Healthcare business owner, worried about ObamacareSubmitted by Atreidies on Fri, 11/01/2013 - 13:59
To protect the identity of this person, I can't release too much info, but this email will be sent out regarding Obamacare. The kicker, is that the author considers themselves a Democrat and a liberal. They voted for Obama twice. If you think people aren't starting to wake up to the reality of what our government (ALL OF IT) is doing to us, read below. This is going out to hundreds of patients and healthcare industry service providers. Feel free to pass it along. Truth to Power.
"To Whom It May Concern:
I am a Registered Nurse in the state of Texas. I have worked as a case manager for disabled adults and children for the greater part of my career. I work with individuals and families on a community level and the unique nature of that role has given me firsthand knowledge of the many obstacles Americans with disabilities and chronic conditions face daily. I am a proponent of affordable access to the healthcare system for all; however, as the Affordable Care Act (ACA) is being rolled out, I am encountering many red flags that are potentially catastrophic for the disabled population. I am writing to share these concerns with you in hopes that your large collective voice will help clarify these issues and protect disabled Americans in our new Healthcare Marketplace.
• The 10 essential health benefits in the ACA are written about as broadly as the U.S. Constitution. We tend to look at what is said and get excited. We do not look at what is not said. Per the healthcare.gov website, one essential health benefit is Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills) This sounds great and we could interpret that verbiage as implying disabled Americans’ healthcare needs are going to be covered and protected under the ACA regulations. The truth as I understand it is, interpretation is by and large left to the insurance companies.
One would assume Durable Medical Equipment, Medical Supplies, Prosthetics and other costly healthcare items would now be included in the new healthcare plans under Rehabilitative and Habilitative Services and Devices. When you review the new insurance policies, these items are no longer individually listed in the insurance policy’s description of coverage like before as DME, Medical Supplies, Prosthetics, etc. In fact, there is no mention of any of these type of items whatsoever. I thought I was being a little too specific or technical. Surely they were covered and I was missing it somewhere.
However, I have not found a new individual policy that specifically states it covers items such as wheelchairs, prosthetics, ventilators, enteral feeding supplies, tracheostomy care and other items the average American would not even realize exists. I have even found policies that specifically exclude orthotics of any kind. I also have not been able to obtain clarification of these coverages from any of the major health insurance carriers, Medicare, healthcare providers, insurance brokers or other colleagues in the field. I have searched multiple websites and articles. No one knows or no one will tell. The clearest answer I have received was from Blue Cross Blue Shield. The representative told me he asked the same question two weeks prior to the October 1st rollout and he was instructed they were waiting for the federal government to clarify the issue. The answer was very alarming and telling to me; If they do not have to, they will not cover it. Another thing that I realize from a long-standing precedent in the industry, is that if an insurance policy does not specifically state an item is covered, IT IS NOT COVERED!
Can you imagine the devastating effects of losing coverage of custom manual and power wheelchairs, standers, lifts, ventilators, suctioning supplies, cough assists, hospital beds, urological catheters, IV/Enteral feeding pumps and supplies, wound care supplies, diabetes supplies, prosthetics, walkers and so forth? These are all very expensive ongoing healthcare needs and vital to ensuring continued independent living and quality of life for many Americans. If they are not covered, disabled people will be financially forced into Medicaid nursing homes and group homes to survive. They will not be able to live independent and productive lives in the community. We will take huge steps backwards towards the institutionalization of millions of Americans. I hope that I am horribly misinformed through all of my research and multiple contacts for clarification, but I have not encountered one source that has listed or stated, “Yes, these Items are covered.” https://www.healthcare.gov/what-does-marketplace-health-insu...
• Another concern I have regarding Rehabilitative and Habilitative Services and Devices benefit is coverage of therapies. I have worked with similar challenges within the Medicare and Medicaid systems’ coverage of “acute vs. chronic conditions” in the rehabilitation setting for many years. “Gain and recover” are very important and limiting words when you are discussing care of a life-long condition and maintaining function. Although there will not be limits on therapies anymore, this care is unlikely to be covered in a chronically disabled individual. For instance, a stable chronic quadriplegic would certainly benefit from physical therapy and occupational therapy to maintain strength and function, but will not necessarily “gain or recover” enough function to meet medical necessity as defined by the insurance carrier.
• Many of the clients I work with are currently enrolled in catastrophic coverage plans, such as State Health Insurance Risk Pools, the Federal Pre-Existing Insurance Plan or unqualified individual policies that will term on 12/31/2013 secondary to the enactment of the ACA. However, with the exchanges being mostly inoperable since inception on October 1st , they are unable to enroll in the new Health Insurance Marketplace and are not expected to be able to do so for several weeks. As you may be aware, you must enroll, submit payment of your premium and be processed for federal subsidies in the exchange by 12/15/2013 to have a coverage start date on 01/01/2014. How in the world is this going to be possible? In addition to the potential problems with the policies outlined above, disabled Americans who already have coverage will likely be uncovered or face being retroactively covered under the new health insurance policies. They may not technically end up with a gap in coverage, but it will result in a gap in care. Most disabled Americans cannot afford to bankroll the cost of their healthcare and await reimbursement at the pace of bureaucracy. The government needs to extend these programs until they have corrected the issues with enrollment in the new ACA insurance policies. http://www.washingtonpost.com/politics/two-key-parts-of-onli...
• This last item does not only pertain to disabled Americans, but all Americans. I only reference the subject in this e-mail to demonstrate the gargantuan amount of funding being guaranteed to health insurance companies that would surely allow funding of the care I detailed above. INSURANCE COMPANIES ARE the PRIMARY BENEFACTORS of the ACA legislation.
Health insurance companies now have a federally mandated Medical Loss Ratio (MLR) of 80-85%. That sounds great because it means that they have to spend 80-85% of all premiums on healthcare and improving healthcare. Again, we tend to look at what is said and not what is not said. If you take that equation and look at it inversely, Insurance companies are now guaranteed, under federal law, to retain 15-20% of their total sales to cover their administrative costs and profit margins on health insurance premiums for nearly 316,986,000 American citizens. This includes salaries, overhead, marketing, bonuses and profit shares. They are entitled to collect premiums from us individually. They are entitled to collect subsidies to help cover your premiums from the federal government via our tax dollars. And since we are mandated to pay insurance premiums via the private marketplace, employer group coverage or even Medicaid and Medicare, insurance companies are guaranteed a health care premium for each and every individual in the United States of America. If you were not aware, a great deal of Medicaid and Medicare recipients are insured by private health insurance companies who receive premiums from the federal government to manage their care.
The rhetoric that Insurance companies stand to go under because they cannot exclude/charge higher rates for pre-existing conditions and the younger healthier people may not participate to balance it out is ludicrous. They can increase premiums to ensure they are profitable (15-20%) and we still have to buy their products. They are guaranteed to be profitable by the law. The house never loses, which is also why they have been fairly quiet. P.S. If you try to skip out, the IRS will ensure they collect it for them! Sure some people will skip out, but the majority will fear retribution of the IRS and abide by the law. Talk about your government hand-outs and entitlements! https://www.healthcare.gov/how-does-the-health-care-law-prot...
Below is a conservative estimate of potential costs and earnings for private insurance companies after the MLR standard is met. It assumes every single American could be privately insured under employer group coverage, individual coverage, Medicare Advantage Plans with Part D coverage and Medicaid Managed Care Organizations for $250 monthly.
316,986,000 Insured Americans x $250/month average premium x 15% retained revenue after MLR = $11,886,975,000 per month for private health insurance companies administrative costs and profits
$11,775,000,000 retained monthly revenue x 12 months = $142,643,700,000 annually for private health insurance companies administrative costs and profits
Assume 1/3 of that amount (5% of total sales) is actually profits after accounting for salaries, overhead and marketing. The total annual profits are still $47,547,424,521 compared to a mere $13,727,400,000 in 2012
316,986,000 Insured Americans x $250/month average premium x 12 months = $950,958,000,000 annually in total health insurance premiums compared to $301,806,000,000 in 2012
$950,958,000,000 x 85% spent on healthcare = $808,314,300,000 in healthcare costs paid by private health insurance companies for the American population
• It seems as though the more I learn about the ACA, the less knowledgeable and more uncertain I feel. I am very accustomed to contacting government entities and obtaining a different answer every time for the same question. I am not accustomed to contacting insurance carriers, brokers, healthcare providers and other experts in my field and everyone being clueless. I do want access to healthcare for everyone now, but the last 30 days are a warning to us of potentially disastrous repercussions. I cannot understand why this legislation was drafted in such a way that nobody understands it; particularly, those implementing it. I cannot understand why a more suitable model was not utilized. Medicare has been in effect since 1965 and despite of all the propaganda, it still functions 48 years later. Traditional Medicare with a Medigap F is the best insurance policy available to almost anybody. Still, Medicare alone is better than most other types of insurance policies and it is accepted virtually everywhere. Medigap policies, Medicare Part D policies and Medicare Advantage policies are sold by private health insurance carriers. Medicaid has Managed Care Organizations that are run by private health insurance carriers for a profit. So a private market could have been created in a government system based on Medicare.
I do apologize for the lengthy e-mail, but I wanted to be certain I was clearly articulating my concerns and perhaps a few opinions. If you have any feedback or resources available to shed light on the above issues so that I can adequately assist my clients, it would be most appreciated. More importantly, if you have the network to look into these concerns and do something before it is too late, please do so accordingly! I can’t imagine the alternative."