Should you have any questions about US Health insurance, I will try to answer you.  :)

I guess I'll ask one (or at least try to)...

How knowledgeable are you on the subject?

What percentage does health insurance cover for Romnesia?


Cat

I guess I'll ask one (or at least try to)...

How knowledgeable are you on the subject?

I have been working in the healthcare insurance industry for 17 years. I am now in charge of the training and development of training materials department at my company.I currently run a program that teaches people that have no experience how to become a claims processor-it's nice to help people find a new job/career.  :)

I guess I put this here to try to be of value-if you ever have questions about how your coverage works or if you need help appealing denials, etc, I will do my best to help you. I work for the industry, but I hate to see anybody not get everything they can out of their policies. :)

What percentage does health insurance cover for Romnesia?


Cat


Well..I don't know that it is treatable by a general practicioner, so he would have to see a get your head out of your rear specialist. And if Obamacare is repealed, there will be no coverage at all because it would be a pre-existing condition!  ;D ;D ;D ;D

I have been working in the healthcare insurance industry for 17 years. I am now in charge of the training and development of training materials department at my company.I currently run a program that teaches people that have no experience how to become a claims processor-it's nice to help people find a new job/career.  :)

I guess I put this here to try to be of value-if you ever have questions about how your coverage works or if you need help appealing denials, etc, I will do my best to help you. I work for the industry, but I hate to see anybody not get everything they can out of their policies. :)


Serious question - why does the industry offers tons of similarly-named plans with essentially the same premiums, but wildly varying levels of coverage.  To pick a ficticious example for a single person, loosely based on some recent real-world quotes.

Plan A: $200/month, $5K deductible, $3K out of pocket maximum, 25% hospital visits, but a separate $5K deductible on prescription drugs, and only Tier 1 drugs are covered.
Plan B: $201/month, $4K deductible, $4K out of pocket maximum, 50% hospital visits, but only $500 deductible on prescription drugs (but coverage of Tier 1/2/3).

I'll skip over plans C through G - some of them really did reflect different business models.  But using myself as a guinea pig, I was unable to figure out the difference between at least four of them, in part because of the redundancy/equivalency problem I've highlighted above, and also in part because it's very difficult to find out what the actual costs of health care are. 

Not Entirely Your Industry's Fault:
I know how much it costs to replace a totalled car.  I can make an educated guess as to how much it costs to fix a blown head gasket, and I can walk into any mechanic's shop and get an estimate even if my car's fine.  The estimate might not be right, but it'll be within 10-20%.  My mechanic might even say "$100 to find out whether the bill is $500 or $5000", which is also fine.  But when it comes to medical care, I don't know how much it costs for something as simple and routine as setting a bone (diagnosing a simple or compound fracture is free, but I don't even know what an X-ray costs).  When I ask my doctor about how much a broken arm is likely to cost, he doesn't know, because it depends on which hospital I end up at.  And those are the simple cases, unlike chronic diseases like heart disease (dozens of cost scenarios depending on how many arteries are blocked and how much damage was done) and cancer (thousands of cost scenarios because it's thousands of diseases at once).

The Part That Is Your Industry's Fault:
Pricing transparency for medical care isn't entirely the fault of your industry, but pricing transparency on medical insurance is.  So let's go back to plans A and B.  Because the premiums are the same, these plans must reflect about the same actuarial risk. But how is any consumer supposed to know in advance whether they're more likely to wind up in the hospital for a broken arm or chemotherapy? (And for any consumer doing enough extreme sports or smoking heavily enough to make a good guess, how does that advantage the insurance company?)

There really only need to be two plans per insurer, clearly targeted as follows:

Plan Foo: "People who want everything paid by their premiums and almost nothing out of pocket" (This mostly exists in the form of the HMO model)
Plan Bar: "Catastrophic care, I'll pay 100% up till the first $10K/year but you'll cover the rest, no questions asked" (hah, I made that last "no questions asked" bit up myself!)

It's not that "100%" and "$10K" in my Bar) example can't be variables - but there need to be few enough variables that everyone can understand the process.  A human can model a two-variable system in its head.  A 7-variable system is only modelable with a computer and a lot of data that isn't even accessible to the consumer.  With a little research, I could figure out the respective incidences of diseases in my age/lifestyle demographic, and make an educated guess as to what medical risks I need to hedge against.  But I can't map those medical risks to the coverages that are being covered, because I can't find out from the medical professionals what treatment should cost, nor can I figure out what the insurer really covers. 

In the simplified model, I'm quite capable of choosing a level of coverage and deductible for plan "Bar" -- and quite willing to pay enough to let you make a profit off it over a sufficiently large population of insured.  When your business model is based on offering plans A) through G) at premiums ranging from $200 to $500/month, it's clear you're offering different levels of hedging, but it's impossible to figure out what risks are actually being hedged against.

I don't see the benefit to consumer or insurer of having so many variables (deductible, out-of-pocket-maximum, percentage-of-inpatient-visit-coverage, separate-drug-deductible, percentage-of-prescription-drugs-coverage, where "prescription-drug-coverage" is some subset of the formulary) - it's a confusopoly, and it's why the insurance industry's overhead makes up a larger portion of health care costs in the US than it does in any nation on the planet.

Foo Bar,

You bring up the good questions to be sure.

And you struck it right on 'confusopoly'. The industry makes it confusing deliberately. If my plan is confusing I may not take advantage of everything it has to offer, thereby saving the insurance money. And if I have several plans to choose from, I will eventually give up and take the least confusing one that most likely has the highest premium. Example: plans A B C D E F, with A having a higher premium, but the easiest to understand, and the rest slightly less but confusing to understand. They are herding the people towards the higher premium plan because it is less confusing.

This is the simplest way to figure out what plan is right for you when you are offered tons of choices:

Calculate:
deductible+ out of pocket limit per calendar year

Do this for every plan. Then compare because THAT is the total out of pocket of covered expenses. Then compare to the premiums. I would try to find the one that has the least amount of premium for the least amount of out of pocket. If they offer a prescription plan-don't calculate that in. Most of those are separate from the rest of the plan.

For your example of plan A and plan B

You have $8000 out of pocket either way.
Plan B has the better deductible
Plan B has the better hospital coverage and RX plan.
It is only $1 more so that is the plan to go with.

Also, ask questions. When they say "well you have such and such out of pocket", ask for a listing of the limitations and exclusions.
Some things could be excluded from Plan B that aren't from Plan A. Because remember, the plans will always say we will cover this much of the "eligible" or "covered" or "approved" expenses.

The model plans Foo and Bar are great.  :) But they don't happen because the insurance company likes to make you pay up front as much as possible, gambling that over the course of the year you won't have enough care to meet your deductible/out of pocket limit. If they built these plans, the premiums would be unaffordable, unfortunately, unless they are heavily managed such as HMO, Gatekeeper or EPO plans with a whole lot of limitations built in.

Personally, I loved the HMO model as a consumer. Coverage was excellent!

As a claims processor, not so much. There are so many rules to research and check before you process a single claim,not to mention half the time all of the information needed to process the claim isn't there, so you ended up either having to call the primary care physician to have them send the info or denying the claim completely for the info.

The HMO model is quickly going away-most companies have found that it is great on paper and a nightmare in practice, and if there too many catastrophic cases in the HMO, the profits go down really quickly (and it only takes 2 or 3 to start cutting into the profits due to the low premiums). And most physician groups and hospitals discovered that the management of HMO is too much to be profitable as well. I don't blame them. Imagine that you are a large health system, with hospitals and physician groups. You agree to become HMO with such and such company. Such and such company hands you a certain amount of $$ and says "That's all you get this year. Now you manage all of the patients care including the paperwork for authorizations and referrals. If there is anything left, you can have it. Now we will take our premiums and go back to our corporate office." Ya, it just doesn't work.

I agree with you that the pricing is mysterious. When you consider that most companies use either a) a contracted rate for each provider which could be a percentage discount or a flat fee or b) what is considered 'usual and customary' in a geographical area**, it is hard to know what costs what. And speaking of geographical areas, if you have a simple x-ray in Missouri it could cost $100, but that same simple x-ray in certain regions of California could run $400.

Not that anyone would want to, but if you want to find out the usual and customary rate for services in any geographical location, there is a website called Trailblazer, http://www.trailblazerhealth.com/Tools/Fee%20Schedule/MedicareFeeSchedule.aspx
that houses most of CMS' (Center for Medicare Services) information, including fee schedules. The catch is, you have to know which CPT-4 code the provider is using to bill for a service. You have to fill in the date, code, and region of the country. It will return pricing info for you.

If you want to try it, CPT code 99213 is for a middle of the road office visit. 73090 would be an x-ray of the forearm with 2 views. 24500 is for treatment closed fracture. Yep, the provider bills for their time, the xray and the treatment separately.

Hopefully this has answered your questions.  :)

The HMO model is quickly going away-most companies have found that it is great on paper and a nightmare in practice, and if there too many catastrophic cases in the HMO, the profits go down really quickly (and it only takes 2 or 3 to start cutting into the profits due to the low premiums). And most physician groups and hospitals discovered that the management of HMO is too much to be profitable as well. I don't blame them. Imagine that you are a large health system, with hospitals and physician groups. You agree to become HMO with such and such company. Such and such company hands you a certain amount of $$ and says "That's all you get this year. Now you manage all of the patients care including the paperwork for authorizations and referrals. If there is anything left, you can have it. Now we will take our premiums and go back to our corporate office." Ya, it just doesn't work.


Thanks much.  Having survived a presidential debate (what's the going rate for a liver transplant? :) I'm in no condition to go into depth, but this is something I've also observed over the past 10-15 years.  In the end, the fact that the patient populations represent similar actuarial risk should result in similar pricing between PPOs and HMOs, rendering the differences in underlying business models moot.  And that appears to have happened.

At one time, the HMO (health-management-organization) model was presented to employees as the "cheaper" option (relative to the PPO/preferred-provider-organization), because the economies of scale associated with the HMO were, in theory, better than those that were missing from the PPO.  If you wanted to choose your own doctor, you had to pay up, but if you were willing to work with a primary care physician, you could take advantage of the HMO's economy of scale.  Hardly a stretch, 15 years ago, to think that if you can get your checkup in one room of the hospital, walk down the hall (instead of across the street to an independent lab) to get the bloodwork done, and if there's a problem, you walk down a different hall (instead of asking your doctor which specialist he might advise, and getting a second opinion from a second doctor, and bouncing from specialist to specialist) to get the problem fixed.

Fast-forward to 2012 - the HMO plans cost about the same as much as the (low-deductible) PPOs do, but offer the consumer much less choice (but much more convenience) in provider.

Or is it that the PPOs have devolved into HMO-like networks themselves?  Your in-network general practitioner happens to have an in-network indepdendent lab that just happens to be across the street from his office that can do the bloodwork, and just happens to know a couple of in-network oncologists, cardiologists, dieticians, etc., who can help cure what ails ya...

Why is COBRA so f**king expensive?  >:(

Which is better? Medicaid or Medicare?  ???

Why is COBRA so f**king expensive?  >:(


Sorry I missed your question!
COBRA is EXTREMELY high-you take on the whole of the premium and the employer no longer has to pay at all,  due to you are either on an extended leave or no longer with the company. Personally I think they keep these costs high to discourage people from taking it. Reason-some people that take COBRA are having expensive medical issues, and the employers do not want to take that hit when their renewal comes up as it is a sure fire premium rise.  I have been lucky enough so far to not have to deal with it yet, but I know that if my company tanks or whatever, I will be looking around for an individual policy so I can be on COBRA for as short of a time as possible. There are some decent individual plans out there, I don't know how close you are to Kansas City, but there are some Blue Cross Blue Shield  and also HMO individual policies that are pretty decent in that area.

Which is better? Medicaid or Medicare?  ???


Sorry, I missed this!

Comparing Medicaid to Medicare is difficult, because they have two different purposes.

Medicare is a program that is set up for a) retirees and b) disabled persons. It is a guarantee to our elderly population that after their employment ends they can retire with peace of mind that they have some type of coverage. It is also there for people who become disabled and cannot work anymore. You do not qualify by income, but by definition of retirement or disability. Once you qualify, you never have to go through the qualification process again. Medicare is a federal (national) program.

Medicaid is a program that helps people that are living at poverty level or below so that they can afford to have medical care; otherwise that percentage of the population would not be able to receive care due to their limited means. Medicaid goes strictly by income and you have to 're-qualify' every year to continue to receive it. Medicaid is a state by state program.

I don't know that either is 'better', could you explain a little further what you mean, and maybe I can answer better?

Thanks!  :)

I watched the Michael Moore film documentary 'Sicko' a little while back and it showed there are people employed by US health insurance companies specifically to find loopholes in customers health profiles to get out of paying for them to get treatment, even if those customers are paying full premium on their insurance. Does this practice still continue and, if so, is it common-place in US health insurance companies?

I watched the Michael Moore film documentary 'Sicko' a little while back and it showed there are people employed by US health insurance companies specifically to find loopholes in customers health profiles to get out of paying for them to get treatment, even if those customers are paying full premium on their insurance. Does this practice still continue and, if so, is it common-place in US health insurance companies?


I don't know how many companies employ this method today. I currently work for an outsourcing company-we process claims, etc for other companies that fall behind, do a system change, etc and need extra help-so I am no longer working directly for the companies themselves and don't see their inner workings.  When I worked for a call center at an insurance, I would do everything I could to help someone calling in to get their claims paid, or help them get approval for the services they needed. As a consumer, if someone thinks that their insurance company is not treating them fairly their best bet is to contact the insurance commissioner of their state. They will investigate and step in; I have seen that first hand. Nothing scares an insurance company like "I am contacting the insurance commissioner". 

I don't know how many companies employ this method today. I currently work for an outsourcing company-we process claims, etc for other companies that fall behind, do a system change, etc and need extra help-so I am no longer working directly for the companies themselves and don't see their inner workings.  When I worked for a call center at an insurance, I would do everything I could to help someone calling in to get their claims paid, or help them get approval for the services they needed. As a consumer, if someone thinks that their insurance company is not treating them fairly their best bet is to contact the insurance commissioner of their state. They will investigate and step in; I have seen that first hand. Nothing scares an insurance company like "I am contacting the insurance commissioner".


Interesting. I'll bear that in mind. Theatre actors hate the name 'Macbeth', health insurance companies hate the words 'insurance commissioner'.  :)