Monthly Archives: September 2013

Juror Number One – What say you?

With not much else to do and with a great need to avoid the CNN blaring in the Jury Waiting Room, I spent my time pouring over the first concrete result of ObamaCare received in our agency.   The results leave me with a very screwed up look on my face. (no jokes)

We need to hear from the entire jury to even begin to reach a verdict.   What I am posting below is an actual set of results from a mid sized employer group plan.   The rates pulled represent different age categories and family combinations.   This one company is different from the rest of the market because the physician list DOES NOT change.   It will be interesting to see the first set of real numbers from a standard PPO or HMO.

The result is a clear reduction in coverage with rates going -/+ 25%!    Assuming the same rate basis, the rates would have been much higher if they had not reduced the benefits.  Frankly, this makes absolutely no sense.  Although I expected this carrier to look good, I did not expect this result.

Those of you who understand the rate compression rule of 3-1 from ages 19-64, would know that we expected to see older folks getting the best result while the under 30s should get increases.  What we have here makes no sense.   The only explanation is going to be found in the drug formulary, lab and specialty drugs.   I have not made that comparison yet.   Without a actual Summary of Benefits and Coverage, I can’t make a final ruling from this juror.

I submit Exhibit 1 for you perusal:

Before ObamaCare After Obamacare
 Contract 8-1-2013  January 1, 2014
Plan A 2013 ObamaCare version Plan A 2014
Plan Type Staff Model HMO Staff Model HMO
Office visits $30 $30/$50
Co-Insurance none none
Annual Max Risk Per Person $3,000 $6,350
In Patient Hospital $400 day $600 day
Prescription $10 gen/ $35 Brandafter $250 $19 Generic $50 Brand
Age 37 $289.00 $350.00   ^
Age 45 $372.00 $408.00  ^
Age 54 $485.00 $604.00  ^^
Age 24 $261.00 $283.00  ^
Age 45 with 2 children $707.00 $547.00  v
Age 48 with Family $1,130.00 $1,066.00  v
 result Lower benefits – Higher Rates Prevail

You may be wondering if I rigged this comparison.   I did not.   In a previous Blog I explained how insurers will MAP or CHOOSE one of the new ObamaCare plans for your renewal.  This must be done for all non-grandfathered plans because all plans must be canceled at their 2014 renewal.   The insurer chose this new plan.

I look forward to receiving and reviewing the details hidden within this plan to see where benefits have been reduced or enhanced.

I hope to bring you some examples for the national small business insurers shortly.

Who Canceled My Insurance Policy?

If you have a private health plan for you and your family, you will probably receive a notice of plan cancellation shortly.   Please don’t panic and understand that it is all part of the metamorphosis we are all going to be forced to take over the next year.

Remember that pledge:  “If you like your insurance, you can keep it”?  Well, that is a dream for most of the population in the real world.    In reality, any policy written, rewritten or changed substantially since March 23, 2010 is considered NOT grandfathered and therefore will be cancelled and replaced with an ObamaCare approved plan.   If you hear nothing else I write, hear this:   Just because Obama approves it doesn’t mean you will.  And you must review the plan details.

In the new world, choices will be reduced DRASTICALLY.   Your new world will consist of cookie cutter plans with much smaller physician networks.   In California,  PPOs will be replaced widely with EPOs.   Get used to that term because it is going to take hold.   A PPO covers you if you use the a PPO physician while allowing lesser coverage if you don’t use a PPO physician.  An EPO ONLY covers you if you use a network physician.   If you don’t, you are not covered.   This limitation along with a much reduced list of PPO physicians greatly reduces your choices in where you get care.

Why did my family costs go so high?

One of the MAJOR changes with ObamaCare is how a family rate is put together.   In the past, a family could have 3 to 10 members and all be eligible for the same rate.   Not so any longer.   All family participants are now rated separately.   Remember that 22  year old you put back on your plan just because you could?   That adult child will now carry and adult rate to the table with them.   Surprise!

Back to the cancellation letter you are about to receive.  In essence, ObamaCare requires ALL non grandfathered individual policies to be cancelled 1-1-14.  BUT, that doesn’t necessarily mean you don’t have coverage. Your carrier should move you to a plan closest to your current benefits or cost.  Which benchmark they use is up to the carrier.  If you don’t like where they put you, look at the options they give you.  If you plan to make a change, don’t sit on it. You can only make a change during this national open enrollment and annually at future open enrollments. (Again, there are exceptions for qualifying events.)

To recap:

  • You probably can’t keep your plan.
  • Watch for changed family deductibles, higher out of pocket maximums, far higher specialty drug costs, and many hidden co-payments.
  • You might not be able to keep your doctor.
  • Don’t forget to take the time to inquire about the new physician list.  IT WILL BE SMALLER.
  • You aren’t going to be free to change whenever you want.

A guarantee issue market comes with limits.  Rule vary case by case.   This first Open Enrollment will run from October 1, 2013 to 3-31-14.   In subsequent years, Open Enrollment will be the fourth quarter of every year for January 1 effective dates.

There will be new choices.  Use a GOOD insurance agent to guide you.  Look for years of experience and specialty in health care.   Many newbies are picking up overnight expert designations and titles.   Don’t fall for the scam.   A good agent will have all the information available for private market and government subsidized plans through your State Exchange.   If they don’t, use Find an Agent at

Since subsidies are only available if you buy a cookie cutter plan through your State Exchange, you should advise the agent you would like to inquire about the Exchange.  Any agent worth a nickel will be able to give you a good estimate of your subsidy.

Whatever you do.  DO NOT go directly to an Exchange.   They will be staffed with less educated and completely non accountable employees.  Agents are free and will explore ALL of your options, so use them.

If you get to keep your plan and you like it, stay there and let the guinea pigs work out the kinks for a few years.  I know I am holding on to mine!

Paula L. WIlson, RHU, REBC