When looking at costs, try to predict what you/your insured will likely have as normal (for him/her medical expenses. Like colleges, shopping around is prudent.
We’ve talked about this in previous years, but a quick reminder:
For people who make less than 250% of the Federal Poverty Level, which is to say, less than $29,700/yr for a single person, $40,050 for a household of two, or $60,750 for a family of four, there are extra subsidies that are not always talked about, for Silver plans only. **If a person/family under 250% of FPL buys a Silver plan, they get extra help lowering their deductible, their copays and their coinsurance. ** IMPORTANT: This offer is valid for Silver only.
So for example a person who makes $20,000 a year buys a Silver plan. If the deductible is normally $4000, it might be $2000 for that person. (Just an example, with made up numbers. But the savings will be significant.)
Just an observation - for payment of routine labs with preventive care costs you might need to double check.
Since ACA I have been very diligent about my annual physical --and my doctor definitely doesn’t charge extra for asking questions about any concerns. The routine with the visit is that first a nurse comes in and pretty much goes over my health status and asks me if I am having any problems, etc. – and then the doctor comes in and I’ve got a second opportunity to bring things up — though obviously if I brought something up that required some sort of special procedure or further testing - or even a prescription – I can see that morphing into an office visit.
My insurance also pays 100% of the annual lab bill… but never, ever on the first submission. Every single year they send me an EOB denying payment and the I have to look up all the codes on the lab bill so I can know which charge is for what, and then I have to call up the insurance company to ask why it isn’t covered – and then they fix it and pay for it. With some phony excuse or another about why it didn’t get paid in the first place.
I’m pretty sure they have their system rigged to do this 100% of the time, and I am probably part of a small cohort of people who bother to call and protest – especially as the insurance discounts reduce the patient responsibility amount to something that is relatively trivial. So I’ll get a lab bill for $650, but then the insurance reduce everything and tell me I owe $60… and I’m spending time on the phone to argue about the $60 which could easily be paid from my HSA which is well funded. But for me it’s the principal of the thing – my base premium rate with this insurer is going up to $1000 next year, at age 62, on a bronze HSA plan with a $5500 deductible, and I rarely get sick… so I just am disinclined to let Blue Shield off the hook.
Anyway, bottom line, I’m just saying don’t take the initial “not covered” EOB at face value I think that routine labs and tests associated with an annual physical should be covered under ACA, though of course the determination of what is routine may be open to question.
For next year, my bronze plan premium is actually higher than the 2nd lowest Silver – which will cause me to pay about $50 more in monthly premiums if I stick with the plan – and Blue Shield is renegotiating its provider network agreement and might shut out my provider. If they do, I’ll switch to Kaiser, which is considerably cheaper. If not, I’ll stick it out because I like my doctor. But I’d assume I can also find someone I like with Kaiser, if necessary.
I’ll be eligible for Medicare in early 2019… I am definitely looking forward to that day!
My kids have employer provided health care --I think my son’s employer pays 100% of his premiums, he just has to pay a small amount for his son; my daughter’s employer not only pays 100% of her premiums, but would also pay 100% for spouse and dependents, but she’s planning on switching to her new husband’s employer-provided plan.
Yes, medical coverage family plans are a very important employee benefit, particularly if they can take the group plan into retirement, and especially if employer pays most of all of the premium.
@“Cardinal Fang” –
Yes, there are cheaper silver plans, but they are either HMOs or EPOs with extremely limited provider lists, such as Blue Select plans from BCBS. There are only two companies offering silver EPOs in his county - Blue Cross and Ambetter. The only plans that have decent doctors are the BCBS Blue Options plans. There are only 4 of these that are silver and his is the cheapest.
As far as I’m concerned, access to good doctors and hospitals is the most important part of a health insurance plan. That pretty much rules out the HMOs in his county, all of the Blue Select plans and all the plans offered by Ambetter.
Our situation is very similar to MaineLonghorn’s except we’ll be paying $1456/month just for DH and I with a $12000 family deductible. This year, we paid $1020/month for the same policy. We’ll be searching for other options.
A physical is covered 100%, but we always have issues with them covering blood work for the physical. Insurance companies bundle the tests and give them a new code that isn’t covered. It can take months and an appeal to get it straightened out, and then not always.
I ran into this problem. PPO used to pay all the routine lab but this year they paid only $50 out of about $300 charge. I called and called. They reviewed and insisted that some of the lab was not “routine”. How do you argue with that? In the meantime, the lab is calling me every week to pay the bill. EVERY week starting the week they sent the bill out not after it’s due.
Went back to the Healthcare.gov website last night and checked on available plans in North Carolina. Premiums are up almost 50%, but so is the subsidy. Looks like our dermatologist does not participate in any of the 10 plans offered by Blue Cross Blue Shield of NC (the only ACA provider now that Aetna has pulled out), so we will either find a new dermatologist, or pay for our routine exam. This will be our last year before Medicare. We will likely opt for a lower level plan and save approximately $4,000 in annual premiums. That money buys a lot of doctor visits. We lose the bet if somebody gets real sick or goes to the hospital, but even then we are protected by the policy out of pocket max. I think that’s called, “insurance”.
My dermatologist’s office is now primarily a facial spa. He has one room for medical exams, examining moles, etc. the rest of the office space is devoted to facials, dermabrasion, fillers and Botox. This emphasis on cosmetic procedures is also happening in my gynecologist’s office. No insurance paperwork, more cash. Is it just my area or is this happening elsewhere?
@TatinG – same here at new dermatologist I switched to when new insurance plan did not cover old dermatologist. Am not happy about it but do understand how much more profitable this line of work is. I think you forgot to mention ‘lunchtime lipo’.
I have not seen this at the GYN’s office and am afraid to ask what sort of cosmetic procedures are being performed there!
There is only ONE individual plan where DS lives (Phoenix). Not a lot of shopping around to do. I think he is in the incime donut hole…with income between $30k and $40k.
Regarding Silver plans and subsidies, the 2nd lowest plan is the the premium on which the subsidy is based even if you cannot buy those lower cost plans, I had an AZ client who lived in a smaller town, but the lowest half dozen silver plans were only available in the Phoenix area, so his subsidy was based on those plans though he could not even access them.
And now. So far as we can tell, there is only ONE individual plan on the exchange in Phoenix. No choices there.
I emailed thumper privately about this, but just to correct the record: there is no income donut hole between $30K and $40K. In fact, there is no income donut hole for anyone. There is an income cliff, which will not affect thumper’s son, though it might affect some of us. Once some household reaches 400% of the Federal Poverty Level, they get no subsidy. For people whose insurance is expensive, like us older folks, that can hit like a hammer.
Thanks, @“Cardinal Fang”
I was told that subsidies were significantly reduced after that $30,000 income mark. That is what I meant by a donut hole. Significant reduction in subsidy.
I think I know what your interlocutors were talking about, thumper.
For single people like your son, there are two cutoffs. At 250% of poverty, which is about $30K for single people like your son, the extra help with deductibles, copays and coinsurance that I was talking about in message #41 disappears.
Then at 400% of poverty, which is about $48K, all subsidies disappear.
I wouldn’t call either of those donut holes. That term is usually used for a subsidy or payment that disappears at one level, and then reappears again at a higher level-- like the prescription drug benefit for seniors. Seniors had insurance coverage up to a certain amount of spending, then had to pay all drug costs for a certain amount, then were covered again for the drug costs over that amount. It was a donut hole because the costs in the middle weren’t covered but the costs on either side of the donut hole, the lower costs and the higher costs, were covered.
But it’s just semantics. If your son earns more than about $30K, he will lose some cost sharing reductions, and that sucks, even if it’s not a donut hole. An income of $30K isn’t very high.
An income of $30k to $40k isn’t very high…and if you add an additional $100 to health insurance premiums…it really isn’t very high.
I guess donut hole was the wrong wording… it yes… that is what I meant.
@“Cardinal Fang”
The cutoff at $30K doesn’t change insurance premiums. It takes away certain cost sharing subsidies. If your son is healthy and doesn’t go to the doctor much, it won’t make any difference for him.
Interesting @“Cardinal Fang”
In the letter my son received from his provider, it clearly stated that his premium would increase $100 a month or so…if he gets the same subsidy.
In his case, he needs the RX coverage subsidy.
I did hear on TV that Arizona is getting the hardest hit of all 50 states. I know it depends on how many providers are in the area and agree to be part of the exchange but I wonder what it is specifically about some states that make it less attractive to providers than others.