Health insurance question for the hive

Swank Force One wrote: Ugggghhhhhh here we go again. I think what we're missing now is that you get a penalty for NOT having insurance. For each family member. Would you rather pay to have insurance? Or would you rather pay to not have insurance. We've been round and round on the cash option with the providers thing, and long story short, if they're doing that, they're breaching various contracts.

Yes, you are correct on the penalties. This year, they are nominal. Next year, we'll see.

What kind of contracts?

IF there is a breach of contract issue (and I can't imagine why there would be), it is widespread practice.

My kids were born at 4 different major hospitals in 3 different states. Never a hint of an issue.

Most people here would be willing to hire an unlicensed or uninsured contractor to work on their house, or pay the lawn care kid without withholding payroll taxes too.

I am not suggesting or recommending illegalities. I am asking for balanced non-extreme input, in an extreme world.

A lot of hospitals and doctors will negotiate cash payments, usually for a lot less than if you have to file. The reason is two fold. First, they do not have to wait to get paid. Sometimes with things like Medicare, it can take much longer than with "normal" insurance carriers. Second, they do not have to go through the mountain of paperwork to get paid. At my wife's office, her entire job is filing claims and working on collections. In the last few years the amount of paperwork has increased significantly to where the needed to add another person, and they were only a 3 person show to start with.

Toyman01 wrote: #2-Yes. The Supreme Leader will now hit you with multiple thousands in fines if you don't support the insurance industry. You have no choice but to participate or face the consequences. You must also still pretty much pay for everything unless you are a congresscritter.

You are kinda blowing things out of proportion, either that or I wish I earned as much as you do in order to necessitate that kind of fine!

https://www.healthcare.gov/what-if-i-dont-have-health-coverage/

1% of your yearly household income. (Only the amount of income above the tax filing threshold, $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average premium for a bronze plan.

or

$95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.

Whichever is higher.

^^ Yeah, that's what I found. Depending on how you calculate my modified adjusted gross annual income or whatever they call it, My penalty would be north of $6,000.

In reply to DrBoost:

You make $600,000??

In reply to SVreX:

The insurance negotiated rates are based off what they charge for services. If they aren't actually charging those amounts to cash customers, they're breaching their contracts in an unethical way.

It's great that people can take advantage of it, but this is why insurance costs so much. It berkeleys those of us that do choose to purchase insurance, and from an idealistic standpoint, isn't much different than buying stolen goods.

I don't truly have a problem with it, just be aware that if OP doesnt use the same exact providers as you, his experience paying cash may very well be quite different, and there's no way i'd ever suggest cash payment as a cut and dry alternative to insurance, because it's anything but a guaranteed thing.

SVreX wrote: In reply to DrBoost: You make $600,000??

Oops, I thunk I calculated by 0.01, not 0.1. And I was just estimating my MGIA or what ever it was called. Being the gubment, they make it impossible to understand.

Swank Force One wrote: The insurance negotiated rates are based off what they charge for services. If they aren't actually charging those amounts to cash customers, they're breaching their contracts in an unethical way...

Interesting. Sad, but interesting.

Swank Force One wrote: In reply to SVreX: The insurance negotiated rates are based off what they charge for services. If they aren't actually charging those amounts to cash customers, they're breaching their contracts in an unethical way.

OK, so let's translate that into a (hypothetical) car example.

Dealers sell Ubercar X for $25,000. They offer a discount off the price to fleet managers, who can buy them for $20,000.

But they have 3 months worth of paperwork to close the deal, and then have to finance the car for 5 years.

The "price" of what they charge for services, regardless of whether you look at the $25K or the $20K, is based on the expenses and overhead involved. (We all understand that a "sticker" price is not firm).

But, if anyone were to ask what the normal price is for a person off the streets, the answer would be $25K. OK, maybe the dealer would admit there is some wiggle room and say $22K.

In walks Ms. Localcarbuyer, with $18,000 cash. She wants to buy a car sitting on the lot, and would like to drive it home today.

This is a done deal.

So, what is the actual meaning of the word "price"? Is it $25K? $22K? $18K? How about the $16K they paid?

I can see how the equivalent of a "sticker price" can easily be established for insurance products, but it is REALLY difficult to imagine any way to define what the bottom line is on a negotiated product (which is essentially, ALL products).

Plus, not all providers are in the same networks, so the prices could vary between providers.

In reply to Swank Force One:

OK, so a friend who has extensive experience in the insurance industry just walked in.

He says you are (likely) mistaken, but insurance regulations vary by state according to the state insurance commissions. Therefore, as a blanket statement it would be wrong for me to unilaterally say you can always negotiate, but it would be equally wrong for you to say you can't. Varies state by state.

The UCR (Usual Customary Reasonable) charge is essentially the "blue book" price- the going rate. THAT'S what the insurance provider discounts are based on. In GA (and other states), there is NO guideline that says a medical provider can not negotiate with a cash buyer below the UCR (or ANY price).

There is ALSO no limitation for a medical provider regarding negotiating with an insured customer for payments beyond those covered by the insurance provider (the balance, the co-pay, the deductible, out of network charges, etc.)

Make sense?

SVreX wrote: In reply to Swank Force One: OK, so a friend who has extensive experience in the insurance industry just walked in. He says you are (likely) mistaken, but insurance regulations vary by state according to the state insurance commissions. Therefore, as a blanket statement it would be wrong for me to unilaterally say you can always negotiate, but it would be equally wrong for you to say you can't. Varies state by state. The UCR (Usual Customary Reasonable) charge is essentially the "blue book" price- the going rate. THAT'S what the insurance provider discounts are based on. In GA (and other states), there is NO guideline that says a medical provider can not negotiate with a cash buyer below the UCR (or ANY price). There is ALSO no limitation for a medical provider regarding negotiating with an insured customer for payments beyond those covered by the insurance provider (the balance, the co-pay, the deductible, out of network charges, etc.) Make sense?

Depends on what state you're in. When it comes to in network vs. out of network anyhow. Most states, you get your contracted rate, and whatever the customer owes of his portion. You can negotiate on the customers portion (IE cutting a deal on a deductible, etc) but you can't hold them liable for more than their contracted rate. Florida in particular was a giant point of contention with that however, because when it came to facilities in general, they had a loophole. If you signed POA over they could charge precisely whatever the hell they wanted and there was nothing the insurance could do about it due to state law. My old division actually fought a facility down there and we eventually said adios contract, and we're not paying you, ever. The neat trick with non-pars is we could and did issue payments directly to clients due to facilities doing shady business under the table like that. I'm not naming names because there was a whole lot of legal stuff and inside mumbo jumbo (I was actually involved with it, as was our SIU div.) The problem with that was, the moment you go out of network, we can't help you. You're effectively on your own when it comes to battling a provider, and they can charge you whatever they want. Some are willing to negotiate, some are actually willing to negotiate with 3rd party admins that the insurance works with (Hazelden is actually famous for this, believe it or not) where they agree to take a fat discount and accept assigment of benefits. This means, we pay them what your benefits cover- non par, and you're on the hook for the rest. When you're talking about a 30k pie, a guaranteed 10k check is better than nothing. And contrary to popular belief, insurance is on your side. We (I keep saying we, it's been nearly 2 years since I Was there) wanted you happy and healthy. Srsly. Bottom line, I'd say take the insurance if it's offered. No sense going cowboy if you don't have to.

The insurance negotiated rates are based off what they charge for services. If they aren't actually charging those amounts to cash customers, they're breaching their contracts in an unethical way.

Up until Obamacare, many of the "uninsured" were in fact self insured. They had the money to cover most costs should they need it. The benefit is that they will likely pay less overall for their healthcare. Should they need healthcare, they would negotiate with doctors and agree upon a price, usually much less then insurance would pay for the same procedure. Insurance isn't about paying for healthcare. It's about managing risk. When you buy insurance, you are paying someone else to assume that risk. They make money in exchange for taking on that risk. Most people and business with money don't buy insurance. They assume the risk themselves, as they can afford to absorb the cost if something bad happens, and it's usually less expensive in the long run.

It's also not possible to compare insurance providers just by their name. Two different people could have completely different plans, depending on what the employer chose to provide. I had the same health care provider with two different companies, and the plans were very different. It could be like buying a Toyota because you like how your neighbor's Tundra tows, and wondering why your new Prius is having trouble with your 20' travel trailer.

In reply to Boost_Crazy: very true about the company name having little to do with the premiums. My wife has had blue cross with the past 3 employers. The current one is fully paid for her, horribly expensive for adding family so I insure myself and the kids. The previous employer insured all married women at close to the family rate and split the premiums so adding the rest of the family made sense. The other had a rate plan somewhere in between. You have to know what they really are offering to make the comparisons you want.

Consider a high-deductible plan, if available. The purpose of health insurance isn't so much to get free care as to protect your assets in the event something really bad happens and a massive health event is incurred.

In reply to conesare2seconds: don't forget to include a low maximum out of pocket cost with your high deductible.

conesare2seconds wrote: Consider a high-deductible plan, if available. The purpose of health insurance isn't so much to get free care as to protect your assets in the event something really bad happens and a massive health event is incurred.

Every plan is different, so you really need to look at the details, but a high deductible (CDHP) plan can save money.

The big items to compare are the premiums, deductible and max out of pocket.

For example: I went from a high priced BCBS PPO to a consumer driven health plan. That changes my cost from approx $6500/yr to $2600/yr. PPO deductible is $1250, CDHP deductible is $2500.

On the PPO preventative care was covered 100%. Other visits were a $20 copay. Prescriptions were also covered so only a copay.

On the CDHP preventative care is covered, but everything else is out of pocket (including rx) until the $2500 deductible is met then I pay 10%. The worst case is I reach the max out of pocket amount of $5,000, then everything is covered 100%.

Because of the lack of predefined copay a for service the CDHP seems like a riskier (or less well defined) proposition, but once you do the math it's lower cost. Even if I reach the max out if pocket the CDHP will end up being cheaper when premiums, copay and deductibles are considered.

Apexcarver wrote:

Toyman01 wrote: #2-Yes. The Supreme Leader will now hit you with multiple thousands in fines if you don't support the insurance industry. You have no choice but to participate or face the consequences. You must also still pretty much pay for everything unless you are a congresscritter.

You are kinda blowing things out of proportion, either that or I wish I earned as much as you do in order to necessitate that kind of fine! https://www.healthcare.gov/what-if-i-dont-have-health-coverage/ 1% of your yearly household income. (Only the amount of income above the tax filing threshold, $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average premium for a bronze plan. or $95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285. Whichever is higher.

Mine is higher. By 2016 it will be a couple of challenge cars worth.

In reply to Toyman01:

Correct. By 2016, $695 per adult. $347.50 per child. Up to $2,085 per household flat amount or 2.5% of household income (whichever is greater).

http://obamacarefacts.com/obamacare-individual-mandate.php

OP. I have had UHC for over ten years at my current employer. I really haven't used it too much the past few years. The biggest thing is it takes FOREVER to get a claim through. I had a stress test done in December and didn't get it processed until late this spring. Does your employer offer an HSA plan where they contribute to the deductible? I switched from traditional to that plan since my employer pays 60% of the ded. I noticed they are pushing mail-order to order medicine now rather than retail. I really haven't had too much to complain about with them.

SVreX wrote:

Swank Force One wrote: In reply to SVreX: The insurance negotiated rates are based off what they charge for services. If they aren't actually charging those amounts to cash customers, they're breaching their contracts in an unethical way.

OK, so let's translate that into a (hypothetical) car example. Dealers sell Ubercar X for $25,000. They offer a discount off the price to fleet managers, who can buy them for $20,000. But they have 3 months worth of paperwork to close the deal, and then have to finance the car for 5 years. The "price" of what they charge for services, regardless of whether you look at the $25K or the $20K, is based on the expenses and overhead involved. (We all understand that a "sticker" price is not firm). But, if anyone were to ask what the normal price is for a person off the streets, the answer would be $25K. OK, maybe the dealer would admit there is some wiggle room and say $22K. In walks Ms. Localcarbuyer, with $18,000 cash. She wants to buy a car sitting on the lot, and would like to drive it home today. This is a done deal. So, what is the actual meaning of the word "price"? Is it $25K? $22K? $18K? How about the $16K they paid? I can see how the equivalent of a "sticker price" can easily be established for insurance products, but it is REALLY difficult to imagine any way to define what the bottom line is on a negotiated product (which is essentially, ALL products). Plus, not all providers are in the same networks, so the prices could vary between providers.

You missed the point.

The point is that the providers, if they're networked with ANY insurance company, have billed charges for services.

Those charges are what is used to start negotiations for the contracted amounts the the insurance companies base their payments off of. Those charges are expected and as part of their contract, are what is charged to everybody.

If they're offering the same (or higher) discounts to those people NOT using insurance, then they've done something really unethical while negotiating contracted rates. Not to mention, technically a breach of their contract.

It's bad enough that they artificially inflate their charges in the first place in order to start with a better bargaining chip, it's a whole 'nother level of berkeleying slimy to not charge those prices to the un-insured.

The network has absolutely nothing to do with it.

I'm not condemning anyone for taking advantage of it, free money is free money. But this stuff is exactly why the current state of things is berkeleying awful. This is why insurance premiums go up. This is why billed charges for services are obscene. It's great for the present, it just continues to make the future worse.

In reply to Swank Force One:

You missed the point.

Varies by state.

Not illegal in my state.

I see nothing unethical in your previous statement, unless there is ALSO a representation that the prices presented are somehow "the lowest", or based on a measurable standard. According to what you said, they are not. The only thing you said was that the discounts are based off previous charges to insurance companies. You said nothing about charges to cash customers, nor if there was any representation thereof.

You are presuming "standards" that I don't think exist.

The insurance industry is probably the best industry on the planet for gathering data. They know better than anyone EXACTLY what they pay for everything- that's how they build actuarial tables. But they DO NOT know what other customers pay. It's not really any of their business.

There is a real and legitimate difference in actual expenses incurred to a business that sells to insurance companies, and also to cash customers. Might be higher, might be lower. But it is clearly different, and the difference is up to the business to determine.

This is a red herring. I asked for balanced advice, and shared actual true experiences I have had. I'm not too interested in arguments over technical differences in insurance regulations that vary by state. I KNOW that I have committed no illegalities, and that there is NOTHING illegal about ANYONE asking a provider for a discount. Ever.

SVreX wrote: In reply to Swank Force One: You missed the point. Varies by state. Not illegal in my state.

I never used the word "illegal."

SVreX wrote: I see nothing unethical in your previous statement, unless there is ALSO a representation that the prices presented are somehow "the lowest", or based on a measurable standard. According to what you said, they are not. The only thing you said was that the discounts are based off previous charges to insurance companies. You said nothing about charges to cash customers, nor if there was any representation thereof.

No offense meant, but i can't understand what this means.

The way this works is:
1) Provider says "This is what we charge for these services"
2) Provider and insurance bargain from there for a contracted rate specific to insurance.

I don't know what "previous charges to insurance companies" means. That's not a metric that's used in anything.

Cash vs. insured customers doesn't have anything to do with billed charge. At least, it shouldn't.

There's no standard for billed charges.

SVreX wrote: You are presuming "standards" that I don't think exist. The insurance industry is probably the best industry on the planet for gathering data. They know better than anyone EXACTLY what they pay for everything- that's how they build actuarial tables. But they DO NOT know what other customers pay. It's not really any of their business.

It IS their business when providers aren't actually charging the rates they used to determine contracted rates.

We know what we pay for everything because of two reasons: Either 1) It's what the goverment told us to pay (Medicare standard) or 2) it's because it's what we agreed upon with the providers. We don't make the rules.

SVreX wrote: There is a real and legitimate difference in actual expenses incurred to a business that sells to insurance companies, and also to cash customers. Might be higher, might be lower. But it is clearly different, and the difference is up to the business to determine. This is a red herring. I asked for balanced advice, and shared actual true experiences I have had. I'm not too interested in arguments over technical differences in insurance regulations that vary by state. I KNOW that I have committed no illegalities, and that there is NOTHING illegal about ANYONE asking a provider for a discount. Ever.

I say this everytime i get into one of these threads: I need to just stay out. I always end up the minority that doesn't know what he's talking about, somehow.

Carry on!

FYI. If insurance is offered from your employer, I don't think you would be eligible for subsidized exchange coverage. I'd take the UHC from your employer. Again, check with your employer about HSA. Our family plan is a $5,000 ded with $7000 out-of-pocket. My company puts in $3600 throughout the year, which of course is half of the max out-of-pocket. It only cost $80/month also. You can also contribute and it would be pre-tax $. At first it sucks because you have nothing put back, but you can keep saving and rolling it over every year. Your employer may not be as generous as mine though.

In reply to Swank Force One: Is your argument really saying a cash paying consumer shouldn't be allowed to pay the rate the insurance company pays but should pay the rate that is billed to the insurance?