Tips on finding "doctor appointment space"?

DanR

Level 2 Member
The poor already were taken care of. And, insurance still doesn't have to cover pre-existing conditions for a year after you sign up (according to employers I've spoken to). So, you pay out a whole year of premiums for no care that you need and therefore you're paying for your present care (which isn't covered in the first year of "coverage") and insurance premiums for a year.
I'm not going to try to convince you of anything about the ACA. I would ask that you make sure you know what you're upset about, though. Hey - if you want to change something, at least know what you want to change and why. What I've quoted of yours above is absolutely false. All insurance is guaranteed issue and there is no allowance for pre-existing condition clauses, period.

The major reason for high costs and high deductibles in the exchange market is exactly for this reason. Millions of people in this country who had pre-existing conditions and no ability to get health insurance before now have a mechanism to sign up for coverage. They are very expensive to pay claims for and what they pay in premiums/co-insurance/deductible doesn't cover those costs. "Healthy" people who were previously uninsured haven't necessarily signed up (or are eligible for expanded Medicaid) and there aren't enough of them in the risk pool to get premiums down to the point that they are "affordable". This continues the vicious cycle of healthy objectors (those who don't think it is worth it to pay the premium) not entering the market and the "sick" being in the market and the premiums going ever higher.

I'm telling you as straight as I can. Your employer based plan premiums and benefit design did not change significantly because of the ACA (not more than a few %). They changed because of a combination of: the high claims costs of the people in your employer insurance pool and what your employer decided they wanted to do to with the plan benefit design (ie - reduce coverage and increase employee cost share to reduce their portion of health care costs).
 

DanR

Level 2 Member
@churnman:

The reality is that, absent extremely strict laws governing health insurance companies, they WILL screw their customers, just as banks will, absent strict laws governing them.

"
Nationwide, I'd mostly agree with your statement. Here in our home state, where the 4 major health plans are all non-profit with very low (relatively) administrative expenses, I'd disagree. Minnesotan's have it pretty good. Nothing is as simple as it seems when it comes to where health insurance companies make their $$. It varies greatly based upon the buyer of the insurance (government vs employer fully-insured vs employer self-insured vs. individual vs individual exchange).
 

churnman

Level 2 Member
DanR, I just checked with my employer and the insurance does not cover pre-existing in at least the first six months of initial sign-up. I thought most of the grandfathered plans wouldn't be able to do that anymore, but it is happening. There are insurance plans that have grandfathered in exceptions into the law due to lobbyists having success when this was pushed through. The insurance can refuse to pay for care on pre-existing conditions during the first part even while collecting premiums paid (for certain employer offered plans). I'm glad you didn't run into that, but I know many who can't afford to pay months worth of premiums and deductibles plus the money they pay out on their existing condition. And, because they work and don't qualify for the Marketplace subsidized plans they can't afford the current plans offered by employer. Therefore, they also qualify for the tax mandate exemption based on hardship. We had a meeting with the insurance company on this issue and I was present. Wish it was different. I know people leaving the U.S. to live where they can get good health care for a fraction of the price. Insurance companies have meddled too much with the system, the government acted like they were fixing it, but still refuse to allow across the state competition among insurance plans which the lobbyists have so far successfully fought against and I blame both parties for being influenced.

Can anyone here provide a link to the actual federal law section which states that insurance companies will no longer be able to exclude pre-existing conditions in the first 6 to 12 months of signup no matter what state they are in? At this point, I'm still finding that only a few states have their own laws in place which prevent the exclusion. I thought at some point no insurance company operating in any state would be able to exclude pre-existing conditions in the first months of enrollment, but I can't find that in the federal law. Maybe I was dreaming?
 
Last edited:

Sloebrake

Level 2 Member
Nice. I do wonder what's the incentive for doctors to join. Are there actually good doctors who lack patients via traditional channels? Sure doesn't feel that way.
If I would guess; Medicare's push towards electronic records and things like email communication/presciptions means that patient's found through that channel are already fairly internet savvy which also implies younger with less health problems that translates into short follow up visits, less prescriptions, less authorization paperwork, arguably less risk and ultimately more money via volume. Or the doctor prefers dealing with that type of patient and it's for their quality of life.

With traditional channels just having an ethnic name puts many doctors out in the cold from the "here is your list of in-network providers". Some areas have a very solid old-boy referral network and others have unattached ER calls that are like drinking from a fire hose.
 

Sloebrake

Level 2 Member
Can anyone here provide a link to the actual federal law section which states that insurance companies will no longer be able to exclude pre-existing conditions in the first 6 to 12 months of signup no matter what state they are in?
www.gpo[dot]gov/fdsys/pkg/CFR-2015-title29-vol9/pdf/CFR-2015-title29-vol9-sec2590-715-2704.pdf

Existing conditions: CFR 2590.715-2704
Delay might be covered in 2590.715-2708.
And than wouldn't you invoke article VI of the constitution to apply to all states.
 

churnman

Level 2 Member
Thanks, but unfortunately the law allows grandfathered plans to have a pre-existing condition exclusion for new enrollees for the first 6 to 12 months depending on the state. In fact, it states it right on the government's website (look for One Exception: Grandfathered Plans). http://www.hhs (DOT) gov/healthcare/about-the-law/pre-existing-conditions/index.html

The insurance lobbyist worked hard to ensure this pre-existing condition exclusion for the first year continued. After researching I've found that the law has nothing to stop this in the future, no plans to stop the exclusion. Until that is changed we will continue to see some workers going without insurance because they have a pre-existing condition which they continue to pay monthly for out of pocket and therefore can't afford the additional insurance premiums at the same time (paying without actual coverage). It's kind of like taxation without representation.
 

DanR

Level 2 Member
Thanks, but unfortunately the law allows grandfathered plans to have a pre-existing condition exclusion for new enrollees for the first 6 to 12 months depending on the state. In fact, it states it right on the government's website (look for One Exception: Grandfathered Plans). http://www.hhs (DOT) gov/healthcare/about-the-law/pre-existing-conditions/index.html

The insurance lobbyist worked hard to ensure this pre-existing condition exclusion for the first year continued. After researching I've found that the law has nothing to stop this in the future, no plans to stop the exclusion. Until that is changed we will continue to see some workers going without insurance because they have a pre-existing condition which they continue to pay monthly for out of pocket and therefore can't afford the additional insurance premiums at the same time (paying without actual coverage). It's kind of like taxation without representation.
They'll go away through attrition. Grandfathered plans have strict limits on how they can change their benefit design and remain grandfathered. A 2010 benefit design in a 2020 healthcare world is going to not do well. Additionally, as I stated in the other thread, pre-existing condition exclusions only count if you go for some period of time without insurance before being covered again. The number of people who are uninsured today is lower than it has been and the number who are uninsured with chronic medical conditions is much much less. More and more people starting a position with an employer who has a grandfathered plan with a pre-existing exclusion clause are going to be coming in having been covered previously - making that clause a moot point.
 

churnman

Level 2 Member
There are still millions of workers being offered grandfathered plans and most states allow pre-existing condition exclusions for new enrollees. This directly effects my family since we have no insurance (premiums too high compared to value) and the Marketplace won't help because we work and the employer offers insurance which qualifies under the new rules. Half the employees have elected to remain without due to cost and pre-existing conditions. I see no way out except to quit which I'm not willing to do yet. The employer would just hire a worker to replace me. Recent studies have shown there are millions of workers in the same boat in the U.S. My wife knows someone who quit, had a couple kids (not married, no dad around) just because it's easier in the way things are set up. She now doesn't have to worry about insurance premiums. Now, that is extreme and something we would never do. We are workers, like having our own home and enjoy credit card rewards like everyone here. The system isn't working for all workers and there's room for improvement. In fact, if the pre-existing exclusion was no longer allowed in a lot of states we'd see more premium payers and some don't have that bad of health (like my family). If insurance companies want more enrollees they need to get rid of that last pre-existing condition exclusion which still exists for the millions of grandfathered plans that are still being offered.
 

MickiSue

Level 2 Member
Supporter
churnman, unless you are independently wealthy, or have a reliable source of gigantic amounts of cash available, there is no such thing as premiums too high compared to value IF YOU ARE SICK OR INJURED.

The uninsured take the brunt of the cost of medical care. Hospitals, urgent care centers and doctors' offices all have at least three payment levels. The lowest is government: Medicare pays the least. The second is insurance companies, which pay the second least. That is, unless the hospital or doctor is a capitated provider for an HMO. In that case, they are better off if you never show up, as they get paid, per capita, month in and month out, for being available for your care. NOT for providing it. That comes out of their own budget.

Last, and highest of all, is the uninsured person. It MAY be possible to negotiate a lower cost for care as an individual. But you'd be lucky to get 10% off, when insurers routinely chop off 30% or more, and the government usually up to 50%.

We don't buy insurance because we need it today, most of us. We buy it because we either can't afford, or don't want to pay the tens to hundreds of thousands of dollars that easily are racked up in medical care costs for severe accidental injuries, or severe diseases.

I was in a car accident two and a half years ago. I never went to the hospital, but I had a severe whiplash injury, and significant traumatic brain injury that required therapy. Just for those, my bills exceeded $60K.

Absent insurance, I would have been lucky to get away with $50K, and a payment plan.

Insurance matters.
 

MickiSue

Level 2 Member
Supporter
churnman, unless you are independently wealthy, or have a reliable source of gigantic amounts of cash available, there is no such thing as premiums too high compared to value IF YOU ARE SICK OR INJURED.

The uninsured take the brunt of the cost of medical care. Hospitals, urgent care centers and doctors' offices all have at least three payment levels. The lowest is government: Medicare pays the least. The second is insurance companies, which pay the second least. That is, unless the hospital or doctor is a capitated provider for an HMO. In that case, they are better off if you never show up, as they get paid, per capita, month in and month out, for being available for your care. NOT for providing it. That comes out of their own budget.

Last, and highest of all, is the uninsured person. It MAY be possible to negotiate a lower cost for care as an individual. But you'd be lucky to get 10% off, when insurers routinely chop off 30% or more, and the government usually up to 50%.

We don't buy insurance because we need it today, most of us. We buy it because we either can't afford, or don't want to pay the tens to hundreds of thousands of dollars that easily are racked up in medical care costs for severe accidental injuries, or severe diseases.

I was in a car accident two and a half years ago. I never went to the hospital, but I had a severe whiplash injury, and significant traumatic brain injury that required therapy. Just for those, my bills exceeded $60K.

Absent insurance, I would have been lucky to get away with $50K, and a payment plan.

Insurance matters.
 

churnman

Level 2 Member
That's why we have auto insurance with high medical payout if needed (if our fault). My car was totaled in an accident when a drunk driver crashed into me. He was driving without auto insurance therefore my auto insurance took care of me completely then took him to court. He had nothing, but they may have garnished his future wages, if any. His car ended up taking out a tree and was flipped upside down. We chased him down when he crawled over the broken glass to get away. We had to stop him or he would have bled to death. I visited him in the hospital to try to help him get his life straightened up. He was an addict. It pays to have good auto insurance.

My brother just got out of surgery. He said he would have been better off as a cash payer due to the program they have, but we live in an unusually great medical area. Their programs for the uninsured are amazing. The way he put it, he's going to pay out every month for insurance premiums and still be on the hook for all the out of pocket/high deductible which will take him years to pay in monthly installments. When he didn't have insurance and his wife had cancer, they paid monthly, but the hospital knocked the cost down so far because they didn't have insurance therefore they could afford to live. Now, he's not sure how to pay the many thousands that the insurance won't pay. But, saying all that I believe its best if families get insurance if they have enough income to pay the monthly amount after the amount they need for food and shelter. It all depends on where they work and if they have kids. Those with kids will benefit much greater from the current system than couples who work. The lower middle class worker with no kids is hurt the most unless their employer offers decent insurance. My fight now is to help eliminate grandfathered plans which have pre-existing condition exclusions. Everyone I spoke with thought the new law eliminated pre-existing condition exclusions. Now, they're finding out that it isn't true and the insurance companies were allowed to keep that exclusion in most states for new enrollees for up to a year. Paying insurance premiums yet without coverage is a ripoff. That was supposed to be the big point about having a new law, but lobbyists prevailed once again.
 
Last edited:
Top