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What Happens If and When Obamacare is Repealed


cartoon

Donald Trump and the Republicans have vowed to repeal and replace the Affordable Care Act and it is very likely they will follow through. If they repeal the ACA and do not replace it with something comparable or better, as many as 25 million people could be without insurance by 2020. Additionally, many if not most people may have less comprehensive coverage and higher co-pays, but that all depends on what kind of replacement plan the congress approves if any. And that — is only the tip of this ugly iceberg.

This blog only deals with repeal while the House has approved a replacement bill, the U.S. Senate has not. We will cover that as thoroughly as possible when it happens.

Few remember this, but just before ACA passed in 2010 the health insurance companies hiked their rates significantly. Since then they have raised rates several more times. Let’s be clear here, ACA is NOT raising your rates, there is no provision in the act that allows for that. Many have complained that ACA is responsible for increased rates, but that’s really an empty claim because we don’t know what insurance rates would have done if there was no ACA. One thing for sure, rate hikes always come from the Insurance companies. If ACA is repealed you will get far less coverage, but you can be sure the insurance companies don’t reduce their rates by a single dime.

If ACA is repealed everyone will feel it, even the very wealthy. The difference is they can afford to self-insure– maybe. Today the cost of some procedures and care is so high that it might even hurt the mega rich to have to pay out-of-pocket. 10 years ago I had a heart transplant. According to the National Transplant Foundation, the average cost today for the same procedure would be $1.2 million. That price includes first-year medications and care. You can review other costs here. (http://www.transplants.org/faq/how-much-does-transplant-cost). A heart/lung transplant would cost $2.3 million. That would make even a wealthy person sit up and take notice.  (If you would like to examine the effect of ACA on health care costs Gary Cameron of the Reuters news service.wrote this for Time.http://time.com/money/4503325/obama-health-care-costs-obamacare/ )

The Trump administration is also talking about cuts to both Medicare and Medicaid. It remains to be seen what that means but this congress is in a cutting mood, so it is unlikely that their actions will result in anything beneficial to many with chronic illnesses. You can also expect that if there was ever any hope of extending coverage for anti-rejection drugs past 36 months for Kidney transplant patients it ended with Trump’s Inauguration.

Very few people are aware that Medicare is also affected by repeal of Obamacare. There are several areas that will be negatively impacted but the part that helps seniors with Prescription costs will take the biggest hit.

The Senate bill slashes tax revenues by $701 billion over a decade, while reducing Medicaid spending by $772 billion versus current law. Overall, the Senate bill reduces federal health care spending by $1 trillion.

The Center for Budget and Policy Priorities estimates the bill’s tax benefits for the 400 highest earning households in America alone are equal to the cost of keeping Obamacare’s Medicaid expansion in four states that cover 726,000 people.

  • The ACA helps seniors in the donut hole until it is closed. Copayments required for brand-name and generic drugs are being phased down to the standard 25 percent by 2020. Brand-name drugs discounts from manufacturers increase each year in the coverage gap. Copayments for generic drugs are reduced by seven percentage points each year until the coverage gap is eliminated.
  • In 2016, seniors receive a 55 percent discount on brand-name prescription drugs and a 42 percent discount on generic drugs, which is applied at the pharmacy. Below are the amounts that beneficiaries will pay for their medications until the donut hole is closed in 2020.
    • 2016: 45 percent for brand-names and 58 percent for generics
    • 2017: 40 percent for brand-names and 51 percent for generics
    • 2018: 35 percent for brand-names and 44 percent for generics
    • 2019: 30 percent for brand-names and 37 percent for generics
    • 2020: 25 percent for brand-names and 25 percent for generics

Ever since the Affordable Care Act (ACA) passed in 2010, Republicans have vowed to repeal acait. They have made many claims about what a “Disaster” it is, but offer little in the way of evidence other than point to increased premiums. Premiums, though, were out of control long before there was an ACA and many experts say that if anything the sweeping health care bill slowed their increase. If Republicans are successful in repealing the act you will be affected in many ways, now and in the future. I’d like to keep this blog relatively short so I will only address four issues here, but they are big ones.

  1. Pre-existing conditions
  2. Children on your policy until age 26
  3. Medicaid changes
  4. Medicare adjustments

Effect Number One. Pre-existing Conditions

People have short memories so let me remind you what the health insurance environment was like prior to 2010. Example. A woman I know was having problems sleeping,, that’s all. She was in otherwise excellent health. To help her sleep, her doctor prescribed Remeron which is also an anti-depressant. Due to family circumstances, she had to move to a different state, a state in which her current health insurance had no coverage. She thought nothing of it because she was healthy, so she shopped around for new insurance, found one she liked and applied. Almost immediately she was denied coverage due to a pre-existing condition of depression even though she was not suffering from depression. The drug, Remeron, was prescribed to help her sleep but the new insurance company ignored that detail. Her only option was to keep her old insurance from another state even though she was out of network. Under those circumstances, this healthy woman had become uninsurable because of one medication that was not even prescribed for the purpose identified in the rejection notice. That is what we likely will be returning to. But there’s more.

conditionsIf the ACA is repealed without a replacement plan and maybe even with one here’s what you can expect.

Let’s say a young couple finds they are about to have a child. The husband just got a new job in another state so they will have to move and get new insurance as well. Here’s what they are likely to run into if ACA is repealed.

  • Pregnancy could easily be considered a pre-existing condition, at least the insurance companies would have that option. That means when this family looks for new coverage insurers could deny it or charge exorbitant rates.
  • Even if they got insurance, the plan would likely not include maternity coverage, as was the case for over 60 percent of enrollees in individual market plans in 2011.
  • They’d get no financial assistance to help ensure they can find a good plan within their budget and there would be no help in paying their out-of-pocket costs.
  • Healthy pregnancy, births, and newborns programs would no longer exist, putting the family at greater risk for other health problems.
  • And the family would likely have to pay out of pocket for each new baby visit and any ensuing treatments, injections or other procedures.

Some estimates indicate that nearly a half of all Americans have a pre-existing medical condition that could make it difficult to find insurance, and about 3 million of them are now insured under the ACA. If and when it is repealed those who have insurance could lose it and those without insurance, or who leave their old plans for any reason such as job change, divorce, or relocation, may find it impossible to get a new plan. The Kaiser Family Foundation projects that if the pre-existing conditions provision is repealed, 52 million Americans could be at risk of being denied health care coverage.

Effect Number Two. Children Covered by Parent’s Insurance to Age 26

If ACA is repealed and not replaced with something equivalent or better, that means thatyoung-healthy-adults once you turn 19 or are no longer a full-time student, you are on your own for insurance coverage, increasing the financial burden on young adults who are unemployed, underemployed, contractors, working for small companies, or those starting their own businesses. Young people are less likely to get seriously ill and often don’t use insurance when they have it. Insurance companies would love to have these men and women paying premiums again, though, because they use so little of the coverage and help to defray the cost of covering others.

This is a popular benefit among some Republican office holders because their children are affected so it might be added to whatever replacement the GOP drafts, although the age limit could potentially get lowered by a year or two.

Effect Number Three. Medicaid

One of the most appealing aspects of health-care reform for many was the ability to get subsidized insurance policies, reducing out-of-pocket costs. According to Kaiser Health medicaidNews, all but 19 states expanded the income limits for people to get Medicaid insurance and in some cases limits were pushed to 300 percent of the federal poverty level. Also, tax credits beyond that helped even middle-class workers and families afford their monthly premiums. The Affordable Care Act was affordable largely because of the Government subsidies. While all Republicans in congress opposed the expansion of Medicaid, many Republican State Governors accepted the plan for their states. Medicaid is funded by the Feds but run by the states. If ACA is repealed and Medicaid expansion goes out the window the states will be left with the choice of funding it or telling their citizens that they are cutting the program. That could have disastrous effects for Republicans in coming elections.

Based on the resistance that red states had to the idea of expanding Medicaid coverage in the first place — even with the federal government covering almost all of the expense — it will not be surprising to see a GOP plan that either decreases or completely remove the tax credits or other subsidies. Almost all Republicans agree it must go. There seems to be little agreement on if or how to replace it.

Effect Number Four. Medicare  Cuts

Here comes trouble. Like Social Security this is the healthcare third rail, it can mean political suicide for anyone that makes any negative changes in the national health care system for people age 65 and over. The great majority of them are not working, have no income other than Social Security and some savings and they are uninsurable outside of Medicare (supplemental programs excepted). Some see Medicare as totally separate from the ACA and in some ways it is, but they are also intertwined. Too many seniors think they are immune from change, they are not.

According to the Kaiser Foundation, a full repeal of ACA would restore higher payments fordonut-hole services performed under the managed-care portion of Medicare known as Medicare Advantage.  That, then, could lead to increased Medicare Advantage premiums. It could also mean an end to free preventive services and could result in greater premiums and increased out-of-pocket costs, or both.

Perhaps the most notable change would be to reverse efforts to close the “doughnut hole” for prescription drugs. One provision of the Affordable Care Act dramatically cut the amount that seniors on Medicare have to pay for their medicines under Medicare Part D. prior to the ACA’s passage, beneficiaries got some coverage up to a certain dollar amount, and then none until high-dollar, catastrophic coverage provisions kicked in. Once in that “donut hole” seniors paid the full price. Under ACA that coverage gap was supposed to end in 2020.

Now here’s what they are NOT telling you. It is now projected that ACA spending between now and 2020 is $1 trillion LOWER than the original Congressional Budget Office estimate. That means the trust fund for Medicare is now projected to remain solvent 11 years longer than before the Affordable Care Act was enacted. Strangely none of the repeal advocates has mentioned that fact.

For these reasons, it is important to be clear. The repeal of Obamacare will mean that Medicare beneficiaries will have to pay millions more for prescription drugs and won’t have access to free preventive care, while the program itself will be put in financial jeopardy.

As long as this blog is,  it doesn’t begin to cover the full impact of ACA repeal and it says nothing about replacement because we have been unable to find a single plan for doing that that has been released. There are several people who say they have plans, but none have provided documents yet.  We’ll keep our eye on it and do what we can to keep you informed. We’ll report more as we can.

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bobBob Aronson is the founder of Facebook’s 4300 member Organ Transplant Initiative and also of this site, Bob’s Newheart. Look through the index and you’ll find nearly 300 blogs of interest to Transplant patients, their families, friends, caregivers, donors and donor families. 

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Medicaid and Medicaid Expansion. Where and How to Get it.


medicaid cartoon

By Bob Aronson

I will start this post by saying that you are about to get more information about Medicaid than you wanted or likely have seen in one place before.  I am doing that so that you have to do as little homework as possible.

In order to eliminate confusion the reader should know that as of this writing every U.S. state provides some sort of Medicaid.  When you read stories that a state has opted out of “Expanded Medicaid” under the Affordable Care Act (ACA) that doesn’t mean they have decided not to fund Medicaid at all.  It only means they will not participate in the expanded program offered by the U.S. Government.  It also means that fewer people will be treated for fewer medical problems.

Every state in the union currently has some sort of Medicaid program.  Medicaid is the largest source of funding for medical and health-related services for lomedicaid logow-income people in the United States. It is means-tested that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program.  Some states are far more generous than others but none are required to participate in the program.

Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities.  Poverty alone does not necessarily qualify someone for Medicaid as poverty guidelines differ from state to state.

How to apply for Medicaid.  

Many states offer the ability to apply for Medicaid directly on their websites. These applications can generally take anywhere from a half an hour to an hour to complete. If your state doesn’t have an online application, you may be able to at least access a copy of it online that you can download and fill out at your convenience. If it doesn’t, you will need to take a trip to your local Department of Social Services and request their assistance with filling out your application. In most cases, you’ll have the option of taking the application with you and bringing it back in, or mailing it back in, or you will be seen immediately, if you wish.  More details can be found here http://tinyurl.com/kfg34bv

Do You Qualify for Medicaid?

If the previous link did not answer your questions this link should.   https://www.healthcare.gov/do-i-qualify-for-medicaid/#howmed

Medicaid Then and Now

Prior to Medicaid expansion on the Affordable Care Act (ACA) of 2010 Medicaid was and is administered as a partnership jointly funded by the federal government and the states, with the feds contributing anywhere from 50 percent to 74 percent of expenses (the average nationwide is 57%). For states who sought to provide care to the disadvantaged and others it was a pretty good deal.

ACA expansion greatly increased the federal investment in state programs.  Under the ACA the federal match rate, starts at 100 percent in 2014 and gradually declines starting in 2017 until it reaches 90 percent for 2022 and beyond.

Unfortunately for those who need Medicaid 26 states have chosen not to participate in the expansion.  They have that option because of a U.S. Supreme court decision that upheld all other aspects of the Affordable Care Act except making the expansion mandatory. Again, Medicaid programs are only available to people with low incomes, limited resources, or certain diseases or disabilities

ACA otherwise known as Obamacare has been the subject of a bitter political battle since long before it was passed into law. The Republican controlled U.S. House of Representatives  believes the law is ineffective and unaffordable.  As a result House Republicans not only voted against it they have unsuccessfully tried to repeal the law 40 times.  The great majority of states that have rejected expansion are Republican controlled.

Let us begin with where the states are with regard to Medicaid expansion.   The following states have said yes to the Medicaid expansion:

Arizona, Arkansas, California, Colorado, Connecticut, Delaware, D.C., Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Dakota, Oregon, Rhode Island, Vermont, Washington, West Virginia

The following states have said no to the Medicaid expansion.

Alabama, Alaska, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Wyoming

I wish there was a way to tell readers exactly what to expect for their situation but that just can’t be done because there are so many variables.  Medicaid is a complex and often difficult to understand program.  If you are curious about your eligibility the best we can do is to refer you to links for more information but at least you won’t have to spend time searching for them, we’ve done that for you.  Once you begin your search though, be sure you have plenty of time and hot coffee because you will be doing a bit of studying.

National Public Radio has done a tremendous job of sorting out questions and answers about Medicaid.  Here’s just one of their many “Explainers.”

FAQ: Where Medicaid’s Reach Has Expanded — And Where It Hasn’t

http://tinyurl.com/l5nnxyr

October 11, 2013 3:00 PM

This is one of several explainers to help consumers navigate their health insurance choices under the Affordable Care Act, or as some call it, nprObamacare.  For answers to other common questions you can click here http://tinyurl.com/lwtqtsv Have a question we missed? Send it to www.health.npr.org  We may use it in a future on-air or online segment.

Could I be eligible for Medicaid now?

The Affordable Care Act greatly expanded the number of people who qualify for Medicaid, the state-run health insurance program for people with low incomes. Previously, it was difficult for anyone other than pregnant women, parents and children to qualify. The law expands eligibility in ways that will allow many more people, including single and childless men or women, to qualify.

How do I know if I’m eligible for Medicaid?

The law extends eligibility to all adults under the age of 65 whose modified adjusted gross incomes fall below just under $16,000 for individuals and $32,500 for a family of four.

In states that decided not to participate in the Medicaid expansion, the rules are different and vary from state to state. About half of the states opted out of the Medicaid expansion, which is something that the U.S. Supreme Court gave them permission to do. In those states, the income cutoff to be eligible for Medicaid is generally much lower than what was set in the Affordable Care Act, so fewer people will qualify. And if you’re a childless adult, you’re most likely not eligible in states that rejected the Medicaid expansion.

To find out the income cutoff in your state, you can check out the tables here http://tinyurl.com/n55suho

Or, just try signing up for coverage at your health insurance exchange. The exchange will calculate if you are eligible for Medicaid in your state, and if you are, direct you to the proper state agency to get signed up. http://tinyurl.com/meyyzgs

What if my state didn’t expand Medicaid?

If your income is too high to qualify for Medicaid under your state’s rules, you can still try enrolling at an insurance exchange. You may not qualify for subsidies, though. The subsidies are for people whose income falls between 100 percent of the ($11,490 for an individual) and 400 percent ($45,960).

If you make too much to qualify for Medicaid but too little to qualify for subsidies on the exchange, then you are exempted from the new mandate to carry health insurance. http://aspe.hhs.gov/poverty/13poverty.cfm

If that’s your situation — you’re poor and still have no health insurance — you can still seek health care with other safety net providers, such as federal community health centers and free clinics run by local nonprofits.

If I am sick and unable to work and have no income, can I get a plan on an exchange for free?

If you are disabled and have no income, you most likely won’t be shopping for insurance on the exchanges. Rather, you may qualify for Medicaid. In , if you qualify to collect Supplemental Security Income, or SSI, you also qualify for Medicaid. For more information on Medicaid eligibility and links to your state’s Medicaid office, click here http://tinyurl.com/7mevcmw

See other Frequently Asked Questions on Medicaid and the Affordable Care Act:

While I would very much like to be able to provide details about every state’s Medicaid program neither time nor space allow for that undertaking.  I will, by way of this post, try to provide some general guidelines but it will be up to you to determine exactly what your state offers.

Although the federal government sets up general guidelines, each state runs its own Medicaid program. States establish what health care services are covered and which groups of people get coverage. As a result, Medicaid programs vary a great deal from state to state.

Keep in mind, too, that even if you can’t get Medicaid benefits, your child still may be eligible.

More Frequently Asked Questions About Medicaid

Q.        How Much Do Medicaid Programs Cost?

A.        The cost of a Medicaid program depends on the state. Some programs require you to make a small co-payment for medical services in addition to what Medicaid pays.

Q.        What Does Medicaid Cover?

A.        In general, Medicaid programs offer more comprehensive medical coverage than Medicare. They usually include hospital stays, visits to doctors, tests, some home medical care, and more. Again, the specifics vary from state to state.

Q.        What Else Do I Need to Know About Medicaid?

A.        Some people qualify for both Medicare and Medicaid programs. They are called “dual eligibles.” In these cases, Medicaid may pay some of your Medicare fees.

  • If you qualify for both Medicare and Medicaid and enroll in a Medicare Prescription Drug Plan, you are eligible for help in paying your drug plan’s monthly premium, deductible, and co-pays.

To learn more about Medicaid programs, visit the U.S. government’s Centers for Medicare and Medicaid Services (CMS) web site. 

Fiscal Impact of the Medicaid Expansion on State Budgets

Medicaid as of September 4, 2013 The Supreme Court ’s decision on National Federation of Independent Business et al v. Sebelius1 upheld all provisions of the Affordable Care Act (ACA) including the individual responsibility requirement, health insurance exchanges and subsidies, and the Medicaid expansion. However, the Court restricted the federal government’s ability to withhold federal Medicaid funds if a state

Emphasis on Primary Care and on Primary Care Physicians

The Affordable Care Act emphasizes primary care and seeks to increase the number of primary care physicians willing to provide services to Medicaid patients. To that end, Medicaid payments to primary care physicians will increase to 100 percent of the Medicare payment rates for the years 2013 and 2014. Current payment rates for primary care physicians under Medicaid vary markedly from state to state, but on average they are 66 percent of Medicare reimbursement rates.

Physicians who will be receiving the higher rates are those engaged in family practice, general internal medicine and pediatric medicine. As with the cost of making more individuals eligible for Medicaid, the federal government will pay 100 percent of the added costs for payments to primary care physicians. Payment rates after 2014, and the division of responsibility between the federal and state governments to pay them, has not been determined.

Additional Information Resources

http://www.medicaid.gov/

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 3,000 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our new music video “Dawn Anita The Gift of Life” on YouTube https://www.youtube.com/watch?v=eYFFJoHJwHs.  This video is free to anyone who wants to use it and no permission is needed. 

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just email me bob@baronson.org and ask for a copy of “Life, Pass it on.“  This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. 

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

How to Choose a Health Plan Under the Affordable Care Act (ACA-Obamacare)


cant afford that dianosisBy

Bob Aronson

While the Affordable Health Care Act got off to a very rocky start due to massive computer glitches there’s plenty of time for consumers to do research to find the best plan.

The problem faced by most people is trying to make sense of all the legal gobbledegoop.  How do you sort it all out so that you know which health insurance plan to choose?  Well, we think we have some answers for you but it is still going to take some work on your part.

Before we get into any advice here’s the link for information for the Affordable Care Act. It is where you will ultimately determine what kind of coverage you should have and from which company. https://www.healthcare.gov/

The first-ever open enrollment period for individual and family health insurance plans under the Affordable Care Act (ACA) began October 1 and ends March 31, 2014. Open enrollment periods in following years will be shorter than this one-time six-month period.

According to HealthCare.gov the law offers you these rights and protections.

If you have questions you can call 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325).  Judging from the initial experience, however, you can probably expect long wait times and delays.

There are lots of questions so to  help you make your way through the insurance maze.  We relied on several sources for our information among them are:

1)  Consumer reports magazine ( their report is here http://tinyurl.com/odmjmq2

2) The Health Insurance Resource Center http://tinyurl.com/n38asm6   and

3) Forbes Magazine http://tinyurl.com/mrce8lg

4. Politifact http://tinyurl.com/m5pbarx

5. U.S. Dept of labor http://www.dol.gov/ebsa/healthreform/

6. Henry J. Kaiser Family Foundation http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/

7. eHealth https://www.ehealthinsurance.com/affordable-care-act/faqs

8. National Public Radio (NPR) http://www.npr.org/2013/10/11/231101137/faq-what-retirees-and-seniors-need-to-know-about-the-affordable-care-act

Each one of the preceding links is worth reading.  Your health and your financial stability may be on the line so this is absolutely necessary homework.

Health Coverage for Seniors

We’re going to offer information for everyone in this post but I’m going to start with Senior citizens.

The first thing seniors need to know is this. Medicare is not part of the  health insurance exchanges. The exchanges won’t be selling so-called “Medigap” policies that supplement the coverage seniors get through Medicare.

Seniors will still get health coverage through Medicms logocare’s traditional fee-for-service program or Medicare Advantage plans.  Beneficiaries receive more preventive care, including a yearly “wellness” visit, mammograms, colorectal screening, and more savings on prescription drug coverage.  By 2020, the law will close the coverage gap which is also known as the “Donut Hole but  Seniors will still be responsible for 25 percent of their prescription drug costs.

Medigap Coverage

Seniors will still get health coverage through Medicare’s traditional fee-for-service program or Medicare Advantage plans, private health insurance plans that are approved by Medicare. Those who are enrolled in , which covers hospital care, or the Advantage plans will meet the health law’s .

Seniors were pretty much left out of consideration when ACA passed.  They get some benefits like the closing of the donut hole and health screening.  A glaring omission is that while pre-existing conditions cannot be considered for others, they are still a factor for seniors.  Medigap is not bound by that provision of the law.  Medicare is but not the Medigap supplemental policies.   But….and this is a very important But:

The most critical time for Senior Citizens is the six months after you first enroll in Medicare Part B. During that period, you can buy any Medigap policy you want, and the insurer can’t turn you down or charge you more than anyone else your age even if you have pre-existing conditions.

According to Consumer Reports Magazine (CR) you also have the same rights if you have a retiree or union plan that fills in Medicare’s coverage gaps but it ceases operation, or if your Medicare Advantage plan closes up shop or you move out of its coverage area. Read more about the difference between Medigap and Medicare Advantage.

CR goes on to say that Senior Citizens may be stuck with what they have.  “Although it never hurts to shop around. “Medigap plans are generally more permissive about underwriting than health plans sold to younger people,” said Bonnie Burns, a Medicare expert with California Health Advocates, a nonprofit consumer group. “Some are more strict than others.”

Medicare Advantage

Another issue of importance to Seniors is Medicare Advantage.   A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare.

There has been a lot of publicity about cuts to Advantage and a lot of seniors are worried so let’s address that issue.  According to Politifact, an on line, Pulitzer Prize winning organization that checks the accuracy of political stories Advantage is growing in size not getting smaller.  Here’s what they say:

“Today, around 14.4 million seniors and disabled people — that’s 28 percent of all Medicare beneficiaries — are in Medicare Advantage, the most ever.

Advantage plans are required to offer basic health benefits that are at least as rich as original Medicare. But many offer extras, such as rebates on premiums, routine dental care, gym memberships and rides to the doctor, in order to compete for business.

Medicare Advantage members pay premiums just like people who get their benefits through original Medicare.  The private companies turn a profit depending in part on how well they manage costs of care. Sweetening the deal: The government spends more per person — 7 percent more last year for Advantage beneficiaries compared with those in original Medicare, estimated the Medicare Payment Advisory Commission.

The Affordable Care Act aims to gradually bring costs of the two programs in line. At the same time, it seeks to reward private insurers that offer the best care — these are the plans that top the new star rating system.   You might think shrinking payments for Medicare Advantage would mean fewer enrollees, but that hasn’t happened. Since passage of the Affordable Care Act in 2010, enrollment in Medicare Advantage plans has grown by 30 percent.”

The Politifact analysis continues with this:

politifact“After the health law passed in 2010, several government and private analysts predicted Advantage enrollment would decline. More recently, the Congressional Budget Office projected slow growth through 2022, while the CMS Office of the Actuary expects a decline between 2015 and 2018, then an increase.

It’s similarly tough to predict what will happen with costs and benefits, though it’s important to note that Advantage plans can never offer skimpier coverage than original Medicare. Government payments may go down, but they’re only one of the many factors that go into how insurers determine their offerings.

“The payment formula to Medicare Advantage is complex,’’ said Dan Mendelson, CEO of strategic analysis firm Avalere Health. “Honestly, to say that as a result of Obamacare there would be a reduction to Medicare Advantage would be misleading at best, because there are a lot of other things that come into play.’’

“We don’t know what’s going to happen, but that’s true every year,’’ said Joe Baker, president of the Medicare Rights Center, the national nonprofit advocacy group that fields around 12,000 calls a year to its consumer help line.

Still, Baker and others doubt seniors will find a September surprise in their mailboxes.
“If the last few years under the (health law) and this administration is any indication, it’s going to be a pretty smooth year and a pretty even year,’’ Baker said.

Mendelson, too, is dubious of a rate spike.

“In all likelihood, rates are going to be stable, and they’re going to be workable,’’ he said.

Medicaid

Medicaid presented a special difficulty in our effort to offer assistance  to those who need this service.  A U.S. Supreme Court decision left the decision about whether to participate in the Medicaid program under ACA up to the individual states and not all states chose to do so.  While we can offer this link that will help  you gain some understanding of your options, we likely will supplement this blog in a few days with a more detailed report.  http://www.apha.org/advocacy/Health+Reform/ACAbasics/medicaid.htm

Health Care Coverage for Everyone Else

The Exchanges

Plans offered will be in standardized “metal tiers” with various combinations of premiums and cost-sharing.  There are four distinct kinds of plans:

  • Bronze plans will pay 60 percent of the bill and cost the least
  • Silver plans will pay 70 percent.
  • Gold plans will pay 80 percent.
  • Platinum plans will pay 90 percent and cost the most.

Keep in mind that as the percentage of coverage increases so does the premium you pay — but it also means that you will pay less when you get the hospital bill.

Before you consider any plan you should begin by answering these four critical questions so you can make the best possible decision when you finally select a health insurance plan.   The questions are:

1. What does health care cost in your area?

2. How much have you budgeted for health care or, what can you afford?

3. What do you want from your coverage?  Do you have any special medical needs?

4. Does the plan cover the physicians and hospitals you prefer?

As I began my research for this blog I discovered almost immediately that finding the right health insurance coverage is not easy by any means.  It’s going to take some research and diligence on your part if you want the most bang for your buck.

So let us start with the first question.  What does health care cost in your area? Let’s make this as simple as possible.  The really important question is not what they charge but what do you have to pay?  Even that can get complicated because no plan pays a hundred percent and that means you pay something.  If the bill is a thousand dollars and your plan pays ninety percent then your share is one hundred dollars but if the bill is two thousand dollars and you plan still pays ninety percent you pay one hundred eighty dollars.  The ninety percent payment only becomes meaningful when you know the cost of the service or procedure.

Determining what a health care facility will charge you is not easy but we’ll try to help.  The problem is health care costs vary so greatly.   Here are some examples.

The Washington Post did an in-depth analysis of medical pricing in May of 2013 and found what to me is a shocking disparity between hospitals.  For exwashington postample:

Virginia’s highest average rate for a lower limb replacement was at CJW Medical Center in Richmond, more than $117,000, compared with Winchester Medical Center charging $25,600 per procedure. CJW charged more than $38,000 for esophagitis and gastrointestinal conditions, while Carilion Tazewell Community Hospital averaged $8,100 in those cases.”  The entire Washington Post article can be found here http://tinyurl.com/d3xm3g6

We advise you to read the Post report but thought we would include one more relevant piece of information from it.

“In our analysis of the 10 most common medical procedures we found certain patterns by state. Hospitals in six states — California, Florida, Nevada, New Jersey, Pennsylvania and Texas — routinely had higher prices than the rest of the country.

For-profit hospitals tended to bill Medicare at a 29 percent higher rate, on average, than nonprofit or government-owned hospitals.

Is this confusing?  You bet it is because hospitals and insurance companies play games with each other.  The prices and reimbursements they toss around make sense only to them and relate only to situations in which patients are either covered by insurance or Medicare.”

So, as I said earlier,In the end what matters is what you pay, not what the hospitals charge or what either the government or the private insurers pay.

Deciphering Your Hospital Bill

When you get a hospital bill you must know what the codes mean or the bill is meaningless.  You need to be able to do some comparisons between faclities so we found the resources listed and outlined below. I have included information provided by the Centers for Medicare and Medicaid Services (CMS) the government agency that runs Medicare because they keep track of pricing for everyone, not just seniors.  Be aware, though, that even this attempt at clarification can be confusing and that’s because health care is confusing.

Here’s the link to CMS it is very complete http://tinyurl.com/blv4cwg

Here’s another helpful site but….in order to look up a price you will need the CPT code.  http://www.fairhealthconsumer.org/medicalcostlookup/.  Of course you probably don’t know what a CPT code is, right?  Ok — CPT codes (Current Procedural Terminology) are found and used to identify procedures for which you will be charged. A CPT code is a five digit alphanumeric code with no decimal marks. When you receive a bill from your doctor before or after it has been sent to the payer (insurance or Medicare), it will have a list of services. Next to each service will be a 5-digit code. That’s the CPT code.

The American Medical Association (AMA) has every code there is — but you can’t have them all unless you are a physician member who haama logos paid a great deal for them. AMA has the copyright on CPT codes and guards it like it is a nuclear weapons cache.  They will give out one code at a time but they want you to suffer a little so its not easy.  Here’s how to do your AMA CPT code look-up:

  • Step 1: Link to the AMA website
  • Step 2: You’ll find an End-Use License. In essence it tells you that you may look up these codes only for your personal information and that you cannot sell them to anyone else. Further, it tells you that if they think you are using the system too much, they may limit your searches and/or limit the number of CPT codes you look up at one time. There is additional legaleese which you should probably read. You can also print the agreement.
  • Step 3: Click on ACCEPT or DECLINE. If you click on DECLINE, you will not be allowed access to the code lookup.
  • Step 4: The next page is your search page. Choose your state and city. If your city isn’t there, there will be a choice that makes sense. For example, if you live in Tampa, Florida, you’ll find that Tampa isn’t listed (only Miami and Ft. Lauderdale are listed) but there is a designation for “Rest of Florida.”
  • Step 5: If you already have the CPT code and want to see what it means: Simply input the 5-digit CPT code to the field, hit SUBMIT, and you’ll get your result on the next page. Included will be the RVU – see below.
  • Step 6: If you do not have the CPT code, but you know what the procedure or service was, you can do a search to try to figure out the right code. This can get tricky, though.

CMS uses CPT codes, too, but they are called HCPCS codes (why does government always have to change the name of commonly used terms?) and unlike AMA the codes are readily available and free but still take some work to ferret them out.  Here’s a link. http://patients.about.com/od/medicalcodes/a/Look-Up-Hcpcs-Codes.htm

Finally you can try these links for prices of common procedures.

Quality of Care

One of the great mysteries in all of this is that while the government and others have done extensive studies on medical procedure costs in nearly every city and every facility the costs quoted bear no relationship to the quality of care and the outcomes of the procedures. That’s another story completely.  Major medical centers, especially the teaching centers seem to charge a lot more than other facilities.  Many believe that the more something costs the better it is.  That’s not ever true with anything and particularly with health care.  You just can’t judge the quality of care by the price that is charged for it.

The famed Cleveland Clinic suggests you ask these questions.cleveland clinic

  • Is the hospital accredited by the Joint Commission?
  • Is the hospital rated highly by state or consumer groups?
  • Does the hospital have experience and success with your condition?
  • Is the hospital one where your doctor has privileges?
  • Is the hospital covered by your health plan?
  • Does the hospital review and continuously improve its own quality of care?

Finding the best quality care can be another daunting task and that’s entirely up to you.  This site may give you some help as you begin your search. http://www.ahrq.gov/legacy/consumer/guidetoq/guidetoq8.htm

OK.  Once you have determined costs in your area and the facility that offers the quality of care that you desire you now have three very important questions to answer before you make a decision on a health insurance policy.

  1. How much have you budgeted for health care or, what can you afford?
  2. What do you want from your coverage?  Do you have any special medical needs?
  3. Are the physicians and hospitals you prefer included in the plan.

I’m not even going to attempt to help you with any of those questions because only you have the answers.  The  information I provided earlier, though, should help.

Consumer Reports says:consumer reports logo

“Before health reform, companies could sell plansthat didn’t cover all types of medical care. For example, some might not cover doctor visits, or prescription drugs, or maternity care.

That was bad for consumers because no one can predict what kind of medical care they might need in the future. The only way to protect yourself financially is to have health insurance that covers every kind of health care.

The new health care law has fixed this problem.

Insurance sold to individuals and small businesses must now cover 10 “essential health benefits.”

  • Emergency services
  • Hospitalization
  • Laboratory tests
  • Maternity and newborn care
  • Mental health and substance-abuse treatment
  • Outpatient care (doctors and other services you receive outside of a hospital)
  • Pediatric services including dental and vision care.
  • Prescription drugs
  • Preventive services (such as immunizations and mammograms) and management of chronic diseases such as diabetes
  • Rehabilitation services

The rules for insurance provided by large employers are a little different but most of them will cover the same set of benefits. To make sure, ask your employer for the Summary of Benefits and Coverage, a standard form that will state exactly what the plan covers and doesn’t cover.

Get health insurance rankings

In general, if you pay a higher premium upfront, you will pay less when you receive medical care, and vice versa.”

I strongly advise readers to click on and read the links at the top of this blog provided by Consumer Reports, the Health Insurance Resource Center,  Forbes Magazine and the others.  They are all credible resources.

If you want to know all the details of the Affordable Care Act and how they are implemented year by year click on this site. http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html

And finally, I’m sure I’ve missed a great deal here and I’m just as sure some of you will have suggestions. They are welcome. Please leave them in the comment section below.


We hope you found this helpful.  Please let us know if you have questions or comments.

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 3,000 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our new music video “Dawn Anita The Gift of Life” on YouTube https://www.youtube.com/watch?v=eYFFJoHJwHs.  This video is free to anyone who wants to use it and no permission is needed. 

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just email me bob@baronson.org and ask for a copy of “Life, Pass it on.“  This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. 

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.

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