Trump Signs Executive Order for Insurance Reform ?

I've seen employers close the doors and watched people have claims pouring in after stop loss has ended. I've seen a dependent spouse file with Medicare only. Three years later, Medicare audited and dropped the claim back on the EMPLOYER. It was not the members responsibility but the employer's per federal law. The list goes on.

Of course, people selling ASO say "if it had been properly set up and understood bla, bla, bla". It was properly set up and people got stung.

Now, there are agents coming out of the woodwork promoting fully insured backed by an unknown trust with unknowable financial strength. They are also promoting ASO to small group because they don't have to follow ACA plan design and "if you don't want XXX benefit, why should you have to pay for it"? Also "if you have a good claims year, you get this nice big pile of money back (or don't have to pay it in the 1st place).

I'd buy it for my family however, I have control over premium payment, stop loss etc and a better understanding than Johnny factory worker who has no control or understanding. I also spend more on dental claims than medical and know better than to buy a trust product thinking that it is the same as fully insured with a major carrier.

I had an 800 member case that BCBST said was 100% credible. I had the numbers and ran the regression. It was almost 0% credible looking at monthly claims, increased to 35% credible when looking at a rolling 12 month period and about 65% credible at rolling 24 months. This is no where near 100% and with standard deviation the justifiable premium range was greater than $100. Carriers promote these calculations because the entire block is credible and any loss with a particular group will be made up by over charging another. Most agents don't have the data and wouldn't know what calculations to do it they did thus take the carrier's word.

Getting into ASO with the expectation of saving money is a myth unless you know that claims will be low. This business of cross border carrier competition and cutting benefits does nothing to control the medical procedure cost or utilization thus meets my definition of "smoke and mirrors" - AND, I'll have the quotes just in case and to keep the other agents on the outside.
 
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I do not disagree with you on most of this too. Each of these issues you raise can be true. I have also seen fully insured claims denied due to time constraints. Either way, the plan needs some level of guidance and help.
 
The worst I've seen on fully insured is having to explain to the insured that the provider didn't file timely and got threatened with having to write it off. They eventually got paid and it wasn't my task to solve. Another time the Doc was selling a hysterectomy on a 20 something yr old. The carrier wouldn't authorize the procedure until another remedy was tried first. There was lots of name calling and accusing the carrier of practicing medicine. The alternate procedure solved the problem and the lady got to keep her internals.

Unfortunately, rates are so high that even those earning in the neighborhood of $200k are bailing to things that would never have been considered in the past - AND I've seen nothing that looks like it has a chance of reversing this trend.
 
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