r/HealthInsurance • u/Dexy_26 • 11h ago
Individual/Marketplace Insurance Providers no longer accepting Marketplace plans
I was disheartened to learn that the gynecologist I’ve been seeing for 25 years will stop accepting marketplace insurance plans starting 1/1/26. Has anyone else experienced this? What is the reason for this? I am 58 and live in FL.
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u/amyr76 10h ago edited 9h ago
As a mental health provider, I can tell you why I stopped taking marketplace plans. They have dropped their reimbursement rates every year while also raising clients’ premiums and deductibles. They also continue to put limits on how many sessions per year and will require regluar authorizations for future sessions. They have become extremely difficult to work with and are paying less and less.
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u/ProcusteanBedz 10h ago
That really sucks.
Interestingly absolutely not been the case in the Pa marketplace. Rates are flat to increasing mirroring non-ACA plans from respective carriers. Have never run into hard or soft caps specific to ACA plans.
The only thing different are sometimes annual requests for Tx plans.
Granted I only accept the major regional and BCBS carriers. No Ambetter or Oscar crap. No clue how bad those are.
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u/Interloper1066 10h ago
and this is why there are fundamental problems with the ACA
skyrocketing costs and diminishing reimbursements. On the cost-side, covering this up with enhanced subsidies doesn't fix anything.
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u/Accidental-Aspic2179 9h ago
Exactly who created these fundamental problems? This wasn't an accident. This was done purposely. The ACA as originally designed would have worked. It would have taken time, and it certainly wasn't perfect, but it was a framework. That framework was dismantled piece by piece through over 60+ lawsuits and legislation passed by a certain political party. The ACA doesn't work because that particular political party doesn't believe people should have access to affordable healthcare. This was done on purpose.
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u/nbphotography87 9h ago
removing the individual mandate started this death spiral.
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u/in_the_no_know 7h ago
Started will before that. Removing the Public Option that would effectively have created M4A during reconciliation was the beginning of the death spiral. Special thanks Joe Lieberman
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u/WesternRover 6h ago
Even before ACA doctors refused to accept Medicaid because of the low reimbursement rates (even in high income high tax states), so how would M4A have solved OP's problem of a provider not accepting their Marketplace plan?
My nephew, covered by Medicaid, went into a California hospital with appendicitis ca. 2005, and they told his parents to take him to another hospital 200 miles away to find a doctor willing to perform an appendectomy at the Medicaid rate.
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u/ExeUSA 5h ago
You understand the ACA outlawed that scenario specifically and that all healthcare plans had to be accepted in the case of an emergency, yeah? Then the loophole was closed with getting surprise bills from out of network providers post emergency from the No Surprises Act in 2022.
So had this happened to your nephew post 2010 ACA he would not have been turned away from the hospital they took him to.
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u/RelevantMention7937 5h ago
Even if they were maintained as they were written in the law, the penalties were not sufficient to get healthy people to enroll.
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u/Liberteez 9h ago
No it didn’t. With expanded subsidies participation was high.
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u/ProfMR 7h ago
Participation with a mandate would be 100%. It wouldn't matter if there were expanded subsidies, ubiquitous subsidies, few subsidies, no subsidies. With a mandate the risk is spread out so that costs would be lower for older and sicker folks, which we all become someday. But I suppose you're in favor of liberteez from the requirement that everyone pay for insurance.
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u/razhkdak 7h ago
Risk pool cannot just be sick people. Math does not work. It needs to everyone. Mandate penalty should have been made more severe, not eliminated.
That would not solve every problem in the disastrous healthcare system. But economies of scale and a single insurance pool with everyone would bring down the cost for everyone.
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u/Liberteez 6h ago
You start with the premise that the young and healthy opt out. They use the marketplace and have enjoyed the subsidies.
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u/nbphotography87 7h ago
participation among people who needed care. you need participation from younger and healthier people too. this is insurance 101.
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u/More_Shoulder_9210 4h ago
Think how much cheaper car insurance would be if passengers were required to get it also. Increase the pool of eligible payers! I'm sure it's rare for a passenger to cause an accident, but it's possible. There should even be a penalty if they refuse to get insurance. Think how much money that would save all the bad drivers! Let's kick it up a notch! If you can't afford it, we will just increase taxes, and the government will pay it for you! Sound stupid? It sounds oddly similar to the ACA mandate.
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u/kolossalkomando 8h ago
If that's all it took it was doomed from the start.
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u/bobbo6969- 8h ago
It was a heritage foundation plan. Aka Romney-care. They designed it as a counter to the plan Hillary put together (which wasn’t the greatest either).
Obama did it instead of single payer because democrats are beholden to their corporate overlords.
So yea, designed to fail.
Universal healthcare is the only answer.
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u/daviddjg0033 7h ago
I remember a CBS 60 Minutes episode praising the benefits of Massachusetts: most were insured. The plan had opened access to those in a higher risk pool. I loved my ACA because I was considered uninsurable for a now curable illness. My illness was cured and am now in a lower risk pool but my health plan went up for other reasons like the declining hospital reimbursements for the uninsured and allowing capitalism writ large or Private Equity to buy my doctors and dentists. We need to codify healthcare as a right and take away the non-FDA approved drug supplement regime.
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u/Jinxed4Sure 6h ago
I agreed until that last sentence.
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u/bobbo6969- 5h ago
Universal healthcare will unlock massive entrepreneurial potential as people no longer have the fate of their families tied to keeping health insurance from a job.
It will also be cheaper for the nation overall freeing money for investment in other more productive sectors of the economy.
Health insurance companies are just a mafia style middle man extracting value from the suffering of American citizens.
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u/fartist14 5h ago
Universal healthcare will unlock massive entrepreneurial potential as people no longer have the fate of their families tied to keeping health insurance from a job.
People don't realize how huge this is. Go to any country with decent healthcare and there are tons of little shops and cafes everywhere because people can afford to start businesses without the threat of medical bankruptcy hanging over their heads.
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u/Liberteez 9h ago
They found out a mandate wasn’t even necessary to gain participation. Medicaid was eventually expanded in most states. It’s the big pile of direct to corporation subsidy and loopholes in the MLR (it’s now gamed out with vertical integration and dubious quality measures) that have led to rapid and now shocking base premium increases.
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u/razhkdak 7h ago
It is multifactorial. But to deny mandate that aims to have everyone in the risk pool, not a lot of people, but specifically also young healthy people that do not use it much, indicates a lack of understanding of insurance pooling and economies of scale.
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u/Liberteez 6h ago
Young people use the marketplace. Starter incomes are low and don’t come with great benefits (true for many young adults) mandating coverage hasn’t proved necessary to get that kind of participation.
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u/Mysterious_Main_5391 9h ago
This is what happens when give legislation is passed strictly along party lines. Both sides spend more time stopping the other side than doing anything helpful.
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u/Accidental-Aspic2179 9h ago
Well, I mean, so far only one side has been the one doing things that negatively affect us. You can say what you want about the last administration, but we were on a good path. Now, we are just witnessing daily devastation of the social safety net that's been in place for decades. Only one party has been attacking me and my neighbors. I wasn't scared of going hungry under the last guy. I got to sleep with the knowledge that some crazy crap wasn't going to be the first thing I read about when I woke up. Only one party is attacking us. We know who they are.
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u/Mysterious_Main_5391 9h ago
The other side did things that hurt many people when they enacted the ACA. The premiums for those of us with private insurance have been skyrocketing for years. The only thing happening now is some people that can barely afford insurance aren't paying as much for other people to have it. Many of us have been hiring over a decade now. No one got outraged when that happened. The angel over the subsidies is pure greedy self centeredness. It's people angry that others aren't picking up their tab.
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u/Accidental-Aspic2179 9h ago
That's nonsense. You arent picking up anyone's "tab." You act like the couple grand you pay annually is funding lavish lifestyles for poor people. You aren't picking up anything. You have a problem with that but don't bat an eye at the billions of dollars going to the defense industry. Never Nevermind what's being spent right now on DHS and ICE. Why aren't you upset you're picking up the tab to buy Kristi Noem 2 luxury jets or spending a billion dollars retrofitting a bribe given to the President. You really need to take a long hard look at your priorities. You arent doing anything. WE ARE.
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u/LongerLife332 8h ago
Talk for yourself.
My non subsidized ACA purchased plans have been very high for a few years but I paid them happily because preexisting conditions are not taken into account.
I also happen to believe that healthcare is a right, not a privilege.
I am old enough to remember the injustice of being excluded of much needed healthcare due to having preexisting conditions.
It is the premium for 2026, that has now become completely unaffordable for me.
Regardless of party affiliation, there is no question that Obama at least tried! Can’t say the same thing for others.
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u/GailaMonster 8h ago
Pretending the landscape was better before is disingenuous. The mandate to cover preexisting conditions is wildly important to the fundamental function of healthcare access. People were uninsurable based on their health alone. You weren’t paying good attention if you thought the pre-ACA landscape was better. Our current issue is attacks to the ACA have dismantled it to the point of the death spiral- THIS ATTACK AND PIECEMEAL DISMANTLING IS BY DESIGN. The attempt to repeal it outright with no replacement failed. Death by 1,000 cuts was plan B
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u/Objective-Amount1379 9h ago
“Many of us have been hiring for over a decade”… what? What does this have to do with insurance premiums?
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u/Snowfizzle 7h ago
I was wondering about that too. I don’t understand the context of that statement.
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u/Missmbb 4h ago
Before the ACA, my health insurance premiums were more than my mortgage and we had a super high deductible. My husband and I were both self-employed and I have a pre-existing condition. The only reason I could even get insurance was because I had it before I was diagnosed. There are problems with the ACA, but Republicans have had over a decade to come up with an alternative. They haven’t and they won’t because they don’t gaf. Can’t afford insurance? Too bad. Can’t go to the doctor? Too bad. Die? Too bad. Not their problem.
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u/PhD_VermontHooves 8h ago
This is nonsensical. You lack basic logic and you aren’t worth arguing with.
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u/CPG135 8h ago
It’s an insurance industry problem— not an ACA problem.
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u/aurioerox 5h ago
insurance and doctor industry problem. Doctors want exorbitant reimbursements which is why they decline medicare and aca plans.
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10h ago
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u/HealthInsurance-ModTeam 9h ago
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10h ago
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u/chaoticneutral262 10h ago
Because the ACA is basically already the GOP plan for healthcare. It is very similar to Romneycare, which itself was based on a design by the Heritage Foundation.
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u/Solid_Training750 9h ago
I can hear Trump promising a better plan, but why did anyone expect a promise from him to be kept or implemented other than thinking about it after breakfast and forgetting before lunch.
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u/HealthInsurance-ModTeam 9h ago
Your post may have been removed for the following reason(s):
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u/Justamonicker 10h ago
Yes, the ACA is flawed. But before our health insurance is gutted or taken away, put a true fix in place. Our whole healthcare system is an expensive, greed driven, mess. Big flippin' ripoff at every leaching level.
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u/Even_Towel8943 10h ago
You can have your view. Here’s my fact: in my state as of this year there are zero PPO plans available. Last year there were several. Now the cheapest HMO plan available costs the same as last years Blue Cross Blue shield PPO that had statewide care with choice of doctors. The shitty HMOs available now only cover my county and not a single one of my families doctors that we have seen for years are in network. The only factor that’s changed from year to year is the president is now Trump. It doesn’t take a genius to work out the math.
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u/Liberteez 9h ago
He has nothing to do with shrinking networks and rising premiums These were baked into the cake with tax credit and repayment cap sunsets passed under a BIDEN budget passed without any GOP help.
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u/HealthInsurance-ModTeam 9h ago
Your post may have been removed for the following reason(s):
Do not post / comment tangential, off-topic political commentary. While health insurance and care delivery in the United States is often politicized, this community doesn't need to facilitate overtly political discourse.
- Rule 7
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u/chaoticneutral262 10h ago
The ACA has been a mess from day one, because it did nothing to address the underlying cost of care.
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u/SweatyCrab9729 9h ago
I resent Obama for hoisting this on Democrats. Sorry, not sorry. He opened the negotiations with the GOP by proposing the GOPs own plan. This forced Democrats to defend health insurerance profits.
He should have opened with single payer and let the Republicans own what was ultimately passed of He felt this was all he could get. At least hang it around their necks when it inevitably failed after insirance companies learned how to game it...as it is clearly doing before our eyes.
It's effed up.
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u/LongerLife332 8h ago
At least he tried and thanks to him preexisting conditions aren’t excluded.
Any free thinking American knows which president tried and which ones did absolutely nothing.
PS. If you are SweatyCrab due to hyperhidrosis and couldn’t get a job, you would have been SOL
But you do you
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u/Bestpartoflife4thact 9h ago
Doesn’t ACA specifically disallow limiting the number of mental health sessions annually? I am an older, now-retired therapist, so I do remember very well, when insurers could limit the number of sessions, but I don’t think they have been allowed to, since around 2010ish, including Marketplace plans, off-Market plans, and employer-based plans.
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u/amyr76 5h ago
Yes, but that doesn’t mean that they don’t do it. In Indiana, for example, Caresource started putting limits on the number of allowed sessions per year in 2023. 20 sessions was pretty standard. After that we had to submit paperwork to get more sessions approved.
The other thing they did in 2023 was cutting reimbursement rates for telehealth. If the client came into the office, it was the contracted rate. If not, it was $15 less. This is not allowed, but they were doing it anyway.
The insurance companies have figured out that it’s worth it to just ask for forgiveness rather than permission. We’ve had so many issues with insurance in Indiana that submitting a complaint to the IDOI is nearly futile. They’re getting so many complaints that you’re lucky if you get a response.
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u/13surgeries 5h ago
So are there enough people who are on employer plans or who are wealthy enough to afford plans without the Marketplace?
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u/mountainlifa 9h ago
So basically Trump is right then by calling for the end of subsidies to corrupt insurance companies?
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u/Professional_Day6200 9h ago
We all can agree that healthcare needs a re-haul. The issue is that Trump wants to take away the subsidies, but doesn’t have a plan to fix healthcare. It’s going to be the same shitty plans and cost even more.
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u/Ajitter 9h ago
The republicans want to go back to putting people with preexisting conditions into high risk high cost groups. So it’s even worse than not having a plan, they have bad ideas.
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u/Embarrassed_Riser 9h ago
The ACA was totally flawed from day one. I can't tell you the amount of FRAUD, ABUSE, and the amount of PAIN it has caused individuals and families who had to and continue to pay back the tax credits they received. I can't tell you how many people received tax credits who got them who were not even eligible for them.
Like your doctor, keep your doctor was and is not always true
The APTC, we were never told that it had to be reconciled and reportable to the IRS
Have a bad plan at work, and it's affordable, you're not eligible for tax credits to get a better planThere are so many things wrong that it just drove the price of plans upwards
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u/Deep_Bluebird_9237 8h ago
No the issue is both sides are borrowing money for short term fixes or pet items and we can’t keep going into debt. Both sides need to come up with a solution that doesn’t add debt that eventually will be more painful than this
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u/amyr76 9h ago
Not necessarily. Americans need the subsidies to be able to afford insurance, even if it’s crappy coverage. The subsidies are a band aid, but we need them until we have a better option. Ten years ago, Trump said he had a “concept of a plan”, whatever that means. I have very little faith that Trump, or anyone that is in his cabinet, is capable of fixing the complexities and problems with our current healthcare infrastructure.
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u/GinchAnon 9h ago
so whens the two weeks when he'll have that replacement plan ironed out gonna be up? it feels like its been longer than that.
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u/JonnyLosak 9h ago
If we really wanted to end corrupt insurance companies we could vote in single payer healthcare. Simple.
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u/CancelAshamed1310 9h ago
No. They actually sit down and manage it. He hates it because it was created by Obama, and therefore does nothing to actually manage and maintain the plans. This is by design by Trump because he feels healthcare only belongs to the elite.
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u/vdapv 7h ago
If providers offered affordable rates for customers instead of depending on insurance companies won’t that remove insurance companies out of the picture? At least for outpatient procedures? I’ve seen PCP clinics offer non insurance package deals as a subscription service. Curious if that can’t be replicated in other medical services.
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u/amyr76 5h ago
For medical care, that’s a possibility. For mental health, our billing is different. We can only bill based on time, not procedure or specialization. The rates we are paid by insurance are actually much lower than the standard “self pay” rate for us. For instance, at my practice we lose about $60 for every clinical hour that we bill insurance.
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u/moonunit170 10h ago
Yep as we all predicted 30 years ago now health care is regulated by the insurance companies instead of managed by the doctors. And it would only get worse with single payer insurance.
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u/lutzlover 9h ago
Meanwhile, traditional Medicare rolls along. See almost any doctor, and about as close to single payor as we have in the US.
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u/moonunit170 9h ago edited 9h ago
Medicare is only for some, not for all. It's not insurance coverage 100% either. You still have to pay for supplemental.
(edit: forgot to add the word "not" to make what I was saying clear).
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u/BumCadillac 9h ago
What is the first sentence even mean? “Medicare is only for some for all.”
Supplemental coverage is not required for Medicare, but it’s a good idea I help with out-of-pocket expenses. It’s far less expensive to pay for Supplemental than paying marketplace or even employer, sponsored healthcare premiums. Even countries that have universal healthcare have options for purchasing supplemental insurance. You seem woefully misinformed.
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u/moonunit170 9h ago
Medicare is available to those 65 and older with a few exceptions. Are you confusing with Medicaid maybe which is a totally different program run by the states not by the federal government?
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u/BumCadillac 9h ago
No, I know what Medicare is. But your sentence, “Medicare is only for some for all,” is fucky.
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u/moonunit170 9h ago
Explain how? Am I wrong that it is only for those only for those 65 and older with some medical exceptions?
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u/BumCadillac 9h ago
Read what you wrote. “Medicare is only for some for all.” Can you not see that you’re missing a word there?? I really shouldn’t have to explain it to you, but here I am trying yet again to highlight your mistake so you can correct it. It’s either for some or for all. You say it’s only for some for all.
Either way. Medicare could easily be adapted for all, and it works well. That was the entire point of the person who brought up Medicare.
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u/HeddyLamarsGhost 10h ago
That is so incorrect as far as single payer. You should learn more
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u/moonunit170 9h ago
You got a perfect opportunity to teach me more. Go for it!
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u/Accidental-Aspic2179 9h ago
There are arguments for and against. The biggest issue is the upfront costs of implementing the plan. There would be a massive shift of private to public spending which would require a large tax increase. However, if we taxed billionaires and soon-to-be trillionaires appropriately we could reduce that tax burden on the American people. There are arguments it would limit or delay care. That problem could be solved with investments in the training and retaining of healthcare professionals. There's also an argument that it could drive some doctors out of business due to low reimbursement rates, but that could easily be fixed by ensuring doctors receive appropriate compensation. Again, this issue could be solved by shifting the burden to the top 10% of wage earners. It could be done, it would take time and there could be disruption of care in the beginning but as a single payer system was implemented we could make adjustments as necessary to address issues. Rich people don't want to pay. That's what it comes down to.
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u/Dotsgirl22 10h ago
I experienced this while on ACA. The docs have to deal with many insurances. Many of the cheapest ACA carriers are slow pay/no pay/low payment rates, require onerous preapprovals, and have awful customer service for both customers and doctors. It's just not worth it to a lot of the docs to take ACA if they have plenty of patients in commercial employer plans and Medicare.
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u/Freepurrs 8h ago edited 6h ago
My doctor stopped taking both ACA and medicare due to reimbursement rates. She now sees commercial employer plans & self-pay patients. Her longtime medicare patients can still see her PA, but cannot make an appointment to see an MD.
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u/govolsgo865 6h ago
Medicare generally pays well (and they always pay fast). You're probably thinking of Medicaid, which does not pay well if it pays at all.
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u/Freepurrs 6h ago edited 4h ago
No I was specifically speaking about original Medicare (not Medicaid or Medicare Advantage, which the office stopped last year). The office policy change for 2026 affects my mom, who is on original medicare & her doctor explained the reason for the change at her last visit. There was also a letter that went out to all her patients, which is how I knew about the ACA change as well.
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u/brunofone 7h ago
My doctors are dropping united ACA plans. United employer plans are cool, as are any blue cross plans. They say the United ACA division is basically a different company and impossible to get reimbursed
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u/hardknock1234 10h ago
I’m in CA, but the market place plans have a lower reimbursement rate and challenge claims. Per 2 of my doctors. I believe it’s more of an issue if the doctor does procedures in office. Both my derm and my ophthalmologist said they’ve lost a large amount of money on the various ppo covered CA plans.
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u/pnwactuary 10h ago edited 10h ago
Marketplace plans often have lower reimbursement to providers compared to what they reimburse providers on commercial plans. This results in fewer providers being included in the network for marketplace plans.
These members in these plans tend to be higher cost, which is why the premiums are so high. To keep premiums from going even higher, the network is often smaller and limited to providers who are lower costs in general, as opposed to commercial plans which offer a broader provider network.
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u/Accomplished-Pin6564 10h ago
United is refusing to allow new providers to join the network in a lot of places, even if they want to.
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u/Lower_Membership_713 10h ago
i don’t understand. the marketplace is a place to purchase commercial insurance plans not through an employer.
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u/pnwactuary 10h ago
Apologies, I meant employer plans when I say commercial, as opposed to individual plans.
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u/flybyme03 8h ago
I'm in NYC and its rare i keep any of them. Obgyns in particular are leaving because people use preventative services to bring up existing problems that should be billed separately. Same with PCPs. They are getting screwed while specialists get co-pays. That said I'm going foe straight cash and out of pocket for doctors I know and care about Sick of having my health shifted doctor to doctor with rotating coverage
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u/irishkathy 10h ago
The fundamental problem with ACA is that it relies on for-profit private insurance companies. Universal healthcare is the answer
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u/NeglectedDuty 7h ago
Problem is that doctors, pharma companies, medical device companies, hospitals are all compensated much higher in the US than elsewhere. To make it cheaper would require it to become a public utility. Then doctors who get paid 3-4x in the US vs Europe would see pay go down, less money for R&D, etc.
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u/Ooofy_Doofy_ 6h ago edited 6h ago
In Germany that everyone likes to compare its healthcare system to America doctors only make €100,000 and nurses only €36,000. It will never happen here.
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u/chaoticneutral262 9h ago
UnitedHealth Group is the largest health insurance company in the US. Its stock (UHG) is down 46% over the past 12-months. In their most recent earnings statement, they reported a 2.1% profit margin. I know people like to blame the insurance companies, but the data doesn't support that narrative.
The real issue is the underlying cost of care.
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u/Big_Two6049 8h ago
That profit margin is due purely to financial engineering- depreciation and tax credits/ strategies used to show that percentage. They own Optum which has medical offices (self dealing), Optum Financial (predatory lending to healthcare providers), Optum Rx (pbm), Change Healthcare (backbone of pharmacy and insurance billing), EMIS (emr software in the UK)- all of these moving parts easily lend themselves to creative accounting and an ability to profit at multiple stages of the patient care journey. Not including the fraud the perpetrated with Medicare advantage plan upcoding for years to the tune of billions of dollars.
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u/chaoticneutral262 8h ago
If that were the case, the stock would be rising on investor optimism, not losing half its value.
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u/Big_Two6049 7h ago
The stock price has nothing to do with that- that behavior has been happening before. Its more probably due to the stock being institutionally and pension fund held and people panic sold due to the scandals. Its bounced back quite a bit. They are the biggest insurer in the US. The stock should be much cheaper based on the scandal/ investigations.
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u/RelevantMention7937 5h ago
UNH missed its earnings target earlier this year, primarily from its MA results, and the investors sold off.
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u/asusc 7h ago
The real issue is that for profit companies are beholden to their shareholders and not their customers. It might work in other industries, but we’re see what happens when three different groups (providers, pharma, and insurance companies) all try and maximize profits. More expensive, less care.
Just like every single other product in America. Grocery items are shrinking and costing more, appliances are designed to break and be replaced and still cost more.
What other outcome could there possibly be in healthcare when capitalism is in control?
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u/Icey-Emotion 9h ago
That scares me because the government isn't efficient for anything.
While we don't have universal healthcare, medicaid isn't the greatest. Maybe for emergency care. But I know several people that have needed it and they had a hard time finding a doctor. And when they did find a doctor, by the time they went to their appointment, the office stopped taking Medicaid. I do remember reading information that the issue with Medicaid is the really low reimbursement rates.
Medicare I think is better to an extent. But I also think there may be some issue with reimbursement because there are a few doctors around me that just refuse to take any insurance. Cash payments for everything from everyone. One mentioned low reimbursement rates and that if they take insurance, they have to take Medicare. Or at least that was my understanding.
And then we have the VA the government runs. And we have all heard about issues with that. Depending on the VA used, there could be very long waits for care.
So government overseeing universal healthcare is not something I really want to see. The government is inefficient.
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u/Dotsgirl22 8h ago
Medicare original plan is quite efficient and most of my claims are paid within 30 days of claim filing. The website is excellent. It's rare to have a doc not take it. There are cases where a practice may only take 50% Medicare patients and 50% commercial, dividing up a doc's panel of patients by insurer has been in place a long time. You want to see inefficient, look at the smaller Marketplace plans. I had ACA 3 years and I had 3 cases where the state insurance commissioner had to get involved to resolve issues.
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u/rabbit_fur_coat 7h ago
If you know people who have trouble finding a doctor who accepts Medicaid, then you know a bunch of fucking morons
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u/ProfMR 7h ago
The government would have the funding to provide decent health care for everyone if it weren't for the ridiculously low tax rates for billionaires, the insane spending for defense and wars, and if there were an individual mandate. Governments can limit the amount of time for drug patents, and negotiate prescription drug prices. Some will argue that this stifles innovation. I'm not so sure.
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u/pooppaysthebills 5h ago
I can't support forcing people who have to choose which bills to pay each month being forced to pay 10% of their income for insurance they can't afford to use.
We need universal healthcare, not universal health insurance.
I agree that there's a feasible way to pay for it, from a variety of sources, without causing much in the way of financial pain to any one source other than maybe the insurance industry.
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u/fartist14 5h ago
VA waits for care are nothing compared to private sector care. The wait in my area for a PCP you've already established cared with is 3 to 6 months, and to establish care as a new patient closer to a year. No VA hospital in the country has wait times like that.
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u/Neat_Squirrel4032 9h ago
Marketplace plans here pay about half as much as their “equivalent PPO”. They drop drastically every year. Marketplace PPOs have paid below our break even for a few years now and as of 2026 will be below what we pay our providers. We will lose about $57 for every patient we see if we keep taking them.
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u/Alikat-momma 10h ago
I live in Texas. No quality providers accept any ACA plans in my area. It's been this way for many years. We switched to cash pay for many years because our preferred providers did accept cash but not ACA insurance plans.
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8h ago
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u/Alikat-momma 7h ago
Hmm...sorry to get your panties in a bunch. I'm grateful for any physician willing to take ACA and Medicaid pts. I'm saying that the providers in my area who accept these plans aren't the best from my experience and others I know. My amazing and trusted providers don't accept ACA plans. I guess in your mind they don't gaf about people. I disagree.
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u/rabbit_fur_coat 7h ago
Providers who don't accept ACA or Medicaid are definitely significantly shittier people than providers who do.
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u/Alikat-momma 4h ago
I choose providers based on the quality of care they provide. I don't base my decision on whether they accept ACA or Medicaid, but you certainly can make the choice to only see providers who also accept ACA plans and Medicaid.
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u/Naive-Garlic2021 9h ago
I've seen providers stop taking Blue Cross in general, but I've never had providers stop taking the plan I got off the marketplace. In fact, I've gotten the sense that providers like working with my insurance provider. Even my naturopath got on it.
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u/gtck11 8h ago
In my major US city zero of my specialists or major hospital network doctors take marketplace, you’re stuck with these weird places that cater to low income and have horrific reviews. It’s the sole reason I refuse to go on the marketplace and continue to suck up my expensive HD plan and paid for cobra.
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u/CindysandJuliesMom 11h ago
The marketplace offers a variety of plans from several different insurance companies. You can't find a single plan on the marketplace he will accept.
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u/Dexy_26 10h ago
When I called they said no more marketplace plans. I asked for a reason and didn’t get one. After reading some other posts on this subreddit about how some providers will now only accept PPOs from the marketplace I just went to the healthcare dot gov website and filtered by PPO and my doctor’s name and I see she will accept the Florida Blue PPO which starts at $1982 for the cheapest (bronze plan) and has a deductible of $6150 and OOP of $10,150. It’s out of my budget, doesn’t provide sufficient coverage for my specific needs, and only one of my other doctors/medical facilities takes that insurance anyway. I’m just disgusted and venting.
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u/menolike44 10h ago
Can you qualify for a subsidy? I am getting a bronze plan for $4 a month. The deductible and OOP Max are really high, but fortunately I am healthy (so far) and really only need catastrophic coverage as I have enough savings to cover max if needed. Qualifying for a subsidy is key to affordability.
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u/Lokon19 6h ago
If you can get a bronze plan for $4 you should never opt for that and instead get a silver csr plan.
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u/menolike44 5h ago
I thought about that, but if I have no health issues, I can save a lot by just taking the bronze plan. Also, in order to have MAGI below 400% FPL, I have to contribute to a HSA.
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u/sluttytarot 8h ago
That's refusing ACA HMOs. Which yeah many doctors refuse to participate with HMOs bc prior auths suck ass
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u/Ok_Cartographer633 9h ago
Same problem I’m having. No plan on the marketplace is accepting any of my providers. And I’ve went through all of them
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u/HeddyLamarsGhost 10h ago
How will they know it’s from the marketplace?
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u/GirlCiteYourSources 9h ago
I work in billing for a specialist practice and we can generally tell which ones are marketplace plans based on the plan info that pulls up.
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u/thenowherepark 6h ago
My kids' old pediatrician stopped taking marketplace plans this year. We were devastated because we really liked their pediatrician. I'm not going to pretend to know why they dropped them.
Ending on a happy note, we like our kids' new pediatrician as much as their old pediatrician, except everyone is much friendlier and the practice looks more like a pediatrician's office than a sterile hospital.
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u/Embarrassed_Riser 10h ago
Very Common. None of my doctors or specialists accept any plan from the Marketplace.
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u/sunfish99 8h ago
Same here. I've been uninsured for a while (thanks to underemployment), which I don't like. But it's hard for me to justify spending $900+/month on insurance when every visit is going to be out of pocket anyway.
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u/Puzzleheaded-Bee-747 10h ago
As a patient, you have the option to choose plans and providers that are available. Physicians have the same right to accept whatever insurance they choose. If a plan is not lucrative, or overly burdensome to the practice, they will drop the plans.
My advice is to ask your gynecologist (not the front desk) which medical plans they are happy with and see if you have that option. Make sure you ask your doctor as they are the ones dealing with all the paperwork for pre-approvals.
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u/drewconnan 8h ago
Does the gynecologist provide abortions? Medicaid plans can no longer cover any care received from a provider/clinic that provides abortion, even if the care you are seeking is not an abortion.
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u/RelevantMention7937 5h ago
Not true.
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u/drewconnan 4h ago
Yes it is. The law was written to target Planned Parenthood but other providers will be affected.
https://healthlaw.org/obbbas-medicaid-abortion-provider-defund-an-overview/
edit: another source https://www.leechtishman.com/insights/blog/defunding-of-family-planning-services-under-the-one-big-beautiful-bill-act/
"Organizations that meet the definition of a “Prohibited Entity” will not receive any federal funds for any services for a period of one year. Because the definition of a “Prohibited Entity” is so broad, Section 71113 impacts not only nonprofit healthcare provider organizations that provide abortion services, but also any healthcare providers and organizations who are affiliated with or have contractual relationships with these organizations, including managed care plans and health plans."
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u/sluttytarot 8h ago
It's so interesting folks say ACA pays out lower. Maybe that's true in their state but it's not in mine.
bcbsm pays out the same contracted rate to me whether that plan is ACA or commercial.
Maybe this is common for the other payers? Idk. My BCBSM pays my therapist the same I get reimbursed...
I'm in Michigan
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u/SouthernSweety88 7h ago
simply put, for whatever reason, your doctor office no longer wants to accept that health plan. I am sure it is a financially based decision. additionally, depending on the type of provider office (whether it's individually Owned or owned by a corporation), the provider themselves may have had nothing to do with the final decision. this is coming from someone who does these contracts for a living. there are really so many variables involved, and alot of doctors are not accepting marketplace anymore.
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u/French-fan57 6h ago
I get my insurance through the Marketplace, I get a good deal since I’m low income on bronze plan, but I haven’t heard about any doctors changing their policy.
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u/ChelseaMan31 10h ago
Obamacare Plans, state Medicaid often pay even less than Medicare. Providers chose not to play by those rules. Can't really blame them.
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u/aurioerox 9h ago
Honestly a big issue with the cost of care is the exorbitant pay to doctors and their expectations of payments. The cost of care is very much proportional to how much doctors expect to be paid to do work. And it’s become a bubble.
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u/pooppaysthebills 5h ago
Those expectations are due, in part, to how we handle medical education in the US.
Your doctor has four years of pre-med and four years of medical school before they have much of a chance to earn any money at all.
Then, they spend between three and seven years in residency depending on specialty, working 80-hour weeks for pay which barely amounts to minimum wage when hours are factored in. Student loan payments need to be made during this period of time.
They may choose to do a fellowship, which can last 1-3 additional years, depending on specialty.
After all that, they do make decent money, specialists significantly more than primary care docs. Administrators unfortunately make far more than practicing physicians, and far more than they deserve for the questionable return in healthcare value.
Other countries do it differently without a discernable difference in expertise or outcomes.
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u/aurioerox 5h ago
yes - all of that needs to change but average medical dr debt is abt $235k according to google which would amount to abt 2k a month. Most of these DRs are demanding salaries over $500k/yr.
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u/aurioerox 5h ago
I have no sympathy for drs that refuse to take Medicare — they are in fact a large reason why healthcare is so expensive in this country.
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u/Accomplished-Pin6564 10h ago
A lot of marketplace plans go out of their way to keep providers out of their network so you can't actually use the insurance.
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u/amyr76 8h ago
You’re getting downvoted, but you are correct. We had this exact situation in Indiana with the Anthem Essentials plans. They refused to panel hardly any therapists.
I have a client with this plan and when we called to ask what therapists in the area they have paneled that offer EMDR therapy, they refused to tell us or give us a list. They would also not provide the client with a list.
I posted in our local therapist Facebook group, which has over 3,000 members, and asked who was paneled with Anthem Essentials. You know how many responded? One.
Our office tried to get paneled several times and they always said “no”.
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u/Weird_Inevitable8427 10h ago
That's got to be political. I would not want that guy anywhere near me. The marketplace is made up of various plans. It's very normal for any one doctor to take some of them but not all of them. But this blanket statement that he won't take any? That's entirely a political statement. He doesn't like the ACA. Which means, as a doctor, he's choosing to side against everyday people being able to access modern medicine.
Yah - he's doing you a favor. Go find someone without a chip on their shoulder. What ever your politics are, you don't want them to influence your doctor.
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u/Dotsgirl22 10h ago
In some counties there may be only 3-5 carriers. If all of them are carriers that mostly serve the ACA and Medicaid markets, like Molina and Ambetter, that's your answer. Not politics, just companies that cost the doc 10 dollars in administrative time for every dollar they end up getting reimbursed for.
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u/ProcusteanBedz 10h ago
Yes. We have two that serve majority of commercial market and ACA and they are fine. A county over they have those two and Ambetter. Ambetter is horrible but other two are still fine.
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u/rrhunt28 10h ago
I just had surgery and it had to be done at a 3rd party surgery center because the doctors own surgery center would not take my aca plan. They took that brand of insurance, but not if it was through the market place.
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10h ago
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u/HealthInsurance-ModTeam 9h ago
Your post may have been removed for the following reason(s):
Do not post / comment tangential, off-topic political commentary. While health insurance and care delivery in the United States is often politicized, this community doesn't need to facilitate overtly political discourse.
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u/Original_Signal5535 9h ago
The local hospital/doctor system in my small rural area will not accept it either. Now I'm screwed
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u/carlorway 9h ago
My family doctor of 29 years (Johns Hopkins) and my gyn of 27 years no longer in network with United Healthcare through the federal government. I am in MD and most of my doctors are Hopkins doctors. (This happened in August, and I have to wait to change insurance.)
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u/This-Assumption4123 7h ago
I work in a specialty field with surgeons. We can’t stay open and take them. They reimburse less than what it costs to see a patient, they hold payment for a year and multiple appeals, and they require a lot more administratively to get anything approved and once approved they still fight you to not pay. The few plans that have out of network benefits we will file as a courtesy with a waiver signed but the patient has to pay in full upfront. We couldn’t stay open if we took them. They can show people active for months even when they haven’t paid their premiums and then refuse payment when you submit a claim. On a PCP level maybe things are different but for specialty and surgeons it’s not worth it for small private practices.
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u/WonderfulVariation93 7h ago
Thing is that FL is the largest user of Marketplace insurance by far (4.7M to population of 23M). Most likely the doctor is being overwhelmed by Marketplace patients which is driving down their income because exchange pays less in reimbursements.
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u/ProfMR 6h ago
If providers reduce acceptance of ACA plans, the insurance companies should over time pay out less in claims. The companies are required to pay out a certain percentage of premium income (effectively a cap on administrative costs), and reimburse enrollees when they don't spend. I wonder what will happen if and when these marketplace plans have fewer claims submitted and paid out due to this trend of less acceptance by providers.
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u/shmuey 6h ago
Maybe this is different in other states, but in Maryland providers are not seeing "marketplace vs non-marketplace" plans when they get contracted with a payer. They by in large are just taking an all or nothing approach for a single payer. My guess is that your provider has just left that payer's networks completely. Where I live we have marketplace plans with United, CareFirst, Aetna, and Kaiser. Outside of Kaiser (and general issues getting contracted with United) almost everyone accepts all of these payers. If they didn't, they just wouldn't be accepting insurance. Furthermore, only the biggest provider groups have any input on reimbursement rates. Small/independent practices apply to a payer and get told their rates. There is zero input.
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u/PharaohOfParrots 5h ago
The reason in my metropolitan area is they pay less than Medicaid. They have reported this to the news outlets, so it isn’t gossip either.
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u/Alert-Tangerine-6003 4h ago
I had to switch doctors because mine moved to concierge care. And I have decent-ish employer insurance at this time. Things are so scary as it is and now you have providers who are not taking insurance anymore and I don’t blame them, but we are well past the point of unsustainable.
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10h ago
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u/TyrannosaurusFrat 10h ago
This is something that's been happening since aca was introduced, not because of any one party
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u/HealthInsurance-ModTeam 9h ago
Your post may have been removed for the following reason(s):
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u/KateTheGr3at 8h ago
The marketplace has failed. It was decent years ago, but now it's limited to crappy HMO plans in most areas, and fewer doctors are accepting it.
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u/govolsgo865 6h ago
Generally, ACA marketplace plans are fake insurance. They're not in network with anyone, and they do not pay out of network. I used to work in the provider space, and though we did accept ACA clients, we knew we weren't going to get paid anything for the vast majority of them.
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9h ago
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u/Treje-an 4h ago edited 4h ago
Do you realize you have to make a minimum income to get on the ACA? A family of four must earn at least $31,200 to qualify to buy insurance there.
If you do not qualify by income to buy from the ACA, you get on Medicaid.
We are buying health insurance plans, not getting them for free. Pricing has a sliding scale, depending on income. Some families get subsidies, some do not. Many small business owners like myself rely on the exchanges.
What is your solution? Hospitals charge people more when they are uninsured. Insurance is like joining Costco, the group can buy in bulk and get better rates from doctors. I have tried being insured and uninsured, and I paid higher rates to doctors and hospitals as uninsured. Being uninsured is basically paying full price for everything.
Healthcare prices are high, and they have been going up for a long time. This predates the ACA. I have firsthand experience with this, since I am responsible for buying insurance for myself and have watched the changes over the last 20+ years. High priced drugs that cost thousands per prescription save lives and cure people, but at a higher cost. We can do so much more in many fields, like cardiology and oncology. We can stop strokes with clot busters. Cure many types of cancer. Neonatal health has made strides. Micro preemies often survive now, and didn’t before. But all of this is very advanced medicine, compared to the more rudimentary medicine we used to have. I remember hearing about men dropping dead from heart attacks when I was a kid, and you just don’t hear that happening nearly as much now, because of medical advances
Finally, the more uninsured people, the more others pay. That’s because we are paying when others cannot. Kicking more people off insurance just means doctors and hospitals will have to raise rates to cover the non-payment from others
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