Questions about health insurance

[Anthony1971]

I believe there is no such thing as a 0 deductible plan any more if there is the company will pay extra to offer the so called older now called Cadillac plans --however 0 refers to out of pocket for Hospital not a doctors visit those can be copay only. They need to define what the out if pocket is before you can make a decision.

 

[Twohsieh]

We receive our health insurance through my employer in CA. We used to have a PPO plan with Blue Shield which had a 20% co-insurance with in-network providers and hospitals. When my daughter was three years old, she had an highly allergic reaction to something she ate. We took her to the ER and the in-network hospital bill for the several hours of admission and testing cost us $5000 with our insurance. We could choose any doctor or hospital to visit with this PPO plan, but it came with a high price if we were to ever use this insurance. Basically, we were afraid to use this insurance because of the unknown costs of services when in an emergency situation.

Most of the time, the cost to see the doctor without insurance is feasible however going to the ER or having surgery without insurance can be catastrophic to your finances.

Soon after the hospital visit, we changed our health insurance plan to a HMO plan with Blue Shield. We have the Blue Shield Platinum Trio HMO 0/25 OffEX. It is a $0 deductible plan with out of pocket $2,350 individual/$4,700 family costs. We love that it is a flat rate for labs/imaging $20-$50, free preventative care, office copay $25, specialty copay $50, ER visit $250 (including doctor services) but no charge if admitted and out patient surgery $150. We have never been surprised with hidden fees with this plan.

In this plan, you choose a hospital of choice then all of the doctors who are affiliated with that hospital are available in-network. When we switched over from the PPO to the HMO plan, we were able to keep all of our doctors. We have been with this plan for over ten years now and it has given us the peace of mind that we won't ever go into financial ruin over our medical treatments/prcoedures.

 

[Kestryl]

I %?!a&$ hate my high deductible plan. My employer dropped the low deductible plan after my first year. The whole idea was premiums would be so much lower, so most would see decrease in payments! Uh huh, sure. I have paid more every year since than I would have under the former nom deductible plan, even accounting for the premium changes. And I’m not particularly complicated- we’re talking the general wellness physical, two derm appointments, two ophthalmologist appointments a year.

 

[SharonZ]

I'm so lucky - I have Highmark PPO Blue, I don't pay a monthly premium (Employer pays). We do have a $1750 deductible for individuals (me). However, my Employer funds that money through an HRA. My copays are $25.00 for primary care, $40 for specialist. I've had minor heart surgery this year which my plan completely paid. I would definitely have someone discuss your options with you, as it can be confusing.

 

[danceintherain]

He really needs to run the numbers for his specific situation.
Premiums for low deductible plans are typically very high. It's easy for people to pay a TON for the convenience. All it really does is fix your base out of pocket at a high number. This is rarely the most cost effective option for people. You're essentially just "pre-paying" your health expenses, but you don't get a refund if you use less than the amount of services you've bought. Mid-range plans are usually the best for most people. Lower premiums, with some shield against crazy high healthcare expenses.

To put it into Disney terms, it's like the Dining Plan. Lots of people LOVE that they get to prepay for it. But, when you actually do the math, it's not actually a good deal for MOST people.


Overall, healthcare.gov is pretty easy to use. He can even estimate his healthcare use and see how much he would pay OOP for various options.
Also, Texas still has subsidies, they just didn't expand Medicaid, so there's a gap between where Medicaid comes into play, and where people qualify for subsidies. For example, my sister had to pay her subsidies back when she filed her taxes this year, because she didn't earn over $12,000 (or something like that).

That said, I would tell him to pay attention to his EOBs this year regardless of which plan he picks, or at least save them until November. Once he has a better idea of how much healthcare he actually uses, he'll have a better idea of which plan fits his needs.

 

[tasha99]

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.

Was this a long time ago? My husband is retiring in a couple weeks. He could obviously get Cobra, but that would cost us a lot. We applied for the marketplace and got approved, though we still have to finish everything when he's fully retired. The advantage of a marketplace plan over Cobra is that with our reduced income, we'll qualify for some subsidies. We're still in our 50s and will be living on savings. We can pull his retirement savings since he'll be 59 1/2, and it will count as income, but we'll be frugal and stay within eligibility guidelines.

I just don't see how Cobra could bar you from the marketplace. Literally anyone who has insurance and loses their job is eligible for Cobra, but losing a job is listed as a qualifying life event. ???

 

[tvguy]

Was this a long time ago? My husband is retiring in a couple weeks. He could obviously get Cobra, but that would cost us a lot. We applied for the marketplace and got approved, though we still have to finish everything when he's fully retired. The advantage of a marketplace plan over Cobra is that with our reduced income, we'll qualify for some subsidies. We're still in our 50s and will be living on savings. We can pull his retirement savings since he'll be 59 1/2, and it will count as income, but we'll be frugal and stay within eligibility guidelines.

I just don't see how Cobra could bar you from the marketplace. Literally anyone who has insurance and loses their job is eligible for Cobra, but losing a job is listed as a qualifying life event. ???

I went on Medicare in June of 2022, so a year ago.

 

[Eastern]

I was not eligible for coverage through the Marketplace because I had COBRA coverage through my former employer as an option.

You are still eligible for Marketplace coverage, but it has to be during open enrollment. You can't cancel COBRA mid-year and then be eligible.

 

[Eastern]

Was this a long time ago? My husband is retiring in a couple weeks. He could obviously get Cobra, but that would cost us a lot. We applied for the marketplace and got approved, though we still have to finish everything when he's fully retired. The advantage of a marketplace plan over Cobra is that with our reduced income, we'll qualify for some subsidies. We're still in our 50s and will be living on savings. We can pull his retirement savings since he'll be 59 1/2, and it will count as income, but we'll be frugal and stay within eligibility guidelines.

I just don't see how Cobra could bar you from the marketplace. Literally anyone who has insurance and loses their job is eligible for Cobra, but losing a job is listed as a qualifying life event. ???

Yes, losing a job is a qualifying event. You have to start marketplace coverage within 60 days of leaving.

You can't begin Cobra and then decide to switch to Marketplace anytime you want. If you are on/start Cobra, you have to wait for open enrollment to swtich to Marketplace. (or experience another qualifying life event)

https://www.healthcare.gov/retirees/#:~:text=If you're retired and,have different choices to consider.

 

[tvguy]

You are still eligible for Marketplace coverage, but it has to be during open enrollment. You can't cancel COBRA mid-year and then be eligible.

Well, it really is a moot point since the market place rates were unaffordable since we didn't qualify for help, and I have been on Medicare for a year now. But I was told in California that you only qualify for Covered California if you DON'T have ANY other insurance option. And as expensive as COBRA was, Covered California was nearly twice as much.

 

[tvguy]

You are still eligible for Marketplace coverage, but it has to be during open enrollment. You can't cancel COBRA mid-year and then be eligible.

Just double checked. This is what the website says, so I was NOT eligible since I had over cheaper coverage available.
California residents who don't have an offer of affordable coverage can get a health plan through Covered California. In addition, most immigrants qualify for health coverage, including the following groups: Lawful permanent residents (green card holders). Lawful temporary residents.

 

[tasha99]

You are still eligible for Marketplace coverage, but it has to be during open enrollment. You can't cancel COBRA mid-year and then be eligible.

Yes, losing a job is a qualifying event. You have to start marketplace coverage within 60 days of leaving.

You can't begin Cobra and then decide to switch to Marketplace anytime you want. If you are on/start Cobra, you have to wait for open enrollment to swtich to Marketplace. (or experience another qualifying life event)

https://www.healthcare.gov/retirees/#:~:text=If you're retired and,have different choices to consider.

Thank you. For us, Cobra would be very expensive since DH's plan was really sweet (employer paid 95%--$250 deductible with great coverage, but that would be really high for Cobra since we'd be paying 100%.) Our income is going to tumble to half this year, then next year will be controlled by how much we take out of 401Ks/IRAs, so it looks like we'll get some subsidies, making the marketplace a much cheaper choice for us.

 

[tvguy]

Thank you. For us, Cobra would be very expensive since DH's plan was really sweet (employer paid 95%--$250 deductible with great coverage, but that would be really high for Cobra since we'd be paying 100%.) Our income is going to tumble to half this year, then next year will be controlled by how much we take out of 401Ks/IRAs, so it looks like we'll get some subsidies, making the marketplace a much cheaper choice for us.

My problem was we retired in July 2021, so we had 7 months income on the books which meant no subsidies. And I went on Medicare in June 2022, so I would have had Marketplace coverage for 6 months.
My Market place quote was $3,000 a month for the two of us. COBRA was $1,700 a month. Medicare with a supplement, dental vision hearing and prescription coverage for both of us is $600 a month

 

[fla4fun]

I chose the high deductible plan. I put the difference in premium between the high/low deductible plans in a savings account until I built up the out of pocket I would need to pay. Once I pay the full out of pocket amount, the insurance covers at 100%. It was difficult financially until I had the savings built up, but now I appreciate the lower (although not really low) premiums I am paying. The nice thing is, if I don’t need to use the insurance, I haven’t paid the higher premiums. The money in savings is still mine.

I can’t get a premium subsidy because I am unemployed right now, but I still had the savings for my max out of pocket expenses in the bank from when I was working and had a similar plan, so I just had to budget for paying the premium on my own.

Each person, and policy, is going to be different. There’s no way to get around doing the research if you want to get the best coverage you can for the price.

 

[MrsPete]

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!!

I don't know anything about Texas, but I can address the topic of high-deductibles. No right or wrong answer -- more of a, Know your own needs assessment.

A high-deductible plan comes with lower premiums (less money paid each month), but you'll pay a good bit out of pocket before the insurance kicks in. A young, healthy person who goes to the doctor rarely could do well to choose this plan, Yes, if he catches strep throat he's going to pay the whole thing out of pocket ... but he's going to pay significantly less every month in premiums, which means he can pack money away in his savings account. And if he gets into a car accident or develops cancer, he insurance will pay those big costs. Of course, no one should opt for a high-deductible plan unless he has the money to pay for those little visits for strep throat, etc.

A no-deductible plan is the opposite: It means insurance will pay for your little appointments (again, stuff like strep throat), medicines, and it'll be there for big problems like the car accident or cancer -- BUT you're going to pay significantly more every month for that surety. So if you don't get sick, you've paid for nothing. This plan is better for people with chronic conditions, small children who need to go get their vaccines, or older people with normal aging issues that should be monitored -- it's better for people who know they're going to have lots of appointments. It also might be the right choice for people who need medicines (or allergy shots) on a regular basis.

Regardless of what you choose, be aware that insurance has to pay for certain "preventative care" appointments -- mammograms, colonoscopies, and the like. Read carefully to see exactly what preventative care is included in the policy you're considering.

Pay attention to the co-pay. Many mid-point plans (which fall somewhere between high-deductible and no-deductible) require a co-pay. This means when you go to the doctor -- maybe for strep throat, maybe because your kid is due for a vaccine -- you'll pay $30-40, and the insurance will pay the rest.

Consider, too, that what works for you today may no longer be the right choice tomorrow. My husband and I started out our adult lives with a standard plan (a mid-point deductible). When we were in our 30s we were healthy and our kids were past all those vaccination appointments, so we changed to the high-deductible. We saved a ton for about a decade. We "lost" the year one child broke her arm across a growth plate and needed multiple specialized care appointments, but it was okay -- we were still well ahead. Then we "lost" when my husband developed some health problems, spent the night in the hospital and came out a Diabetic. That was the end: the next year we switched back to a standard plan. We don't regret the years we spent in the high-deductible plan because we "won" 8 years out of 10 and put that money away in savings.

Insurance is complicated -- I think purposefully so.

 

[reddog21]

A no-deductible plan is the opposite: It means insurance will pay for your little appointments (again, stuff like strep throat), medicines, and it'll be there for big problems like the car accident or cancer -- BUT you're going to pay significantly more every month for that surety. So if you don't get sick, you've paid for nothing. This plan is better for people with chronic conditions, small children who need to go get their vaccines, or older people with normal aging issues that should be monitored -- it's better for people who know they're going to have lots of appointments. It also might be the right choice for people who need medicines (or allergy shots) on a regular basis.

This plan is better for everyone, health is something that can change in a hartbeat(literally). Just because your young doesn't mean stuff doesn't happen and your covered with very little to nothing out of pocket. Medical care is outrageously expensive and just one thing can put you underwater real quick.

 

[AnnaS]

I browsed the Marketplace quickly. Expensive/more than COBRA sometimes and high deductibles even if I qualified for just a few dollars off the quotes. So many choices.

I chose COBRA for now (need it for two years) since my DH recently passed. I have the same coverage (80% coverage) as I did before he passed. I can switch during the enrollment period if I want next year. We shall see. One less thing to worry about right now. I might speak to someone if I decide I might want to switch. I will most likely speak to someone when I reach Medicare age too.

 

[Sportypyro]

Helping your family member navigate insurance can be tricky, but I’d recommend being cautious with high-deductible plans if they’ll be scheduling a lot of appointments soon. Until they hit that deductible, they’ll be paying out of pocket for most things. It might be worth comparing how much they’d likely spend on care versus premium savings. Also, big companies like Blue Cross and Aetna tend to have more provider options, which is super important!

 

[Uk145081]

I’ve been through similar headaches when trying to figure out health insurance options for my parents after my dad's diagnosis a couple of years back. We quickly realized how much regular appointments and treatments could cost out of pocket with a high-deductible plan. So we ended up opting for a plan that had more predictable costs, higher premiums, but manageable co-pays and no surprises. It gave us peace of mind knowing his care wouldn't be delayed or limited by financial concerns.

If your family member is in the UK, I’d also suggest exploring specialized plans like those with cancer cover. Plans like these can really ease access to treatments and private consultations , check out options here: https://premierpmi.co.uk/health-insurance-cancer-cover/.