Questions about health insurance

[Skywalker3]

I'm trying the help a family member choose a health insurance plan. They've never really had health insurance in the past, but want to start addressing some health issues,and just start taking better care of themselves, being more proactive on preventive care, etc. So hoping to schedule a bit of appts for the upcoming months/year. They are looking through the marketplace in Texas (Houston area) , and leaning towards higher deductible plans, lower monthly premiums. DH and I have had insurance through govt jobs for over 25 years, and we prefer the no deductible plans.. I am not familiar at all with all the choices on the Marketplace. Just looking for opinion/suggestions on how it really works w a deductible. Like does one pay everything cost/lab work, office visits until that deductible is met? Also I have always leaned toward larger, more familiar companies for any type of business, so for the insurance, looking at Blue Cross, Aetna, United Healthcare. Thanks in advance for any insights. and if this is not the right forum, please move . Thanks!!

 

[lanejudy]

I'm not familiar with the Texas marketplace options, but every plan is different even from the same company. So one Blue Cross high-deductible plan may not be the same as another Blue Cross high-deductible plan, or two PPO plans may be different, etc. So it may be important to look at the specifics of each plan. Watch for not only the deductible amount but also the max out-of-pocket amount.

That said generally speaking a high-deductible plan will mean the subscriber pays for pretty much everything until they reach that deductible. Office visits, lab work, etc. But there is usually a "discount" or maximum allowable charge that the insurance sets. So the doctor's office may charge $300 but the insurance says the max allowed is $225, so if the subscriber pays the $225 rate. Until they reach their deductible. Then once the deductible is met and depending on the plan, the insurance may kick-in to pay 80% of the fee or may pay in full.

Some things should be "free" such as an annual well visit, well-woman care, etc. In these situations there is no need to meet the deductible first. But be careful that there aren't any problems found or discussed during a well visit because it then may not fall into the "free" visit.

 

[StevieB81]

Look at the difference in cost between the HSA/high deductible plan and the other types of plans. In my case, the difference in premiums (PPO vs HSA) for the year pretty much equals the deductible amount, so the high deductible plan makes financial sense. Plus the HSA is tax-free and can be invested once there is enough money in it. HSAs almost always make better financial sense, IMO.

 

[mjkacmom]

We have Aetna, we pay OOP until we reach $7000 in network (I think some things are covered with a $50 copay like annual checkups), and $7000 out of network. After we hit deductibles insurance pays a certain amount, at some point they pay everything. Omg I can’t imagine not having health insurance, we’d be bankrupt by now without it.

 

[tvguy]

You really really really have to do your homework and make a decision on what works best for you coverage and deductible wise. I was not eligible for coverage through the Marketplace because I had COBRA coverage through my former employer as an option. I went on Medicare in June of 2022, and was on COBRA coverage for the first 6 months of 2022 and my out of pocket deductibles were $10,000 ! Medicare is a whole other can of worms, but I will say that my out of pocket for the last half of 2022 was only $233.

 

[lanejudy]

We have Aetna, we pay OOP until we reach $7000 in network (I think some things are covered with a $50 copay like annual checkups), and $7000 out of network. After we hit deductibles insurance pays a certain amount, at some point they pay everything.

every plan is different even from the same company

See this is what I mean... we also have Aetna but our in-network family deductible is $3700 at which point I only pay a 20% coinsurance until we hit out-of-pocket max of $6500. Same insurance company, both high-deductible plans, but still very different in what is covered and how much OOP.

So for OP or anyone researching insurance options -- don't just go by the insurance company name thinking "so-and-so said they have XYZ and it's good." There are so very many different plans within the same company. Do the research -- look at the deductibles, the out-of-pocket maximum, the copay or coinsurance, the premiums. Then check with the providers to make sure they will be considered in-network and what are some "typical" charges.

 

[KPeterso]

So for OP or anyone researching insurance options -- don't just go by the insurance company name thinking "so-and-so said they have XYZ and it's good." There are so very many different plans within the same company. Do the research -- look at the deductibles, the out-of-pocket maximum, the copay or coinsurance, the premiums. Then check with the providers to make sure they will be considered in-network and what are some "typical" charges.

Just want to reiterate the above! This is the best advice. I work at one of the big insurance companies and while I consider it the best, it may not be the best option for everyone who are looking for insurance. You need to check if your providers to ensure that they participate with the plans you considering. My parents changed from a retiree plan through my dad's former employer to a Medicare Advantage and one of the providers he had been seeing was not contracted for his medical group under the MA plan, so we had to change (like the new one better so I guess it was a good thing) and now have another doctor who is no longer covered so changing that specialist now.

 

[MsOnceUponATime]

I'm trying the help a family member choose a health insurance plan. They've never really had health insurance in the past, but want to start addressing some health issues,and just start taking better care of themselves, being more proactive on preventive care, etc. So hoping to schedule a bit of appts for the upcoming months/year. They are looking through the marketplace in Texas (Houston area) , and leaning towards higher deductible plans, lower monthly premiums. DH and I have had insurance through govt jobs for over 25 years, and we prefer the no deductible plans.. I am not familiar at all with all the choices on the Marketplace. Just looking for opinion/suggestions on how it really works w a deductible. Like does one pay everything cost/lab work, office visits until that deductible is met? Also I have always leaned toward larger, more familiar companies for any type of business, so for the insurance, looking at Blue Cross, Aetna, United Healthcare. Thanks in advance for any insights. and if this is not the right forum, please move . Thanks!!

Soo many things to comment on ...

I live in Texas. I have a high deductible insurance plan through my employer. I also have an HSA, STD, LTD, etc. through that plan. I pay for the vision and dental plans associated with my plan too.

"how it really works"; As long as you do your research on your plan's website and choose ALL in-network providers, and you can cough up that high deductible out of your pocket as you need it -a high deductible plan is do-able.
Yes, when you visit a provider (for items aside from preventative care -- read well women, annual physicals), you pay all costs for services- labs, office visits, pharmacy services, behavioral health, etc., until that deductible is met. Once you meet that in-network deductible you and the plan share the costs for covered services. (At the point where you've met your deductible, but not the out of pocket max you pay a percentage. Like 10% until you reach that out of pocket max.) For me, when I, or my family, reaches the out of pocket maximum, the plan pays 100% for covered services.
I need to meet either my individual or the family out of pocket maxiumum, but not both. My max is $3500. My family max is $7,000. The out of pocket maximum sets a limit on what I pay for covered services before the plan pays 100% for all eligible services.

The key here is to NOT use out of network providers (just check the plan's website for only in network providers).
Also if you're away from home, and need to see someone in an emergency situation most plans cover 100% of those costs. I had that happen two years ago in Hawaii and we never even received a bill.
Also also - anesthsiology (and their providers) is almost not ever covered in Texas. I am not sure why, but it's rare that plans pay (found that out the hard way this year) for anesthesiologists.

Clear as mud, right??

 

[Skywalker3]

Thank you all for the advice, information. We've had federal plan for ourselves for so, so many years, and are so comfortable with it, just not at all familiar with other options. We have no deductible at all, and some co-pays, but a decent sized montly premium, and are very satisfied. The person, young 30s, searching for insurance is not currently regularly employed, but does have a job, just more on a freelance basis. Not a set monthly income with a company, etc. They've not seen a regular doctor in years, and want to get started. So they'll be hoping to have quite a few visits, lab work, who knows what else in the coming months. I see now looking on healthcare.gov that like y'all mentioned, companies have SO many choices, and various types of plans. I am not good with too many choices, I need just a few, so glad the feds only give us a few to choose from.....anyway, thanks so much everyone for the info, and especially info on the deductible plans.
We'll keep researching. have already warned him to stay in network!!!

 

[louper04]

I use the marketplace but in a different state. When I was signing up there was a place to have an agent call you and I chose that option and was SO thankful to have someone walk me through the process and options. She got detailed info on my health needs including any doctors or hospital networks I wanted to be able to use. Then she narrowed it down to 3 options for me with various things to consider, monthly costs, overall deductible, dr/lab costs. Each year we check in and she tweaks my numbers and gives me my options. Overall I have been extremely happy with the coverage and costs. I would try to find someone who can walk them through the process!

 

[njcarita]

Does he qualify for " special enrollment" outside of when the open enrollment for 2023 was?
You may be able to enroll in 2023 Marketplace coverage during a Special Enrollment Period if you have limited income, or if you had certain life events, like:
Losing qualifying health coverage
Getting married
Having a baby or adopting a child
Moving

You usually have a window in time every year to enroll for coverage..
Usually Runs from November to mid Jan 15th. You may want to call your states health exchange to confirm the dates of open enrollment

 

[starry_solo]

Thank you all for the advice, information. We've had federal plan for ourselves for so, so many years, and are so comfortable with it, just not at all familiar with other options. We have no deductible at all, and some co-pays, but a decent sized montly premium, and are very satisfied. The person, young 30s, searching for insurance is not currently regularly employed, but does have a job, just more on a freelance basis. Not a set monthly income with a company, etc. They've not seen a regular doctor in years, and want to get started. So they'll be hoping to have quite a few visits, lab work, who knows what else in the coming months. I see now looking on healthcare.gov that like y'all mentioned, companies have SO many choices, and various types of plans. I am not good with too many choices, I need just a few, so glad the feds only give us a few to choose from.....anyway, thanks so much everyone for the info, and especially info on the deductible plans.
We'll keep researching. have already warned him to stay in network!!!

Does this individual make an amount low enough that they would qualify for Texas' equivalent of Medicaid? That may be something to look at too...

 

[DisneyTexan]

Also also - anesthsiology (and their providers) is almost not ever covered in Texas. I am not sure why, but it's rare that plans pay (found that out the hard way this year) for anesthesiologists.

Interesting to know! I ran into this situation recently. As noted above for many healthcare policies, there may be no insurance coverage for something, but it is offered at a discounted rate. For me, the full price (non-insurance rate) for anesthesia for my outpatient procedure was about $1,000. However, Blue Cross had previously contracted the price at $330. So I paid $330, and that $330 was applied to my annual deductible of $3,000.

 

[afan]

But be careful that there aren't any problems found or discussed during a well visit because it then may not fall into the "free" visit.

This so much and it didn't used to be this way and it's such a money grab. I go for my yearly checkup and generally that's it. She asks about how I'm doing. I mention an issue I've had with the dry air and she says it's allergies and gives me some suggestions and an rx. Few weeks later I get a bill for $70 because of the allergies.

It's wellness, which encompasses everything, new or old to me. This issue wasn't something I'd have gone to the Dr about but since I was there I mentioned it when asked. Was never an issue before doing this. Next year I'm not discussing anything which is also stupid. But they shouldn't be charging an additional office visit fee for discussing your health at a visit meant to prevent stuff.

 

[HopperFan]

It varies greatly by location, plans and whether their state has ACA etc. Texas does not.

DS is in a non-ACA state and had to get his own insurance via marketplace. Without ACA costs are higher. Being a young person who did not anticipate any ongoing issues he went with high deductible which in my terms is catastrophic insurance. It really wasn't going to pay anything unless he got into a bad accident or had a major health issue.

If he were older and anticipating ongoing doctor visits and prescriptions he might have gone with a more midline deductible assuming he might hit that deductible and get benefit after that.

Sadly no way he could have afforded a lower deductible premiums without knowledge he would have huge medicals bills it could assist with.

I would compare what basics each might cover or discount BEFORE any deductible kicks in. There are some that will cover your annual physical and lab work without hitting deductible, likely not many, but DS last insurance did. At least they would get that out of it. And as lanejudy says, having the insurance and using in network doctors, they will get their bills discounted.

 

[kathy884]

I helped my son pick a marketplace plan when he turned 26 and could no longer be on my work insurance. His employer doesn't offer insurance to him. He's fairly low income and qualified for a subsidy for premiums which is super helpful. We looked primarily at Silver plans.

All of the plans covered his primary care physician and his choice for urgent care. But for his preferred hospital to go in our state which is not Texas only BCBS covered our preferred hospital (seemed to have the best network). With that information we then picked one of those plans. He pays 1/3rd of a $330 a month premium with the government kicking in the balance. People need to be careful on that, as if your income goes up, you may need to pay back some of that subsidy on your taxes. It's a high deductible plan - $3450 and then with a $7250 max out of pocket. It's an EPO, so you are only covered if you go in-network which is the situation with all of the marketplace plans in our state.

I believe it covered 100% for a physical. And there are co-pays for some things, deals on telephone medical care, etc.

It's super expensive as another poster alluded to, to get the lower deductibles, and you often pay what that deductible amount would have been in extra premiums practically.

Do I love the coverage he has? -- no. I am though grateful for Obamacare and subsidies so at least people can get insurance and so that lower income people can get subsidies.

I wouldn't be without health insurance or want anyone in my family to be without health insurance. One day in the hospital can easily be $8000 or so (more than many plan's maximum out of pocket, so at least you are covered after your out of pocket and don't have to deplete assets. It's way too risky IMHO financially not to have coverage.

 

[HopperFan]

Do I love the coverage he has? -- no. I am though grateful for Obamacare and subsidies so at least people can get insurance and so that lower income people can get subsidies.

I wouldn't be without health insurance or want anyone in my family to be without health insurance. One day in the hospital can easily be $8000 or so (more than many plan's maximum out of pocket, so at least you are covered after your out of pocket and don't have to deplete assets. It's way too risky IMHO financially not to have coverage.

And sadly there are too many that don't have this option. My DS was not on our plan, in graduate school and had to get his own insurance. Without the subsidies his insurance equaled over 20% of his gross income. Kinda rough when you have basic expenses and tuition to pay. So many still don't have health insurance because of where they live.

 

[Skywalker3]

Reading through all the replies, thanks to everyone who has taken the time. He's still looking. He does qualify for a life event, to join now, and makes more than what would qualify for medicaid. I'm still wanting him to choose a no or lower deductible plan. didn't have time today to devote to more research. Thanks to the poster suggesting contacting the marketplace to speak with a guide that may be able to steer him in the right direction. He also just needs to hunker down and really compare the plans, side by side, coverages, etc. am hoping he'll come around VERY soon to accepting paying for medical care and insurance is worth it

 

[lanejudy]

I'm still wanting him to choose a no or lower deductible plan.

Crunch the numbers. He might end up paying premiums for the no/low deductible plan equal to the high deductible. It's really all just whether he can afford the high premium and low OOP for the actual medical care, or lower monthly premium and higher OOP when he has care. If he choses a high deductible plan, he qualifies for an HSA (Health Savings Account) that can build over time to save up for medical expenses. It carries forward year-after-year if he doesn't use that much.

He does qualify for a life event, to join now, ... am hoping he'll come around VERY soon to accepting paying for medical care and insurance is worth it

Well if he qualifies for a life event situation to enroll now, that isn't usually a very long window. Maybe 3 months at most, sometimes as short as 30 days.

 

[amylevan]

I'm still wanting him to choose a no or lower deductible plan.

Always run all the numbers. Premiums of a low/no deductible plan can sometimes add up to just be as high as the deductible of a high deductible plan. And you could end up saving money if you never reach that deductible, while premiums have to be paid either way.

And as mentioned, if you get a high deductible plan, you can set up an HSA.