Help me understand what happens with the new law and ACA subsidies

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2015
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Re: Help me understand what happen with the new law and ACA subsidies

Post by 2015 » Sat Oct 14, 2017 8:40 am

Phineas J. Whoopee wrote:
Fri Oct 13, 2017 6:42 pm
2015 wrote:
Fri Oct 13, 2017 6:20 pm
...
So I want to be really clear about this. The second executive order halts federal CSR reimbursement to insurance companies, but does not relieve insurance companies of their obligation to offer these reduced copays, coinsurance, and deductibles.
Yes, that's factually correct.
2015 wrote:Therefore, it's possible those lost reimbursements could have all kinds of negative ramifications on the ACA marketplace (e.g., insurers leave markets). We just don't know what those ramifications are. Yet.
We have a fairly good idea, but not every state is the same. Many pre-planned for the possibility the cutoff would happen.

Here's a link to a spreadsheet showing what each state planned.

Here's a link to an explanation of the four basic strategies states and insurers chose. The link is from the spreadsheet, but I thought it would be easier on readers if I listed it separately.
2015 wrote:I still don't see how this is actionable at this stage of the game. Plan on getting a job with health insurance maybe if you're retired and not close to Medicare age?
I am correcting widely-spread misinformation. You may or may not think doing so has any relevance to taking action.

PJW
To the contrary, I think correcting misinformation is not only relevant, but highly valuable. However, it does in fact appear there are 19 states now suing the administration over the discontinuance of subsidies. I still believe such litigation will slow, if not altogether stop (should the litigation prevail) any immediate effects from whichever executive order led to the discontinuance.

https://www.bostonglobe.com/business/20 ... story.html
Attorney General Maura Healey said she was joining 18 other states, including Connecticut and Rhode Island, in suing the Trump administration, arguing that it is required by law to continue the payments, known as cost-sharing reductions.

Healey, a Democrat who has filed several lawsuits against the Trump administration, said the new court action seeks an injunction to ensure that the administration continues making payments.
OTOH, as this article points out, both orders are having a negative impact on the ACA markets due to the uncertainty and disruption caused. I'm still not convinced all of this news is actionable at this point. It reminds me of the hooplah this summer over the repeal (which I now wish I hadn't wasted time following), at the end of which nothing happened.

2015
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Re: Help me understand what happen with the new law and ACA subsidies

Post by 2015 » Sat Oct 14, 2017 8:52 am

LadyGeek wrote:
Fri Oct 13, 2017 7:16 pm
2015 wrote:
Fri Oct 13, 2017 5:39 pm
Actionable: Hold your horses, pardner. Signing and implementation are two different things. It's just an executive order, and already two state attorney generals (CA and NY) are talking litigation. Even if it survives lawsuits, changes will take time (although how much time remains unknown)...
Here's additional information on Executive Orders: What is an Executive Order?, from the American Bar Association.
Both executive orders and proclamations have the force of law, much like regulations issued by federal agencies, so they are codified under Title 3 of the Code of Federal Regulations, which is the formal collection of all of the rules and regulations issued by the executive branch and other federal agencies.

...
Executive orders are not legislation; they require no approval from Congress, and Congress cannot simply overturn them. Congress may pass legislation that might make it difficult, or even impossible, to carry out the order, such as removing funding. Only a sitting U.S. President may overturn an existing executive order by issuing another executive order to that effect.
Congress may not overturn them, but litigation may. One of the links I posted up thread discussed how the Republicans sued the Obama administration previously over these very same subsidies. I just don't want to waste my time following this stuff like I did this summer during the seemingly endless repeal hearings when nothing may come of it, as was the case with the repeal.

I do think it's unfortunate those counting on the ACA for medical coverage have to live under such uncertainty, but regulatory reform (tax, social security, medicare, etc.) will always be a fact of life in any retiree's plans. We just have to have financial and other contingency plans in the event things turn out different (don't they always?).

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Watty
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Re: Help me understand what happen with the new law and ACA subsidies

Post by Watty » Sat Oct 14, 2017 9:12 am

pintail07 wrote:
Sat Oct 14, 2017 7:54 am
And for those of us who prefer to be self-employed, the choices are?

I've bought my own health insurance my entire adult life, because I've never had a job. I was doing this well before the ACA. So if I'm pushed out of the federal Marketplace, are insurers even offering private plans any more?

Is there some alternative, catastrophic coverage available that may not be ACA compliant, but would at least cover me in the event of a major medical problem?
If you don't have any pre existing conditions, and they extend the plans to 1 year, short term plans can be an option.
That is not really a good option. Years ago when even an employer provided plan would exclude preexisting conditions I know someone that took a new job and about a year later they had a small growth in their nose that the doctor did a routine biopsy of to see if it was cancer. The insurance company would not pay for that because they had a sinus infection several years before so the insurance company considered it to be a preexisting condition. They got lucky and it was benign so they only had to pay for about $500 in costs but if it had been cancer then they would be facing cancer without insurance.

2015
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Re: Help me understand what happen with the new law and ACA subsidies

Post by 2015 » Sat Oct 14, 2017 9:30 am

More on this:

https://www.bloomberg.com/news/articles ... -subsidies
With the health insurance of millions at stake, California Attorney General Xavier Becerra and New York Attorney General Eric Schneiderman, leading 18 states and the District of Columbia, asked a U.S. court for an order compelling the Trump administration to continue making Obamacare subsidy payments while their states and others fight to save them.

The filing by the attorneys general in San Francisco comes just a day after the White House announced it was ending those Affordable Care Act payments immediately. The next monthly installment is due Oct. 18, leaving a federal judge there only days to act on the request if the payments are to continue uninterrupted.
and

[OT comment removed by admin LadyGeek]

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Re: Help me understand what happen with the new law and ACA subsidies

Post by scrabbler1 » Sat Oct 14, 2017 9:59 am

PJW, I'm glad you mentioned the SLCSP, or Second Lowest Cost SIlver Plan, because it is a key amount when determining the ACA premium subsidy one receives. Because my MAGI is toward the higher end of the range which qualifies for a subsidy, how much I actually pay in premiums has no effect on my subsidy, even it I pay less than what the SLCSP is. What I have to root for is the SLCSP rising by the same amount my actual premium rises, in actual dollars, not percentagewise. Then it will offset my premium increase.

In my locality, the SLCSP rise about 4% in 2015 and 2016. I don't know how much it rose in 2017; I called my state marketplace (exchange) because I figured they should know this already, but they didn't or couldn't tell me (yet). Pretty pointless to ask how it will change in 2018.

pintail07
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Re: Help me understand what happen with the new law and ACA subsidies

Post by pintail07 » Sat Oct 14, 2017 10:09 am

That is not really a good option. Years ago when even an employer provided plan would exclude preexisting conditions I know someone that took a new job and about a year later they had a small growth in their nose that the doctor did a routine biopsy of to see if it was cancer. The insurance company would not pay for that because they had a sinus infection several years before so the insurance company considered it to be a preexisting condition. They got lucky and it was benign so they only had to pay for about $500 in costs but if it had been cancer then they would be facing cancer without insurance.

I disagree, it is much better if one can't afford the ACA premiums versus going naked.

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Re: Help me understand what happen with the new law and ACA subsidies

Post by stlutz » Sat Oct 14, 2017 10:38 am

Thanks for the link, 2015! That is a very interesting article.

Since people on BH generally actually like to read, it's worth adding a link to the CBO analysis of the move: https://www.cbo.gov/system/files/115th- ... ctions.pdf

I think the actionable part for most people here is that a Bronze or Gold plan will likely be better deals going forward. Cost sharing subsidies did not impact those plans but they will benefit from higher premium subsidies that will result from cutoff of those funds.

2015
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Re: Help me understand what happen with the new law and ACA subsidies

Post by 2015 » Sat Oct 14, 2017 10:44 am

stlutz wrote:
Sat Oct 14, 2017 10:38 am
Thanks for the link, 2015! That is a very interesting article.

Since people on BH generally actually like to read, it's worth adding a link to the CBO analysis of the move: https://www.cbo.gov/system/files/115th- ... ctions.pdf

I think the actionable part for most people here is that a Bronze or Gold plan will likely be better deals going forward. Cost sharing subsidies did not impact those plans but they will benefit from higher premium subsidies that will result from cutoff of those funds.
This! My decision to end COBRA this ACA enrollment season was based on an analysis I did earlier this year on CoveredCA which led me to Silver Plans. This past week when I visited CoveredCA it led me to Bronze and Gold plans. At first glance, I was unable to ascertain whether costs would be the same as my analysis earlier this year. Unfortunately, I'm going to have to wait until 11/1 to really dig into the enrollment weeds because right now I have other priorities I'm working on.

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Re: Help me understand what happen with the new law and ACA subsidies

Post by michaeljc70 » Sat Oct 14, 2017 11:03 am

I don't want to get too far off topic, but it is regarding (premium) subsidies . My insurance company offered no plans on the exchanges for 2017. So, since we never got a subsidy, we moved to them off the exchange. Then, due to somewhat unforeseen circumstances, I didn't work this year. My spouse made a little money, but had we stayed on the exchange (and switched companies), we would have gotten a subsidy.

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Re: Help me understand what happens with the new law and ACA subsidies

Post by Moneybags1 » Sat Oct 14, 2017 12:57 pm

I searched high and low and every media outlet is saying everyone in ACA is screwed. Seems the real news is right here at Bogleheads.org... Nobody is saying we would get a better deal with the subsidies based on Silver Plans going up, not even the politicians grasp the facts I read in the post papers on this thread, what gives? Are we wrong to assume we might get a better deal on Bronze and Gold Plans?

Mike

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Re: Help me understand what happens with the new law and ACA subsidies

Post by baw703916 » Sat Oct 14, 2017 3:56 pm

Moneybags1 wrote:
Sat Oct 14, 2017 12:57 pm
I searched high and low and every media outlet is saying everyone in ACA is screwed. Seems the real news is right here at Bogleheads.org... Nobody is saying we would get a better deal with the subsidies based on Silver Plans going up, not even the politicians grasp the facts I read in the post papers on this thread, what gives? Are we wrong to assume we might get a better deal on Bronze and Gold Plans?

Mike
I think it may be a case of attracting eyeballs. Which headline will get more attention: "Everyone in ACA is screwed!" or "If you're in ACA, Bronze or Gold plans might be your best bet"? Same thing as making outrageous predictions about financial markets: "Dow 36,000" or "We're going to have a worse crash than 1929 and 2008 in the next six months!"

"Health Insurance Porn", if you will.

The Gold/Bronze vs. Silver does make some sense, although I haven't thought through all the details. If the subsidies were based on Silver plans, and now their existence is in doubt, that would tend to remove a factor favoring Silver plans in a somewhat artificial way. Still, (assuming the ACA remains available where one lives) it makes sense to base selection of your situation.

But yes, Bogleheads can be a great resource on many topics.
Most of my posts assume no behavioral errors.

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Phineas J. Whoopee
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Re: Help me understand what happens with the new law and ACA subsidies

Post by Phineas J. Whoopee » Sat Oct 14, 2017 4:03 pm

Moneybags1 wrote:
Sat Oct 14, 2017 12:57 pm
I searched high and low and every media outlet is saying everyone in ACA is screwed.
They get paid for selling Ford F-150s. Nobody, except those who need one, will buy such a truck unless they think everything else is unsteady and uncertain.
Moneybags1 wrote: Seems the real news is right here at Bogleheads.org... Nobody is saying we would get a better deal with the subsidies based on Silver Plans going up, not even the politicians grasp the facts I read in the post papers on this thread, what gives? Are we wrong to assume we might get a better deal on Bronze and Gold Plans?
...
When the scary story and the facts disagree it has become customary to change the facts to fit the scary story.

PJW

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Phineas J. Whoopee
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Re: Help me understand what happens with the new law and ACA subsidies

Post by Phineas J. Whoopee » Sat Oct 14, 2017 4:37 pm

baw703916 wrote:
Sat Oct 14, 2017 3:56 pm
...
The Gold/Bronze vs. Silver does make some sense, although I haven't thought through all the details. If the subsidies were based on Silver plans, and now their existence is in doubt, that would tend to remove a factor favoring Silver plans in a somewhat artificial way. Still, (assuming the ACA remains available where one lives) it makes sense to base selection of your situation.
...
I'm afraid I must insist on both accuracy and precision.

The cost sharing reductions are only available on silver plans purchased on the exchange.

The premium tax credits are based on the second-lowest cost silver plan, SLCSP, but can be applied to any exchange plan.

The word subsidy may obfuscate the distinction.

The Patient Protection and Affordable Care Act mandates premium tax credits for anybody whose current-year income falls below 400% of the federal poverty guideline for the previous year, and cost sharing reductions for anybody whose current-year income falls below 250% of the guideline for the previous year. The law does not make cost sharing reductions contingent on federal reimbursement for them. They are clearly mandated either way.

In states which chose, after the US Supreme Court decided they could, not to expand Medicaid neither benefit is available for people whose income is below 100% of the poverty guideline. Such an outcome was not envisioned by the writers of the law.

The Chief Justice of the United States, in an opinion he wrote in a second case, and which was joined by four Associate Justices, referred to the law as poorly drafted, but nonetheless concluded Congress would not intentionally invalidate its own extensive legislation with four improvidently-chosen words.

PJW

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Re: Help me understand what happens with the new law and ACA subsidies

Post by Moneybags1 » Sat Oct 14, 2017 4:48 pm

You guys are the real story. For the helluva it, after reading another thread here about ACA 2018 rates being in, I checked out HC.gov to no avail and then checked FLorida Blue which has the plans and the subsidies. I can get a Bronze HSA (6350. Max OP)for free vs $40 a mo last year and the Silver CSR for $2 more than last year at $82 with the same income. I'm torn between taking being real safe with CSR or being able to churn an extra $4500 in income to be zeroed out with a HSA. I'm in great health and had great numbers this year being 55. Going vegan for the most part really helped.. Meat and crap food is 10% of my diet.

Thanks to all.. I love this site..

Mike

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Re: Help me understand what happens with the new law and ACA subsidies

Post by Bigbonds » Sat Oct 14, 2017 5:07 pm

Actionable items:

1.) and this is key, have a paid off house in a lcol area with low property taxes such as Colorado.
2.) don't work so hard, make less, if your wife works considered letting her stay home and take care of the kids. Take the time to do the math and make sure it's really worth it to make that high income after subtracting taxes and health insurance versus making less.
3.) learn to live on much less. There are tons of blogs on this, rootofgood is a nice starting place. Learn to enjoy the simple things in life, exercising, hiking, camping, reading etc.

This is the actionable actions to take. After doing the math on taxes and health insurance this seems like a good solution.

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Phineas J. Whoopee
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Re: Help me understand what happens with the new law and ACA subsidies

Post by Phineas J. Whoopee » Sat Oct 14, 2017 5:57 pm

Moneybags1 wrote:
Sat Oct 14, 2017 4:48 pm
You guys are the real story. ...

Thanks to all.. I love this site. ...
If I may caution you, you guys in this thread is mostly me. I stand by what I wrote and by my links, but please be careful about concluding something economically important to you based primarily on one voice.

An important cognitive bias to defend against is the illusory truth effect.

PJW

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magellan
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Re: Help me understand what happens with the new law and ACA subsidies

Post by magellan » Sun Oct 15, 2017 8:45 am

I don't want to repost everything I said on a different thread about this, so here's a link:
viewtopic.php?f=2&t=229476&start=50#p3573510

The most important thing is to know is how your state's insurance regulators have instructed insurers to handle things if the CSR reimbursements get halted (which they have now). Here's a link that details how each state is handling it:
https://www.balloon-juice.com/2017/10/1 ... t-be-paid/

Most states instructed insurers to increase premiums just on silver plans. Notable exceptions include Colorado, Indiana, Oklahoma, and Kentucky. In these states, regulators bucked the national trend and instead instructed insurers to spread the premium increases across all policies both on and off the exchanges.

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Re: Help me understand what happens with the new law and ACA subsidies

Post by Moneybags1 » Sun Oct 15, 2017 9:06 am

Phineas J. Whoopee wrote:
Sat Oct 14, 2017 5:57 pm
Moneybags1 wrote:
Sat Oct 14, 2017 4:48 pm
You guys are the real story. ...

Thanks to all.. I love this site. ...
If I may caution you, you guys in this thread is mostly me. I stand by what I wrote and by my links, but please be careful about concluding something economically important to you based primarily on one voice.

An important cognitive bias to defend against is the illusory truth effect.

PJW
PJW, before reading this thread I naturally assumed rates would skyrocket across the board, especially for those w/o subsidies and CSR plans would revert to High deductible plans like most of the rest. After reading your links I investigated more, including my own insurance carrier and was pleasantly surprised. Yes, I get your meaning, Trust, but verify. What you have been saying is slowly in one form or another creeping into news articles.

Mike

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Re: Help me understand what happens with the new law and ACA subsidies

Post by JGoneRiding » Sun Oct 15, 2017 12:03 pm

Bigbonds wrote:
Sat Oct 14, 2017 5:07 pm
Actionable items:

1.) and this is key, have a paid off house in a lcol area with low property taxes such as Colorado.
2.) don't work so hard, make less, if your wife works considered letting her stay home and take care of the kids. Take the time to do the math and make sure it's really worth it to make that high income after subtracting taxes and health insurance versus making less.
3.) learn to live on much less. There are tons of blogs on this, rootofgood is a nice starting place. Learn to enjoy the simple things in life, exercising, hiking, camping, reading etc.

This is the actionable actions to take. After doing the math on taxes and health insurance this seems like a good solution.
Debt free I could live on 400% of the FPL but who can really enjoy life on 250% of it?? That is why there is so many more benefits for them. its the people that hit 255% that have a real problem. So for early retirees that can get their income down below 400% and then purchase a gold plan this change might be actually beneficial because they were never going to get a CSR in the first place.

Bigbonds
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Re: Help me understand what happens with the new law and ACA subsidies

Post by Bigbonds » Sun Oct 15, 2017 1:11 pm

JGoneRiding wrote:
Sun Oct 15, 2017 12:03 pm
Bigbonds wrote:
Sat Oct 14, 2017 5:07 pm
Actionable items:

1.) and this is key, have a paid off house in a lcol area with low property taxes such as Colorado.
2.) don't work so hard, make less, if your wife works considered letting her stay home and take care of the kids. Take the time to do the math and make sure it's really worth it to make that high income after subtracting taxes and health insurance versus making less.
3.) learn to live on much less. There are tons of blogs on this, rootofgood is a nice starting place. Learn to enjoy the simple things in life, exercising, hiking, camping, reading etc.

This is the actionable actions to take. After doing the math on taxes and health insurance this seems like a good solution.
Debt free I could live on 400% of the FPL but who can really enjoy life on 250% of it?? That is why there is so many more benefits for them. its the people that hit 255% that have a real problem. So for early retirees that can get their income down below 400% and then purchase a gold plan this change might be actually beneficial because they were never going to get a CSR in the first place.
You and many others are definitely going to want to look into income manipulation. You don't actually have to live at the 200% level to enjoy all the benefits of it. ;)

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Re: Help me understand what happens with the new law and ACA subsidies

Post by Phineas J. Whoopee » Sun Oct 15, 2017 3:04 pm

magellan wrote:
Sun Oct 15, 2017 8:45 am
I don't want to repost everything I said on a different thread about this, so here's a link:
viewtopic.php?f=2&t=229476&start=50#p3573510
...
Welcome to "you guys." :happy

PJW

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Re: Help me understand what happen with the new law and ACA subsidies

Post by mouses » Sun Oct 15, 2017 5:27 pm

Lynette wrote:
Fri Oct 13, 2017 3:42 pm
HueyLD wrote:
Fri Oct 13, 2017 3:22 pm
stan1 wrote:
Fri Oct 13, 2017 2:54 pm
Actionable items:
Get a job with group insurance
Marry someone with group insurance
Houston, we may have a problem.

(1) I may be too old to get a job, but too young to be on Medicare.

(2) I can't find someone with group insurance to marry.
Unless one is ill, I think many under 65 will be able to find some type of job with medical coverage. I think employer funded health care is far superior to Medicare.
Ha, ha. Oh, sorry. You have obviously not been job hunting in your 50s. Even if you can find some job, it is unlikely to have medical insurance,

Having had employer-funded insurance and then Medicare+MedigapPlanF, both for a long time, I would never trade Medicare for the former. All that stuff about going to the mat with the insurance company just does not happen with the latter.

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Re: Help me understand what happens with the new law and ACA subsidies

Post by nisiprius » Sun Oct 15, 2017 8:28 pm

Moneybags1 wrote:
Sat Oct 14, 2017 12:57 pm
...I searched high and low and every media outlet is saying everyone in ACA is screwed...
This article in this media outlet is fairly heavy on information. The title summarizes the content.
Why [killing] Obamacare insurance subsidies might not matter much.
Last edited by nisiprius on Mon Oct 16, 2017 10:15 am, edited 1 time in total.
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Re: Help me understand what happens with the new law and ACA subsidies

Post by ERISA Stone » Sun Oct 15, 2017 9:30 pm

magellan wrote:
Sun Oct 15, 2017 8:45 am
I don't want to repost everything I said on a different thread about this, so here's a link:
viewtopic.php?f=2&t=229476&start=50#p3573510

The most important thing is to know is how your state's insurance regulators have instructed insurers to handle things if the CSR reimbursements get halted (which they have now). Here's a link that details how each state is handling it:
https://www.balloon-juice.com/2017/10/1 ... t-be-paid/

Most states instructed insurers to increase premiums just on silver plans. Notable exceptions include Colorado, Indiana, Oklahoma, and Kentucky. In these states, regulators bucked the national trend and instead instructed insurers to spread the premium increases across all policies both on and off the exchanges.
Am I reading this correctly? In GA, it says Kaiser is pricing as if CSRs are paid. Another article I read says Kaiser intends to increase GA rates by an average of 57%. Those two pieces of information don't seem to connect.

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Re: Help me understand what happens with the new law and ACA subsidies

Post by indexfundfan » Sun Oct 15, 2017 9:38 pm

ERISA Stone wrote:
Sun Oct 15, 2017 9:30 pm
magellan wrote:
Sun Oct 15, 2017 8:45 am
I don't want to repost everything I said on a different thread about this, so here's a link:
viewtopic.php?f=2&t=229476&start=50#p3573510

The most important thing is to know is how your state's insurance regulators have instructed insurers to handle things if the CSR reimbursements get halted (which they have now). Here's a link that details how each state is handling it:
https://www.balloon-juice.com/2017/10/1 ... t-be-paid/

Most states instructed insurers to increase premiums just on silver plans. Notable exceptions include Colorado, Indiana, Oklahoma, and Kentucky. In these states, regulators bucked the national trend and instead instructed insurers to spread the premium increases across all policies both on and off the exchanges.
Am I reading this correctly? In GA, it says Kaiser is pricing as if CSRs are paid. Another article I read says Kaiser intends to increase GA rates by an average of 57%. Those two pieces of information don't seem to connect.
The article I have read says that the hikes are "Kaiser: 30.6 percent if CSR funding continues; 56.7 percent if it doesn’t." I think this one is more recent since it provides the breakdown.
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Re: Help me understand what happens with the new law and ACA subsidies

Post by indexfundfan » Sun Oct 15, 2017 9:45 pm

This article, dated 9/28, confirms that GA's insurance officials have approved the rates hikes and have sent them to the federal officials for approval.

http://www.macon.com/news/local/article175842756.html
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Lynette
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Re: Help me understand what happen with the new law and ACA subsidies

Post by Lynette » Mon Oct 16, 2017 12:00 am

mouses wrote:
Sun Oct 15, 2017 5:27 pm
Lynette wrote:
Fri Oct 13, 2017 3:42 pm
HueyLD wrote:
Fri Oct 13, 2017 3:22 pm
stan1 wrote:
Fri Oct 13, 2017 2:54 pm
Actionable items:
Get a job with group insurance
Marry someone with group insurance
Houston, we may have a problem.

(1) I may be too old to get a job, but too young to be on Medicare.

(2) I can't find someone with group insurance to marry.
Unless one is ill, I think many under 65 will be able to find some type of job with medical coverage. I think employer funded health care is far superior to Medicare.
Ha, ha. Oh, sorry. You have obviously not been job hunting in your 50s. Even if you can find some job, it is unlikely to have medical insurance,

Having had employer-funded insurance and then Medicare+MedigapPlanF, both for a long time, I would never trade Medicare for the former. All that stuff about going to the mat with the insurance company just does not happen with the latter.
I guess experience differs. I had absolutely no problems with employer-funded healthcare. I had a primary care physician who referred me to different specialists. I never had any follow-up on any bill in the 40 years I worked in the US. I also have Medicare+MedigapF+D. I have absolutely no idea what Medicare will cover. I asked the Medicare what they cover because of the problems I had. The answer was they would cover something if it was necessary. The doctor's office told me that Medicare would not pay for some part of the procedure. So how am I to know if it is necessary? I had none of this bureaucracy with my employer-funded healthcare. They paid for everything that my primary care physician recommended and the specialists to whom he referred me. I had a wide range of hospitals and specialists I liked who accepted my insurance.

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Re: Help me understand what happen with the new law and ACA subsidies

Post by nisiprius » Mon Oct 16, 2017 10:32 am

Lynette wrote:
Mon Oct 16, 2017 12:00 am
...The answer was they would cover something if it was necessary. The doctor's office told me that Medicare would not pay for some part of the procedure. So how am I to know if it is necessary? I had none of this bureaucracy with my employer-funded healthcare. They paid for everything that my primary care physician recommended and the specialists to whom he referred me. I had a wide range of hospitals and specialists I liked who accepted my insurance...
I've now been on Medicare + supplemental for a while. Before that I was on several local-major-insurer HMOs at work. My experience with both has been excellent--no real problems with either. However, to date, I've had many more times when I needed to get on the telephone with HMOs. The two most frustrating included an $800 bill for a polysomnography (sleep study) that had been pre-approved. Long story short, although they approved the study and the facility, they had a problem with the fact that the clinician who ran the sleep center and read all the charts had an MD degree in psychiatry, and I fell through the crack between them and their separate "behavioral medicine" insurer. All resolved after a lot of phone calls.

So far, with Medicare, with more experience and more medical procedures than I'd have liked, there have been no denials and no problems at all. Well, more correctly, there have been denials but they never have affected me--gotten summary notices showing denied claims, but I never got a bill and on the next summary notice it had been re-submitted and paid.

I agree with you that it is frustrating not to be able to get a positive pre-approval for a procedure from Medicare. As you say, it is always "if medically necessary." But so far, no problems. I don't think doctors' offices really want to have Medicare patients undergo non-Medicare-reimburseable procedures. Closest call that I know of so far was when my dentist sent me to a "dental surgeon" and the dental surgeon's office seemed quite unfamiliar with Medicare and refused to even guess whether it was covered, and of course had me sign off on paying the bill if Medicare didn't cover it--but they did.
Annual income twenty pounds, annual expenditure nineteen nineteen and six, result happiness; Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery.

Lynette
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Re: Help me understand what happens with the new law and ACA subsidies

Post by Lynette » Mon Oct 16, 2017 11:40 am

Thanks Nisiprius. I guess I'll simply have to get used to Medicare. I'll see what happens with the appointment at the ophthalomologist for a regular examinations. My Megacorp HMO paid for this for several years. Now I'm on Medicare, the ophthalomologist's office told me that Medicare would pay for everything except part of the exam which was called refraction - or something like that. This will cost me $50. I have no idea or not if this is necessary. My highly experienced ophthalomologist seems to think so. I don't think he needs to make an extra $50 by giving me an unnecessary test. I'll have to wait and see if I get billed.

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Re: Help me understand what happens with the new law and ACA subsidies

Post by nisiprius » Mon Oct 16, 2017 12:16 pm

Not to get onto an actual medical topic, I think I can say that "refraction" means measuring your eyes to see if you need new glasses and determining the prescription for them. As you probably know Medicare does not pay for eyeglasses (or hearing aids!) and therefore, somewhat logically, doesn't pay for the refraction needed to prescribe them. So, yes, if your HMO paid for eyeglasses, that is a definite Medicare annoyance. However, when I have visited an eye doctor for some other reason beyond just getting prescriptions for new glasses, my experience has been that I often do not get billed for the refraction.
Annual income twenty pounds, annual expenditure nineteen nineteen and six, result happiness; Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery.

Lynette
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Joined: Sun Jul 27, 2014 9:47 am

Re: Help me understand what happens with the new law and ACA subsidies

Post by Lynette » Mon Oct 16, 2017 12:36 pm

Thanks - that makes sense. My HMO did not pay for eyeglasses but they paid for the refraction test for years. I was referred to the ophthalomologist by my primary care physician as I had some other problem with an eye. The HMO never questioned the test for refraction - likely not worth their time. I'll see what Medicare decides.

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