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Bohuntr

What do you tell your 26 year olds whose "coverage ends tomorrow"

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I get a lot of patients whose coverage under their parents policy "ends tomorrow."  What they really mean is that they are turning 26 and want their birth control and/or whatever written up now and changed to generic if possible so they don't have to come to the doctor anytime soon.  I have actually had 2-3 patients in the past month who, when I check their birthdate, were celebrating birthdays that day.  At least they are attentive.

 

I often get asked "should I sign up for Obamacare?" or "Do I even need insurance?"

 

How about you?

 

For most healthy 26 year olds that aren't offered healthcare plans at work or don't have a job yet, I tell them to get a health savings account.  They can put up to 3,500.00 away tax free, it accumulates, and it's more than they typically need unless they get a catastrophic illness or injury.  If they ride a motorcycle I tell them to get a catastrophic policy like I carry anyway.  Even if my patient is a single female, two years of contributions will cover pre-natal care and delivery if she works out a cash deal in advance.

Cheapest policy on exchanges, with a 5K deductible is about 2,400 a year for anyone right out of college, so they are 7,500 in hole before their insurance pays a dime.

The way I see it is that it's my job to look after my patient, not another providers.  It's not in my patients best interest to sign up for a policy he won't use to subsidize someone else poor lifestyle choices.

 

If my patient is already obese, has metabolic syndrome, HTN, HLD, NIDDM, etc... the basic lifestyle issues I tell them to go ahead and sign up for health insurance as soon as they can.  Chances are they will need it within the next 10 years.

 

Maybe it's just because of where I work that a high number of my patients are finishing graduate school and in that age where they are no longer covered on their parents policies, but I was wondering how other providers are handling this issue.

 

It has to be coming up a lot and I'm kind of curious as to the solutions other providers recommend.

 

John

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I tell my patients that they need to be responsible for themselves. 

 

Hopefully, they have been educating themselves or seeking gainful employment.  If their job does not include insurance, then get your own policy through the ACA and / or seek better employment. Or, go back to school.

 

We each owe it to ourselves to make our way in this world.  We should each contribute to society in a positive way.  The rest of society does not owe us money or medicine.  Having said that, I do believe in helping those is need.  I'm not heartless, in fact, I'm really a softy.   I contribute both time and money to charities that help people. I believe in helping people to stand for themselves, and not to make them dependent.  It's better to teach someone to fish...

 

To answer your question, I often help patients avail themselves of government programs, charities, and assistance programs, but I make it clear that these are temporary.  They should also seek job counseling, vocational rehab, educational benefits, etc.  In the long run, we all need to rely on ourselves.

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John

 

While I think you are trying to do your patients a needed service, what I have learned is that the social workers and ACA navigators can do a much better job dispensing advice and actually finding out what patients are eligible for. 

 

For example, one of the ED nurses I work with is not employed full time, she is just under the weekly hour requirement for benefits and enjoys the flexibility she has with that including the ability to travel when she wants. When the exchanges went live, she went to the state site and starting looking. She got confused and asked me what I thought since the small company that employs me had to go to the exchanges instead of working with the insurance company directly. We went over what she wanted and she plugged her stats in and got back a monthly premium she was going to have a hard time financially swallowing. She then called the assistance line, spent time on the phone with a navigator whom after looking at income and other circumstances was putting her in the plan she wanted at almost a third less per month.

 

The ACA and the exchanges are complicated and they are glitchy. There was nothing to indicate my friend could have had that plan at that premium she eventually got. I would steer your patients to navigators, they are available through:

 

https://www.healthcare.gov/how-do-i-get-help-enrolling-in-the-marketplace/

 

There is also a page concerning insuring the under 26 crowd and at the bottom is a drop down menu with the answer to when the child turns 26 mid year.

 

https://www.healthcare.gov/can-i-keep-my-child-on-my-insurance-until-age-26/

Answer: they have a special 30 day enrollment period to get coverage till the next open enrollment period.

 

Depending on the state you live in, some of these 26 year olds may be eligible to be enrolled in state medicaid due to income reasons especially if the state has raised the limit. Many of the states that raised the limit stipulate for an individual adult, the modified adjusted gross income cant exceed $1293 per month, some are a bit above or below that number for whatever reason. Any 26 year old that is working for federal minimum wage wont hit that mark, hopefully they live in a state where they can qualify.

 

As for HSAs, they are a great idea but there are caveats. You cant have one without a high deductible plan, so your advice to open one and avoid the insurance plan wont work. Also when considering the high deductible plan, not only the deductible needs to be considered but also out of pocket maximums which are in the 10 to 15k range for HDHPs depending upon the status of the enrollee ie single, couple, family. For minimal users, an HSA can build up over a couple of low utilization years. For a heavy user, avoiding the HSA and HDHP and going with a standard deductible plan may be a better option.

 

For those you are advising not to get insurance, are you also telling them they will have to pay a fine with their taxes? If they make under $19650, they will only pay $95 but if they make over that #, they owe 1% of their income in fines. So at tax time your 26 y/o making 20k has to fork over $200 for taking your advice. Next year it goes to 2% ($400) then 2.5% ($500) then adjusted to inflation. The more they make, the more they pay. This is also a prorated fine, every month they spend uninsured, they pay 1/12 of the fine. Doesnt sound like much but $200 looks different when you make $100k vs $20k.

 

I flat out tell all patients I dont know anything about insurance, IMO it is f8ck8d up and adds a layer of complexity to health care we dont need. I also tell them to write their elected reps and senators and implore them to fight for single payer universal coverage. Then I point them in the right direction for advice.

 

Good luck.

G. Brothers PA-C

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It's not just the 26 y/o coming in for care and no insurance.  I have had plenty of people come in who still have no insurance, are unaware of the ACA law or tell me they'll just pay the $95 fine (I then explain the fine schedule like G.Brothers mentioned) and their eyes light up like.......huh?  Really?  

 

Just for fun I ask a few people to tell me the name of the President.  

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My first response would be "you're damn lucky you were able to stay on your parents' insurance past 21--let alone 26." My parents had 7 of us and to support us to 26 would have broken them! I've been self-sufficient since 19 (yes, my own health insurance too) and it baffles me that parents enable their children long past the time they should be GROWN.

But that just makes me an old fogey I suppose.

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I tell them that they should work with a navigator and purchase an approved plan. Partly, because I worked on the ACA. Partly, because I have seen, personally, FAR, FAR too many young people encounter tragic accidents (farming being a big one around here, but also MVA's, falls, etc.) and end up in the hospital for months with multiple surgeries and a 200,000 plus bill at the end.

 

I'm not opposed to catastrophic coverage only, but they need some coverage. Last kid I saw was working on the farm, 19 years old, college student, got knocked into the PTO, and then bulldozed by the combine because he was walking alongside and they couldn't stop in time. He was in the hospital for 3  months, had 5 surgeries, has a TBI, had bilateral femur fx's, R Tib/Fib fx, multiple rib fx's, thoracolumbar burst fx's (why I saw him), and bilateral hand fx's.

 

He also had no insurance. This kid is now paying the equivalent of a mortgage on his health bills. Of course all of these young kids think that it can't happen to them.....so did this kid I'm sure. The fact is that it DOES happen. They need insurance.

 

Final point, in 2010, the uninsured rang up almost 100 billion in healthcare charges (not huge considering a 2.5 trillion dollar industry). Roughly 60% actually paid their bills. However, about 40% did not...this, when looking at it from an insurance perspective, basically increased everyone who is insureds premiums by 1,000 per year. You are, if you are insured (and prior to the 8 million signing up for the exchanges) paying an extra 1,000.00 premium on your insurance to subsidize the uninsured.

 

I'd like my 1,000 back.

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I don't think you can start a health savings account UNLESS you have a high ded plan

 

If you are saying forgo insurance and just have a savings account, that is bad advice as there is no way you can save enough to protect against a major illness...... not sure if this is what you are saying

 

 

honestly, everyone should have insurance, 

 

If your state has not done and exchange, and they have created the HOLE between Medicaid coverage and the ACA plans this is the solution....

 

You can sign up for an ACA plan on the exchange based on your 'projected income' for the next year, this is not what you are going to make, but what you think you are going to make.  Overestimate and you will can reach the threshold where you will get a subsidized plan (usually it costs about $30/month) and you get insurance.   The gov't pays the other portion due.  At the end of the year there is not penalty, or fees assessed if you did not make as much $$ as you thought.  If you make more money then you estimated, then you can have monies due.

 

 

To explain more

 

If your state did not set up an exchange

You will have to make atleast 100% of FPL (federal poverty level) to qualify for a subsidized plan through the federal exchange

Many states restrict their Medicaid enrollment to a small % of the FPL - ie must make < 50% of the FPL to qualify

 

So there is this hole that develops between 50-100% of FPL where you literally have to pay FULL price

 

For some made up numbers

if FPL is $20k/year

your state might set Medicaid qualification at < 10k year income

that means that if you anywhere from 10k-20k in income you don't qualify for Medicaid or a subsidized plan, so you get to pay 100% of premiums - likely $300+/month - which is unreasonable and not possible.

 

So the solution is that you "estimate" that you will make more in the year because you are going to get a part time job, or some other way to make more $$

 

You qualify for the federal exchange and you can get affordable insurance..... 

 

broken system where someone makes 19k and has to pay 100% of insurance cost and someone making $20k gets almost a fully subsidized plan....

 

 

****** all numbers are made up, I have no idea what the FPL is and which states are "screwing their citizens" but no doing a state exchange.......  but they are many.

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Physassist, I remember your lectures/ comments to us on the glories and wonder of the ACA, and how it was gonna save us individually and by family thousands of dollars, and how there would be no disruption in the caregivers we all had, and how the roles of the uninsured would over time disappear.

 

How is that program workin out for ya?

 

Multiple presidential executive exemptions to political cronies and the insurance companies, millions of people losing the insurance they were perfectly happy with, supplanting the minority of the previously uninsured to the point that we now have the same number of medically uninsured/underinsured as we had before, 6-7 million of the newly insured are "on shakey grounds" when it comes to having told the truth and are falsely claiming eligibility for subsidies we taxpayers need to pay, etc, etc etc.

 

What a disaster.

 

Thanks a lot. You should have known better, but you have drunk the progressive kool aid and used your position here to buttress a flawed program supported by 2 essential lies ( "can keep my doctor", "can keep my insurance") which now is beginning to be appreciated as the sham it is.

 

Review your postings circa 2010 .

 

You might want your 1000 back. I'd like to see the grief this program has wrought immediately fixed by abandoning it.

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My first response would be "you're damn lucky you were able to stay on your parents' insurance past 21--let alone 26." My parents had 7 of us and to support us to 26 would have broken them! I've been self-sufficient since 19 (yes, my own health insurance too) and it baffles me that parents enable their children long past the time they should be GROWN.

But that just makes me an old fogey I suppose.

While I applaud self sufficiency in all shapes and forms, the reality today is that employment and wages are not what they were 10-20 years ago. Extending health insurance till the age of 26 is a long delayed acknowledgement that while the wealthy have continued to benefit over this time period, working class and middle income citizens are being squeezed more and more. One may suggest going without the niceties of today, smartphone, internet, car, morning latte but other than the latte, the other things are not niceties but becoming necessities to function in society today.

 

A great example are the struggling BS students I interview for the local PA program. Many are living with parents in order to pay off their school loans from the BS program that enabled them to get the minimum to apply to another phase of education that will then double to quadruple their indebtedness. If they are not living with their parents, they are living with multiple roomates and working 2-4 low end part time jobs to make ends meet and keep their head above the financial waterline.

 

Maybe I was harder working than these individuals, maybe I was more fortunate. I really doubt that though. I think the avg 20 something year old has a much steeper and difficult climb than when I was in my 20s during the late 80s/early 90s. If the least they can get is some health insurance through their parents (the one's with good paying jobs and equity in their homes) , I dont fault that. I just hope they dont give up.

 

G Brothers PA-C

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Physassist, I remember your lectures/ comments to us on the glories and wonder of the ACA, and how it was gonna save us individually and by family thousands of dollars, and how there would be no disruption in the caregivers we all had, and how the roles of the uninsured would over time disappear.

 

How is that program workin out for ya?

 

Multiple presidential executive exemptions to political cronies and the insurance companies, millions of people losing the insurance they were perfectly happy with, supplanting the minority of the previously uninsured to the point that we now have the same number of medically uninsured/underinsured as we had before, 6-7 million of the newly insured are "on shakey grounds" when it comes to having told the truth and are falsely claiming eligibility for subsidies we taxpayers need to pay, etc, etc etc.

 

What a disaster.

 

Thanks a lot. You should have known better, but you have drunk the progressive kool aid and used your position here to buttress a flawed program supported by 2 essential lies ( "can keep my doctor", "can keep my insurance") which now is beginning to be appreciated as the sham it is.

 

Review your postings circa 2010 .

 

You might want your 1000 back. I'd like to see the grief this program has wrought immediately fixed by abandoning it.

 

Well, I never claimed that everyone could keep their insurance. In fact, I remember saying that the majority would be able to keep their insurance. Point being, the President should never have said what he did. I will admit to being surprised at how many people had substandard insurance policies.

 

http://www.factcheck.org/2014/04/millions-lost-insurance/

 

I also remember saying that this wasn't perfect, and that it was only a start, and that it would need a lot of adjustments down the road, but that we had to start somewhere. Correct me if I am wrong, but I have been fairly consistent in saying that the ACA would not save a lot of money, but that it would expand coverage. Which it has done.

 

Roughly 2.6 million lost coverage. 8 million have signed up. I'd still call that a win.

 

I'm also still a supporter of the ACA, with the same belief that I had back in 2010. This cannot be the end of reform. This was only the beginning. We need to completely reform the financing of healthcare (get rid of employer based coverage) and we need to reform healthcare delivery from top to bottom.

The ACA was predominately health insurance reform. I was also angry and saddened to see the POTUS sign so many exceptions. That weakens the law...

 

OH, and I'm not really just a progressive.

 

I'm a full blown, academic, elitist, progressive, ivory tower, socialist (as one Congressman referred to me once). And I am proud to be one (which is what I told him).....LOL.

 

Mike

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An AP story that ran Dec. 26 said that “at least 4.7 million Americans received the cancellation notices,” and gave state-by-state figures for the “number of policies scheduled to be canceled.”

But the news agency didn’t say exactly how it arrived at the other figures that went into the 4.7 million total, making the reporting impossible for outsiders to verify. In three states, the figures appear to be inflated. Washington state’s insurance commissioner, for example, has publicly stated that the AP’s figure of 290,000 discontinued policies in that state is “inaccurate.” In a news release on his official website, Insurance Commissioner Michael Kreidler said that there were only 278,000 total in the individual market at the end of September. Recent reports by our fact-checking colleagues at Politifact.com and the Washington Post show the numbers were too high in Florida and Kentucky.

And now, new research also gives reason to think the AP estimate may be inflated.

In a March 3 posting on the website of the journal Health Affairs, two researchers from the Urban Institute analyzed findings from a nationwide poll and said, “Our findings imply that roughly 2.6 million people would have reported that their plan would no longer be offered due to noncompliance with the ACA.” And in this case, the methodology is made explicit.

In December 2013, the Urban Institute’s quarterly Health Reform Monitoring Survey of adults ages 18-64 included this question: “Did you receive a notice in the past few months from a health insurance company saying that your policy is cancelled or will no longer be offered at the end of 2013?” And of the 522 people polled who were covered by non-group policies, 18.6 percent said yes, their old plan would no longer be offered because it didn’t meet the new coverage standards that went into effect Jan. 1.

And if 14 million people were covered by non-group policies nationwide (as indicated by the National Health Information Survey of the U.S. Centers for Disease Control and Prevention), that percentage translates to 2.6 million non-group policies discontinued, the authors stated.

To be sure, there is always a statistical margin of error in any random-sample poll. Lead author Lisa Clemans-Cope told us in an email that statistically, there is a 95 percent certainty that the true percentage whose non-group policies were discontinued falls somewhere between 16.2 percent and 23.3 percent. That would put the number at anywhere between about 2.3 million and 3.3 million.

That range could be higher or lower depending on what number is used for the total who had non-group coverage in the first place. The Urban Institute authors cite a study published last year that found estimates of the total number of people covered by non-group policies ranged from 9.55 million to 25.3 million. So if 18.6 percent of non-group policyholders got notices that their policies were being dropped because of the new law, as the poll indicates, then the actual number whose plans were dropped could be as low as about 1.8 million or as high as 4.7 million (coincidentally, the same as the AP’s figure), depending on how many had such policies in the first place.

The authors, as noted, picked an estimate that fell in the middle of this range to arrive at their figure of 2.6 million discontinued policies. Until and unless better evidence comes along, that’s the most solidly based figure available.

How many “millions” so far have gained coverage?

The early numbers on enrollment in the exchanges and Medicaid don’t tell us how many of the enrollees were previously uninsured — despite some claims from Democrats to the contrary. The Obama administration disclosed on April 10 that 7.5 million had signed up for plans on the exchanges, but we don’t know how many previously had insurance. The Medicaid rolls increased by more than 3 million through the end of February, the administration also said, a figure that would reflect both those newly eligible under the law and previously eligible but now signing up.

But a survey funded by the Robert Wood Johnson Foundation and conducted by the Urban Institute indicates that many of those signing up for the exchanges and Medicaid may have been uninsured. It found that 5.4 million of the previously uninsured had gained coverage between September and the beginning of March. The exchanges launched Oct. 1.

An April 8 report by the nonprofit RAND Corp. put the figure of newly insured higher. Based on a nationwide poll, Rand estimated that there had been a net gain of 9.3 million insured “adults” as of mid-March, when the poll was being conducted. That includes marketplace and Medicaid enrollment, as well as an increase in employer-based enrollment.

Neither of those figures includes an estimated 3 million young adults who gained coverage in 2010 and 2011, likely because of the law’s provision allowing them to stay on their parents’ policies.

RAND also estimated that 700,000 who previously had individual market plans were now uninsured. The survey didn’t ascertain whether those newly uninsured were due to cancellations or voluntarily dropped coverage.

It will be some time before more concrete coverage numbers are available. The RAND numbers are extrapolated from a survey, and one with sizable margins of error. The estimate of 9.3 million newly insured has a margin of error of 3.5 million people, meaning researchers have a high degree of confidence that the true number would be between 5.8 million and 12.8 million. And the estimate of 700,000 uninsured who previously had individual market plans carries a margin of error of 900,000, putting the likely real number somewhere between zero and 1.6 million people.

Millions more are expected to gain insurance because of the law nationwide in the coming years. The nonpartisan Congressional Budget Office estimates that there will be 25 million fewer uninsured due to the ACA as early as 2016

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I am around your patient's age and paid 111/mo for pretty good coverage, this month being upped to 134/mo.  This is through independent blue cross/shield.  I never looked at at obamacare.  I would advise them to check obamacare and blue cross independent shield.  Or look for an employer who can provide it.  I went through my 18-20s without insurance, despite working a full time job, because my employer didn't provide it.  Thank God I never have had an expensive issue.

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My first response would be "you're damn lucky you were able to stay on your parents' insurance past 21--let alone 26." My parents had 7 of us and to support us to 26 would have broken them! I've been self-sufficient since 19 (yes, my own health insurance too) and it baffles me that parents enable their children long past the time they should be GROWN.

But that just makes me an old fogey I suppose.

 

The law says kids can stay on their parent's plan until 26. It doesn't say they have to. Nothing in the law says that the parents can't charge their kids for the premium.

 

Heck... the only reason they even stop it at 26 is because the insurance industry is so focused on a "divide and conquer" approach and would much rather offer multiple more expensive individual policies than a larger discounted group policy.

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I'm young, but salty. I haven't asked for or received a nickel from my folks since I moved out, 8 days after graduating high school. I joined the Army, did an overseas tour, came back, took the SAT and started taking night, weekend and online courses using tuition assistance. Earned my BS. Took the GRE at Seoul National University since I was overseas at the time, flew from Korea to the US for interviews, and started PA school using the GI Bill a few months after finishing my active duty time. So, I have little sympathy for those pts I see whining that their coverage is ending at 26. At 26, I already had a wife, 1 child, 2 houses, a paid off car, 7 years of active duty time, 3 overseas tours and was halfway through PA school. Kids these days and all that, hahaha. You just got to want it, and put in the work using the numerous resources out there. I often hear about how kids these days can't succeed, but I am living proof that it can be done. Geez, at this rate I am going to be yelling at kids to stay off my lawn at 40.

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The law says kids can stay on their parent's plan until 26. It doesn't say they have to. Nothing in the law says that the parents can't charge their kids for the premium.

 

Heck... the only reason they even stop it at 26 is because the insurance industry is so focused on a "divide and conquer" approach and would much rather offer multiple more expensive individual policies than a larger discounted group policy.

I have a fear that the Government will FORCE parents to keep their kid's on their insurance plans.  It's coming.  

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I have a fear that the Government will FORCE parents to keep their kid's on their insurance plans.  It's coming.  

 

Really? You honestly "have a fear" that this will happen? Seriously?

 

No offense, but that is just silly.

If you believe the government is a big oppressive socialist taxing machine, it would be in its interest to fine the 18-26 year-olds who are out of compliance with the insurance mandate.

If you believe the government is in the pocket of the capitalist insurance industry, then it would be in their interest to force separate policies (as opposed to staying on an existing family plan) because the insurance industry can charge more and make more money.

Regardless, the big bad government is not going to say that an independent 22 year old who can get insurance through his employer will instead be forced to buy his insurance via his parents' policy. Nor is there any established law anywhere saying that a parent is legally responsible for the actions and civic compliance of independent adult children.

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I admit it.  I am silly.  Many 18-26 y/o will be awakened when they get the insurance fine. 50 lashes with a wet noodle to me. It's not fear.  I chose the wrong word.  I will think of the right one when I'm no longer silly. And the wet noodle has dried up and my wounds are healed.

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Continuing my health insurance through COBRA, once I aged out, was equal to paying my rent twice each month. At least with the ACA, my premiums were halved.

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