Some questions about health insurance (1 Viewer)

[shadyridr]

I have been very lucky the last ten years as my wife has a ####ty paying union job. However, this ####ty paying job comes with great benefits. One of the great benefits is her health insurance. She pays no premiums for health insurance for our whole family. Not only that, but she has a PPO plan and we pay no deductible and only $15 copay each doctor visit.

Well, that's all about to change as we are having a baby in May and I will have to move us over to our plan. Not only is our plan going to cost $400-$500 a month in premiums but the only options available are a High Deductible plan (which includes an HSA), 80/20, or 90/10. This means I have to pay for each doctor visit up until I hit the deductible ($2k-$3k depending on which plan) and then AFTER I hit the deductible, I have to pay coinsurance (10% or 20% of each doctor visit). We already know our daughter has a genetic condition that will require many visits to the doctor in her first few months. So which plan should I choose: Higher deductible but lower premiums or lower deductible and higher premiums? Also, how much do doctor visits typically cost? Am I going to have to lay out hundreds of dollars for each doctor visit until I hit the deductible? And then once coinsurance kicks in, how much does that typically come out to at 10% or 20%? At least the coverage is CIGNA PPO so I am happy about that.

Any help is appreciated. I still have a lot of time to decide.

 

[matttyl]

First off, why must the family come off the plan through her employer and go on your plan?

Also, do both of you work for "large employers" (20+ employees)?

 

[shadyridr]

First off, why must the family come off the plan through her employer and go on your plan?

Also, do both of you work for "large employers" (20+ employees)?

My wife is planning on staying out of work up to a year (last time she only stayed out 12 weeks). I believe her coverage expires after FMLA ends (12 weeks)

Yes, we both work for large employers.

 

[El Floppo]

I don't have a good answer for you,  shady,  but I wish you and your family the best.  Gl, gb.

 

[Limp Ditka]

thanks obummer

 

[eoMMan]

Depends and we won't be able to give you the right answer (different doctors will have different costs, we don't know the premium amounts, etc etc.)

You will need to do an analysis and basically estimate how many office visits you will make and what not.

In general, if your family is healthy and your don't go to the doctor often,  high deductible plan with low premiums is best. In your case though with your daughter's condition, a high premium plan with low deductible might be best.

 

[Cjw_55106]

First off, why must the family come off the plan through her employer and go on your plan?

Also, do both of you work for "large employers" (20+ employees)? how are you doing? 

 

[fantasycurse42]

What about Cobra, cost will prob similar to your plan, but benefits will be better.

 

[matttyl]

My wife is planning on staying out of work up to a year (last time she only stayed out 12 weeks). I believe her coverage expires after FMLA ends (12 weeks)

Yes, we both work for large employers.

If this is the case, each family member (how many people?) would be eligible for COBRA (continuation of the same coverage you've had).  Her coverage may continue to be funded by her employer through FMLA, but after that she can (and you all can) keep that coverage if you pay for it yourselves. 

It may make sense that anyone who continues to have medical stuff (the baby, and your other child?) stay on that plan, and if you're pretty healthy maybe just move yourself to your plan.

Also, with your employer plan - ask if you have a "calendar year" or "plan year" deductible.  If you have a calendar year deductible, and some or all of you join that plan in July/August (12 weeks after baby), you will really only have a 4-5 month deductible before it "resets" 1/1/17.

 

[shadyridr]

Depends and we won't be able to give you the right answer (different doctors will have different costs, we don't know the premium amounts, etc etc.)

You will need to do an analysis and basically estimate how many office visits you will make and what not.

In general, if your family is healthy and your don't go to the doctor often,  high deductible plan with low premiums is best. In your case though with your daughter's condition, a high premium plan with low deductible might be best.

Yeah I know, I am not looking for exact answers but your response is very helpful, thanks. I will analyze my current plan's visits over the last year and then increase them to come up with a projected cost.

 

[shadyridr]

What about Cobra, cost will prob similar to your plan, but benefits will be better.

We checked into this. Would cost around $2000 a month to keep us on her plan.

 

[shadyridr]

If this is the case, each family member (how many people?) would be eligible for COBRA (continuation of the same coverage you've had).  Her coverage may continue to be funded by her employer through FMLA, but after that she can (and you all can) keep that coverage if you pay for it yourselves. 

It may make sense that anyone who continues to have medical stuff (the baby, and your other child?) stay on that plan, and if you're pretty healthy maybe just move yourself to your plan.

Also, with your employer plan - ask if you have a "calendar year" or "plan year" deductible.  If you have a calendar year deductible, and some or all of you join that plan in July/August (12 weeks after baby), you will really only have a 4-5 month deductible before it "resets" 1/1/17.

Thanks, yeah we looked into COBRA and the cost would be too much (around $2000 a month)

I did not look into the costs of just keeping her and the kids on her plan and me on my own. Good idea.

 

[matttyl]

We checked into this. Would cost around $2000 a month to keep us on her plan.

That's likely for all of you.  You don't have to have all of you decide that.  COBRA is an individual right (though many employers don't realize that).  You can choose it just for the kids, and you and the wife go to your plan.  It does make things complicated - but wouldn't introduce a new 4-5 month deductible for each kid. 

Also, to really, really, really make things complicated for you (PM me if you want, and so you know, I'm an insurance agent) you might want to look into individual plans for yourselves (or any combination of you).  "Loss of employer coverage" is a qualifying event (aka QLE) and you can purchase any ACA compliant individual plan of your choice.  This means you wouldn't be "locked in" to only the plans offered by your employer.  Say one of your kids has to go to a doc that doesn't accept the CIGNA PPO, this would be a good choice to look into.  I just had a son (well, my wife did) 7 months ago.  We could have put him on my plan, or my wife's plan.  We did neither and put him on his own individual plan, as it was the best choice for his coverage for the remainder of 2015.

 

[shadyridr]

That's likely for all of you.  You don't have to have all of you decide that.  COBRA is an individual right (though many employers don't realize that).  You can choose it just for the kids, and you and the wife go to your plan.  It does make things complicated - but wouldn't introduce a new 4-5 month deductible for each kid. 

Also, to really, really, really make things complicated for you (PM me if you want, and so you know, I'm an insurance agent) you might want to look into individual plans for yourselves (or any combination of you).  "Loss of employer coverage" is a qualifying event (aka QLE) and you can purchase any ACA compliant individual plan of your choice.  This means you wouldn't be "locked in" to only the plans offered by your employer.  Say one of your kids has to go to a doc that doesn't accept the CIGNA PPO, this would be a good choice to look into.  I just had a son (well, my wife did) 7 months ago.  We could have put him on my plan, or my wife's plan.  We did neither and put him on his own individual plan, as it was the best choice for his coverage for the remainder of 2015.

That was another question I had (and I was going to ask our HR person). I have 30 days after a QLE to change. Can that be after she loses her coverage (ie 12 weeks after the baby is born?) so technically I have until August to change coverage?

 

[Johnnymac]

I would strongly consider having your wife stay in her job.  Unfortunately healthcare is incredibly expensive and if you can keep her plan I would at least see if that could work for you guys.

 

[matttyl]

That was another question I had (and I was going to ask our HR person). I have 30 days after a QLE to change. Can that be after she loses her coverage (ie 12 weeks after the baby is born?) so technically I have until August to change coverage?

Yes, that should be the case.  Also, though, that QLE applies to the individual market as well.  If there is an individual product (think Obamacare) that better suits your needs (what doctors are in what network and such) for less money, that would be worth pursuing.

Also, even if COBRA is $2000 a month for all of you - that might be better for Sept-December since there is no deductible - than $500 a month and a new $2-3k deductible for each of you.  It's at least worth considering.

So really you have 3 options for each family member come August (if that's when everyone's coverage expires) - stay on her plan via COBRA; go on your plan (you'd at least have to make that switch for any other family members to take this option); or obtain an individual policy.

 

[El Floppo]

fwiw, we went through the Cobra thing (2200). finally, we put the kids on some mickey-mouse NY thing (United Healthcare?)- costs $30/month for both, and doesn't have a lot of coverage or doctors, but so far is more than enough for them and will cover them in case of something catastrophic.

Wife and I are on obama-care and had to juggle the same monthly cost vs deductible you're going through now. We're on Oscar (eta: Market Gold PLan), paying for all visits up to a $600 deductible, after that it's copays: PCP (25), Specialist (40), Urgent Care (60), ER (150)... drugs copay per tier (10, 35, 70). We are paying $610 per month. 

 

[NutterButter]

I thought deductibles only applied to medical procedures?  I've never had to pay for office visits other than co-pays for routine doctor visits.

 

[El Floppo]

Seems like Insurance companies are offering this pay for everything up to a deductible and then start paying co-pay thing as a way of lowering monthlies. I don't follow insurance (the wife did all the leg-work on this), but this seems like a new thing to me.

 

[shadyridr]

I thought deductibles only applied to medical procedures?  I've never had to pay for office visits other than co-pays for routine doctor visits.

According to this plan, only doctors visits for preventative reasons (ie physicals) are not subject to the deductible. Everything else (ie sick visits) are.

 

[matttyl]

Seems like Insurance companies are offering this pay for everything up to a deductible and then start paying co-pay thing as a way of lowering monthlies. I don't follow insurance (the wife did all the leg-work on this), but this seems like a new thing to me.

A new thing.  Kinda a hybrid between a traditional plan and an HDHP (high deductible health plan, that puts everything after deductible). 

Actually have heard some pretty cool things about Oscar.

 

[JoeSteeler]

any chance she could work part time (after the 12 weeks) and keep the benefits?

 

[pandora]

Switch to Obamacare, everything should be fine then.

 

[NutterButter]

So is this new thing just another way to squeeze us or have people done the math and determined that this is actually a good thing for the consumer?

 

[shadyridr]

any chance she could work part time (after the 12 weeks) and keep the benefits?

I wish she could work part time all the time

 

[El Floppo]

According to this plan, only doctors visits for preventative reasons (ie physicals) are not subject to the deductible. Everything else (ie sick visits) are.

I think that's the same for us.

the real problem with all of these Obama-care carriers is that there are not as many doctors taking it. so every specialist appointment takes months (here in NYC) to get, if you can get it. that said- as independent contractors, it's great that we're paying almost a quarter what we were paying for Cobra.

mattyl- I'll let you know how Oscar goes... it's new for us. our previous obama-care carrier (who we liked) went belly up.

 

[matttyl]

According to this plan, only doctors visits for preventative reasons (ie physicals) are not subject to the deductible. Everything else (ie sick visits) are.

That's a mandate of the ACA - that's not specific to this plan.  All ACA plans have to have that.

 

[matttyl]

any chance she could work part time (after the 12 weeks) and keep the benefits?

She'd likely have to work at least 30 hours a week to be eligible for benefits, due to ACA regulation. 

 

[Thorpe]

Is it a deductible for the whole family combined, or is it separate individual deductibles?

You are probably better off with the lower deductible plan, but assuming the HSA is only available for the high deductible plan, that may be the better option depending on your tax bracket.

It is complicated but it is possible to calculate your expected costs with each plan.  I would estimate $125 per doctor visit.  You also have to factor in prescriptions.

 

[matttyl]

I think that's the same for us.

the real problem with all of these Obama-care carriers is that there are not as many doctors taking it. so every specialist appointment takes months (here in NYC) to get, if you can get it. that said- as independent contractors, it's great that we're paying almost a quarter what we were paying for Cobra.

mattyl- I'll let you know how Oscar goes... it's new for us. our previous obama-care carrier (who we liked) went belly up.

Thanks.  Oscar is pretty new to everything, they are a start up.  I think just started offering stuff in 2014 when the ACA went live.

I assume you had the co-op in New York, Health Rebuplic last year?  They were a start up as well, and (as you know) it didn't go well for them and they got a lot of older sicker folks.  If all those folks went to Oscar this year, you may need to again do some shopping next year....  Their marketing, though, as the "hip" insurance company may help them attract the younger healthier folks, which would be good for you.

 

[shadyridr]

My daughter will have to have her eyes checked weekly for the first month of her life. Those visits will decrease over time. That actually might be considered preventative care though.

 

[El Floppo]

Thanks.  Oscar is pretty new to everything, they are a start up.  I think just started offering stuff in 2014 when the ACA went live.

I assume you had the co-op in New York, Health Rebuplic last year?  They were a start up as well, and (as you know) it didn't go well for them and they got a lot of older sicker folks.  If all those folks went to Oscar this year, you may need to again do some shopping next year....  Their marketing, though, as the "hip" insurance company may help them attract the younger healthier folks, which would be good for you.

ugh... yeah- Health Republic. interesting to hear that bit of news. I hope this one sticks... Oscar's doing a lot of advertising in the subways, so maybe they'll break through to the youngsters. I really don't want to have to go through this again next year.

eta: there's another newish company... United? hopefully more than one will spread the elderly/sick around.

 

[matttyl]

My daughter will have to have her eyes checked weekly for the first month of her life. Those visits will decrease over time. That actually might be considered preventative care though.

Very, very much doubt it.  Only so many things can be considered "preventive".  There is a list you can find online of the things docs can code as preventive when they bill you, and it' snot nearly as long as you'd think it is. 

Just spit-balling here, but your wife will likely continue to have services after delivery.  You may want to keep her and your daughter on COBRA, as neither will have a new deductible.  Likely the same for the new baby, same idea.  My son had about $20k in medicals bills as he had to stay at the hospital for 6 days after birth.  You'll want as much of that covered with no deductible as possible.  Just move yourself to your employer plan (and they will likely pay the majority of that cost for you).

Continue with that arrangement through 2016 - and move everyone to your plan for 2017 (assuming your company has open enrollment then).  This will give you a brand new deductible for a full 12 months for everyone next year.  In case you don't like your employer plan for any individual family member, shop individual plans for them during the open enrollment period in November. 

 

[matttyl]

ugh... yeah- Health Republic. interesting to hear that bit of news. I hope this one sticks... Oscar's doing a lot of advertising in the subways, so maybe they'll break through to the youngsters. I really don't want to have to go through this again next year.

Doesn't matter how much advertising they do now, open enrollment is over.  They will still get some folks during the year who have had a "qualifying event" (lost other coverage, got married, whatever).  Keep in mind, though, "youngsters" are the ones that typically have babies.  Just look at myself (son born 7 months ago) and Shady (wife preggers now).  Those aren't small claims....

 

[shadyridr]

Very, very much doubt it.  Only so many things can be considered "preventive".  There is a list you can find online of the things docs can code as preventive when they bill you, and it' snot nearly as long as you'd think it is. 

Just spit-balling here, but your wife will likely continue to have services after delivery.  You may want to keep her and your daughter on COBRA, as neither will have a new deductible.  Likely the same for the new baby, same idea.  My son had about $20k in medicals bills as he had to stay at the hospital for 6 days after birth.  You'll want as much of that covered with no deductible as possible.  Just move yourself to your employer plan (and they will likely pay the majority of that cost for you).

Continue with that arrangement through 2016 - and move everyone to your plan for 2017 (assuming your company has open enrollment then).  This will give you a brand new deductible for a full 12 months for everyone next year.  In case you don't like your employer plan for any individual family member, shop individual plans for them during the open enrollment period in November. 

Thanks, Im thinking this makes the most sense as well.

 

[cincredfan]

Is your wife working up to delivery date?  If so then her insurance will carry over - have her go back and put her notice in asap upon return to work.  Kind of a #### move but would save a ton of money.

To determine cost you need to run the numbers.  Sounds like you will meet the deductibles no problem.  Be sure to max out your HSA as well.

 

[GoFishTN]

Does your company fund anything towards your HSA? Mine does and the higher premiums were the way to go. YMMV.

 

[matttyl]

I think that's the same for us.

the real problem with all of these Obama-care carriers is that there are not as many doctors taking it. so every specialist appointment takes months (here in NYC) to get, if you can get it. that said- as independent contractors, it's great that we're paying almost a quarter what we were paying for Cobra.

mattyl- I'll let you know how Oscar goes... it's new for us. our previous obama-care carrier (who we liked) went belly up.

Looks like they might, too.

 

[sbonomo]

If your insurance is anything like mine (i work for large bank) then pay the extra for cobra and no co insurance.  I have the middle of the line plan which forces me to pay up to 2200 out of pocket (myself only) and then 80/20 after that.  Problem is that the negotiated rates with my insurance provider are terrible.  For instance, i was hit by a car a few months back.  Nothing major but my elbow was killilng me.  I had an xray done just to be safe.  The negotiated rate, through my employer, for the xray was $300 + 250 to have it read.  I had to pay 20% of that.  You can call any radiology center in the US and pay 50 cash for the same proceedure.  Now if you have to go regularly to a doc for your kid, it is going to add up very quickly.  Our health care system is a joke.  Thank you Obama.  

 

[El Floppo]

Looks like they might, too.

well, damn.

even less options in terms of doctors and hospitals? and that's if they survive.

from that link:

Oscar CEO Mario Schlosser has said the market remains viable, Bloomberg reported. The company has narrowed its network of doctors and hospitals, and Schlosser said, as Oscar enrollment increases, it has been able to negotiate prices with providers. Still, in 2015, Oscar took in $127.3 million in net premiums, but in New York, it spent more that that medical costs. 

Other, more established insurers like UnitedHealth Group Inc. and Aetna have grappled with similar challenges on plans sold through Obamacare exchanges. In November, UnitedHealth, the largest health insurer in the U.S., said it was considering leaving those marketplaces in 2017 because of struggles to turn a profit on these plans because of low enrollment. It has projected it will lose $650 million from these plans in 2015 and 2016.

Aetna said its policies sold on Obamacare exchanges posted losses of 3-4 percent in 2015. “We continue to have serious concerns about the sustainability of the public exchanges,” Mark Bertolini, Aetna’s CEO, said in February.