Who is Losing their PPO Health Plans?

[GreyDawg]

It is true .Countries that have "national health care" pay for it through high tax rates . Someone always has to pay for it.

 

I'm not so sure about that. Yes, someone has to pay, but ...

 

About five years ago I worked for a multi-national corporation and was a resident of North Carolina. At a dinner one evening with collleagues from various countries, the question of social support and taxes came up (ACA was top of the US news). My colleague from Denmark said she was taxed at about 40% of her income for their social services -- and later in the year would go on 12 months of paid maternity leave. My colleague in Sweden had about 45% in taxes, and similar benefits. My colleague from South Africa was in the same ballpark: 40-45% in taxes.

 

Hmmm. When I totaled up my Federal Income Tax, State Income Tax, and the FICA-OASDI that I paid, it came out to about 38%. And it was even higher when I lived in Oregon and California, where the state income tax rate was higher.

 

So I'm not at all convinced that having "national health care" and other social benefits -- government funded pre-school, long family leave, etc -- means higher taxes. it is more complex. It reflects a simpler, and more monolithic government structure and a more homogeneous population. It is the price we pay for being a federation of states.

 

Denmark and Sweden are very homogeneous in terms of income and education. THe USA is heterogeneous -- poor/rich, urban/rural, literate/illerate, and so on Extreme urban poverty (Newark NJ), extreme rural poverty (Appalachia, Browning SD), extreme wealth (NYC.) So tax at the same level, and it won't go as far.

 

So "national" in the US is far more complicated that "national" elsewhere. It really is like the USA is made up of 50 little nations...

 

[patty98311]

hm

[Zulu]

So "national" in the US is far more complicated that "national" elsewhere.

 

Yep. Any explanation requires quantum physics.

[Mariner]

Mariner, Can you explain why the coops came into existence and why they are failing?

 

 

Sure. The premise was for the CO-OPS to offer low cost healthcare, which on paper looks great. Problem is they were set up & run by people who had little or no experience in healthcare. With very little or no oversight people were able to set up & run these CO-OPS to do nothing more than line their pockets at taxpayer expense. I read a prediction yesterday that said that ALL the CO-OPS will be gone by next year at a cost of over $5 Billion dollars to the American taxpayer that will also NEVER be recouped. When will people learn that just throwing money at a problem won't fix it.

[Kirk W]

I read a prediction yesterday that said that ALL the CO-OPS will be gone by next year at a cost of over $5 Billion dollars to the American taxpayer that will also NEVER be recouped.

 

that is indeed interesting reading.....pick your source.

With all of the sources available, most with their own ax to grind, it is very easy to find one that will "prove" your chosen view to be correct. About the only thing one can safely predict with accuracy about health care in the US is that it is changing rapidly and will likely continue to do so in the foreseeable future. It comes down to choosing which source you wish to believe and take your chances. It is complicated enough if you leave politics out of the debate, but today the political side is probably the one with the greatest impact on our health care future and the least predictable part of it. Too many simple answers to a complicated problem.

 

[Jack Mayer]

 

With all of the sources available, most with their own ax to grind, it is very easy to find one that will "prove" your chosen view to be correct. Too many simple answers to a complicated problem.

 

Perhaps there ARE too many simple answers. But one thing is predictable and I would bet a LOT of money on it. The co-ops will be GONE by the end of next year unless the taxpayers continue to pour money into them. This was a very predictable outcome, and most of the health care watchdog groups predicted it correctly.

[airstream harry]

It just get worse every year. We are lucky as we are no longer traveling and have an Advantage Plan. I believe we need a single payer system, sooner not later.

c u on the road

[Kirk W]

But one thing is predictable and I would bet a LOT of money on it. The co-ops will be GONE by the end of next year unless the taxpayers continue to pour money into them. This was a very predictable outcome, and most of the health care watchdog groups predicted it correctly.

Are you telling us that there is tax money going into the "Health Sharing" programs, most of whiich are faith based??? I'm afraid you are going to have to document that one if you expect me to believe it.

 

I am no prognosticator so I'll not make predictions about who will or will not survive the current and future situation in health care. I leave that you you and others, although I have no doubt that there will be some providers that do not survive.

[richfaa]

It is interesting reading to try to understand how the Co ops came to be and why they are failing.

[Kirk W]

Most of the very early insurance companies began as cooperative organizations. I don't know of any health underwriters who are coops today, but there are plenty of health underwriters that are and mutual companies are not that far from a coop as they are customer owned.

 

A mutual insurance company is an insurance company owned entirely by its policyholders. Any profits earned by a mutual insurance company are rebated to policyholders in the form of dividend distributions or reduced future premiums.

[2gypsies]

For those pre-Medicare age, here is an excellent article just published which sorts some issues out.

 

http://wheelingit.us/2015/11/04/health-insurance-time-less-ppos-harder-choices-for-pre-medicare-fulltimers/

[jmarxen]

Regardless of what insurance policy any health insurance offers, the ACA requires a minimum coverage to be provided, making this minimum coverage the same unless you wish to purchase a more 'premium plan. The ACA limits health insurance companies providing individual plans to a maximum of 6% to cover their costs, including profit, or they must refund their policyholders any premiums over that. It's simple mathematics, they are concentrating on providing healthcare plans that they can control costs, and HMO's are the easiest to control costs. PPO's allow you to go to any doctor or provider whose costs are not as easily controlled, hence the reason many PPO plans are being dropped. Some state insurance commissions/regulations will supplement insurance policies in coverage over and above ACA minimums.

 

- Jim

[chirakawa]

PPO's allow you to go to any doctor or provider whose costs are not as easily controlled, - Jim

 

I've been a participant in PPO's for over 35 years. This statement is just not true.

[Kirk W]

Before the ACA, the differences were more clear. An HMO required each patient to have a specific doctor as "gate keeper" who had to refer patents to any specialists seen. Thus the patent was tied to one doctor in a single location. With the PPO, the patient could see any doctor who was in the network and the networks were quite extensive and in most states and localities. In addition, a PPO would allow the patent to visit any emergency medical service anywhere. Since the advent of the ACA, many things have changed and continue to do so.

[richfaa]

 

I've been a participant in PPO's for over 35 years. This statement is just not true.

PPO's do control cost been on one for over 30 years. You must go t o a dr in the plan and there are many we have never had a issue anywhere.

[chirakawa]

PPO's do control cost been on one for over 30 years. You must go t o a dr in the plan and there are many we have never had a issue anywhere.

 

I agree. His statement was that cost was not easily controlled in PPO's. PPO's allow you to go to any doctor. However, if that doctor is not in their network, they will only pay the amount that they would have paid in their network. Plus, at least in my PPO's over the years, if you went outside the network you had to pay a higher percentage.

[richfaa]

In all the years we have been in a PPO...BC/BS we have never had top go outside the network.

[chirakawa]

In all the years we have been in a PPO...BC/BS we have never had top go outside the network.

 

Only twice to me. Both times a network doctor used non-network providers (pathology and anesthesia).

[sailwing2003]

We are one of those 360,000+, loosing our TX BCBS PPO. It has been a scramble to find new options and one that will allow us to remain in the hospita system and with the Dr.s that we have been using for the last 2 years, to great success.

 

The almost total lack of options for a replacement policy, at any cost, with the new increased deductibles, and coverage beyond our state is sad. We have always been self employed and well insurered, and that has changed for the worst for us.

 

We are going to buy what we can that will offer us the best we can find, and add travel insurance when we are out of our state. The zero out of network payments parts of every policy we checked should be a huge worry to everyone.

[Zulu]

In all the years we have been in a PPO...BC/BS we have never had top go outside the network.

 

As far as I know, neither have I. But that's not the point. The point is . . . What if you have to go out of network?

 

I guess I'm lucky having an AZ domicile because there are PPO plans in AZ.

 

However, the devil's in the details . . . my old BCBS plan (which ends in December) had an Out-Of-Pocket limit of $12,700 for Out-Of-Network costs.

 

Now all of the available AZ PPO plans Out-Of-Pocket Out-Of-Network limit is unlimited.

 

 

We are one of those 360,000+, loosing our TX BCBS PPO.

First, there are PPO plans available in TX. You just have to live in the "right" Zip code. For example, look up the plans available for Travis county, TX (78713). There are a number of PPO plans from Scott & White Health Plan (NCQA rating of 3.5 out of 5 = Above Average).

 

Anyway, a lot of us landed in the wrong Zip code. I was lucky. But for those of you who have to purchase health insurance and haven't chosen a domicile, see what's available for your Zip code before jumping.

 

BTW, selecting a Zip code like 77351 or 77399 is probably a bad idea.

 

[mkc]

We are one of those 360,000+, loosing our TX BCBS PPO.

 

 

The zero out of network payments parts of every policy we checked should be a huge worry to everyone.

 

Dave and Dolly - look at the Humana bronze off-exchange PPO. Higher deductible but $0 cost after you meet that deductible. It will likely be a wash, cost-wise, for us compared to our current BCBSTX PPO that's going away. Kyle Henson helped us decide on that one - has all our doctors, all the hospitals and other facilities we would use.

 

In other TX zip codes (not for us here in north DFW but certainly 77399), United Healthcare has some good PPO options off-exchange (with Choice network; not the ones with Compass network. Choice is a MUCH larger/more inclusive network. Compass looks like their HMO network).

 

As an RVer, the Scott & White PPO plans wouldn't work for us. Their network seems very limited and no docs or hospitals in our immediate home area (we'd have to travel at least 1/2 hour to reach any in-network providers, including a hospital).

 

I highly recommend folks contact Kyle at rverinsurance.com for help. He helped me navigate the options.

 

Michelle

[Mariner]

It's sad that we've come to the point where we're having to pick where we want to live, by what healthcare plan might be available in that particular area.

[Zulu]

It's sad that we've come to the point where we're having to pick where we want to live, by what healthcare plan might be available in that particular area.

 

No "sadder" than picking a town for its good schools, housing, or other services.

[sailwing2003]

Thank you Michelle for the suggestions.

 

As we are traveling till we are forced to stop. As you mentioned Scott & White plan does not work for us, as none of the 10+ Drs at UT Southwestern we have used since 7/14 are listed to take their plan, or the hospital at UTSW we are likely to need and use.

 

As to Humana, that might work. Humana shows they would pay the UTSW Drs, and the UTSW hospital is listed on on the Humana site. We hope that by the beginning of December all parties will have their sites and agreements figured out on what is a huge mess. Dolly's coverage is going to be $17,334, (907*12+6450), for her monthly premiums and deductible next year, for the first dollar of coverage. That does not seem affordable, compared to her last year on the Texas Risk Pool high dollar coverage that closed 12/13. At that time in 2013, she paid only $12,648 (804*12+3000) for her first dollar of coverage.

 

Going off exchange is going to increase our cost over $1400 per month as things look now for the two of us. For those that do not have a medical condition, or in treatment for a life threatening disease count your blessings. For those over 65, like I will be mid year, we should all enjoy our less than $300 per month medicare and supplements costs.

 

Again, it is amazing no one in the press or anywhere seems concerned about the almost total lack of any coverage when we travel beyond out sign up neighborhoods. Not sure many people know that a vacation illness could bankrupt them and their families. Yesterday we kept saying "out of network next year" as we saw out of state license plates.

[bobk3d]

Well thankfully some of the Florida Blue EPO's offer some out-of-network coverage, albeit with a $12K deductible and OOP limit. That's a lot, but at least it's a cap.

 

My biggest concern as a single person is that if I had an extended illness like cancer, I'd want to be treated closer to family & friends in the northeast, assuming I was healthy enough to get there. What I realized is that I could change my residence and change my insurance to the new state if it would make a difference. Not perfect, but I can probably get care and avoid bankruptcy.

 

But it's stunning that no matter how much I pay, I can't get the same coverage I've always had in the past.

 

Please take this as economic observation rather than strictly political: Europe does not have a single payer system! Europe has 20+ systems, which compete with each other in subtle and often invisible ways. That's not my preferred structure, but in trying to avoid it, we've ended up with a monstrosity that's even more wasteful and anti-competitive. For those not bound to a hard ideological position, it's food for thought. I think we could have a better safety net and still respect market forces. But in Washington the debate is either-or, and the result is that we have neither.