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ObamaCare Clusterfuck: Can somebody decode this CMS fact sheet on emergency care?

Via Timothy Yost, we have a "Fact Sheet" on the ER. Quoting in relevant part (it's a PDF, fer chrissakes):

Getting Emergency Care
In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance. Your insurance company can't charge you more for getting emergency room services at an “out-of-network” hospital.

I’m having an emergency. Should I go straight to the hospital or do I need to call my insurer first?
In a true emergency, go straight to the hospital. Insurers can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.

What does it mean that insurance companies can’t charge me more?
Insurance plans can’t make you pay more in copayments or coinsurance if you get emergency care from an out-of-network hospital. They also can’t require you to get prior approval before getting emergency room services from a provider or hospital outside your plan’s network.

Will I have to pay anything?
This depends on the plan that you chose and the hospital you go to. This care may be subject to a deductible, for example, or a hospital may have particular rules in place.

For example, the definition of "can't charge you more" turns out to mean "can’t make you pay more in copayments or coinsurance if you get emergency care from an out-of-network hospital," which seems like a significant qualification, though I confess I don't know what it means.

And apparently this all applies to "emergency room services" only. What happens if they need to move you somewhere else?

And what is a "true emergency" in question two and who decides that? How is it different from a mere "emergency" in question one?

And then there are the these terms: copayments, coinsurance, and deductibles. What the heck is coinsurance?

And then there's this: "a hospital may have particular rules in place." What does that mean?

Anyhow, not having purchased insurance, and so far having avoided involvement with the "health" "care" "system" successfully, I'm not at all expert in decoding "Fact sheets" like this. Readers?

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Submitted by Dromaius on

or a hospital may have particular rules in place.

That means balance billing.

It is horrible that they are not warning people about this, in this document. People need to be warned.

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Submitted by Rainbow Girl on

If this is not a clear example of the US Government intentionally defrauding people into potentially financially disastrous circumstances by use of execrably misleading language I do not know what is.

This is a bloody scandal.

Submitted by Dromaius on

And a sign that the powers that be KNOW without a doubt what a fiasco they've created.

Sorry Obama Admin. This isn't Benghazi. You can't lie your way out of it. People WILL find out. Of course, they'll be devastated when they do.

Submitted by Dromaius on

And a sign that the powers that be KNOW without a doubt what a fiasco they've created.

Sorry Obama Admin. This isn't Benghazi. You can't lie your way out of it. People WILL find out. Of course, they'll be devastated when they do.

Submitted by Dromaius on

Sometimes insurance plans are set up so that you have a $25 co-pay for care. Most good employer provided insurance plans have this. Whether you've met the deductible or not, you pay that $25 co-pay up front to your provider. My old plan that has since been canceled in favor of Obamacare junk had 4 up-front visits not subject to deductible, each with $25 copay. So to see a doctor 4 times a year (more than enough for me), it cost $25 per visit.

Once you meet a deductible, say a $3000 deductible, then co-insurance kicks in. Some plans have 80%/20% coinsurance. The 80% is the amount of the insurance reimbursed rate that the insurer will pay. The 20% is what the patient pays.

Often times out of network visits have a higher coinsurance rate, say, 50%/50% and maybe a higher copay.

Under Obamacare, true ER visits (whatever the hell that means, looks floppy as you've said) have to be insurance covered at the IN-NETWORK co-pay and co-insurance rates. I assume also that the in-network out of pocket maximum applies.

As I've said, because of balance billing, there is no true cap on costs if you go to an out of network ER even in the case of true emergency, because the hospital is under no obligation to accept the insurance level of reimbursement as the final payment (even with the new rules about how much insurance has to reimburse).

I would say if a person were having cardiac arrest or an obvious stroke, bleeding to death from a shotgun wound, etc then they should go to any ER. If the emergency is a broken leg or anything that can wait at all, NEVER go to an out of network ER. An informative fact sheet would make this distinction. A political fact sheet that tries to hide the realities of care under narrow networks would obscure the facts as this document has done.

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Submitted by Rainbow Girl on

IIRC we had a thread not too long ago where HealthCare.Gov's explainer sheet on this topic quite plainly said that it is up to insurance companies to decide what all out of pocket expenses they apply to your annual max out of pocket.

So in the situation(s) described by Dromaius, there is this additional Joker Card (Nasty Easter Egg) to take into account.

Let's say that a "good" insurance company applies all your copays and co-insurance costs to the Annual Max. You get to the OON Emergency Room and - best case scenario - you end up paying whatever co-insurance and co-pays your policy has for care -- recall that with Bronze and Silver, the hapless policy holders are on the hook for -- respectively -- 60% and 70% of the costs as co-insurance (in a "good" scenario) and whatever sliced and diced co-payments for this-that-the-other the insurance company has "designed" into your policy for emergency room visits. So this sucks bad enough -- most people end up in bankruptcy. [And this is BEFORE balance billing by a hospital that's OON.]

But a nasty insurance company that has all sorts of tricks and snares in your policy where none of your copays/deductibles ever apply to your out of pocket max, leaves you with a potentially unlimited amount of out of pocket costs that you are paying for at 100% (because you never reached the co-insurance break point past the deductible/out of pocket max).

So another thing this CMS "fact" sheet misleads American citizens about is the very real possibility that even "in network" ER care could turn out to be a 100% Not Covered financial catastrophe -- to a person WITH an ObamaCare Bronze, Silver and whatever other metals.

The sad truth is that if CMS were truly in the business of providing critical, accurate information to ObamaCare "consumers," this fact sheet would say: receiving ER care -- whether in or out of network -- has a high probability of causing you a financial catastrophe and personal bankruptcy, whether you have a health-insurance policy or not.

Submitted by lambert on

It's like Yves rattling on about CDOs or something. Let me pick one sentence out of the flying shrapnel:

- recall that with Bronze and Silver, the hapless policy holders are on the hook for -- respectively -- 60% and 70% of the costs as co-insurance (in a "good" scenario)

I thought it was the other way around, 60 to 70% were being picked up. Am I not understanding co-insurance?

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Submitted by Rainbow Girl on

You are correctly puzzled and I wrote a dyslexic sentence. Yes, the hapless policy holder is on the hook for 40% and 30% (respectively) -- which, when you apply those percentages to the astronomical costs of anything that they do to you in a hospital (including $100 saline bags), is a whole lot of money.

I'm sorry I made your head spin needlessly, given that you are already juggling on the fly and really well! (At least it was a bug not a feature :) ).

Submitted by lambert on

... although I hate it when people assign work to me, so I'm not doing that, but maybe next time, would be a worked example.

"I take the ambulance to the ER, and that's $1,000.... And... And... And... And so when the bill come in the mail I'm on the hook for $10,000, all because of a ________."

So far my life as been pretty simple (thought it may get more complicated soon) and I have avoided these horrifying cascades.

Adding, that means the obfuscation is working, I guess....

I literally have no sense of the flow of events (and money) here because I have never had to deal with them. Power relations I can do just fine (see Liz Fowler) but this money stuff makes my eyes glaze over.....

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Submitted by Rainbow Girl on

Well, I think the flow of events and money for purposes of this thread and related others is simply that a medical event happens (I have heart attack), then I get taken to the ER where dozens of things are done to me (medical services), from xrays, blood infusions, maybe surgery, anesthesia, etc. At some point you get released because you are stabilized. Once home, you start getting bills from the hospital which, from what I understand (second hand), can look like a phone book of separate bills sent by different doctors within the hospitals who did things to you, various bits and pieces of medical equipment that was used for you or on you, drugs and such that were administered to you.

So the flow is: medical event => ER => treatment => billing to you and insurance company. Dromaius did a good job of explaining some of the innumerable scenarios how how much you could or could not be on the hook for depending on your policy, what's in and out of network, etc.

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Submitted by Alexa on

for purchasing insurance--if you're not familiar with a product--consult a professional broker (or a family member who is one, if possible) before committing to any policy.

And since it's been a while since you've carried health insurance, Lambert, regarding "decoding" benefit language, if it gets confusing, I would run every appointment and medical transaction through the insurer just to be on the safe side.

And be sure and check to see if a provider is "in-network" literally the morning of your appointment, tests, etc.

Even with Mr A's prior (years ago) experience, we often get a predetermination of our medical, dental and vision benefits before committing to procedures, etc.

Obviously, in emergency situations, this may not be possible.

And it can get very dicey. Be prepared to be assertive.

When Mr A had an emergency room situation almost two years ago, the insurer tried to discourage him from calling an ambulance. I won't go into the details, but it was ugly.

Finally, I called the ambulance service for him--he was literally "yelping in pain."

The insurer paid.

Sometimes you just have to go out on a limb. There are few "absolutes."

It was the very next plan year--2013--that our employer-sponsored plan began levying a "co-pay" for all emergency room visits--both in- and out-of-network--UNLESS one is admitted to the hospital from the ER.

And this is a plan that has no "co-pays" for doctors visits (and never has). Only RX benefits--and now, the ER. (Obviously in an attempt to limit the use of this service.)

Good luck!

Submitted by Dromaius on

I laugh about something I've lately seen on comments on message boards. People lament the high deductibles on the Exchange plans. Of course, almost invariably, an Obamabot comes forward and says, "no the number you're quoting isn't the deductible, it's the out of pocket max!" And then said Obamabot goes into a lecture on what co-pays, deductibles, OOP max, etc. are. LOL. In fact as it turns out, the original commenter WAS quoting the deductible, not the OOP max. Unfortunately, the Obamabot is long gone by then, can't be straightened out, and will live on to confuse him/herself another day.

It's no wonder the Obamabot is confused. The very idea of spending $500/mo for a plan with a $5000 deductible is just unreal. But that is Obamacare. That is MY reality. (That is why I opt out.)

I think as the realities of Obamacare hit the fan, even the true Obamabots will change their tunes. Third party, third party!

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Submitted by jo6pac on

they wake up but I truly doubt it.

I think as the realities of Obamacare hit the fan, even the true Obamabots will change their tunes. Third party, third party!