ACA plan for 26 year old: What to consider and how to choose?

Yikes…thanks. We will investigate that further, for sure. I remember when ACA first started, there were a lot of issues with the accuracy of providers listed in networks. I naively assumed that had all been resolved by now.

However, i got the name of her specialist/surgeon and the only 4star option for which he is in network is a Premera BC plan (EPO plan). There are some 3 star rated plans I have not heard of (Molina and Lifewise? I think) that included both of her providers. I have no idea what the quality ratings indicate though, but 3 out of 5 stars sends up red flags for me.

Pre- and post-ACA, network membership of providers was always something to watch for. Kaiser is usually easiest to figure out, since the insurance plan is tightly coupled with the Kaiser facilities and providers. For other plans, the patient has to carefully check from both the provider side and insurance company side to ensure that every provider involved is in-network. When something like surgery involves multiple providers (surgeon, facility, anesthesiologist), one has to check all of them; a common complaint example is that surgeries would bring in whichever anesthesiologist was available that day who may not be in-network for the patient’s insurance plan without the ability for the patient to choose, resulting in a “surprise bill” to the patient.


The therapist’s biller and surgeon’s may also confirm that they are in network for the potential plans. The in and out of network lists are not always current.

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Even before seeing the narrow premium differential, I would have suggested Gold for the remaining half year b/c your D has surgery planned and that always runs so much higher than projected. Her six month premium difference is low compared to the gap in coverage between the two metal levels.

Each state’s marketplace site seems to vary, so no way to guess how WA will operate vs. CT. In CT, I can easily plug any provider’s name into each carrier’s site to see if the provider participates. The names each carrier gives to each type of plan are very close to each other, so you really do need to read carefully to confirm that a provider participates. I have found that providers’ office staff do not always know which plans are accepted, and I do not blame them, given the wide array of plans.

One word of caution about going OON, assuming the plan even allows OON care: Even after satisfying the unique OON deductible, the plan will only reimburse at the OON level up to the carrier’s allowable fee, which may be half the amount the provider charges. $400 office visit, $200 allowed, but reimbursed at OON level of 70% of the $200 allowed means patient still has to pay $260. Also, in-network and OON deductible amounts are separate and in-network charges do not accumulate toward OON deductible.

The Gold plan may still make sense for her next year. I find that young people should either elect a Catastrophic plan or the Gold plan.

Income cap on subsidy has been altered significantly until the end of 2022. If I plug $50K for 26 year old into CT’s Access Health, I see a monthly subsidy of $160 and a monthly premium difference of $200 between Bronze & Gold.

I found that brokers do not sell the Marketplace plans. They sell other plans, but they price out higher even before considering the premium subsidy she may receive.

Best of luck to her!

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Thank you! My daughter is both overwhelmed and annoyed that this is so complicated.

I have only looked seriously at 6 or 7 plans, both HMOs and EPOs (apparently similar to PPOs, but some requirement for referrals), but of all of them I have looked at, they all say out of network is not covered. This makes me very nervous. She is about to leave for a 2 week trip to CA and then has 3 more weeks in the midwest this fall. She is FAR too optimistic and I fear that if she needs medical treatment while out of her home area, she will not do her due diligence on in-network providers. I have explained that blowing off a 5 minute phone call to confirm network providers could cost her both her small emergency fund, her travel fund, or worse.

It really is best to assume there is no OON coverage, other than emergency care, which I assume would have to be paid at the in-network level of coverage. Haven’t tested this yet!

I just checked the plan design, and both in and OON show a $400 ER per visit copay for the Gold plan, but the Bronze plan ER coverage is harsh: 20% coinsurance after satisfying in-network deductible of $6300 for all services. Both in and OON ERs are paid at same level, whereas any other OON care would be subject to OON deductible. So don’t go to the ER when out of the area or in the area either if on the Bronze plan. (She will have to check her plans’ summaries of benefits.)

The OON deductibles are so high and the allowable charges so low that one is left with very little reimbursed.

The two carriers that operate in CT do not include out-of-state providers in their networks, even though NY and CT are adjacent. One of the two participating carriers is BC, and many people would assume that BC would include a national network of providers, but they do not for the Marketplace plans. (They list a handful of doctors with NY addresses, but these are all CT providers who also have a NY office.)

The coverage is excellent, once one takes the time to understand what is and is not covered. I completely understand why your D is overwhelmed and annoyed! It is a lot to absorb.

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Medical expenses are a common reason for personal bankruptcy, even with medical insurance.


Thank you for checking those two plans and explaining the details.

Ugghhh…that is what I did assume and figured one of the upshots to paying the higher premium with the BC plans was that she’d have a lot more in-network options while out of state. Disappointed to learn that is not the case.

Definitely worth verifying that the info I provided is true for the plan your D is considering. These state Marketplace plans differ greatly; they are terrible in some states and quite decent in others.

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Be very careful with an EPO plan. The EPO on our state’s exchange has a very narrow network and $0 OON benefits…nada,zip,zilch.

Thanks. That’s the case here too. But our only choices are HMOs and EPOs. There are no PROS. All of the plans I’ve looked at had 0 out of network coverage.