, I haven't seen any cuts of that amount, but maybe in some combination or business setup, the way they get theirs paid to them have been cut 27%.

    As far as the hospitals go, they're just weathering it so far. I think the average margin for hospitals around here in the last year is approaching 1-1.5%. That's dangerous territory for individuals who rely on community hospitals.

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