Community Chat

[MyGirlsMom]

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@physicsnut wrote:

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@CelticCrafter wrote:

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@MyGirlsMom wrote:

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@physicsnut wrote:
O care is a joke for the majority of people and the deductibles are ridiculous. Just pray you don't get sick!!!!!

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@physicsnut

It's the best thing that happened to people without health care as well as college aged children able to stay under their parents plans. 

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No, it's the best thing that happened to people without health care that are eligible or entitled to subsidies.....$5300 annual premium with a $5000 deductible is not the best thing that happened to a healthy 27 year old.....

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You are exactly right!!!

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A healthy 27 year old has other choices, such as an HMO.  WE ALL pay higher insurance premiums long before the 21st century. 

[bebe777]

@Jordan2, @labs and @terrier3, my background is that I sold health insurance for a number of years. 

I wanted to bring up the confusing factor of reimbursement for "reasonable and customary" expenses. -- A year ago, when I helped a good friend navigate her way through the marketplace, I thought I remembered seeing different plans -- or even different tiers within plans -- offering reimbursement (between the various plans) at different percentiles of "reasonable and customary" charges.

As labs and terrier3 have mentioned, your insurance company begins reimbursing you for your medical expenses only after you have reached your deductible (which is your responsibility to pay). 

Once you have reached your deductible, your insurance company pays for most of the bills and you are responsible for either the copays (generally for doctors/specialists office visits) and for coinsurance for a hospitalization. 

The copay is generally a flat fee that you pay for an office visit (eg. $25 or $50 copays for office visits). 

The coinsurance generally is for hospitalizations (although it can also be for in office procedures and for expensive medical testing). For example, the coinsurance might be 20% or 30% of the hospital charges (it depends on the plan you have chosen). -- Generally there is a cap (ceiling) on the maximum number of dollars you will pay before your insurance starts paying 100% of your reasonable and customary charges.

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The reasonable and customary charges wording is where it can get a bit tricky, and this should be a factor you consider when choosing the plan that is right for you...

Insurance companies all have statistical lists which show them the spread/range of what hospitals charge for every procedure (they have the same sort of lists for doctors and specialists charges as well). 

Each insurance company, on their own, makes a determination as to what they consider to be the top (most expensive) chargesfor a particular procedure that is done in a particular locality (i.e. NYC and Los Angeles are likely to charge more for a procedure than a city in the middle of the country does).

If you look at the wording in a number of these health plans, you will notice language such as (for example): 

* We reimburse at the 70% percentile of reasonable and customary

* We reimburse at the 80% percentile of reasonable and customary 

* We reimburse at the 90% percentile of reasonable and customary

Insurance companies can offer lower premiums when they are reimbursing at a lower percentile of reasonable and customary.

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For example, let's say that you have a hospital procedure that costs $10,000. And for simplicity sake, let's say that your insurance company agrees that $10,000 is their top reimbursement rate for that procedure.

For the purpose of this example, the plan you chose only reimburses you at the 70% percentile of reasonable and customary. And in this example, you have  30% hospitalization coinsurance charge. And after you have paid out $2,000 coinsurance -- based on the insurance's reasonable and customary chart -- the hospital will pay 100% of the charges....

Right off the top, you are responsible for the $3,000 difference. Period. Your deductibles, copays and coinsurance are not a part of this equation. -- This is because you chose a plan that only reimburses you at the 70% percentile fo reasonable and customary charges.

You are also responsible for the 30% coinsurance charges on the $7000 of reasonable and customary charges. 

Here's the math: $7,000 x .3 = $2,100

So you would think that since you only are responsible for the first $2,000 of hospitalization coinsurance, and that the insurance would be paying 100% of all costs after that.

Unfortunately, since your insurance will pay 100% of the reasonable and customary charges at the 70% percentile, you continue to be responsible for charges that are above that percentile. -- In this case, you would be responsible for $30 of that last $100. -- Now in this example, that's not much but if the hospital bill was $20,000 you would be on the hook for much more.

Since you have chosen a plan that only reimburses you at the 70% percentile -- and your particular hospital's charges seem to be more than the insurance company's statistical maximum -- even after you reach your maximum hospitalization coinsurance amount you will continue to be responsible for part of the hospital bill. 

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The percentile of reasonable and customary charges part of insurance coverage is a tough concept to wrap your brain around, and most folks don't understand what it means until they get socked with a large hospitalization charge that isn't covered by their insurance carrier. 

So here's my suggestion on this...

* if you are young and healthy, you may want to roll the dice and choose a plan that has a lower percentile reimbursement. Just keep in mind that anyone can get into an accident and that costs for high risk pregnancies can go sky high. 

* If you have existing health challenges, I would seriously recommend that you don't roll the dice and take your chances. Just get a plan in which a high percentile of reasonable and customary charges are covered. Also get a plan with a lower deductible. -- You'll pay more up front, but you'll have the peace of mind of knowing that your hospitalization costs will be kept more in line. 

* If you are middle aged and in good health, I'd recommend that you get the best plan you can afford understanding what the trade offs can be. 

Best of luck to everyone!!

-- bebe

[Jordan2]

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@terrier3 wrote:

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@Jordan2 wrote:

I'm hoping someone can help me. I live in New York state and must purchase a health insurance plan on the exchange. I currently have a platinum plan but was wondering if I should get a gold plan. Currently I don't have a deductible. The new plan has a $600 deductible. I was wondering what things get applied to the deductible? Are they your copays, cost of doctor's visits, etc? Also what is out of pocket expenses? Are these expenses you incur if you go out of network?Also does anyone know the deadline to buy insurance for it to start in January?Lastly are you automatically rolled into your current plan if you take no action?Thanks for any advice you can give.

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I sell ACA insurance in NY State, so I'm happy to help.

Well visits and shots (flu, tetanus, anti-shingles, etc.)are not subject to deductibles. Everything else is - doctor visits, hospital stays, prescriptions.

If you have a $600 deductible, you pay the first $600 of payments out of your own money. Ex.: You have a sore throat and go to the doctor. He charges $50 (insurance company rate) for the visit. You have to get a lab test, another $50 and a prescription for an antibiotic, $10. You have to pay 100% of it (in this case $50 plus $75 plus 10 = $135). You pay until your $600 deductible is met.

AFTER that, you switch to co-pay (or co-insurance if you pay a percentage of services/charges). 

If your policy has a $1,000 out of pocket for the year...you add the $600 deductible and your co-pays - once you reach the out of pocket MAXIMUM for the year $1,000 - you pay nothing else for the rest of the year (just monthly premiums).

If you are healthy and rarely see the doctor, the policies with deductibles can work.

If yu are on a lot of meds (chronic condition like diabetes), sticking with a platinum plan might work.

If you use a lot of medical services - figure out if the lower monthly premium and the $50/month average of your deductible) is LESS than the difference between the monthly premium for the platinum and the gold plan. If the platinum has a $600 monthly premium, and the gold has a $450 monthly premium, the gold would be better for you.

The deadline to have new insurance for January 1st is December 15th.

Let me know if you have any other questions!

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I remember you from last year when I was shopping for health insurance. You are very helpful and kind with your advice and I thank you. I think I have decided on the highest of the platinum Oscar plans. I was comparing it with the next step down Oscar platinum plan and am deciding between the two. There is only about a $22 difference a month. The higher price plan has no deductible the other has $1000 one. If you factor in the $1000 deductible it comes out to more than the higher price one for the year. Also something new this year, if I use Quest lab no co-pays. Generic drugs are free. Also it's like having good coverage in case anything unforeseen crops up. Thanks again to everyone for their help. 

[60sgirl]

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@reiki604 wrote:

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@60sgirl wrote:

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@reiki604 wrote:

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@60sgirl wrote:

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@reiki604 wrote:

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@maryebrown wrote:
My DH brought home the new Health Insurance info from work today. For the 2 of us a Cigna EPO Middle Plan would cost $797 per pay period (biweekly). The .OOP is $8000 per year, deductibles $3000. That's a Huge chunk of change and I don't call that "affordable"...

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Mary..........clearly his company did not negotiate for the benefit of its employees. Perhaps you should go to the exchange and see what's available. I've been pricing plans and for about the same that you are paying I could get a platinum plan with 0 deductible and low copays. I'm on COBRA right now and will be paying just about the same for a 300 deductible. Complaining may fit an agenda but until you investigate alternatives it all just ether.

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you cannot buy on the exchange if you have employer sponsored coverage. My son just tried that since his employer's coverage is so high. 

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I understand what you're  saying. What I don't understand is how an employer sponsored plan is more expensive than a privately purchased one that has lower deductibles and lower out of pocket costs. There is something wrong if an employer offers a gold plan for more money that an unsubsidized platinum plan costs.

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well, I guess if and when you are poor enough to not be able to afford $300 out of every paycheck just to avoid penalty tax, (and don't even see a doctor because you are young enough and healthy enough)  and still make enough money for your basic needs, you will understand it. When you go to the exchange and think maybe you can find a subsidized plan while you are working, think again. The website tells you that you are not eligible since you can get it at work.

Therein lies the dilemma. What one person thinks is affordable, another cannot make ends meet. And that's one reason that a)young adults who are paying back enormous school loans have to move back in with parents, and b)many people would rather pay the penalty tax at filing time because it costs less than $7500 A YEAR.

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60's girl...........clearly you are talking about an entirely different set of circumstances than the one I am questioning. Again, I am saying that I don't understand how an employer subsidized gold plan can be more expensive than an unsubsidized privately paid platinum plan. Please let me know if you have an answer or idea about that without deflecting and changing the focus of my question.

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well, since you changed your original statement adding "gold" to employer subsidized plan and "unsubsidized privately paid platinum plan" then yes, it would be a different set of circumstances, it was not me who deflected and changed the focus. 

I merely relayed a real life situation, apparently you seem to want to make this into a debate, which I am not interested in.  There is nothing more for me to say about this. 

[reiki604]

60sgirl............given the fact that I was originally questioning maryebrowne's post about what her husband claims his company is offering (a gold plan) and my investigating costs of a privately purchased platinum plan.You jumped in offering a unrelated situation so I can understand you're not wanting to enter a discussion on the issue at hand. Be well and stay healthy.

[maryebrown]

I went to my agents office today, and brought the handouts from my husband's employer. She figured that the Cigna EPO Middle Plan was their Silver Plan, and it is an HMO - only Cigna Doctors within the network can be used (except for emergency care). Plus my PCP would have to be a Cigna Doctor. The co-insurance is 70% for that plan, after the deductible. Out of network, 0% is covered. Crunching the numbers, paying $20,722 for premiums and having to meet the deductibles ($1500 for each of us) and the OOPs it is NOT worth the costs of the plan. Still need to pay for the dental and vision plans which are separate ($833 for the year). The Cigna PPO plan would cost us $42,010 ! My agent cannot offer us an AFFORDABLE plan, as they really don't exist anymore. Anthem BCBS is out of the Health Insurance business,but providing LTC coverage. However, most of the ALFs in my region are Self Pay now. We have decided that we will opt for the Affordable Care Plan, since it will provide Doctor's Office visits & Wellness at 100% (deductible waived), Hospitalization, ER, UC, and ambulance are covered at 90% of the Medicare Reimbursement Rate (whatever that means) - but it's "something". shrug That plan will cost $8138 for the year but it's better than receiving a Bill before leaving the office, or the hospital facility if the need arises.

[terrier3]

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@maryebrown wrote:
I went to my agents office today, and brought the handouts from my husband's employer. She figured that the Cigna EPO Middle Plan was their Silver Plan, and it is an HMO - only Cigna Doctors within the network can be used (except for emergency care). Plus my PCP would have to be a Cigna Doctor. The co-insurance is 70% for that plan, after the deductible. Out of network, 0% is covered. Crunching the numbers, paying $20,722 for premiums and having to meet the deductibles ($1500 for each of us) and the OOPs it is NOT worth the costs of the plan. Still need to pay for the dental and vision plans which are separate ($833 for the year). The Cigna PPO plan would cost us $42,010 ! My agent cannot offer us an AFFORDABLE plan, as they really don't exist anymore. Anthem BCBS is out of the Health Insurance business,but providing LTC coverage. However, most of the ALFs in my region are Self Pay now. We have decided that we will opt for the Affordable Care Plan, since it will provide Doctor's Office visits & Wellness at 100% (deductible waived), Hospitalization, ER, UC, and ambulance are covered at 90% of the Medicare Reimbursement Rate (whatever that means) - but it's "something". shrug That plan will cost $8138 for the year but it's better than receiving a Bill before leaving the office, or the hospital facility if the need arises.

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You have found a "loophole" in the law that some employers are using to get their workers off their HI plans. By law, they have to offer one option with all the coverage necessary by law. The cost for it can be whatever they wish, but it has to be available to all workers.

Some employers work with insurance companies to make sure it is OUT OF REACH for the average rank & file worker. When it is SO out of line price wise (more than 9% of a worker's annual pay) - then the workers can get insurance on the exchange, along with any premium assistance and cost share reductions they may be eligible for.

It's tricky - but effective - the employer cuts benefits costs and pockets money he used to spend for his workers' health insurance.

[maryebrown]

Terrier3, Thank You for explaining the Current Health Insurances for us ! I appreciate it, and I appreciated your helping me and others last Winter (specifically, navigating the O'Care stuff for my Son). It varies, state to state, but I got him enrolled after wading through the mud. Next Year (for 2016) is even harder since several Providers have dropped their coverage in My State. My DH's employer is in NJ and they had to go with several Plans to cover employees in Many States >>> what a headache ! SMH

[puglover1]

I was not signed up for auto renewal and my insurance co auto renewed it anyway and didn't even notify me. Good thing I called and asked because the premium tripled on top of doubling this year.  And on top of tripling the premium they increased everything I had to pay substantially.