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Embedded Out-of-Pocket Medical Requirement

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posted on Oct, 27 2015 @ 05:11 PM
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Just when you thought you'd heard it all about the un-ACA, about how it just could not get anymore bizarre or expensive, the government is rolling out Embedded Out-of-Pocket Medical Requirement....that means, if you are married for example....whatever you pay toward your deductible will not count toward your spouse's deductible.
Nice, huh?

Did they pass this one in the middle of the night...I never heard about it.
Until I got the letter from my insurer....YAY my plan will continue next year, but it will cost me almost $40 MORE per month, plus teh $6300 deductible....read the article and see if your head spins...

On May 26, 2015, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (collectively, the Departments) issued new FAQs further clarifying this new rule, confirming that it applies to all non-grandfathered group health plans including,:

self--insured plans
large group health plans
high deductible health plans

www.linkedin.com...

www.consultbb.dreamhosters.com... [.pdf]


Under the HHS notice, however, group health plans must “embed” an individual OOPM within any “other than self-only” coverage limit. So, if one family member incurs costs for EHBs that exceed the statutorily required OOPM for self-only coverage, the plan must pay 100% of that family member’s remaining expenses, even if the aggregate out-of-pocket expenses of all family members have not reached the cost-sharing limit for family coverage.

www.towerswatson.com...
edit on Tue Oct 27 2015 by DontTreadOnMe because: clarity



+1 more 
posted on Oct, 27 2015 @ 05:19 PM
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It's the Obamacare's version of trick or treat...

If I said what I really wanted to about the "ACA", I'd be modding myself into a ban.

So I'll stick with... Obamacare is the biggest farce I believe I've ever seen in my lifetime, yet they somehow keep improving the "farceness" (made it up) of it all the time. The sheer effort that must take is mind boggling.

edit on 10/27/2015 by Kangaruex4Ewe because: (no reason given)



posted on Oct, 27 2015 @ 05:20 PM
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originally posted by: DontTreadOnMe
Just when you thought you'd heard it all about the un-ACA, about how it just could not get anymore bizarre or expensive, the government is rolling out Embedded Out-of-Pocket Medical Requirement....that means, if you are married for example....whatever you pay toward your deductible will not count toward your spouse's deductible.
Nice, huh?


In all the years I have had medical insurance, since 1975 or so, my deductible and my wife's deductible have never been considered the same, and we've been through probably a dozen plans since then. They have ALWAYS been separate and separately counted. I have actually never heard of a couple's deductible being counted together. I would be surprised if this is common.



posted on Oct, 27 2015 @ 05:24 PM
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a reply to: schuyler

hmmm.....my husband has never been on my policy....so this is new to me.
I wonder if that holds for children as well.

You're telling me if one spouse has some huge mountain of medical bills....none of it counts toward the deductible or out of pocket maximum?????



posted on Oct, 27 2015 @ 05:25 PM
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a reply to: Kangaruex4Ewe

I actually look forward to getting on Medicare.....in XXXX years.



posted on Oct, 27 2015 @ 05:29 PM
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a reply to: DontTreadOnMe

That right there is a VERY telling statement...




posted on Oct, 27 2015 @ 05:39 PM
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And yet if you live off the government and get on Medicaid you get EVERYTHING covered. It is the Cadillac of ins plans.

Work for a living and you get screwed.

Makes perfect sense in this black is white, lie is truth, good is evil, backassward crazy world.



posted on Oct, 27 2015 @ 05:43 PM
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a reply to: DontTreadOnMe

Huh. I know on my statements, there are individual deductibles for each family member, then a "family deductible". I was under the impression that if the total of the individual deductibles was over the family deductible, that was it, deductible met.



posted on Oct, 27 2015 @ 05:48 PM
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a reply to: Mountainmeg

It looks like, beginning in 2016....you cannot have one family member go over the individual deduction amount....of what they call a limitation. So, if person one had $10,000 in bills, only $6,850 counts toward the aggregate deductible...maybe that is the change?
See the example
www.linkedin.com...



posted on Oct, 27 2015 @ 06:14 PM
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originally posted by: DontTreadOnMe
a reply to: Kangaruex4Ewe

I actually look forward to getting on Medicare.....in XXXX years.


Oh, no, don't look forward to that---it's even worse on Medicare. Reams of paper appear, written in insurance jargon that is impossible for the normal person to decipher, even for those of us who used to be considered medical professionals. Simply having a prescription filled becomes a big deal if you happen to appear at the pharmacy three days early for your script because you're leaving on vacation. And no, I'm not even talking about controlled substances, just a standard medication.

For the record, our health insurance plan's deductible was always calculated by the amount spent by the family covered, never had individual deductibles. Even though the plan was a "self-insured" plan of the university it was administered by Blue Cross/Blue Shield, under their rules.

I suggest that we ban all health insurance policies. Put the parasites out of business and use the funds that are now going to prop up and investigate them to fund health care for the truly needy.

What you have today is actually legalized highway robbery as a result of the conspiracy between the medical community, the insurance community, BigPharma and the legislators bought and paid-for by those interests. As a result, I've decided to pay the fine for not having insurance since it is minuscule in proportion to the premiums they want to charge me, an extremely healthy 61 year-old female. The mere fact that I would be required to purchase a policy that included childbirth coverage shows just how utterly stupid the scheme has become.

Prior to the passage of ACA, I had a high-deductible, catastrophic-coverage policy that recognized the fact that I would never need childbirth services because I'd had my uterus removed. In addition it included a health-savings account into which I could make contributions to cover the deductible and out-of-pocket costs. I was able to obtain that coverage at a reasonable (to me it seemed entirely reasonable since I never even met a deductible in all the years I held it---they never paid a dime on my account) price. That policy is no longer available to me or anyone else in my situation. That policy cost me $2700/yr in 2006. The quote I got recently for a policy today would have cost me almost $900/month. My health care costs run about $100/month so why should I be required BY LAW to hand over $900/month to an insurance company and still have to pay my health care providers? It is truly one of the greatest for-profit, social engineering schemes ever pulled on the citizens.



posted on Oct, 27 2015 @ 06:21 PM
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a reply to: diggindirt

BUT....at least I can afford to go to the damn doctor!!!!!
I hope to continue with BCBS as my supplemental, so hopefully, they will keep the paperwork to a minimum.
I've heard it does take a long time to process claims.

BUT, on unACA...it took two months for me to get a bill for some ER services.
Is Medicare worse??

And seriously.....I never could get scrips filled even a day earlier....even when I had good employer insurance.
So....



posted on Oct, 27 2015 @ 06:35 PM
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originally posted by: DontTreadOnMe
a reply to: schuyler

hmmm.....my husband has never been on my policy....so this is new to me.
I wonder if that holds for children as well.

You're telling me if one spouse has some huge mountain of medical bills....none of it counts toward the deductible or out of pocket maximum?????


Gratitude - paying $40.00 for health insurance!



posted on Oct, 27 2015 @ 06:38 PM
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originally posted by: DontTreadOnMe
a reply to: schuyler

hmmm.....my husband has never been on my policy....so this is new to me.
I wonder if that holds for children as well.

You're telling me if one spouse has some huge mountain of medical bills....none of it counts toward the deductible or out of pocket maximum?????


Correct. I think I see the glimmer of the issue here. Many employers have over the years agreed to a "family plan" medical system that covers an entire family for a generic single price. I know with one employer the single people complained that they were being discriminated against by unfairly subsidizing those with large families, which artificially lowered their wages. These guys were in a sticky situation because the fact was that "their" union negotiated this kind of plan, so they were told by the employer to take it up with the union. These were "Group Plans" offered by employers rather than "Individual Plans." In theory, it was supposed to be cheaper if your formed a group.

In my own case our Management Team, of which I was a member, debated the issue in a case where every single one of us could have benefited from such a system. The anti argument was something like this, "If you decide to have four kids, that's your choice. Why should I have to pay for your choices? The pro argument was something like, "Everyone benefits if everyone in society is insured." In our case, choosing to do that would have cost us an extra $250,000 per year in premiums, and we couldn't afford to do it without laying off a number of people and cutting hours. So the argument became, "If we insure your kids we have to lay off Mildred and ten of her co-workers who will then not have any coverage at all. What's this about fairness again?" They were still arguing about this over 11 years ago when I left.

Now with Obamacare what you have is individual policies, not group plans, and I think this is how the issue came up. It's a shock to people who have always been covered on the Group Plans, but not so much to those of us who have always been forced into Individual Plans from the beginning.

BTW, I am not an Obamacare fan. It cost me thousands of dollars when it started up as my insurance carrier was forced to convert to the new requirements. Just trying to explain and intuit what the issue is here.



posted on Oct, 27 2015 @ 06:50 PM
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originally posted by: DontTreadOnMe
a reply to: Kangaruex4Ewe

I actually look forward to getting on Medicare.....in XXXX years.


DO look forward to that. It makes life a whole lot simpler, and you've paid for it every month of your working life anyway, so time for some return on that investment they forced you to make. The paperwork is minimal and it couldn't be easier to sign up. They have to make the forms understandable to the average citizen, so no one here will have an issue--since we're all geniuses. I did it all online.

The choice you have to make is whether to go the Medicare - Medigap route, where you buy "gap" insurance to fill in where Medicare does not pay, or whether you go the Medicare Advantage route, where it's all rolled into one. Each has its advantages and disadvantages. I chose the latter route, and my premium is now $27 a month for full coverage. This includes prescription drugs. My wife has some different requirements and issues. She also chose Medicare Advantage with a different set of doctors (Mine is an HMO. Hers is not), but she pays $167 a month. Off-topic to go into details. Just wanted to get the basics out there.

But...compared to being on the open market ineligible for Medicare, or getting onto Medicare, I'll take Medicare any day. Good - Fast - Cheap. It does all three, and that's very rare, especially for a government program. Of course, I still fight the pharmacy all the time because they are blithering bureaucratic idiots with no sense of customer support, but I can't fault my health care itself.



posted on Oct, 27 2015 @ 06:54 PM
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My brain just can't process that today. We used to have a thousand dollar deductible and a five thousand max. out of pocket limit but we never paid a thousand dollars in deductible, just copays on services and medicines. I do not understand what the deductible was.

I remember when insurance wasn't confusing. I remember when insurances paid everything
edit on 27-10-2015 by rickymouse because: (no reason given)



posted on Oct, 27 2015 @ 07:14 PM
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a reply to: DontTreadOnMe

no, but it also means that your deductable has been met and the insurance will now start paying the 80% or whatever it's supposed to on the bill!!!



posted on Oct, 27 2015 @ 07:31 PM
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This *might* not be a bad policy, if I am understanding it correctly. The plan my family has contains individual deductables, a family deductable, and an OOPM. (If we ever hit the OOPM, I'll be filing Chapter 11 within days, because it is outrageous.) Amazingly, one individual can top out all 3 under the present guidelines, making this individual deductable ceiling something of a good thing if one member on the plan happens to suffer a serious prolonged illness or major malady.

*Sigh* I was looking at my paperwork from 2010 the other day. I did some number crunching and found, in pure and total disgust, that my premium has increased by 335% while my individual deductables have gone up by 400%, there's an added family deductable, and my max out of pocket has gone up 1,000%... I'm paying 335% more for 1/7th the benefit I once had... (and people wonder why I am viciously opposed to socialist horsecrap)

Thanks voters!



posted on Oct, 27 2015 @ 07:57 PM
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originally posted by: DontTreadOnMe
a reply to: Kangaruex4Ewe

I actually look forward to getting on Medicare.....in XXXX years.

Not married for financial reasons; if we (Lassie and Rin-Tin-Tin) were to get married (what we paid into individual Social Security Accounts) is not going be refunded *same amount* being married; no idea why (widows pension) etc. Every time Social Security is revised (slots) those of us that have funded the system from inception seem more at risk; the 85 year old youngsters. Car or health care insurance deductible 1000.00 for each occurrence. I could have invested this money myself and made more money on what the government thinks it did in my best interests; but it needed my share to invest in other countries economies.
edit on 27-10-2015 by vethumanbeing because: (no reason given)



posted on Oct, 27 2015 @ 08:14 PM
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a reply to: burdman30ott6

That's crazy! No, it's insane.

I hope you don't live in AK,AZ, OK TX, or some of those states where premiums for the Silver plan (70% of the US population is on that plan) will rise approximately 31-41%. Even though the US average increase is said to be about 7.5%, some states are going to be hit much harder than others.


Premiums for BlueCross BlueShield of Tennessee will be 36 percent higher, on average, than they were last year. For policies by Moda Health, the largest insurer in Oregon, premiums will be 25.6 percent higher. And in Minnesota, the average monthly premiums for BlueCross BlueShield are rising between 45 and 49 percent, depending on the plan.

www.huffingtonpost.com...



posted on Oct, 27 2015 @ 08:18 PM
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a reply to: StoutBroux

Yeah, I'm an Alaskan.



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