[partially retired, need help choosing health insurance]

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kat78613
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[partially retired, need help choosing health insurance]

Post by kat78613 »

I am 61, partially retired, and needing to purchase health insurance on the exchange. I live in TX, so it's the federal exchange. I am baffled by all of the choices. PPO? HMO? EPO? United, Cigna, Blue Cross, Humana...so many choices. I am rarely sick, thankfully. If you are shopping or have chosen a plan, what criteria did you use? I am eligible for a subsidy, but the prices and high deductibles seem less than "affordable." I'd love to hear about your experience and your final decision. Thanks.
stlutz
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Re: Obamacare shoppers: How did you choose?

Post by stlutz »

Are you also eligible for a cost-sharing subsidy?

http://healthinsurance.about.com/od/ref ... -Works.htm
Alex Frakt
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Re: [partially retired, need help choosing health insurance]

Post by Alex Frakt »

I changed the title.

kat78613, posts here have to be personal - about your situation. Calling for a bunch of anecdotes on what other people have done is not the way to go about it. You have stated your issue, so I edited the title to fit. I don't think you have provided enough information to get a direct answer. But please read the replies and respond to the best of your ability and I'm confident we'll get there eventually.
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dm200
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Re: [partially retired, need help choosing health insurance]

Post by dm200 »

kat78613 wrote:I am 61, partially retired, and needing to purchase health insurance on the exchange. I live in TX, so it's the federal exchange. I am baffled by all of the choices. PPO? HMO? EPO? United, Cigna, Blue Cross, Humana...so many choices. I am rarely sick, thankfully. If you are shopping or have chosen a plan, what criteria did you use? I am eligible for a subsidy, but the prices and high deductibles seem less than "affordable." I'd love to hear about your experience and your final decision. Thanks.
My wife is in a similar situation (several years before Medicare) and she enrolled in an HMO (Silver) and receives a credit/subsidy. She went through the federal exchange (Virginia).

Try to talk with others who may be enrolled in the various plans. Based on our plans (my wife and I are in the same HMO - but my plan Is Medicare), we have concluded that our costs (in experience) are lower than if enrolled in many other plans. Some services (requirement of the ACA) are no charge (such as an annual health assessment) and usually (perhaps always) many things like office visits require only the copay without having to satisfy the annual deductible.

Since you are not that far from Medicare eligibility, I suggest considering how the transition from whatever plan you choose will be to Medicare. In this area, I have heard from many friends and acquaintances that a great many primary care physicians will not accept new Medicare patients - but will continue to see existing patients.

Consider also the provider network available from the choices you have. [Not always that easy!!]

Good Luck.
Topic Author
kat78613
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Re: [partially retired, need help choosing health insurance]

Post by kat78613 »

Sorry Alex. I'm new to these boards and didn't realize the "rules". Yes, I am eligible for a cost-sharing subsidy based on my income. I was just looking for how people "approached" ACA, i.e. high deductible with HSA, vs. HMO, vs. PPO etc. Thank you dm200. That's a good point about Medicare transition. Right now, I'm up against the Feb. 15 deadline so I'm just going to have to trust that the company I choose will do what they say they're going to do. I've read too many horror stories about "balance billing" and people going into hospitals that were supposedly "in network" but had doctors that would not accept the insurance.
cheesepep
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Re: [partially retired, need help choosing health insurance]

Post by cheesepep »

A related question, can I enroll in the bronze plan (in CA) and then later on in the year, change to the silver or gold plan?
bluemarlin08
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Re: [partially retired, need help choosing health insurance]

Post by bluemarlin08 »

If you qualify for cost sharing you will have to use a silver plan. I am an agent and advise my clients to pay close attention to the network you choose. The cheaper plans often have narrow provide networks. If you could find an independent agent to help you that would be my recommendation but many agents refuse to work the subsidy market.
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gasdoc
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Re: [partially retired, need help choosing health insurance]

Post by gasdoc »

bluemarlin08 wrote:If you qualify for cost sharing you will have to use a silver plan. I am an agent and advise my clients to pay close attention to the network you choose. The cheaper plans often have narrow provide networks. If you could find an independent agent to help you that would be my recommendation but many agents refuse to work the subsidy market.
+1. I appreciate the perspective of the agent. From a provider's prospective (hospital and docs), the cheaper plans are cheaper because they either 1)have higher deductibles and copays or 2)have poorer reimbursement for the providers. When the providers don't get reimbursed for their time and experience, fewer docs accept the contracts. The docs that don't accept the contracts tend to be the ones that are busy enough without the additional business, and thus the more popular docs. Choose wisely, and always check the provider list provided before you sign up for the plan.
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kat78613
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Re: [partially retired, need help choosing health insurance]

Post by kat78613 »

Yes, Blue Marlin, that's what I'm finding. I've been advised to call the doctor's office directly to confirm that they are in network. When I do, some of the doctors offices either can't be reached or act downright annoyed that you are asking the question. Right now, I'm covered by my former school district's policy, which is an HMO in California (I now live in Texas). I pay full price for it, since I'm retired. Basically it amounts to catastrophic coverage because the only thing that would be covered in Texas is urgent care and emergency room. I'm leaning towards a Humana silver plan 4250 POS plan (open access) through the exchange. Any suggestions for companies or plans in the silver range? I can choose from Blue Cross, United, Humana, Ambetter, Scott and White, Sendero, Cigna, Aetna.
bluemarlin08
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Re: [partially retired, need help choosing health insurance]

Post by bluemarlin08 »

I am in Tennessee and Blue Cross dominates the market with over 80% of the business. Their rates are the most competitive and most everyone accepts their preferred network. I have personally been with them over 35 years. But, they can and do vary from state to state. One issue I have tried to determine is how much are charges I have to pay for services below the deductible compared with what one pays for services with other carriers? I t would seem logical that a carrier that has over 80% of the business can negotiate better discounts than a carrier that only has 5% of the business. Be very careful about the advice the folks at healthcare.gov provides regarding choosing plans
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Flobes
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Re: [partially retired, need help choosing health insurance]

Post by Flobes »

Welcome to the Forum, Kat.

I am 63, and loving my ACA insurance. I qualify for subsidy and cost-sharing benefits.

The subsidy reduces the cost of the monthly premium to buy the insurance. For me, the subsidy is almost $900/month. The subsidy is actually a tax credit, and you'll decide when or not to take it in "advance" or to use it when you file your income taxes next year. There are two very good reasons to take it in advance: first is simply cash flow; second is that the paybacks are capped. Either way, you will reconcile on your tax return.

Cost-sharing benefits reduce the price of actually using health care services, by lowering deductibles, co-pays, co-insurance, and out-of-pocket expenses. You purchase a "retail" plan on the Exchange, and then these cost-sharing benefits are applied. As an example, my Silver Plan is listed on my Exchange (and on my insurance card) as $3,000 deductible, $6000 maximum annual out-of-pocket plus various co-pays, coinsurance etc in-network; amounts doubled for out-of-network. But with my cost-sharing benefits applied, that plan becomes $0 deductible (yup, zero!), $500 annual out-of-pocket in-network, $1000 out-of-network. There is never any payback of cost-sharing benefits.

The choices of which plan and which company work best for you depend on your anticipated needs balanced with your comfort level should something catastrophic occur. Which PPO or HMO is best is entirely dependent on where you live. For many on the Forum, Blue Cross was the no-brainer choice while for me where I live it's absolutely the least good option.

In making your decision, determine which of your likely providers and facilities are in or out of network. Evaluate the out-of-network coverage: for some plans there is none, for some there is co-insurance without limits, for some there is a separate deductible and out-of-pocket limit.

All of the insurance companies have customer service representatives who will answer your questions, and they have complete, up-to-date info. They've been trained to help ACA customers who make a zillion asks, and they understand differences between offerings. And, they are seeking you as a customer, so you are not treated as an annoyance.

Myself, I chose to pay more to enjoy good out-of-network coverage with a cap because I road-trip often. And to be with a company that has excellent customer service and advocates for patients.

FWIW I'm in a state with its own Exchange, with a statewide non-profit insurance company.
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kat78613
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Re: [partially retired, need help choosing health insurance]

Post by kat78613 »

Flobes, thank you so much for your thoughtful reply! It was tremendously helpful and made me hopeful that ACA can work for me. I have heard so many horror stories!

I never thought to look at out-of-networks costs/caps, so thanks for that tip.

Blue Cross is not looking like my best option here in Texas. The HMO Networks are very limited and the PPO monthly premium is prohibitive. Would it be intrusive to ask what insurance company you finally decided on and how you determined it had excellent customer service? Once again, all I hear/read are the horror stories. I was with my excellent CA plan for 17 years, and this change is big for me.
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Flobes
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Re: [partially retired, need help choosing health insurance]

Post by Flobes »

Yes, there are ACA winners and losers. As with all matters, the complainers and whiners make the most noise.

To understand how ACA subsidies work:
http://www.healthreformbeyondthebasics. ... questions/

To understand how ACA cost-sharing benefits work:
http://www.healthreformbeyondthebasics. ... ns-part-2/

NB These links will fully explain the architecture and mechanics of the ACA. But they were produced in 2013, so the numbers for income ranges have changed.

You will only be able to evaluate your insurance options once you've figured how how subsidy and cost-sharing benefits may work for you. Your monthly payment might go down significantly, and your deductibles etc may be greatly reduced or evaporated. There is homework involved, but the rewards can be great... And they might save your life.

I too came from a school district deluxe plan when I retired. Then I was on AARP high-deductible HSA plan for several years (and it offered in-network in all 50 states, but I don't know if it's still offered for purchase après ACA). And then I "won" with Obamacare, last year and this year.

My current insurance company is a statewide nonprofit, only available here. I'd heard good things about them for years from friends and neighbors, but they were pricier than other options. My primary care physician helped me make my initial ACA plan decision, and she said they were a pleasure to work with, physician friendly about payments as well as covering doctor recommendations without a fight.

This year, they've been a godsend. Our state Exchange bought a spanking new super-expensive computer system and website, which succeeded in snagging 20% in "known system errors" that've stalled the enrollment process. I needed surgery, and the insurance company fought the bureaucracy for my sign-up. And now they've approved every part of my surgeries and aftercare, no problem. (I'm in the snow zone which becomes the ice zone as spring approaches, and insurance co bought my spiffy crutches with convertible crampons!) There are no in-network anesthesiologists within >100 miles, and I assumed that'd be an out-of-network expense, but insurance co says that it's part of in-network out-of-pocket bcz they did not provide an in-network option; I'd already called the anesthesiology group who said, "Glad you're with that company. We never have problems getting payment." So customer service can affect not only costs but healthcare outcomes as well as keeping providers and patients happy.
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kat78613
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Re: [partially retired, need help choosing health insurance]

Post by kat78613 »

Flobes, I can't begin to tell you how much you have helped me! For starters, I was using my anticipated GROSS income on the application. Why? Because that's what the woman at healthcare.gov told me to use. Unbelievable! All I have to use is MAGI, which for me is my AGI - i.e. line 37 on my 1040. This amount is almost $10,000 less than I had been reporting in filling out my application. I can't wait to see what my premium reduction and cost sharing will be with this lower income.

I feel really stupid, but I thought I was doing my due diligence by calling healthcare.gov. The young gal probably didn't know the difference between AGI and GROSS income. Much to my chagrin, however, I just saw that the healthcare.gov website clearly states what to include as income.

The links to Beyond the Basics and their other webinars from the Center on Budget and Policy is a wealth of information and I plan to study it tomorrow. This is what I have been "googling" but not finding for months now. I can't thank you enough. I see what you mean about the "caps" on payback penalties by underestimating your income. Your points are well taken.
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