Where’s the Free stuff
Consultations are always FREE - and so is my blog.
Many workdays I have the task of explaining how Medicare and Medicaid work. I’m sure many of you may not even know the difference between the 2, I know I didn’t before I entered this field!
Medicaid is medical coverage offered to people with low incomes. I remember the difference by -Aid as in financial aid. Medicaid will cover you very well but the network of Doctors willing to accept about $.10 on the $1 is limited, not bad, but limited. As Medicaid is strictly a goverment program and you have no choices if you accept financial assistance, the government does not feel the need to publish a summary of benefits. As one government employee expressed it to me – “you get what you get”. Presently an individual earning less than $16,683 per year should be eligible for Medicaid. NY has expanded the Medicaid program to offer low cost coverage to individuals earning up to $23,540. This expanded Medicaid is called The Esseential Plan.
Medicare is what people over 65 or under 65 having a disability for over 2 years are entitled to from the government. Medicare Part A is free to most people if they have worked and contributed to the system for 40 Quarters. Medicare Part B is an option (that may incur a penalty if you do not opt for it) that will likely cost you $134 per month.
Part A covers your Hospital related medical expenses at 80% after you have met the deductible of $1340 per admission.
Part B covers your outpatient related medical expenses at 80% after you have met the annual deductible of $183.
MediGap or Medicare Supplements (2 names for the same thing) fill in some or all of the gaps in Part A and Part B.
Part C is basically the combination of A+B with several important extras. Also referred to as an Advantage Plan/MA or MAPD if it includes Prescription Drug coverage.
Part D is Prescription Drug coverage/ PDP (that may also incur a penalty if you do not opt for it)
Simple? Yes, but oh so complicated. Within all of these choices are, of course, many more details but also the difficult choice of picking the plan that is right for you without knowing what the future will bring.
Can I help?
(amounts quoted are as of 9/2018)
Geez, what will they come up with next to undermine the ACA, reduce Health Benefits and increase revenue for Corporations?
You may think that plans to allow individuals to become part of Associations in order to purchase Health Insurance sounds like a good idea but please look deeper into the offerings.
An Insurer selling an “association plan” would be permitted to reduce or eliminate the Essential Health Benefits required to be offered by the ACA. (This type of offering is also specifically contradicts the federal ERISA laws which govern employee benefits). Why? Because in order for the ACA to succeed all levels of risk must be part of the Health Insurance “pool”. As with all types of insurance rates are determined by actual usage averaged by the participants, i.e. a large pool of older sicker people will have higher rates that a pool including younger and healthier people. Those that opt for lesser benefits will remove themselves from the healthier pool and raise rates for others.
And, just imagine one of those who opted for fewer benefits gets sick and their needs are not met by their Health Insurance? You guessed it, they wind up right back needing taxpayer money (medicaid) to meet their medical needs and, hopefully, avoid bankruptcy.
Agree or disagree? Let me know!
To begin I would like to point out that I am conflicted over the notion of Government run Health Care for all. There are several reasons but to state the obvious I earn my living from the commission paid by the insurance companies when assisting people and businesses in attaining coverage. I am certain that I provide a needed service and that my role will disappear to the detriment of the enrollees. However, I am also of the opinion that as a technologically advanced and educated civilization (wishful thinking sometimes) I believe it is our duty to elevate the standard of care for all our citizens (at least) and provide “Health Care for All”.
What is Single Payer?
I am specifically responding to the NY Health Act when I say that the idea of Single Payer is to create a government monopoly whereby the government is the only entity negotiating rates directly with hospitals, doctors and other medical providers and is also responsible for paying them for covered services whenever they are needed. The idea is that eliminating the intermediaries (the insurance companies) and adding Federal funds already earmarked for Medicare and Medicaid and the Affordable Care Act will finance the administration and care costs. So, to recap: “Single Payer” is putting the government in charge of your access to and negotiating the costs and payment of your healthcare costs.
The formula which has been presented to communities, but which does not seem to appear in the NY Health Act is that those earning less than $25000 would not pay for coverage, those earning up to $400,000 would pay 10% of their income and only those who earn over $400K might pay more for their health care. Employers would be taxed to help cover their employees.
- Theoretically, everyone will have access to the medical care they need.
- Providers, Doctors, hospitals other health care professionals, will have a lesser administrative burden in collecting their negotiated rates.
- Government tends to create bureaucratic nightmares of administration. There is absolutely no accountability for government employees to be pleasant, helpful or knowledgeable. (NY State already runs a Health Care Marketplace, so we have an example of NYS administration of your access to health care)
- The NYS Health Act says that it expects to negotiate rates similar to those of the current rates negotiated by insurance companies. That is already an issue with providers and many providers choose not to participate with plans based on their low reimbursement rates. How will Providers afford to maintain quality if all their patients are paying the lowest rates, somewhere between 10 – 25% of their billed rates? Many doctors presently accept Medicare and Medicaid, but they could not possibly maintain a practice or any reasonable standard of care if it were their only fee structure.
The Board of Directors will be comprised a Commissioner, a Superintendent of Financial Services and a Director of the budget and of 19 additional Governor appointees, 5 of whom shall represent healthcare advocacy groups, 2 will represent physicians, 2 will represent healthcare providers other than physicians, 3 will represent hospitals, 1 will represent community health centers, 2 will represent health care organizations, 2 will represent organized labor, 2 will have expertise in health care finance, with 10 additional Governor appointees representing political bureaucracy. That adds up to a board of 32 members with none representing those “covered” under the NY Health Act and all being political appointees!
The NY Health Act will have “Care Coordinators” that are expected to ensure your access to the treatment you need. Again, it is not in the hands of the medical professionals but a 3rd party government employee.
NYS already has some of the toughest oversite of the insurance industry in he US. The Department of Financial Services, DFS, approves the rates that insurance companies propose. If the Government is expected to be trusted to oversee and implement your access to Healthcare, why are they not doing that now?
In 2016 8 CEO’s from the largest Health Insurers earned nearly $172 Million, that’s an average of $21 Million each.
Pharmaceutical costs and profits continue to soar in the US while Canada has been restricted from selling the same drug back to the US for less. Why does the US consume the greatest volume of drugs per capita at the greatest cost? Perhaps we can trust the government to investigate and regulate that?
Why tax employers to add to the funding? Why not offer coverage to all at an even playing field?
The myriad things that are wrong with the US system of Healthcare need to be addressed but I do not believe that Politicians and Governmental bureaucracy will do that adequately.
What do you think?
With the election of Donald Trump and a Republican Majority it is time for the Republicans to put their constructive ideas where their destructive mouths have been.
There is no question that millions more Americans have health coverage than before the Affordable Care Act came into being. Now the Republicans have the unenviable task of turning “Obamacare” into “something terrific”. No surprise that the proposed changes will benefit the upper class and also attempt to limit or deny a woman’s right to choose.
The [Republican] Administration recognizes that the problems with the U.S. health care system did not begin with – and will not end with the repeal of – the ACA. With the assistance of Congress and working with the States, as appropriate, the Administration will act to:
*Protect individual conscience in healthcare
*Protect innocent human life from conception to natural death, including the most defenseless and those Americans with disabilities
*Advance research and development in healthcare
*Reform the Food and Drug Administration, to put greater focus on the need of patients for new and innovative medical products
*Modernize Medicare, so that it will be ready for the challenges with the coming retirement of the Baby Boom generation – and beyond
*Maximize flexibility for States in administering Medicaid, to enable States to experiment with innovative methods to deliver healthcare to our low-income citizens
There is an excellent article on the future of the ACA at http://www.latimes.com/business/hiltzik/la-fi-hiltzik-repealing-obamacare-20161110-story.html
To address your immediate concern, it is highly unlikely that any changes will affect your coverage options for 2017. It may be your last chance to get a Tax Credit toward the cost of your premium. I say take advantage of it now, you know Trump would!
I have been observing, from my intimate perch of acting as a Broker for over 150 Individual Clients seeking Health Insurance, the implementation, accessibility and expense of Health Insurance in NY. I assist people in trying to find insurance that will work for them. I try to be of help but I did not create the system and (as I often say) they didn’t ask my input!
First let me say that I believe that seeking and finding quality medical care should be a fundamental human right. I think it sits right alongside basic (and even higher) education, clean drinking water, feeding the poor and children, and income for our elders (Social Security). I believe that an educated privileged society has a responsibility to all its members to do better. I do not have the answers about how this can be done but I do have some basic tenants;
* Individual rights must be ranked above the rights of Corporations
* All citizens must contribute a fair share of their earnings to the sustainability of the government and infrastructure of the society.
* Government must be minimal, logical, fair, efficient and serve the best interest of ALL its citizens. (I know, I know, I’m a dreamer)
Witnessing the adjustments to the rates and policies offered to New Yorkers is shocking. An ordinary, middle class individual can easily pay $6000 to $10000 per year for Health Insurance and still have to pay out of pocket for a visit to a Doctor! The basic formula of the Affordable Care Act is that an individual earning less than $47,500 (400%) of the Federal Poverty Level should not have to pay more than about 10% of their gross income for health insurance with a deductible of about $2,000. If you make $50,000 you are expected to pay about 15% for the same coverage.
The Insurance companies continue to post profits and pay obscene salaries to their CEO’s and cry that they need to access risk pool funds to pay their way out of the high costs of Insuring sick people. I see several problems: One is that even though NY State oversees the Insurance Industry in NY, compensation to executives does not seem to fall into the profit line item of an Insurer. Another is that many Insurance policies do not cover mail order prescriptions AT ALL. This demonstrates that the Pharmaceutical companies have used their influence to plug up the hole that allowed people to save money by ordering their drugs from across borders that did not have exorbitant prices. Lobby much?
The problem goes back to my 1st tenant, the rights of Corporations. Continually our representatives in Congress choose to accept money and promote the interests of Corporations over their constituents. The laughably named Affordable Care Act does not have a chance if it does not find a way to control the costs associated with medical care. Insurance companies are just 3rd party payers, they try to limit their costs but at the expense of their customers and their providers. Doctors have bills to pay too, not the least of which are school loans, malpractice insurance and a staff whose primary job is to bill the insurance companies!
Basic Arithmetic – A large Corporation employs 1000 who earn $50k each. What if a CEO was paid a % of the earnings of their employees? 10% would be $5 MILLION. Want a bonus? Pay your employees more money and you got it! Too logical. And I’m not even asking for the CEO to pay 10% of their GROSS income on Health Insurance.
With the increased cost of Health Insurance since the advent of the PPACA it is only logical that people turn to an idea that would seem to make costs more reasonable. The notion of a Single Payer system is that the government is the payer (that means all of us taxpayers) rather than the insurance companies. The Hospitals would receive “global” funds instead of per treatment payments.
Touted as “Medicare for All” it would seem that everyone would have access to whatever health care they needed at a modest cost. After all good Medicare coverage is not free either.
The things that I wonder about are;
The ever escalating costs of pharmaceuticals, diagnostic equipment, facility, malpractice insurance and administration fees, what keeps those in check?
Are all medical professionals given a stipend? Even the not so good ones? How do Dr’s repay their student loans?
Most importantly I wonder how the government will administer this program? I can tell you from my nearly 3 years of working on the New York State of Health that a government funded and operated program is not efficient or in the least bit effective. Working with multiple random contacts that are not familiar with the system and not accountable for their “advice” or behavior is not effective. At least with multiple Private Insurers there is the notion of competition, that to earn your business they must to it better than the other guy. Service is the key to satisfaction and service is not something that government run programs do well.
One of the best indications for me to know that someone doesn’t really understand the Patient and Protection Affordable Care Act (PPACA), shortened to the Affordable Care Act (ACA) and nicknamed “Obamacare” is when they refer to it as Obamacare.
Let’s start off with Obamacare is not a Health Insurance plan. If you have Empire or MVP or the like Obamacare is not an alternative. I prefer to call it by it’s abbreviated acronym ACA or more specifically in we have “The New York State of Health”, the NYSoH, which is our state’s access to the Affordable Care Act.
In the simplest terms the ACA is the governments way of helping people afford the monthly premium for their Health Insurance by giving them an upfront tax credit, on a monthly basis, and applying it directly toward their Health Insurance premium. Really, that’s it.
Of course they have little control over the Insurance, Pharmaceutical, Provider or Facility fees. Therein lies the problem. I am not going to tell you that there haven’t been massive changes to what Health coverage is available to you, just that some of the changes are good. Hopefully, with time, the other changes can get the kinks worked out.
Are you a good candidate for the Affordable Care Act? Let’s find out!