Things that are just NOT true about the Affordable Care Act (PPACA)

Here are some thing that I've heard that just are not true:

1) Obama took my insurance away.
First of all, since President Obama has been in office, he's been blamed for everything from taking people's insurance to causing the drought in California.  He must be a really busy guy who gets no sleep at all, because I don't even have time to balance my checkbook, let alone manipulate the price of gasoline single-handed.

Facts:
1- Your state Insurance Commissioner authorizes health plans in your area after the insurer has submitted them for review.
2- HHS manages which plans will be offered through the exchange after the insurer has submitted them for review.
3- Congress made the PPACA a reality.  Since insurance is actually regulated by the states, the President is a great go-between for State Governors and Congress.  The President was highly proactive in arranging exceptions that would ease the blunt-trauma caused by an ineffective system.  Some things couldn't be avoided and no other President has gone to the great lengths to make transitions like this easier to swallow and at the end of the day, it kinda worked.

The health insurance plans that were either cancelled or just non-renewable did not fit into being compliant with new regulations. The fact is, people who had plans that they could not keep had plans that would really not serve them well if something major happened, even if they were called major medical.  Some people were perfectly happy with them, great.  The reality is that a person would pay in good money for a plan they thought was great, but when the time came they would find out otherwise.  This has been controlled in more ways than one.

It's not an issue of 'being a fan' or not.  It's irrelevant. 

2) ACA compliant plans have a higher deductible.
In some cases this is true.  But in many cases it's an example of comparing apples to oranges.  The question I always ask is, "what did you have before?"  Oh, nothing?

It is TRUE that some family plans in some counties would have a high ($12,600) max out of pocket with some insurers.  If we were to compare apples to apples, a similar catastrophic plan pre-2014 could have a $20k max out of pocket quite easily). On the other side of the coin, if you are Native American or Alaska Native, you have a $0 copay, $0 coinsurance, $0 deductible plan.  Many people who I've been able to help also qualified for 'Reduced Cost' plans.  These plans have very low deductibles and out of pocket maximums, at times a $250 deductible and a $750 max out of pocket with $20 copays for someone who last year was not able to get coverage due to health conditions and wouldn't be able to afford it if they could.

3) My doctor doesn't take 'Obamacare'.
Your doctor doesn't know what Obamacare is, because it's fictitious.  The fact is, he is just not in the network that your health plan is also associated with.  This would be true with an off-exchange plan also and has no relevance to it being on or off exchange.

Leading up to the Marketplace opening, most insurance companies adjusted their networks.  Many networks invited doctors to become part of networks which would be offered on the Marketplace.  If the doctor did not accept, then they were out.  Doctors pick and choose and so did the networks.  Doctors are part of networks, not insurance companies, unless they actually work for an insurance company or an exclusive provider, which is not the norm.

TRUE, your doctor may not be in the network that your insurance plan uses.  Solution = 1) change doctors or 2) find a plan/network that will be accepted by your doctor.  Don't want to change doctors but still want to get a tax credit?  Well, that itself can be a challenge again, because of the network membership.  You could, though, pay full premium for an off-exchange plan.  It's all about weighing the options.  THE entire reason for the changes in legislation is to attempt to control healthcare costs, which most people would agree is out of control.  Therefore, the network memberships are a way of controlling these costs.

Some insurance companies offered plans with different networks On-Exchange (Marketplace), such as an HMO (HMOx) or EPO, and other networks off-exchange.  Some did not and kept their current HMO/PPO networks.  I've seen both occur within the same insurer and is normally dictated by the area which the insured person lives.  The doctor is also NOT able to pick and choose who he/she sees based on the plan the person has.  It is the network, either they are part of it or they are not.  It is an agreement between the doctor and the insurance network that is the issue.

Example: Let's say I have ABC insurance and am in the XYZ network.  The doctor is in the XYZ network and I go for a visit.  I tell him I just got an ACA plan with tax credits.  The doctor cannot change the way he bills based on this.  He is in the network and must abide by the network agreement.  He can't refuse to see me based on the plan I have if he is in the network that the plan provides.

However, are some doctors upset that the claim payments have been reduced for them based on the new networks?  Sure, but they agreed to be part of that network.  Just like Medicaid and Medicare, doctors normally make less money for routine items.  So sorry, but you also get more business and normally patients who also will require more treatment.  The smart doctor will make more money accepting these networks in the long run due to economies of scale.

IMPORTANT- I've seen this more than once...  A person calls up for an appointment and tells the doctor they have new insurance, and good news, it's the Gold plan.  Dr replies, "I don't take the Gold plan, but I do take ABC Insurance"  The doctor thinks you are referring to a Medicare plan and takes the Silver plan but not the Gold.  Doctors and their Biller/Coder don't generally know about the specific plan nor the carrier, but they do understand the network, ask about the network.

4) The government is making me get insurance.
 Nobody is making anyone get insurance.  There is a tax penalty under the 'Individual Mandate' that was voted on by Congress for anyone that is not exempt or does not carry 'Creditable Coverage' for 3/4 of the year or more.  During 2014, the exemptions are quite liberal.  The penalties are also relatively low.  But, as time goes on the penalties will increase and the exemptions will be more conservative.

So, you don't 'have to get covered'.  You may face a tax penalty and you may be exempt.

Here's an argument...  Joe says he doesn't like the new law because it penalizes him for not getting health coverage.  So, he refuses any type of insurance.  He doesn't 'like socialized medicine' or 'that a-hole in Washington'.  Two months later he's cleaning leaves from the gutter, gets electrocuted, ends up in the hospital.  Who could foresee that? The bill is $50,000, who pays?  Joe won't because he can't afford it, so who does?  He has permanent injuries needing treatment and now realizes he needs insurance.  The doctors aren't very willing to provide treatment for free.  So, Joe, what are you going to do?  If this happened in 2010, the pre-existing condition clause would ensure that no company would help with his future bills either, again who would pay?  In 2015, he would be able to get covered during open enrollment and get treated.  In the end, we all pay regardless.  However, now at least Joe can get coverage and treatment.

Insurance is meant to protect against 'unforeseen circumstances'.  That's the purpose.  Just like automobile insurance, house insurance, business indemnity insurance, etc.  How important is insuring your body? It's the only one you're going to get.  Many people, including myself, complained when automobile insurance became mandatory.  It's the same thing here.  But, with health insurance, we all won't continue to pick up the tab for Joe.

5) The insurance says my Preventative benefits are free, but my doctor just billed me $800.
Again, your doctor was likely mistaken.  He either 1) didn't include the fact that the visit was preventative, or 2) ran a bundle of tests that you didn't understand or approve.  Go back to your doctor and have him/her fix it ! Seriously.

This is happening quite often, due to one of 3 things:
1) ICD 10 coding.  Doctors send their billing to a 3rd party in many cases.  The billing codes are changing changed from ICD 9 to ICD 10, which reclassifies everything.  Smaller offices have in-house billing.  They may not be properly trained in the new codes.

2) Doctor knowledge.  Here, I'll say it: Doctors don't know everything.  They may not understand how the preventative benefits work.  They can't possibly know what all of your insurance benefits are, because everyone is different.  They can't just run a barrage of tests just to see if they may be able to find something worth treating.  And, they SHOULD disclose to their patient what tests are necessary and which ones aren't.

3) Greed.  A doctor may know that your preventative visit will net him about $65-85.  Not bad for 15 minutes of work.  But, if he/she can add some tests, they can increase the amount they make.  Maybe even add some unnecessary prescriptions for something called 'pre-diabetes' and make that distributor that buys lunch once a week some money.  If the insurer notices that they are not necessary nor preventative, they may not be willing to pay.  These things happen no doubt, this is why it is important to have a good rapport with your doctor and understand what they are doing to help you.

6) The coverage under my Obama-plan is inferior to commercial insurance.
Again, there is no 'Obama-plan' and the policy you have, if you have an On-Exchange (Marketplace) plan, is most likely no different than one that is Off-Exchange.  Treatment should be no different, and if it is, change doctors.  Any differences will be very small if any.  All of these plans are issued by a commercial insurance company, not the government.  The government only supplies a tax credit (APTC - Applied Premium Tax Credit) which you either ARE or ARE NOT eligible for.

HMO plans are not inferior to PPO plans, just better cost control and more limited networks.  However, most insurers recognize that there are times when one needs to go outside the network, and in that case, as long as your PCP recommends the treatment, you should be good.

For assistance in navigating the complexity of the new health options, please contact me through psyberquote.com .