The marketplace has arrived!


Well, it’s been a couple days since the marketplace insurance policies have been released and hopefully by now you’ve had a chance to take a look and see if there are any great options for you.
One thing I’ve noticed is there is a lot of spin on these plans (from all sides of the aisle). I would like to help and clear up a few definitions.

Health Care – a trained professional provides care to an individual to address a symptom(s).

Health Insurance – an independent (for-profit) company that may help cover some medical costs, designed for emergency or accident related services.

Socialized Health Care – a system in which tax dollars are used to pay professionals directly, with no or very little premiums, and sometimes per visit fees. We have two socialized health care systems in this country – Medicaid and Medicare.

Subsidized Health Insurance – a system in which tax dollars are used to pay for health insurance premiums, with the dollars going directly to the health insurance company, offsetting premium costs for the consumer.

Insurance guidelines – a set of rules determined by the insurance company concerning covered services, conditions, and criteria for those covered services and conditions (specific to the chosen plan, not individuals.) Also includes Fee Schedules – reimbursements determined by the insurance companies, non-negotiable. Typically based on Medicare fees, with geographic location factors.

Insurance networks – a group of doctors and facilities that are chosen by the insurance company, based on risk factors. Doctors and facilities in the insurance networks are bound by contracts to follow insurance guidelines. Depending on the plan chosen, there may be out of network coverage.

I’m going to throw something out there that might be shocking and even upsetting – can we agree that we ALL have access to health care? Anyone can walk into a doctor’s office or Emergency Room and receive care. There is one exception – MD’s and DO’s can choose not to see Medicare patients (DC’s are required to see Medicare patients). It’s a fact that you can receive a service and pay the professional directly.

It’s when we start talking PAYMENT that things get “confusing”. So, it’s after you have received that care when we start talking insurance. Let me re-iterate something – we are free to receive and request any service you want or is necessary. We do NOT need to refuse something because it’s “not covered”, right? We just have to pay for it! You can think about breast implants as an example. BUT a lot of times that service or drug is expensive. So expensive for some that the cost prohibits them from following through. But that’s different from not having access, right? Let’s move on.

Going back to the marketplace, I’ll ask one thing – For the plans offered, the reimbursements are lower and the networks and guidelines are stricter. What (more) problems can you anticipate from a for-profit industry that is forced to lower their incoming dollars in order to grant more people access to their product?

Nadia Hare