Doctors that don't take ACA - Does it factor into your FIRE Plans?

[RetirementDreaming]

Today I went to see a dermatologist.  When I was completing the paperwork I read in capital letters – WE DO NOT ACCEPT COVERED CALIFORNIA OR ANY HEALTH PLANS ON THE EXCHANGE.  My children’s pediatrician also as a sign in his office that says he doesn't accept exchange plans. 

My husband and I plan to FIRE in as little as 3 years (and I’m trying to pull that in).  The ACA is a big part of making that happen.  I looked online at the closest dermatologist I could find that would take ACA.  It was 50 miles away.    I’m starting to second guess voluntarily giving up employer sponsored health care.  We seem to be creating “have” and “have nots” related to healthcare at least where I live.

Has anyone else experienced this?  Does it affect your FIRE plans?

[seattlecyclone]

Did you ask them why their policy is the way it is? Was it a political thing? I have a hard time believing that every single plan on the exchange pays doctors less than the average employer-based plan, given that the same companies run both types of plans, and there's a wide variety of cost levels for the exchange plans. Surely there's a platinum plan or something that will pay out comparably, right?

[maizefolk]

Keep in mind Covered California is essentially CA's branding for medicaid isn't it and California's medicaid pays doctors extremely low rates (on average only 52% of what they'd get paid to perform the same services for a patient with medicare).

Nope, I was thinking of Medical, not Covered California. Sorry for the mixup.

[RetirementDreaming]

After a Google search of "doctor doesn't accept covered California" I realize this is an issue.  Glad I found out now.  I need to go back into planning.  If I FIRE at 48 as planned that's a long time to risk not having healthcare available and I won't have the funds to pay out of pocket for all health care. 

[Frankies Girl]

I'm in Texas, FIREd as of last year and on our second year of ACA coverage with BCBS - HMO (used to have the PPO and would have paid more to still have that option, but oh well). My doctor that I'd been seeing for the last decade or so took the ACA coverage. Same with the hospital that is less than a mile from my house and most all of our other regular/specialist docs we've seen over the years. Only had one doctor not in this specific provider network but he was in network for a different group through the ACA (but it's a super specialist that is only seen maybe once every other year, and we decided to cover his cost out of pocket to keep in network with all the rest of the docs we regularly see).

So I guess it really depends on where you live? Which is kinda odd when you consider that Texas blocked everyone from the Medicaid (or is it care?) extension, and also refused to set up a state exchange and were in general huge douche canoes about the whole thing, but I guess the doctors in general were okay with it?

[forummm]

In most states there's a pretty big range in the size of the network. And, as you would expect, the cheaper plans generally have smaller networks (but not always). Plans are required to have some level of network adequacy. They need to have some minimum amount of key providers in their network in geographic areas. I know California had some issues where the lists of providers the plans provided to Covered California was not accurate for awhile. I think that situation has been improved, but am not recalling for certain.

How did you conduct your search? I am very skeptical that there are no dermatologists within 50 miles on any individual market plans (the plans on and off the marketplace are largely the same). I would expect that many do not take those plans. But certainly not all. That's against the requirements for a plan to even be offered in any state. And Dave Jones is pretty on top of things.

I would go look at plans on the marketplace and look at their networks and find a doctor that way. Or call one of the plans up and say you are shopping for a CC plan and want a list of dermatologists in your area.

[Paul der Krake]

Did you search on your insurance website? Back when I was on an a catastrophic exchange plan with a limited network, I naively thought BCBS would have a tool for me to find primary care doctors. Their website told me there were a total of 2 doctors who would want to see me, in a metro area of about 2.5 million.

It turns out that nobody at BCBS thought that looking for doctors directly on a website provided by a company to which customers pay hundreds of dollars per month was a valid use case. Their online search was completely broken for the ACA plans. It has since been fixed, and from what I can tell almost everybody takes ACA plans in this area. I just checked and I could find all types of specialists even in the limited network.

So to answer your question, no I am not worried one bit. Healthcare is a stupid commodity that currently happens to cost an arm. I couldn't care less who my doctor is so long as 1) they do a reasonably good job for a reasonable price, and 2) they are not too far away from me. It boggles my mind to see how the average consumer focuses on getting "the best care there is" with little regard to price, all the while eating crap food and leading terribly unhealthy lifestyles.

There are millions of families on ACA plans, and that number is growing. If some doctors decide for one reason or another not to take these plans, I have full confidence in the market forces to usher in another market participant to fill the void.

[letired]

When I changed jobs and changed insurance providers, I tried to use my insurance providers' website to check if my current doctors accepted my new insurance. None of my doctors were on their website. However, they all actually took my insurance.

TL;DR don't trust website results, make some phone calls to the actual offices.

[EnjoyIt]

Although ACA provides insurance to millions of people, that subsidized insurance has very high deductibles that many who require subsidies can't afford anyways. Therefor seeing a patient with such insurance has a high likelihood you will not get paid for the service provided especially if it is early on in the year and deductibles have been unlikely met yet.

I'm not saying this is the only reason those doctors don't take Exchange issued insurance, but it may be part of the reason.

[mjs111]

Many of the plans offered on the exchanges have lower reimbursement rates than commercial group insurance. The reimbursement rates for many of the exchange plans fall somewhere between Medicaid and Medicare. That being the case, many doctors have chosen not to deal with them.

An additional gotcha for doctors is that subsidized plans offer a 90 day grace period from the point the insured stops paying and when they're not liable for payments. The problem is that insurers often will not reimburse doctors during this grace period if the insured doesn't pay either.

Due to these issues a lot of doctors have decided it doesn't pay to take any ACA patients, or to limit them to a certain percentage of their total patients.

Mike

[kite]

With my high deductible policy, I'm paying anyway for office visits, so the doctor being in or out of network is less of a concern.  I load up my HSA, and invest it agressively, in anticipation of needing to pay for care post FIRE,

[NoStacheOhio]

I think as time goes on, you're going to see less of this. There are huge changes happening to reimbursement across the board, and fewer and fewer doctors are going to be solo private practice. You're also probably going to see a return of more limited insurance networks, and higher costs for "out of network" providers. Do your research before you sign up for a plan, and make sure you're getting the providers and health care system you really want.

[rantk81]

With my high deductible policy, I'm paying anyway for office visits, so the doctor being in or out of network is less of a concern.  I load up my HSA, and invest it agressively, in anticipation of needing to pay for care post FIRE,

You might want to review your policy documents.... All the plans I've ever been in have had separate deductibles for in-network vs out-of-network doctors (and the out-of-network deductible is usually 2x or 3x higher than the in-network-deductible).  So if you have an in-network deductible of 6,000, you might have an out-of-network deductible of 12,000... you could end up paying 18,000 before anything is covered.

[jim555]

I think a lot depends on what state you are in as far as doctor networks.  My plan has the same doctors as my Megacorp plan did, except for the Ophthalmologist.  The only difference is I pay less now since it is Medicaid managed care.

[Gin1984]

I'm curious where in Ca you are because I just helped someone in Palm Springs go through covered Cal (COBRA expired) who had no problem finding a dermatologist under multiple plans as we compared.  No idea on pediatrician though.   

[mjs111]

It would be useful if we could crowdsource some feedback from our doctors.  Next time you go ask what type of private insurance they would accept and what types they reject.  From my reading some insurance carriers have better reimbursement rates than others.  The limitation of the insurance exchanges is that they only talk about monthly premiums and deductibles: there's no mention as to whether or not the insurance company's reimbursement policy is so unattractive to doctors to make the policy effectively useless. :)

I'd rather pay $400 a month for insurance I can use than $300 a month for a policy that is not accepted anywhere.

Medicare has similar problems.  Medicare establishes set fees for any procedure and those fees tend to average roughly 80% of what private group insurance pays.  Due to that some doctors have refused to accept patients who are on Medicare or limit the total number of patients who are on Medicare.  It's every doctor's choice as to what insurance he/she chooses to accept.


Mike

[mjs111]

There are a number of physicians on the boards here as well. It would be great if they could chime in to get their perspective.

Mike

[The Happy Philosopher]

Insurance and medical care in this country are kind of a mess. Honestly though I have not heard of physicians not taking ACA plans. Maybe this is a regional thing. There are plenty of docs who do not take medicare because of poor reimbursement.

The biggest problem is when dealing with specialists, as often times there is just not enough supply in an area and if they don't take your insurance, well, too bad.

The work around is to treat insurance like insurance. It is used to hedge against catastrophic events where you can not manage the risk (A car crash, complex surgery, heart attack, etc.). For routine visits just suck it up and pay the couple hundred dollars out of pocket. The ER will take your insurance.

I know this is not great news, but unfortunately it is reality. The best way to avoid medical costs is to try and interact with the medical industrial complex as little as possible (I sound so doom and gloom, sheesh).

My work around is this: Fund an HSA. This is available to only a minority and if you have one it usually means your primary insurance sucks. Pay for medical care out of pocked and let the HSA grow. When I retire I will draw from the HSA as needed and pray I make it to 62 without having a medical disaster, cancer or expensive chronic disease which will bleed my savings.

Had our first trip to the ER ever this year for a relatively minor (but emergent) thing. I will write about it when all the bills come in. Hopefully I will be pleasantly surprised, but I'm preparing for a pretty large bill. In any event it should be educational :)

Bottom line: Early retirement is probably not in the cards for anyone with serious medical issues unless they have an unusually high income, or they are fine living below the poverty line and living on medicaid and other subsidies. Stay healthy!

[jim555]

The ER bills are a scam.  They literally make up prices out of thin air.  That is why aspirin is $5 a pill.  These guys are scammers and get away with it and no one says anything.

[geekette]

Mid 50's retiree with an expensive chronic condition here.  We retired before HSA plans were widespread (we had one his last year partial of working and spent it down on COBRA premiums)

Plans on the exchange change every year, so I spend a month or so looking over the 30+ plans from at least 3 companies with an eye to keeping our costs down, and our options open. BCBS was our choice for a couple years, but last year, BCBS decided to offer only "Blue Local" plans in our area, and our GP of 20+ years doesn't accept that, so we switched to United Health Care, which has been great.  Now they're leaving the state, so next year we switch again. 

I don't understand why BCBS no longer offers the Blue Select and Blue Value plans they did before, but if you live in one of the larger metro areas in our state, the only ACA plans available are the smaller network Blue Local plans.  If we moved one county south, we could still get a Blue Select plan and go to our regular GP.  Not really worth it though!

Oddly, specialists are not a problem here, they all seem to take every plan, but I would prefer to stick with my GP if at all possible.

[AmandaS1989]

Yeah I'm not really looking forward to switching next year since BCBS is leaving NC in regards to the ACA. I like my plan but I guess I'll have to review my options pretty carefully come November.

[geekette]

I didn't hear the BCBS was leaving!  Just UHC.  There's still Aetna, but getting info on their plans has been difficult (as in their own customer service reps couldn't answer questions).

[AmandaS1989]

I wish we could actually look at plans on the company's website. Some of them I go on and I can't look at anything since its outside of the enrollment period. It would be nice to be able to get an estimate a few months in advance so I could make plans.

[dogboyslim]

The ER bills are a scam.  They literally make up prices out of thin air.  That is why aspirin is $5 a pill.  These guys are scammers and get away with it and no one says anything.

Aspirin costs $5 because for every 5 people billed for it, only 3ish pay for it.  My mom worked to bill out ER procedures in a rural hospital for many years and said they had about a 40% charge-off rate.  ERs must treat first, then check for coverage.  MANY people never pay.  That's why its always better to go to urgent care or your regular doctor's office unless it really is an emergency.

[geekette]

I wish we could actually look at plans on the company's website. Some of them I go on and I can't look at anything since its outside of the enrollment period. It would be nice to be able to get an estimate a few months in advance so I could make plans.

You can get details on current year plans at healthcare.gov, but that won't help for next year.  See plans (no need to create an account, but you have to give some info on ages/sex/tobacco use.  For subsidies, estimate your income).

[Sibley]

Ok, this is general. But.

1. Doctors are free to join or not join an insurer's network. Either side may not like the arrangements and decide to not enter into a contract. Yes, it's a contract.

2. Overall, insurance companies are losing money on ACA/exchanges. That's why some of them (United for example) are pulling out of the exchanges. Their choice. Personally, I think it's a symptom that ACA overall isn't working and needs adjustments.

3. The broader networks, etc that we as consumers like so much (think PPOs) - those cost the insurance companies more. Because they're already losing money (see #2), a lot of them have dropped those plans from the exchange. You can still get them off-exchange, but you don't get subsidies.

4. The online provider searches - they can be helpful, but ALWAYS call the doctor to confirm. The insurance company will make updates they receive, but it's up to the doctor to send in the updates. And they often don't. If the tool is wrong, ask the doctor if they submitted the updates to the insurance company. They probably didn't.

5. Billing - yeah, that's messy. I'm staying out of it. Good luck, and always check the bill.

[forummm]

I didn't hear the BCBS was leaving!  Just UHC.  There's still Aetna, but getting info on their plans has been difficult (as in their own customer service reps couldn't answer questions).

BCBS is separate by state. It's possible that the NC BCBS is leaving that local market. I know they aren't leaving many other markets.

[Spork]

I'm in Texas, FIREd as of last year and on our second year of ACA coverage with BCBS - HMO (used to have the PPO and would have paid more to still have that option, but oh well). My doctor that I'd been seeing for the last decade or so took the ACA coverage. Same with the hospital that is less than a mile from my house and most all of our other regular/specialist docs we've seen over the years. Only had one doctor not in this specific provider network but he was in network for a different group through the ACA (but it's a super specialist that is only seen maybe once every other year, and we decided to cover his cost out of pocket to keep in network with all the rest of the docs we regularly see).

So I guess it really depends on where you live? Which is kinda odd when you consider that Texas blocked everyone from the Medicaid (or is it care?) extension, and also refused to set up a state exchange and were in general huge douche canoes about the whole thing, but I guess the doctors in general were okay with it?

I am also in Texas... and there is a very large number of docs in my town that don't take BCBS HMO.  I suspect it has nothing to do with political objection... that the whole HMO referral/approval chain is just a huge pain in the ass.  It slows them down, creates paperwork and requires more staff to handle everything.

I know my area was one of the first areas in Texas to experiment with HMOs.  The doctors themselves grouped together to start an HMO.  About 5 years into it, they were all complaining about the monster they created.  One doctor stood up and quoted Pogo: "I've met the enemy and he is us."  I think because of that, a lot of the docs that have been around a while are a bit afraid of the HMO pyramid.

I am hoping it will loosen up and more will take it... but it sort of sucks around here right now.

[Paul der Krake]

I didn't hear the BCBS was leaving!  Just UHC.  There's still Aetna, but getting info on their plans has been difficult (as in their own customer service reps couldn't answer questions).

BCBS is separate by state. It's possible that the NC BCBS is leaving that local market. I know they aren't leaving many other markets.

BCBSNC threatened to leave back in February. The latest news from them is that they are seeking large increases:

http://www.newsobserver.com/news/business/article80879447.html

If they leave, it will be a major blow to the ACA and the rural counties of the state.

[geekette]

I didn't hear the BCBS was leaving!  Just UHC.  There's still Aetna, but getting info on their plans has been difficult (as in their own customer service reps couldn't answer questions).

BCBS is separate by state. It's possible that the NC BCBS is leaving that local market. I know they aren't leaving many other markets.

I did some research and found that they considered leaving NC, but as of last week, have "announced their intent" to stay.  Interesting Op-Ed article by the BCBSNC CEO here.

[maizefolk]

Thanks geekette. Also, just wow! From the editorial you linked to.

Last year, the sickest 5 percent of our ACA population paid $108 million in premiums, including their government subsidies. We paid out a staggering $1.29 billion in claims for the same customers.

[mjs111]

My assumption is that you'd be able to buy a nice individual plan that's fairly widely accepted if you're willing to pay for it.  What I'm unsure of is how to locate those plans. The exchange is convenient but likely has the least usable plans. It seems the best way is to call individual doctors once you have a plan in mind and ask if they accept that particular one.

Cost is less of a factor as long as it's useful: I'd rather pay $500 a month for something I can use than $300 a month for insurance that is only rarely accepted.

Mike

[brooklynguy]

There was an article in the NY Times last month about this:  "Sorry, We Don't Take Obamacare"

[Beriberi]

One solution to this is to go to an academic center. In general, they will take all insurance, or work with you on a payment plan.  Yes, they usually charge for parking, have long waits, subject you to students and residents, but they provide adequate (and often superior) care.

Living in a place with few medical providers and crappy insurance options is kind of like living in a place with high housing costs.  There is nothing wrong with doing it, but a bit of flexibility can allow you to save a tremendous amount of money and hassle. Don't like the California options? Move someplace with better options.

[MandalayVA]

My work around is this: Fund an HSA. This is available to only a minority and if you have one it usually means your primary insurance sucks has a high deductible.

FTFY.  That's my employer's tradeoff.  We load our HSAs every year--it came in very handy last year when I got very sick.

[forummm]

Thanks geekette. Also, just wow! From the editorial you linked to.

Last year, the sickest 5 percent of our ACA population paid $108 million in premiums, including their government subsidies. We paid out a staggering $1.29 billion in claims for the same customers.

That's the way it is with all insurance. It's a power law. The sickest people cost the most. Usually it's the sickest 5% cost over 50% of total expenditures. There are similar power law rules in other domains. Like the 10% heaviest drinkers drink 80% of all the alcohol (or something like that). The richest 85 people have more money than the poorest 3.5 billion.

[Sibley]

Since it came, up, quick lesson on the Blues plans.

Each BCBS is a separate license. The Blue Cross Blue Shield Association, based in Chicago, administers the licenses, assists with coordination between the different companies, etc. BCBSA is not an insurance company.

There are, I believe, 37 companies currently which hold the licenses and are insurance companies. Obviously, one company may hold multiple licenses. Anthem holds a lot, I think 15+. Health Care Service Corp holds 5. Others are only one, IE BCBS Michigan is one company, one license. These different companies are separately managed, do not cross into other territories, and have various legal structures. That is one reason why you'll find so much variation from state to state - it frequently is different companies.

If you're curious, BCBSA's website has more information.

[Spitfire]

Unfortunately the ACA website (which added a filter to only show plans that your doctor and hospital accept) is not accurate. I helped a friend of mine get coverage through the site and found out after the fact that none of her doctors accepted the plan. I cross referenced it with the company website also and it had the wrong information. Many doctors on the company site did not accept the plan.

It is a challenge, but hopefully it will improve. I've found that calling the company and asking them for doctors gives better results than the websites, maybe they don't update often enough, or maybe the doctors only take a certain number of ACA patients and are at their maximum.

[Altons Bobs]

Some of the doctors I know are just not taking any individual plans at all, and it's easier for them to do when individual plans are in different networks than the group networks (different for different states and different insurance carriers) because of the reasons some PPs mentioned.

I'm not relying on individual plans for my FIRE planning at all.  I'm going to keep my group plan from my business as long as I can, and my plan uses the largest network in the country and it's cheaper than any individual plans I can find in this market.  The largest carrier in my state (BCBS) is requesting a 58% increase for 2017 on their individual plans.  Not sure if the state will approve.  They requested a 54% increase in another state they did business in for 2016 and got rejected and they pulled out of that state completely for 2016.  I'm guessing that may happen here too for 2017, not sure.

I think gradually there will only be 1 carrier available, which is already happening in some areas.  Or maybe the federal government will take over.  Regardless of how much money you have, you will not be able to buy a decent individual plan, that's a fact in my area.

[mjs111]

It seems like this would be more evidence to buy a bronze plan, i.e. the cheapest plan available, if likely it won't be useful for much other than catastrophic hospital visits.

Mike

[hay_otsuka]

Few relatives have covered can plans in can and the most Dr that accept were community clincs that accept medical patients. This year they switched to kaiser for about $15 month extra and receive much better care. AFAIK kaiser doesn't have member tiers between plans.

Sent from my Nexus 6 using Tapatalk

[David]

Yes, Bronze is mainly the way to go....  I like that Obamacare has standardized the way that health plans are presented. Prior to Obamacare is was difficult to compare plans. Now, you can easily compare the plans apples-to-apples. The nomenclature however is unfortunate in that it gives a false sense that Silver is better than Bronze; Gold better than Silver, and Platinum better than Gold. There is no difference in the actual coverage or the care that you are receiving. The difference essentially is do you want to pay now or pay later. If you believe with a high degree of likelihood that you will have considerable medical expenses, the more expense plans might make sense, but for most people I think Bronze is the way to go.

I quickly became disenchanted with Obamacare because of the available practitioners that most people have covered in this thread already. I experienced this with an individual plan OUTSIDE the exchange. It was a comparable BC plan, but it was directly from BC, not through the exchange.

Right from the start I saw the problems; medical practitioners refusing to cover my wife and me; we had been a group plan through BC previously, but when we switched to an individual plan, our providers informed us that we wouldn't be covered any more. If you are in a large group plan, most providers will happily take on the business, otherwise, it can be a real problem. As someone mentioned earlier in the thread, the closest providers under ACA-like plans can be 50+ miles away.

We quickly elected to change plans and get back into a large group plan. Now we get to see all our providers like we could before.

[Ursus Major]

We quickly elected to change plans and get back into a large group plan. Now we get to see all our providers like we could before.

So how did you get back into a group plan?

[MoneyCat]

How the hell would they know you are using an ACA plan? It's just a healthplan. Unless it's Medicaid, it's a plan from a major insurer. Unless they don't accept the major insurer, then it's none of their business.

[projekt]

"Last year, the sickest 5 percent of our ACA population paid $108 million in premiums, including their government subsidies. We paid out a staggering $1.29 billion in claims for the same customers."

So, assuming that the sickest 5% are similar in age to the rest of the ACA population, they took in over 2.1 billion in premiums overall and paid out most of it on the expensive cases. That's pretty much par for the course with health insurance. It would be more interesting if they just said whether their loss ratio was too high. They're supposed to be paying at least 80% of their income in claims, but I can see how they might start having trouble if the number was pushing 90% (it was around 87%) because of all their overhead. They can either cut overhead or increase premiums. They don't seem to publish an annual report, though, just a few summary numbers, so it's hard to evaluate their statements.

Of course, if NC accepted the medicaid expansion, then BCBS wouldn't have to worry about a lot of the subsidized people who are within 100-133% of the FPL. There are also a lot of people who wouldn't work a lot of extra hours just to stay in the ACA system because they would be eligible for medicaid.

[RetirementDreaming]

Right from the start I saw the problems; medical practitioners refusing to cover my wife and me; we had been a group plan through BC previously, but when we switched to an individual plan, our providers informed us that we wouldn't be covered any more. If you are in a large group plan, most providers will happily take on the business, otherwise, it can be a real problem. As someone mentioned earlier in the thread, the closest providers under ACA-like plans can be 50+ miles away.

We quickly elected to change plans and get back into a large group plan. Now we get to see all our providers like we could before.

This seems to be the case in CA.  I don't personally know anyone with an exchange plan but I called a few doctors listed as in-network for an exchange plan and most said they do not take exchange plans or not accepting new patients.    This means I need to work longer just for the health benefits. I'm researching where I want to work in the future with as few hours necessary to receive health benefits.  Not the FIRE plan I envisioned but better to find out now. 

[goatmom]

I work in the medical field.  We don't take any insurance at our office.  Reimbursement is too low to make it work.  Too much paperwork.  Too much intrusion by insurance company.  We see plenty of medicaid patients who just pay out of pocket.  If you want to see a mental health provider who takes insurance you will be waiting months.

[EnjoyIt]

This thread just proves what I have been saying for years.  Health insurance does not equal health care.

This country has been confusing the two for way too long.

[GrumpyPenguin]

I work in the medical field.  We don't take any insurance at our office.  Reimbursement is too low to make it work.  Too much paperwork.  Too much intrusion by insurance company.  We see plenty of medicaid patients who just pay out of pocket.  If you want to see a mental health provider who takes insurance you will be waiting months.

Sounds like you work in a crappy office.  Seriously, complaining about "too much paperwork"?  Sounds lazy and more interested in ripping off patients to me.  I haven't had any problems finding excellent doctors that take my BCBS insurance plan.  When I needed surgery last year, it was no problem at all having excellent care at a nearby hospital that was covered by insurance (with a relatively tiny deductible).

[David]

We quickly elected to change plans and get back into a large group plan. Now we get to see all our providers like we could before.

So how did you get back into a group plan?

It does mean continuing to work in some capacity