[QUOTE=poltroon;7889911]
Okay, so ACA is certainly not requiring this change from insurance companies. What is happening, possibly, is that insurance companies are trying to cut their costs by making their provider networks as miniscule as possible, and have possibly found a loophole that lets them cut coverage. [/QUOTE]
No, no and emphatically NO.
Let’s review some basics. (well OK, they are basics for people well versed in this subject)
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approximately 4 cents on every premium dollar goes to insurance company profits (that’s a low profit margin by any standard). They are cash rich due to state and federal requirements relating to “reserving”. This is the mechanism by which insurers cover bad years/unexpected losses without significant fluctuations in price. But they can’t spend that cash except on claims. They can invest it though, although that is heavily regulated and very conservative (thus the reason your health insurers didn’t go belly up with the bank/insurer hybrids in the real estate crash. No sub prime mortgage investment for Anthem!!!)
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by law (since 2012), 80 to 85 cents of every premium dollar has to go to your medical care. It was pretty much already there, it’s just if a company had a great year, they could meet reserving requirements without dipping into profitability and they didn’t have to hire another 50 people to track this stuff the way ACA wants it tracked. I’m not lying when I say ACA was quickly renamed the “Actuarial Employment Act” in carrier circles.
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there are extensive regulations in place that dictate comprehensive and effective networks. These regulations range from NCQA accreditation to rules within ACA. Given the state of ACA regs, I would rely on NCQA accrediation over ACA, but I’m pretty sure that is not an issue with Anthem. The network may not be everyfreakinghospitalinthestate, but it meets the network requirements in order to serve its population.
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Medicaid and Medicare provider compensation are below the actual cost of care, so insured individuals pre-65 are paying more for their care to offset the loss. The good news is you get to play in Medicare some day too!
All of the above is not really important to you because your big problem is that you can not afford the inflation associated with medical expenses.
So why can’t you afford insurance?
Is it because of the insurance companies making money hand over fist? Well no doubt they are making money, and the larger ones are hugely diversified now, owning businesses in many areas of the health sector, not just insurance. And then a big chunk of that is self insured, so they are only getting admin fees, not absorbing profits - or losses - on medical claims. But remember, at 4% average profit margin (6% for an AWESOME year), it’s not a big part of the cost, and it has been relatively constant for decades.
The largest underlying cause to inflation is because the system is designed to reward waste. I believe PWC estimated 1.2 TRILLION in waste/unnecessary/duplicative testing. This problem can only be managed if healthcare systems start to work as one “accountable” organism. In such a way that they are rewarded for better outcomes, not more/repeat care.
The only way that will ever happen is in a small regional system that can get its hands around the entire spectrum of your care, not just own a piece of it. It needs to be a comprehensive organism that is rewarded for YOU being as healthy as you can be, not just racking up the bucks for more care, and letting the insurance company pass it along.
So what you are seeing is the beginnings of that philosophy in action.
Some other points to make - when the Anthem rep said once you left the ER, you would no longer be covered.
Right, because if the ER saw fit to discharge you and NOT admit you, they just said the emergency is over. Non-emergent care = NOT COVERED out of network. This is absolutely NOT new, this is how it has been down for the 50 years HMOs have been around. Not a loophole, just the operating rules that have always been in place.
So let’s say you break your arm falling off while competing at WEF.
Scenario #1 - bone exposed. The ambulance takes you to the ER where they quickly move you along to surgery.
ER visits - COVERED at in network level
Surgery and subsequent admission - COVERED at in network level
The surgery/admission was an emergency surgery and as such, covered at in network levels. You may get pressure to move to a par hospital once you are stabilized, but that is something you discuss with the insurance carrier and hospital.
Scenario #2 - You go into the ER, they x-ray, put a soft cast or splint on and tell you that you have a hairline fracture and to see a doctor within 2-3 days and shove you out the door. You go see everyone’s favorite Wellington orthopedic doc that has a booth at WEF’s gate (even Dr. Richy Rich can’t afford real estate AT WEF). He comes highly recommended!
ER visits - COVERED at in network levels
subsequent visit to Wellington doc? NOT COVERED, because that is not an emergency. It’s medically necessary, no doubt. But not emergent. You needed to get yourself home and see a network doc.
So yeah, if you find yourself on the road a lot for extended time, this policy might not be good for you. If you thought you’d pack up and get home to see your regular doc come hell or high water (me), it may be fine. But a POS isn’t really the answer in my opinion. It will have a huge deductible and out of pocket and you will get balance billed by the providers. If you truly think you are going to use non-emergent care outside of your home state on a regular basis, far better to get a PPO plan (muy expensive) with a national network of doctors.
