Would you prefer State or Private Insurance "Why"

[GingerSnaps]

What's the difference in the plans? Which one would be better for us?

My opinion is that a state run insurance plan would be the best plan for our country.

Would this country be saving money if we went with the State Run system?

Is PPO better than HMO?

[One_Life_To_Give]

1. Need to address Costs

It would be easier to reign in costs with a state run mandatory system. Although the mandatory state system loses the ability to private pay for experimental treatments, like bone marrow transplants were. When people would take up collections to pay for a sick persons proceedure.

But if we don't find out why health insurance is running over 6k per person. We will have universal coverage, but it might only be funded at 4k per person. Which would be a net loss for the majority who are
curently insured at 6K.

[GingerSnaps]

2. State Run is Medicaid only right?

:shrug:

[Midlodemocrat]

6. Actually, Medicaid is a federal program

...with carve outs to the states. Once you are in Medicaid in one state, you can transfer it to another state without going through all the hassles of being re-approved. That is why nursing homes, etc, really have to toe the line with a Medicaid patient, they are considered a federally covered life.

[One_Life_To_Give]

7. All if you want to control costs.

A single payer system would be best if you want to reign in costs. They wouldn't be able to charge two different people different rates.

The current Medicaid program is a subsidized program to help low income individuals. You would have to be careful about letting people buy into Medicaid as you could get all of the high dollar patients. If the costliest patents shift from private/no health insurance to state sponsored medicaid only the well would have private insurance.
And additional public money would be needed to keep medicare operating.

Not that this won't work but it needs to be made clear. As much money will be required in new taxes as the amount that companies/people save in medical insurance costs.

[HEyHEY]

3. I prefer both

That way they keep each other honest

[GingerSnaps]

4. The sky is the limit with Private

Doctors are allowed to make as much as they can and that is when assembly line surgeries start taking place whether you need it or not.

[HEyHEY]

5. Yeah, but the same happens with public

ICBC is the government run insurance corp in BC. Their rates are outrageous and they've had multi-million dollar surplus years. They even bought a mall....basically a bunch of shit they aren't supposed to do. And has insurance gone down with all the money they make? Nope.

[Shakespeare]

8. Perhaps a better question to ask:

Would you rather have for-profit or not-for-profit healthcare?

Non-profit, hands-down, which is why I'm in the Kaiser HMO. It's non-profit, my premiums are a fraction of what they'd be with any other healthplan, and the care I get is fantastic.

[GingerSnaps]

9. Do you have to meet a deductible?

Is it a PPO or an HMO plan that you are on?

[Shakespeare]

10. It's a true HMO. Co-pays only, no deductible. n/t

[GingerSnaps]

11. I am still trying to figure out if

Veterans Insurance is a state run program or a federal program. :shrug:

[yellowdogintexas]

12. Veterans are covered federally through a plan called TriCare

When they age up to Medicare, then TriCare becomes their Medicare supplement.
Tricare is managed by various insurance companies, just as Medicare is.
Example: Humana manages Tri Care's claims etc in Indiana, Kentucky and Ohio;

A company called The Hartford Group offers a supplement to TriCare that the military retirees can purchase to pick up their copays, and their RX cost shares. It is managed by a Third Party Administrator..I actually was a service rep for this plan in my last job. I don't know if my old employer still has this contract or not, since they seemed to be doing everything they could to shoot themselves in the foot on all their lines of business....

[GingerSnaps]

14. Hartford Group?

:scared: I hate the Hartford Group they don't like to pay for anything after you pay your premiums :puke:

[yellowdogintexas]

16. In this case, the claims were paid.

TriCare supplement is a very large group, and Hartford was only the underwriter/marketer. The claims and customer service came down to our office here in Ft Worth and were processed according to the policy.
supplements are usually pretty dependable, payment wise anyway.

Of course when we first got it, we had a huge backlog and it took a while to get it all sorted out, plus the usual programming bugs during the transition but it was a pretty smooth plan to run.

[yellowdogintexas]

17. what kind of plan did you have with the Hartford/

It is possible they had a sucky TPA running the plan for them.

[GingerSnaps]

18. My Mom had it

I use past tense because she is no longer around. After she died both of her insurances fought over who wasn't going to pay instead of who was.

[yellowdogintexas]

20. Life Insurance, I take it?

Life insurances are always weird that way.
Although, if she had two separate policies, both should have been redeemable and not interdependent in any way.

Now if she had excess medical insurance...basically you have a plan which is primary and a plan which is secondary and there are specific rules about determining which is which. I can do a big hairy explanation but it is too late in the evening.

But the short version is that two plans will sometimes get into a pissing contest over determining which plan is the primary plan, however once primary status is awarded, the second plan will not touch the claims until the first plan has paid everything it is supposed to pay.
then the secondary comes in and cleans up the leftovers..

There are evil plans out there which use a nasty thing called carveout, which can result in plan #2 not paying a dime. I HATE CARVEOUT.

[GingerSnaps]

21. Medical Insurance

She lived in intensive care for almost 6 months prior to dying.

[yellowdogintexas]

23. was Medicare her primary plan?

How many plans did she have?
I take it you finally got somebody to pay up. Of course the issue of who should pay should have been resolved early on in the confinement.
Sometimes the "other plan" does not surface right away..the family forgets about it, or whatever.

There are also these little creatures called "catastrophic excess major medical plans" with humongo deductibles that pay all the excess costs once that ded is met. Some of them are driven by the diagnosis which can raise hell when a person has all sorts of things going wrong all at once. This type of plan can get really picky about the documentation you send in when you file the claim.

Then there is "Indemnity Plans" those "$___ per day if you are in the hospital" types. Your major plan finds out about one of these and goes nuts trying to prove that this plan really should be paying before they pay, while you have to prove that the indemnity is just an extra plan.

Believe me, any way it can be screwed up or confused, I have seen it happen.

And an insurance company is only as good as its claims department IMHO, all it takes to monkeywrench the whole thing is a stupid claims examiner who doesn't know squat

[GingerSnaps]

24. My Mom was in her 50's

My parents had two different plans. My Dad was sued for the bills because both of them argued over who wasn't going to pay. She didn't have permission from the HMO to go into the hospital.

[yellowdogintexas]

28. I do not really care for HMO plans

Especially the kind where you have to have a thousand people sign off on everything.

Hospitals are supposed to advise the HMO as soon as they get a patient sothe pre auths, etc are done right then. If the facility is not the network facility then they have to justify the patient being there, and there are ways to do that.

I take it you finally got it settled? I have had to help people wrestle with this kind of mess from time to time. It is very frustrating, to say the least. (but very gratifying when you get it settled)

[GingerSnaps]

29. He got to keep the shirt on his back

Everything else he was sued for so he ended up filing bankruptcy.

[yellowdogintexas]

13. We just need to get the 45 million covered, somehow:

OK the old are on Medicare...no pre ex, no under writing, no riders for illnesses etc.
the very poor are on Medicaid..same as above..no pre ex, etc
The folks who work for big companies have excellent coverage: because their unions insist on it or the company sees it is to their advantage to have a healthy workforce...and because the cost risk is spread thinner when the population base of the plan is larger.

The folks who work for smaller businesses have higher premiums and reduced benefits...because their risk is not spread thin..not enough people in the plan.

And the 45 million w/o any coverage because we are:
1. Not old enough for Medicare
2. Not poor enough for Medicaid
3. Not a military retiree
4. Don't work for a company with an affordable plan
or whatever.

Solution Kerry proposed was to open the plans that Federal employees use to the rest of the uninsured public. Yes they would pay premiums.
Yes there would be deductibles. Yes there would be copays or cost shares. Possibly the premiums would be based on ability to pay for some folks, or they could choose higher deductible to offset premium costs.

BUT it is an excellent plan, and adding all those extra lives would infuse the base with a large number of essentially healthy people. When you have a lot of healthy people paying premiums, meeting deductibles, and paying co pays, your risk is reduced.

AND a plan that is this large would have enormous bargaining power with the hospitals, physician groups, labs, etc. The Federal plan already has excellent negotiating clout as it is (which is why it is so criminally evil that Medicare can't get that RX negotiation power, when the regular Federal Plan has it and boy is it good!)

Alternatively, allowing all the small groups to band together for insurance purposes to form a purchasing block would result in a big improvement in coverage nationally.

Or setting up a plan for the 45 million that is patterned after the fed employee plan, which would have a premium contribution from the insureds, a premium contribution from the employer, some good PPO networks for discounting and well benefits etc. It would be the same plan whether the people lived in Alaska or New York, just like Medicare and the military retiree plan.

A consistently administered, uniform plan would cost much less to administer and be much less of a headache for the providers!

I should think the insurance industry would be jumping at the chance to pick up another 45 million paying customers.

[GingerSnaps]

15. Thank you

:hug:

[GingerSnaps]

19. Blue Cross Blue Shield use to be a good plan

They would pay 80% but you got to pick your own Doctors and they never gave you a problem if you didn't get permission to go to a specialists.

[yellowdogintexas]

22. Blue Cross still has plans like that

In fact, lots of insurance companies still MARKET plans like that.
Problem is, they are expensive as hell to purchase.

There are even self funded plans that are like that. The employer foots the bill for the medical care out of the insurance pool that is built from all the premiums paid by the employees and the company. There is usually a $$ cap per person per year. Self funded can set it up pretty much how they want, within reason.

Then they hire a TPA to administer the claims, or sometimes they just pay them in house. No insurance company to pay. So if they want to be totally free market, then no PPO, no discounts, no restrictions.
However the Out of pocket for the insured person tends to be higher.

The PPO plans offer the member the advantage of a good hefty discount on the network purchases, and more and more networks are available that are national in scope, making it easier to find providers in the network.
Or else the plan will have a back up network they can go to for repricing if the member is out of area.

(Can you tell that this is my specialty?, Why am I still unemployed?
could it be because I do not want to drive to Dallas?)

[GingerSnaps]

25. What are the differences of a State Run Plan vs Private Plan?

Is Medicaid the only plan right now that is state run or is Medicare also a state run plan?

[yellowdogintexas]

26. Medicare and Medicaid are actually both Federally funded

Medicare has the qualification of being over 65 or certain types of disability to qualify. The part of Medicare that deals with doctor bills, lab charges, etc (Part B) is optional,(if you have a plan that will continue to cover you w/o Medicare, then you can keep it, or if you are just rich and don't want to have Medicare) and there is a premium pd by the member which is taken out of their Social Security before they receive their check. Also, if you notice on YOUR pay stub, there is a little "Medicare" item: that is the amount we pay to help support the Medicare program for those who are receiving benefits now.

Everybody gets Part A which covers hospital charges; no extra premium there.

Medicaid is means tested and the states each have their own ceiling...
the max amount of $$ you can have and still qualify. This max is the total $$ you actually have and that means after your house is sold, your car is sold, your savings are spent down, etc. It is usually in the neighborhood of $3000 although it can vary from state to state. Southern states are usually lower threshold than Northern ones. You have to file all kinds of forms, and ifyou are still in your home, you have to show you have no money in the bank and all your expenses vs your income.

the states receive the money from the feds, and determine the financial qualifications.

used to be if you had Medicare and Medicaid, Medicaid took over your Medicare premiums and picked up anything that Medicare did not pay. I do not know if this is still the case. With my aunt, Medicaid paid for her nursing home expenses for three years, once we got her approved.

[GingerSnaps]

30. She had a HMO

If she would have lived a few days more she would have been placed on Medicaid Insurance.

[yellowdogintexas]

27. OH yeah, the "running"

That was the financials.

Medicare and Medicaid are contracted out on a bid basis to various insurance companies for the actual claims work. The big players are Blue Cross, Cigna, EDS (Ross Perot) and probably Aetna. There are other local and regional players but these are the big guns (ones with the most contracts) I know that Cigna has several states for part B and Blue Cross has Texas (or at least part of Texas)

Claims are paid according to the same set of standards on Medicare across the board no matter where you live. The company which handles the claims is determined by the location of the provider of services. So if you see physicians in two states, your claims would go to two different places. However, there is a national data base @ Social Security central which updates and downloads to the carriers the deductible info on each and every member..so if you meet your ded in Iowa but you live in Colorado, when you go to the dr in Colorado, your ded is already met and it won't get taken twice.

If you are out of your local network area, the benefits (actual payment) may vary, but those can be appealed and usually are by the providers. However the judgement calls which determine what is and is not covered are all based on the same set of rules nationally.

this is the best part of a nationally based plan. Instead of one set of rules for one group and a different set for another, everybody is on the same playing field. this in itself would cut costs enormously, no matter who is funding the plan. A physician these days has to have two or threepeople just to keep up with the insurance policies his patients have. How much simpler would it be to just send it in and know it would come out the same no matter where you sent it?

National insurance differs in this way: the provider just sends a claim or bill to the government agency and they pay him/her/it. No middle man, no anything.

Private you send claim to the insurance company, it is processed according to the terms of that specific policy and $$ are paid either to the physician or the patient, depending on how the claim is filed.

I would prefer a blending of the two: the features and benefits of a national plan but contracted out with premiums etc in the way that Medicare is set up.

[billyskank]

31. State insurance, here's why:

Private insurers want to make a profit. Therefore they have an incentive to weed out the market segment that is a high risk. If you have a chronic condition, especially an expensive one, they have every incentive to try to get rid of your custom if they can.

State insurance would spread the risk evenly over the whole population, so the healthy majority would cover the costs of treatment for the sick minority. Like it should be.