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A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

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Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#101
post #79

Earlier quoted context omitted.

As I understand it, and your accountant is an expert while I am not, you have to be actually self-employed --- not moonlighting or doing side-work, with your money all coming in through the LLC --- and your spouse can't be eligible for group coverage through their job.

i was sole proprietor of my own pass through llc with no other income and single through oct 2017

I have the entirely opposite experience in NY. It's a Federal guideline though.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#102
post #69

Earlier quoted context omitted.

ACA is horrendous, unless you're receiving a government subsidy. I'm self-employed and we have one option of insurance provider, and the cheapest plan for my family last year was $18,000 a year with a huge deductible. That's after tax, out of pocket, for a healthy family with no pre-existing. Like all self-employed people I know (who aren't getting government subsidy), I moved my family to Christian Medishare, which…

>ACA is horrendous, unless you're receiving a government subsidy. I'm curious as to why you say "the ACA is horrendous" rather than "The income cutoffs for the ACA subsidies are way too low" - I mean, it seems obvious to me that if you make a median salary and have a family of four that you need some sort of health insurance subsidy, but I don't know where the ACA subsidy lines are, or even if they vary per state or…

My own personal "why I hate the ACA"...

In 2016, I decided to take off from work and travel outside the US. I did what I thought was the responsible thing and purchased a travel insurance plan. In total, I was gone for a year...I had an amazing trip.

When I got home, I wanted to sign up for insurance again. But since it wasn't a life event, I wasn't eligible to enroll until the open enrollment period. And when that time rolled around, I wasn't eligible for the subsidized plans because I hadn't gotten a job yet and my monthly salary was $0/mo. Nevermind that I'd done enough contracting work during my trip such that if you divided my annual earnings by 12 to arrive at a monthly earning, it would've easily qualified me for a subsidy to stay on a plan that let me see my previous doctor. But I did eventually get signed up for Medicaid for the month between open enrollment and when I found a job, so...yay?

Then tax time rolls around and, it turns out, you need to be out of the country for 11 out of 12 calendar months to qualify as a non-resident. Since my trip didn't start on Jan 1st, despite being out of the country for an entire year, I didn't qualify as a non-resident for either 2016 or 2017 and had to pay the ACA penalty for the entire time I was gone because I didn't buy health coverage that would've only been useful in a country I wasn't present in. And adding insult to "please don't let me get injured", I had to pay a penalty for the time I was uninsured between when I got home and open enrollment.

In short, I feel like the ACA was rushed and they never seriously considered what was right for people not working a 9-5 job getting regular pay checks. By deciding to opt out of the workforce and do my own thing for a while, even doing it responsibly, the ACA cost me thousands because I somehow managed to find corner cases that were simply not considered or poorly handled by those writing the bill.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#103
post #32

Earlier quoted context omitted.

ACA is horrendous, unless you're receiving a government subsidy. I'm self-employed and we have one option of insurance provider, and the cheapest plan for my family last year was $18,000 a year with a huge deductible. That's after tax, out of pocket, for a healthy family with no pre-existing. Like all self-employed people I know (who aren't getting government subsidy), I moved my family to Christian Medishare, which…

The rate of increase for health insurance prices went down after the ACA was enacted. The motivation for enacting the ACA was, in large part, the untenable increase in insurance prices in the 10 years leading up to it. People have a bad habit of blaming the ACA for insurance prices. The ACA failed at its goal of making individual health insurance affordable, that is true. But it didn't cause that problem, and it did…

So you are saying the acceleration of cost went down? It’s bad enough we have to compare health costs on the 2nd derivative. Maybe soon will need to use the 3rd.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#104
post #14

If you're a tech entrepreneur, it's the first story in here that should alarm you the most. It's about denying coverage altogether, not about denying individual claims. Outside of the "guaranteed issue" ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse. The list of conditions for which insurance outside the ACA will be denied is long and opaque. The s…

ACA is horrendous, unless you're receiving a government subsidy. I'm self-employed and we have one option of insurance provider, and the cheapest plan for my family last year was $18,000 a year with a huge deductible. That's after tax, out of pocket, for a healthy family with no pre-existing. Like all self-employed people I know (who aren't getting government subsidy), I moved my family to Christian Medishare, which…

That $18k was what I was quoted too. Of course no one would believe me.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#105

This story is couched in terms of how bad things were before Obamacare, but I’d like to point out that things aren’t great now either. To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally. A few months ago, I woke up the next morning after eating some fast food and began vomiting. I couldn’t stop throwing up, and I couldn’t…

> To prevent Obamacare from bankrupting them, insurance companies are resorting to legally dubious mass-denials, one of which affected me personally.

What does the policy has to do with Obamacare? Completely unfair denials obviously happened before the ACA (see: this article), and the idea that Anthem is doing this to stave off bankruptcy is laughable (just see their financials since the ACA was enacted).

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#106
post #14

If you're a tech entrepreneur, it's the first story in here that should alarm you the most. It's about denying coverage altogether, not about denying individual claims. Outside of the "guaranteed issue" ACA market, there is virtually no due process for coverage denial. You can be denied on a whim, with little recourse. The list of conditions for which insurance outside the ACA will be denied is long and opaque. The s…

ACA is horrendous, unless you're receiving a government subsidy. I'm self-employed and we have one option of insurance provider, and the cheapest plan for my family last year was $18,000 a year with a huge deductible. That's after tax, out of pocket, for a healthy family with no pre-existing. Like all self-employed people I know (who aren't getting government subsidy), I moved my family to Christian Medishare, which…

We moved to Samaritan Ministries and have been really happy with it. Our “premium” is $500/mo and our total out of pocket costs have just been checkups and misc small prescriptions. Our two major medical incidents have been 100% covered by members and we got some nice cards in the mail, too. I estimate we have saved about $20,000 without increasing risk (possibly reducing it since the uncertainty of the claims process is gone.)

It’s been nice to see that a well designed system can help people take care of people so humanely.

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#107
post #100
post #94

Earlier quoted context omitted.

There is no silver bullet in health care. The field is too large for any one single solution to cover everyone (3 Trillion USD per year is spent on health care). There needs to be a lot of innovation in a lot of different areas in order to solve the problem. I started a company with my brother that is attempting to drastically lower costs for primary care. ( https://scalpel.com ) We build software that allows physici…

I think there's plenty of room for innovation but we should start from the principal that everyone gets full access to medical treatment regardless of their ability to pay.

We technically have this in the United States (for emergencies). It is illegal for someone to be denied emergency services regardless of ability to pay.[0] No government system guarantees "full access" to medical treatment there is some form of rationing everywhere.

https://www.cms.gov/Regulations-and-Guidance/Legislation/EMT...

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#108
post #95

Earlier quoted context omitted.

It’s more complex. Medicare is outcome-based. Providers who do a shitty job don’t get paid, which is why hospitals complain about reimbursement. Medicaid is like an ATM machine for providers in many states. There is usually little or no correlation between outcome and payment, and poor fraud controls. That’s why you always hear about providers in NYC and Miami who “visit” 900 patients a day. Additionally, you have th…

The market would work better if everyone was paying the same prices without "denial-based" inflation. I think the solution would be to give citizens disease/disorder "endowments." i.e. a yearly health stipend account - it's money they can spend at doctors, but they can't spend on unrelated goods/services (i.e. food). On top of that, additional "stipends" for major life ailments. The trick would be in finding budgets…

You may want to read up on Singapore's Central Provident Fund system, as a real-life implementation of something similar: https://en.wikipedia.org/wiki/Central_Provident_Fund

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#109

This is a good article, but it only shows a few parts of a much more complex whole, and extrapolating from these anecdotes to a broader system is not really accurate Many hospitals lose money on every Medicare and Medicaid patient. The only reason they survive is because they can charge private insurance companies more. So hospitals and health systems have been consolidating to strengthen their negotiating position a…

Note that you never mentioned person who actually receives service. IMHO problem is exactly that - none of players you mentioned truly interested in long term cost control. Some might just care about short term budgets, but otherwise all of them will pass it down to the consumer. And consumer being on their own, with little to no competition and information asymmetry has very little leverage..

Re: A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims

#110
post #69

Earlier quoted context omitted.

>ACA is horrendous, unless you're receiving a government subsidy. I'm curious as to why you say "the ACA is horrendous" rather than "The income cutoffs for the ACA subsidies are way too low" - I mean, it seems obvious to me that if you make a median salary and have a family of four that you need some sort of health insurance subsidy, but I don't know where the ACA subsidy lines are, or even if they vary per state or…

My own personal "why I hate the ACA"... In 2016, I decided to take off from work and travel outside the US. I did what I thought was the responsible thing and purchased a travel insurance plan. In total, I was gone for a year...I had an amazing trip. When I got home, I wanted to sign up for insurance again. But since it wasn't a life event, I wasn't eligible to enroll until the open enrollment period. And when that t…

So there's a lower bound on how much you can make and still get the subsidized plan? that seems broken in a very American sort of way.

I think a lot of the bureaucratic issues might be the nature of insurance companies? My (pre-aca) experience was that any lapse in coverage and they don't let you back on. All this 'life event' stuff, I think, was part of how group plans worked back in the day, the rules about when you could change things and when they could kick you off.

I guess what I'm saying is that (aside from charging you the extra tax) I don't think it's worse than it used to be.

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