A Plan to deal with Pre-Existing conditions

Discussion in 'Health Care' started by Lil Mike, May 28, 2017.

  1. Lil Mike

    Lil Mike Well-Known Member

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    If I were writing the bill when it hits the senate, here is how I would handle pre-existing conditions: as a secondary payer plan using Medicaid.

    But first, some background:

    Second payers are plans that pay in addition to regular insurance plans. People most commonly run across them in Workers Comp and Auto accident issues. For example, you’re in a car accident, and are taken to the emergency room. Normally an emergency room visit and associated treatment and tests would be paid by your regular health insurance, but because you have auto insurance and in an auto accident, your auto insurance would be billed first. The auto insurance pays whatever they are contracted to pay in those circumstances, and the bill goes to your health insurance, which pays whatever it’s contracted to pay minus what was paid by the auto insurance.

    Now years ago, some HMO plans would pay for pre-existing conditions, but not right away. You are a new member on an HMO plan, but you have diabetes. You could use your insurance for any medical condition except the procedure codes and diagnosis’s associated with diabetes for a period of time, either a year or two years depending on the plan. After that period was over the HMO would start picking up the costs of diabetic treatment. This way, the health plan didn’t immediately go into the hole over a brand new member who brings expensive health issues to the plan. Obviously, this isn’t great at all if you have diabetes because it means you are paying for all of your diabetic treatment and medicines out of pocket until your waiting period was over. For many however, it was better than no insurance at all.

    So how would my plan work?

    When you sign up for a health plan on the individual health insurance market in your state, part of the application process is identifying if you have a pre-existing condition. If so, you are automatically signed up in your state’s Pre-existing Medicaid plan. This is a secondary payer that only pays if during your first two years in your health plan (or whatever time period is arrived at) you have charges related to your pre-existing condition. So, let’s say you have heart disease as a pre-existing condition, you go to the doctor for some issue related to that, the doctor files insurance like normal, and it goes to your insurance company.

    Since you’re in the first two years of your health plan with this insurance company, and the procedure codes and diagnosis codes are related to your known pre-existing condition, your insurance company denies the claim but then sends it to your state Medicaid, which processes and pays the claim. For you, the process is seamless, your insurance company gets out of paying charges, and Medicaid pays the doctor.

    So, why do I think this is better than the currently proposed high risk pools in the AHCA?

    First, we don’t know what the costs are going to be and who is going to need help. That was the problem with the Obamacare PCIP; far fewer people signed up than expected, but it cost way more per person than expected when they did sign up. So there are a lot of unknown costs associated with this.

    Secondly, under high risk pools there seems to me a thin line between subsidizing patients with pre-existing conditions and subsidizing health insurance company profits. Are the insurance companies just going to present a bill to the high risk pools and they will just pay no matter what? Who knows? There isn’t any transparency in knowing what you’re paying for so you can never predict what the costs are.

    Third, Medicaid pays out under the cheapest rates available, cheaper than Medicare and far cheaper than private insurance rates. If the government is going to subsidize pre-existing conditions somehow, why not do it in the way that provides the cheapest rates, and the most transparency? Medicaid will be able to grow a database of all pre-existing conditions, their frequency, and their costs for the private insurance market.

    One way or the other, the government will be paying for this. Either the Senate puts together a plan that the President signs, or Obamacare continues to fall apart and a new Democratic Congress will be elected to fix healthcare, and if they do it, given previous experience, it won’t be cheap, transparent, or voluntary.
     
  2. CourtJester

    CourtJester Well-Known Member

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    Not a bad plan except the New healthcare bill is cutting Medicaid by 800 billion. The other issue of course is that the Republicans have been claiming that more and more doctors will not accept medicaid patients because of the low pay out rates. That of course might save money since the patients could not get care but that might be defeating the whole purpose of the idea.
     
  3. Lil Mike

    Lil Mike Well-Known Member

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    I honestly don't think much of the House bill is going to survive into the senate version, so the Medicaid cuts most likely will never happen. Really, when have social service cuts ever happened?

    Currently around 70% of doctors accept Medicaid, but since this plan times out after two years, a doctor with a long term patient only gets the Medicaid rates for two years, then it's reimbursed as regular insurance.
     
  4. CourtJester

    CourtJester Well-Known Member

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    I guess we will find out assuming the Republicans ever have the guts to expose the Senate plan.
     
  5. Lil Mike

    Lil Mike Well-Known Member

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    Right before the vote?
     
  6. CourtJester

    CourtJester Well-Known Member

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    Maybe not even then!
     
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  7. Greenbeard

    Greenbeard Active Member

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    There are a number of reasons this would be problematic, but the single most important question is: why bother? If you want an infusion of public money to defray costs currently borne by insurers so they can commensurately lower premiums, that's not difficult. Just put in place a reinsurance program.

    There's no need for the convoluted song-and-dance: if you want to go after high-cost cases associated with existing conditions, do a prospective reinsurance program like Maine's "invisible high-risk pool." Or just do a regular retrospective reinsurance program for any high-cost case. We don't need to reinvent the wheel.
     
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