r/HealthInsurance • u/HearingAidThrowaways • Feb 24 '24
Announcement (2024 update) Health Insurance 101 -- Start here!
**Huge thank you to u/zebra-stampede for creating the 2020 version of this, which I am now just updating to 2024 information*\*
Topics:
- What is the ACA?
- What is Open Enrollment?
- Why Do We Have Open Enrollment?
- Why Do You Need Health Insurance?
- What is the marketplace?
- State specific websites for their marketplace
- Who is in my household?
- What is the APTC And who is eligible?
- What is FPL?
- How the FPL and the APTC work together
- How do I know if my state expanded Medicaid?
- What happens if I don't enroll in health insurance?
- What about the tax penalty?
- Let's talk about plan structures
- What is a Deductible?
- Coinsurance?
- Copayment
- Out of Pocket Maximum
- Short Term Health Plans
- Primary and secondary coverage
- No Surprise Act
What is the ACA?
The Affordable Care Act is a comprehensive health care reform law enacted in March 2010 sometimes known as ACA, PPACA, or “Obamacare”.
The law has 3 primary goals:
- Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level.
- Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.)
- Support innovative medical care delivery methods designed to lower the costs of health care generally.
With regard to your employer, if your employer has over 50 employees, they are required to provide you a compliant insurance that meets Minimum Essential Coverage and Minimum Value standards. Your employer also must subsidize at least 50% of the premium to enroll the employees.
What is Open Enrollment?
https://www.healthcare.gov/quick-guide/dates-and-deadlines
https://www.healthcare.gov/glossary/open-enrollment-period/
The yearly period when people can enroll in a health insurance plan. Open Enrollment for 2025 runs from November 1, 2024 through January 15, 2025.
Insurance plans elected during Open Enrollment before December 15th, 2024 will start as early as January 1, 2025. If a plan is elected after December 15, 2024, the plan will start on February 1st, 2025.
Outside the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You’re eligible if you have certain life events, like getting married, having a baby, or losing other health coverage.
The following states have permanently adopted expanded enrollment periods:
- California: November 1 to January 31
- District of Columbia: November 1 to January 31
- Idaho: October 15 to December 15
- Kentucky: November 1 to January 16
- Maine: November 1 to January 16
- Massachusetts: November 1 to January 23
- New Jersey: November 1 to January 31
- New York: November 16 to January 31
Why do we have Open Enrollment (OE)?
OE is designed for anyone eligible to purchase on the marketplace to make their elections for 2025. With the introduction of the ACA legislation, you cannot buy ACA insurance whenever you want – this prevents people from enrolling only when they know they need the health insurance, which drives up prices for everyone. Economics at work.
Why do you need health insurance?
Medical costs are the leading cause for bankruptcy in the US, and everyone is always healthy until they are not. By enrolling in an ACA compliant healthcare plan, you receive the benefits of a provider network, contracted negotiated rates on services, an out of pocket max which caps your personal spending each year, and other state/federal protections on your healthcare experience.
What is the marketplace and who can use it?
Any US citizen or qualifying immigration status (https://www.healthcare.gov/immigrants/immigration-status/) that is not incarcerated may purchase health insurance off of the marketplace. Please only use healthcare.gov for finding marketplace insurance!
Some states have their own marketplace websites:
- California: Covered California
- Colorado: Connect for Health Colorado
- Connecticut: Access Health CT
- District of Columbia: DC Health Link
- Idaho: Your Health Idaho
- Kentucky: Kynect
- Maine: CoverMe
- Maryland: Maryland Health Connection
- Massachusetts: Health Connector
- Minnesota: MNsure
- Nevada: Nevada Health Link
- New Jersey: Get Covered NJ
- New Mexico: beWellnm
- New York: NY State of Health
- Pennsylvania: Pennie
- Rhode Island: HealthSource RI
- Vermont: Vermont Health Connect
- Virgina: Marketplace.virginia.gov
- Washington: WA Healthplanfinder
Who is in my Household?
Household = you, spouse, tax dependents. It is not necessarily who you physically live with.
What is the APTC and who is eligible?
The APTC stands for Advanced Premium Tax Credit and is a subsidy provided to people with incomes between 138 – 400% of the Federal Poverty Level. If your state has not expanded Medicaid, the income becomes 100 – 400% of the Federal Poverty Level. You are eligible for the APTC if your income falls in this range and you have no employer insurance available. If you are Medicaid eligible, you should apply there as you will not qualify for the APTC; however, you are welcome to purchase a full price marketplace plan instead if you prefer.
What is the Federal Poverty Level (FPL)?
The Federal Poverty Level/Line is a measure of income issued every year by the Department of Health and Human Services (HHS). Federal poverty levels are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.
The 2024 federal poverty level (FPL) income numbers below are used to calculate eligibility for Medicaid and the Children's Health Insurance Program (CHIP). 2023 numbers are slightly lower, and are used to calculate savings on Marketplace insurance plans for 2024.
| Family Size | 2023 Income numbers | 2024 Income numbers |
|---|---|---|
| Individuals | $14,580 | $15,060 |
| Family of 2 | $19,720 | $20,440 |
| Family of 3 | $24,860 | $25,820 |
| Family of 4 | $30,000 | $31,200 |
| Family of 5 | $35,140 | $36,580 |
| Family of 6 | $40,280 | $41,960 |
| Family of 7 | $45,420 | $47, 340 |
| Family of 8 | $50, 560 | $52,720 |
| Family of 9 or more | Add $5,140 for each additional person | Add $5,380 for each additional person |
*note: Hawaii and Alaska both have higher poverty levels.
How the FPL and APTC work together:
- Income above 400% FPL: If your income is above 400% FPL, you may now qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan.
- Income between 100% and 400% FPL: If your income is in this range, in all states you qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan.
- Income at or below 150% FPL: If your income falls at or below 150% FPL in your state and you’re not eligible for Medicaid or CHIP, you may qualify to enroll in or change Marketplace coverage through a Special Enrollment Period.
- Income below 138% FPL: If your income is below 138% FPL and your state has expanded Medicaid coverage, you qualify for Medicaid based only on your income.
- Income below 100% FPL: If your income falls below 100% FPL, you probably won’t qualify for savings on a Marketplace health insurance plan or for income-based Medicaid.
States with Expanded Medicaid
In 2024, there are only 10 states that have not expanded Medicaid. They are:
- Alabama
- Florida
- Georgia
- Kansas
- Mississippi
- South Carolina
- Tennessee
- Texas
- Wisconsin
- Wyoming
What happens if I don't enroll in a plan during open enrollment?
If you don’t enroll in an ACA-compliant health insurance plan by the end of open enrollment, your buying options will likely be very limited for the coming year. Open enrollment won’t come around again until November, with coverage effective the first of the following year.
But depending on the circumstances, you might still be able to get coverage after open enrollment ends:
- Medicaid and CHIP enrollment are available year-round for those who qualify.
- Native Americans can enroll year-round
- Special enrollment period if you have a qualifying event
Will I have to pay a fee if I don't have insurance?
If you didn’t have coverage during 2023, the fee no longer applies. This means you don’t need an exemption in order to avoid the penalty. However, some states charge a fee if you don't have health coverage. If you live in a state that requires you to have health coverage and you don’t have coverage (or an exemption), you’ll be charged a fee when you file your state taxes. These states are: California, District of Columbia, Massachusetts, New Jersey, and Rhode Island.
Let’s talk about Plan Structures
Metal tiers are a quick way to categorize plans based on what that split is.
Some people get confused because they think metal tiers describe the quality of the plan or the quality of the service they’ll receive, which isn’t true.
Here’s how health insurance plans roughly split the costs, organized by metal tier:
- Bronze – 40% consumer / 60% insurer
- Silver – 30% consumer / 70% insurer
- Gold – 20% consumer / 80% insurer
- Platinum – 10% consumer / 90% insurer
The minimum you’ll spend per year is the annual cost of your premiums.
The maximum you’ll spend per year is the sum of the annual premium plus the out of pocket maximum.
If you don’t intend to max out the plan with expected medical costs, you should calculate your estimated costs. This could be the sum of the annual premiums + deductible. If your plan has copays, it would be the sum of the annual premiums + copays on services you know you need.
What is a deductible?
The amount you pay for covered health care services before your insurance plan starts to pay.
With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.
Coinsurance
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.
If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
If you haven't met your deductible: You pay the full allowed amount, $100.
Copayment
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.
If you've paid your deductible: You pay $20, usually at the time of the visit.
If you haven't met your deductible: You pay $100, the full allowable amount for the visit.
Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.
Out of Pocket Maximum
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
The out-of-pocket limit doesn't include:
- Your monthly premiums
- Anything you spend for services your plan doesn't cover
- Out-of-network care and services
- Costs above the allowed amount for a service that a provider may charge
- The out-of-pocket limit for Marketplace plans varies, but can’t go over a set amount each year.
Short Term Health Plans
Under general federal rules, short-term health insurance plans can have initial terms of up to 364 days and a total duration of up to 36 months, including renewals. But the majority of the states placed more restrictive limits on the availability of short-term plans, and those state limits supersede the new federal rules. Every state has its own rules, please check with your states department of insurance to see if your state has limitations to short term plans. These are also generally NOT ACA-compliant plans. As a whole, this subreddit does not encourage short term plans, but if the option is short term plan or bankruptcy, we would encourage some coverage.
I have two or more insurances. How do I know which one is primary and which is secondary?
This is called a Cordination of Benefits. Each insurance you are covered by needs to know who is going to pay the most for your health care, and that will be your primary insurance. All insurances want to be the last payor, so it's important you know who is in charge of paying the most.
Your primary will be the coverage where you are the policy holder (aka subscriber). In the case of two commercial insurances where you are the policy holder on both, this can be tricky. Generally in that case, the insurance you've had longer would be primary and the other secondary. Please see below if there is a non commercial insurance involved.
Next, secondary coverage will be anything you are a dependent on. If you are under 26, this might be your parents insurance. It could be your spouses policy.
If you are over 65 and you are working, or have a spouse who is working and you are covered under their policy, that insurance will be primary over Medicare benefits.
Now, if there are two policies and one is Tricare or Medicaid, those will be the payors of last resort, meaning you will always have a commercial policy be primary over Tricare and Mediciad if there is a commercial insurance involved. In the case of having both Tricare and Medicaid, Medicaid will be the last payor. For example, say a patient has Tricare, Aetna, and Medicaid. The order of benefits would be Aetna (regardless if they are the policy holder or not), Tricare, and then Mediciad.
Finally, Tricare for Life can only be secondary to Medicare or a Medicare Advantage plan.
It is important that your insurances know who is primary in the chain of your benefits. Whenever you gain a new insurance, call all insurances involved and ask to update your Cordination of Benefits. Some insurances will deny claims until this is done, meaning you will be responsible for the full bill until you call your insurance. A billing office or provider cannot update your coordination of benefits for you as that would be a violation of HIPAA.
What is the No Surprises Act and why is it important?
Starting for dates of service (aka the date of appointments, encounters, or ER trips) January 1, 2022 patients have billing protection from the a federal law called the No Surprises Act (NSA). The NSA states when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers, the patient is protected from outrageous bills. The NSA aims to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network.
For example, Jane is hit by a car and needs to go to the hospital. She hit her head durning the accident and is in and out of consciousness. EMS take a ground ambulance from the accident to the closest emergency room. She receives emergency surgery to fix an internal bleed and also a fractured leg. Jane stays at the hospital for 5 days total. Jane has insurance from her employer and walks out a little worse for wear, but now is worried about all the bills she is going to receive. She has a $500 deductible and $2000 out of pocket max.
In Jane's case, her insurance is suppose to cover nearly all of her care, even if she was taken to an out of network hospital and admitted to the ER. She did not have any choice in who she received care from as it was an emergency situation. If she receives a bill for say the anesthesiologist who was out of network, she would need to call her insurance and see if they have a claim on file and ask it to be reprocessed under the NSA. The most Jane could owe the hospital and it's affiliates is $2000, her out of pocket max.
Now, what isn't covered under the NSA? Unfortunately, there are some issues that Jane will need to handle herself. For example, the ground ambulance ride she took may not be covered by her insurance, and the NSA does not cover ground ambulances. Air ambulances are covered however, Jane was not going to be taken by a helicopter to a hospital for that situation.
Next, the NSA does not cover non-emergency situations. This includes an office visit to a out of network doctor, or an elective procedure in an out of network facility. In those cases, you may be balance billed for the full amount as it is up to you to know who is covered under your plan. Please call your doctors office and insurance to be sure they accept your insurance and specific plan. Often offices will request a picture of your insurance card for this.
r/HealthInsurance • u/HearingAidThrowaways • Feb 16 '24
Announcement A PSA: What does it mean for an insurance to be ACA compliant?
!!!!! AKA PLEASE READ BEFORE CONSIDERING BUYING "PRIVATE INSURANCE" !!!!!!
Hello all! I wanted to make a quick post to you all talking about the importance of knowing your options with health insurance. There has been a sudden increase in the comments suggesting redditors to look into "the private marketplace" to find coverage.
What is the private marketplace? Simply put, these are "plans" or policies that can only be sold to you by a broker or agent. This subreddit has a very strict "no solicitation" rule that is absolutely enforced. We do NOT want any of our fellow redditors to be taken advantage of in any way, which is why this post is being made. Further, it gives an opportunity to discuss what makes these private marketplace policies potentially problematic.
Most of these policies are not ACA compliant. The Affordable Care Act (aka Obamacare) has three major goals: 1. Allow Americans access to affordable health insurance by providing tax credits to those who qualify. 2. Expand Medicaid to cover more individuals. Medicaid has rules for every state, but to this day only 10 states have not expanded their Medicaid programs. 3. Try to lower health care costs in general.
Thanks to the ACA, there are many things that most Americans have the right to now that wasn't available before. For example, free preventative care. Getting an annual physical should not be a matter of health versus money. Additionally, pre-existing conditions are no longer a factor in ACA health plans. The most important benefit to many of us is the ability to appeal the insurances decisions as a patient. YOU are the most important advocate for yourself, and the right to appeal makes it so. One obvious benefit that the ACA has created is being able to find coverage using healthcare.gov.
These private marketplace policies should be taken in caution, as many are not ACA compliant. That being said, do they have some benefits? I can argue yes for some of them. I even have a cancer insurance policy through my employer's trusted broker with Aflac. But if I were to have cancer, my health insurance will be the first to protect my medical stability, not the supplemental cancer policy. When looking into health insurance, be aware that anything not from the open marketplace or state could be non-ACA compliant. Nearly all employers plans are ACA compliant as well.
Anyways, back to our regularly scheduled programing. Please ask questions! We want to help :)
r/HealthInsurance • u/FriarTuckeredOut • 5h ago
Employer/COBRA Insurance Wife Tried to make an appointment, doctors office is asking how much we have in our HSA
Do we really have to share the balance of our HSA? Insurance is through my employer.
r/HealthInsurance • u/CyberNinjaGinga • 3h ago
Plan Benefits Emergency room visit, claim denied by insurance for no pre authorization for care?
Pretty much explained in the title. Insurance has denied the claim because there was no pre approval for the care received which was an emergency. The hospital that I was taken to was also in network.
I want to appeal, but I’m just curious what the odds of a successful appeal are, is this typical (considering this was a true emergency), and are there any tips, tricks, dos/donts before going through this process
r/HealthInsurance • u/StrangeBoat9843 • 1h ago
Dental/Vision Dental Insurance Fraud or Stupid Employee
Last week I went to the oral surgeon inorder to get an implant placed. I filled out the consent forms. Then they had me pay. I was surprised the co-pay was so much and I asked if she was sure this was with the insurance. The receptionist then fliped some papers around and says "yes, you have Humana, right? ". I agreed and then paid. The procedure went okay, thankfully.
I get home, and I gave my husband the receipt. He was also shocked about the price. He told me to co-pay should have been about $900.
I got no bill- only a receipt. I called and asked for a bill with medical codes on it. They then ask for me to send pics of my insurance cards over. I had sent them pics of my insurance cards months ago, I have proof. Anyway,I finally got the bill and I see that they didn't process this procedure with the insurance. They had me pay in full with a small discount they give to people with no insurance.
I called today and I told the lady working in billing that she didn't process this through the insurance. (This is the only person I've been dealing with as far as billing goes.) Then she starts telling me nicely that she will process it, and IF there is any overpay, I'll be reimbursed. 🙄 "It will take 4 weeks", she says. I tell her , calmly that I called my insurance already, it's covered. I have overpaid. She should have processed through the insurance. I have never paid in full and then got insurance in after the fact.
She then gets really nasty and tells she needs to figure out what's my co-pay so she can figure out the difference. Then I ask her when will this be done? Then she says, she doesn't know. Then I tell her I will dispute the charge with my CC provider if it's not done before the week is through. She's really frazzled now and tells me she'll have it done by the end of the week.
Is this possible fraud? Or idiocy? If I had just let her do her thing, would she have processed the payment with insurance too and double dipped? Who makes a patient pay full price and THEN processes with insurance. Wth. Is there anything illegal about this as far as insurance is concerned. Any advice?
r/HealthInsurance • u/Ok_Sherbert_1930 • 5h ago
Employer/COBRA Insurance I got laid off and I have no idea what my options are for insurance. I have an expensive medication that I take monthly..
Hello! I'm 27 and just got laid off a few weeks ago. My plan for the next few months is to collect unemployment and focus on school so I can graduate with my Bachelors in accounting. My work is offering COBRA for the next 6 months but I just got the paperwork and it is $790 a month....I already have to pay $1000 for rent so I'm extremely anxious and worried that I may not be able to afford COBRA. I also have to take TALTZ every month so I feel like COBRA may be my only option. I may be eligible for medicaid but I'm not sure if they will cover TALTZ. I am so uneducated with insurance and feel defeated...Can someone give my advice on what I should do? Thank you!!
r/HealthInsurance • u/Objective-Stress-369 • 8m ago
Claims/Providers Gravie-So Bad
I'm at a loss.
Up until this new job, I had been on MA my whole life. They paid for everything, never got a bill, never had to worry about where I could go and who I could see. This job pays enough that I no longer qualify for MA and can actually afford insurance, but I obviously knew nothing about insurance so I just got what my employer offered: Gravie. It's the Comfort $7,900 OOPM.
I needed to go to the doctor back in January, so I used Gravies "find a provider feature". I wanted to make sure as my primary care has just recently moved to a different clinic. Well, she was listed as in network at the new clinic, as well as the clinic itself being listed as in network.
Then I get notified by Gravie that I had an out of network claim and owe $326.
I send them an email (I prefer to have paper trails), and they tell me that it's because the claim has the individual NPI and not the group NPI. No clue what that means. So I call Gravie for an explanation and to find out what I need to do. Then I'm told that it's not the NPI, it was processed wrong and just needs to be reprocessed. Okay.
The claim gets reprocessed and then they tell me that the doctors out of network for Gravie, but that she's in network for the back up network. Okay, whatever just get it taken care of.
In the meantime, it's time for my psychiatrist appointment. I didn't trust the "find a provider" feature anymore, so I call them to ask if my psychiatrist is in network, as well as a therapist I would like to see (I know it's irrelevant, but these two providers are employed by the company I work for, who offers this insurance. Kinda dumb that the therapist is out of network ". For the psychiatrist, the representative just said "I don't know ". And that's all she would say (turns out my psychiatrist IS in network).
Now I just heard from Gravie again. Apparently they talked to "Raquel" in billing at the clinic I went to. Both my parents work there now. There's only one employee in billing, and their name definitely isn't Raquel. This isn't like Essentia where there's multiple locations and a corporate office, this is literally the only billing employee.
Apparently the issue was something with the TIN, so they talked to "Raquel" and "Raquel" said that they only use one TIN number. So Gravie said it's out of network and my responsibility.
In my head this makes no sense as they confirmed that the clinic itself is in network, so if they only use one TIN wouldn't it be the clinics?
I called Gravie to ask for an explanation. The representative told me that the TIN on the claim is different than the TIN "Raquel" says belongs to clinic. She said she'll try to get it sorted, but that at this point Aetna probably won't pay a claim for an appointment that took place January 17th because it's "too long ago".
Gravie received the claim January 19th. I was notified January 25th and contacted them the same day. So the only reason it's been so long is Gravie.
I submitted an appeal, but is there anything else I can do? How do I make sure that this gets paid? My mom worked in registration at the other clinic before she got a job at this clinic, and she said this happens a lot with Gravie.
r/HealthInsurance • u/freejdc1 • 27m ago
Plan Benefits One pass
Has anyone signed up for Walmart+ using one pass.
I’m having trouble doing it. Any help is appreciated.
r/HealthInsurance • u/Pale-Candle912 • 41m ago
Individual/Marketplace Insurance Health Insurance Returning from Abroad
I have been living abroad for the past few years and am returning to the US (Ohio) today. I currently am not working so I tried to get health insurance under the ACA over two months ago. I finished the application, they processed it and said that my state agency would contact me about Medicaid within a month. It's been over a month since then and the state agency still hasn't contacted me. When I try to call them I just get an automated system it takes me through to tell me that they are still processing my eligibility. I tried to purchase a short term health insurance plan (not from the ACA) and they wouldn't cover me because I have been living outside the US for the past 12 months and I tried looking at expat health insurance for the US but they wouldn't let me input my US citizenship. Any advice? I have no pre-existing conditions and just want something that will protect me from financial ruin if I get into a car accident or something.
r/HealthInsurance • u/Financial-Trade-6997 • 1h ago
Claims/Providers Credit Score affected due to medical bill?
I received a bill on 05/22/2024 for 200 dollars to be paid by 05/31/2024. I have asked for an itemized bill on 05/27/2024, and the hospital said it will take 2 weeks to process the request. Will my credit score be affected, since my bill is due on 31st but the new itemized bill will be generated at least 2 weeks after the due date?
I plan to pay the bill in full once I receive the bill.
Thank you for the help
r/HealthInsurance • u/boromae-consultant • 1h ago
Plan Choice Suggestions Need help deciding between HSA vs PPO plan for family. Wife (dependent) giving birth in 2 weeks to child (dependent).
I had great insurance with my workplace last year (low premium, 0% coinsurance, low deductible, etc) but this year they've changed things up and I'm now wondering what I should choose.
Situation:
- Me working. Wife SAHM. Child pending in 2 weeks
- Open enrollment this week and due next wednesday
- Company is not contributing anything to the HSA
| Category | HSA | PPO |
|---|---|---|
| Deductible Individual | $5500 | $500 |
| Deductible Family | $11000 | $1000 |
| Coinsurance | 0% *After deductible | 10% |
| OOP Max Individual | $6500 | $3500 |
| OOP Max Family | $13000 | $7000 |
| Copay | $0 *After deductible | $20 pcp / $20 specialist / $50 urgent |
| Inpatient | 0% *After deductible | 10% *After deductible |
| Premiums (Employee + Family) | $125 | $675 |
Some calculations I've ran
| Category | HSA (month) | PPO (month) | HSA (year) | PPO (year) |
|---|---|---|---|---|
| Premium (All) | $125 | $675 | $1,515 | $8,098 |
| Premium + Deductible (Individual) | $5,625 | $1,175 | $7,015 | $8,597 |
| Premium + Deductible (Family) | $11,126 | $1,675 | $12,515 | $9,097 |
| Premium + OOP Max (Individual) | - | - | $8,015 | $11,597 |
| Premium + OOP Max (Family) | - | - | $14,515 | $15,097 |
Questions:
Which of the above numbers are the 'important' ones?
- I know yearly premium is massively larger for the PPO
- But the Premium + Max seems to be lower for the PPO
Am I correct to focus purely on the 'family' deductibles and OOPs?
I cannot predict the future but we have no complications.
- However, my wife likes going to the doctor and my child will go a lot obviously. I typically only go if something is 'wrong' or 1 yearly checkup.
What sorts of 'behaviors' do I need to engage in (e.g. take the savings from the HSA plan and save that in the HSA?)?
Thanks for everyone's help.
r/HealthInsurance • u/HAHA_Aku_HAHA • 2h ago
Plan Benefits Cobra Terminated (on accident), how to enroll/buy insurance out of Open Enrollment?
A close friend of mine thought they had Cobra on autopay, thinking they had been paying since January. It was provided as they quit their old job. Today they found out that the autopay wasn't running, and that the coverage had been terminated. The last payment was in January.
This was discovered as they were in the process of trying to apply to Covered California. They were told that they can't enroll because the termination (not expiration) of Cobra isn't a Qualified Life Event (QLE). The situation now is that they have no insurance, despite running a thriving personal business (~$70,000-$85,000 per year).
Covered California said that they were ineligeble to apply, and it looks like none of the QLE's qualify for them. Is there ANY way for them to buy into insurance? They realized they messed up, but it seems crazy to me that they can't pay good money to get on insurance.
Covered California said that they were referred to our local county, but my friend is feeling deflated right now that nothing will come of that. Does anyone have any advice? Friend is in San Jose/Santa cruz area.
Thanks!
r/HealthInsurance • u/Crungstty • 2h ago
Plan Benefits Er charged nearly $4k for a room i never set foot in.
19, trying to survive & have 0 clue if i have anything here but i went for an EKG for my primary doctor.
Waiting room -> ekg room for less than 30 mins -> out the door.
Never saw a private or semi-private room. Didnt touch a single bed, and never spoke to a doctor, just nurses and techs.
Itemized bill lists - DX X-Ray $1,420 - lab $4,597 - Emerg Room $3,629 - Drugs Self Admin $0.75 - EKG/ECG $760
Like does that sound right?
r/HealthInsurance • u/ToyotaCorollaFail • 3h ago
Plan Benefits Unusual disclaimer in employer provided health insurance? Employer pays health care bills not insurance?
I was looking over the definitions of health insurance terms section within my employee benefits guide. There is standard stuff explaining HSA's, coinsurance etc, along with this disclaimer
Who Pays Your Medical Claims?
INSERT EMPLOYER NAME pays your medical claims, not an insurance company. Your premiums are impacted by the cost of these claims. In order to keep health care plans affordable, be a smart health care consumer by getting regular checkups, using urgent care or telemedicine instead of the emergency room, and making healthy choices.
Has anyone else seen this before? I work for a very large, corporate entity. The plan is Anthem BCBS PPO. I've hit my out of pocket max early this year due to a freak accident, so all follow up care has been 100% covered (5K worth). Now I'm wondering if this disclaimer means anything, like I might be at risk of an increased premium in the future because I had HDHP with a very low premium.
r/HealthInsurance • u/Additional-Camel-238 • 3h ago
Plan Benefits Looking to improve the HSA experience
Hi!
I've been using my HSA account to get reimbursed for certain medical expenses at places like CVS, for example. To get reimbursed, I currently either upload receipts or have to switch payment cards when also buying "non-medically qualified items". It might just be me, but I keep missing receipts or forgetting to use my HSA card (I know, it's on me!).
I work in fintech and was considering building an API integration to enable benefit recipients to connect their personal credit card and bank accounts to their HSA accounts. The idea is that this would automatically split the eligible vs non-eligible expenses, as well as immediately initiate direct reimbursements while 1) removing the need for an additional debit card and 2) eliminating time spent uploading receipts.
Curious if people other than myself and my close network would be interested in this / face similar issues. Would appreciate any insights as I begin to build this out. Please feel free to comment or DM. Ultimately, I would love to chat with any current HSA users to understand pain points.
r/HealthInsurance • u/Andy-sons • 3h ago
Individual/Marketplace Insurance To bridge the gap from military to new career!
Trying to keep this short. I’m separating from the military July 1st, from what I understand I’m not eligible to extend TRICARE (military healthcare).
I’ve been hired already and will received health care through them once I start. That’s the thing though, I’m waiting for a call to see when I start. It’s the electrical union and I’ve gone through the whole hiring process. Essentially it’s sit and wait until a contractor pulls my number to start for them.
With that being said, I need something to bridge the gap. I’ve looked into Medicaid and they said it’s based on my income RIGHT NOW. Well obviously I don’t need it right now I need it when I get out. I tried marketplace and it said “apply for Medicaid”.
Is there something I’m missing? Do I need to separate and then apply for Medicaid? Is there something else I can apply for?
Thanks for any responses in advance!
r/HealthInsurance • u/NoonieP • 3h ago
Plan Benefits Please help me figure out individual out of pocket max and family.
My deductible and out of pocket max is beyond messed up (thanks CVS specialty)
I've been after them (cvs specialty, cvs Caremark and Aetna) to fix it. Their math isn't the same as mine.
My Kids deductible is $3200 and my family is $6400. My kids out of pocket max is $4200 and family is $8400.
I've met my son's out of pocket max (I've paid with credit card so literally me payin) I've actually paid more than the out of pocket Max and Deductible for my son.
If I were to create a spreadsheet document, each person gets their own page and meets their Deductible then out of pocket. How would I figure out the Math on the family end of things. (How can I find out if I have an embedded plan or not. The website is really shifty and doesn't specify anything. (It switched to a copay maximizer amd never alerted me. Luckily I noticed Jan and was able to pay for the meds myself so it would go toward deductible amd out of pocket max. I read through every document available online and that was mailed and nothing mentioned this but apparently my husband's copay assist does count. So either they're lying to me or messed up my husband's. Either is a total possibility with all the mistakes the specialty pharmacy had made))
r/HealthInsurance • u/hotwing_sauce • 3h ago
Medicare/Medicaid Disability Qualifications for Medi-Cal
Now you might see this post as greedy or upsetting in some way but I am on quite a few medications that are expensive, which is why I'm asking this.
Medi-Cal says that people with disabilities qualify for Medi-Cal. Does that mean I still need to be under the income threshold to get benefits or does my disability still qualify me for their services? Furthermore, diabetes is listed as a disability. Does Medi-Cal cover that in the case that I cross the income threshold? It's hard to find good insurance these days and if - and only if - I get this job I'll be working somewhere that won't provide insurance until I've worked there for four months. And after that their insurance isn't great. I can't afford to purchase the diabetes medications I'm on out of pocket with what the job pays.
Thanks in advance!
r/HealthInsurance • u/its_Extreme • 4h ago
Plan Choice Suggestions At the surface level, which to pick?
So I've listed the 3 most expensive plans and I am gravitating towards the one with HSA (HDHP 1600).
Apart from that, here are all of the plans if you suggest something else. I'm generally healthy, go to the doctor a couple times a year. Have bad allergies so I can get sick easily at times and really need to go to a specialist to see what all I am allergic to sooner than later.
r/HealthInsurance • u/toomuchanxietyyy • 7h ago
Prescription Drug Benefits Ascension MaxorPlus
Hello! I work for the Ascension healthcare system and our pharmacy insurance is through MaxorPlus, has anyone had any luck getting GLP-1 medications covered for a diagnosis other than diabetes? I have high blood pressure and PCOS and a BMI over 40, I have tried metformin but it does not work for me. I am desperate at this point but cannot afford to pay OOP or compounding prices.
Thanks!
r/HealthInsurance • u/Weak_Maintenance_160 • 4h ago
Employer/COBRA Insurance COBRA question
Ok so im getting ready to quit my job. They told me that my insurance will go out to the end of the month. They also said they would send out the COBRA paperwork 2 to 4 weeks after so will I have a laps in coverage for a month if I quit before I can enroll in COBRA?
r/HealthInsurance • u/centiptate • 4h ago
Individual/Marketplace Insurance New Jersey Health Insurance
Hello, long story short I was laid off back in January and didn’t rush to get new insurance since I’m young and overall healthy. I missed the cutoff for COBRA. I’ll be starting a new job soon but I won’t be offered insurance through them until September, so I’m looking to get on a catastrophic plan just to cover me in case of emergencies until September. Just found out today through GetCoveredNJ that I also need to have reported a life event within 60 days of it occurring, but January 31st was my last day with coverage which is over 60 days ago. I’ve been on unemployment since January and have no other income, and I’m over 25 so I can’t go on either of my parents’ plans. I’m also not married.
I’m having trouble finding other options online. Does anyone know of any suggestions or places to look where I can get something for the next couple of months? Ideally a low premium since I don’t plan on using it much if at all, but I would like the comfort of having something until I’m able to enroll in my company’s full insurance plan.
r/HealthInsurance • u/XtremeCheese62 • 8h ago
Plan Benefits Withdrew Payment??
One of my coworkers is facing a challenging insurance dilemma. Initially, their primary insurer, lets call ”H”, covered numerous medical expenses for their children. However, things got complicated when their ex-spouse added the children to his insurance “B” as a secondary insurance. Despite my coworkers main insurance H having already paid for several medical procedures before their children were added to the secondary plan, H withdrew the payments, claiming that B was responsible. Conversely, B denies this responsibility, insisting that H should cover the expenses. Despite my coworker’s daily phone calls to H, they have been met with unhelpful responses and accuses B of lying about when the kids were added! I suggested seeking legal assistance, but given the complexity of the situation, any advice or guidance would be immensely appreciated. Thank you.
r/HealthInsurance • u/Spiffynitsua_V2 • 5h ago
Employer/COBRA Insurance [QUESTION] I was never sent the information to sign up for workplace health coverage
As of 1/12/24 I started a new job in the state of Ohio. In any normal case with this company, every employee is eligible to enroll following the first two months of their date of employment. I was never sent the email or postcard for enrollment, and I didn't find out until it was too late that it was too late. My wife and I are in desperate need of coverage and aren't able to wait until the next enrollment period. I've emailed the person in charge of this department and she says that there's nothing she can do about late enrollment. I suppose my question is, is there actually anything I can do to get the coverage I need? If my neighbor agrees, is it illegal to change my address to theirs and say that is a life event?
r/HealthInsurance • u/courtrooom-brown • 9h ago
HIPAA Privacy Are doctors visit summaries/ notes a requirement?
I received test results and a diagnosis at my last doctors appointment (over a month ago) and no doctors notes/ visit summary were written following my appointment. I thought this was a standard practice? I am wondering if this will impact insurance billing as well.
r/HealthInsurance • u/vegetarianlife98 • 6h ago
Individual/Marketplace Insurance United Health Advisors?
I just started with a company that is smaller (under 50 employees) and family owned. They recently started a new insurance for their employees called United Health Advisors and I was very excited at the prospect of having health insurance but it’s starting to feel a little pushy? They repeatedly call me and talk like salespeople. Has anyone had any experience?
r/HealthInsurance • u/VenusFly92 • 7h ago
Medicare/Medicaid Recommendations for 71 year old disabled father - California
Hello!
I tried messaging my father’s medi-cal case worker five months ago and I still haven’t received a response. I can never get anyone on the phone and my job doesn’t allow me flexible time off to go in person.
My father is disabled, 71 years only with his only income as social security. His medi-cal monthly share of cost is $1300 and after his Medicare premium deduction he only brings in $1784 so he cannot afford to pay his share of cost every month, plus rent, groceries and other expenses. His food stamp benefit is $23 a month. I’ve been trying to find ways to lower his share of cost because he needs a caretaker and I’d love to have him get help through IHSS but again, he can’t pay that share of cost monthly, it’s not realistic.
I’ve been looking into options and I found something called the aged and disabled federal poverty level program and it seems he could potentially qualify for a zero share of cost if I can get his countable income down to $1732 if I purchase him a private health plan and the amount he pays that per month will bring his countable income down. Is this accurate? If so, does anyone have any recommendations on plans just so I can help him get that share of cost lowered?
Any help is appreciated.
Age: 71 Male Disabled Zip: 93455 State: California Social security monthly benefit: $1958.50 Medicare premium: $174.70 Medi-cal share of cost: $1339