Risks of Non-ACA Compliant Health Insurance?

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pintail07
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by pintail07 »

FYI, the US Health Plans have dramatically changed, no longer a discount plan but a PPO 3-5000 deductible, 80/20 to max out of pocket of 5-7000, Cigna network.
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dm200
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by dm200 »

OP, if I were you, I'd go with the HMO, probably Kaiser, and not one of those non-ACA options. You're in northern Virginia, not rural North Dakota. So you'll likely have good care under an HMO. If you were in an extremely rural area where it was likely you'd have to travel out-of-network to receive competent routine care, my advice would be different. I would not choose an insurance policy based on a hypothetical need to receive care for a very rare and unusual condition that you will likely never develop. If something like that should happen to you or one of your family members, re-assess at that time. Since you are semi-retired, you, unlike most people, would always have the option of moving mid-year to a state where good in-network care is available.
As long as you are in their allowed service area of Northern Virginia (check counties and zip codes), I would go with Kaiser - they have all the facilities and Physicians - including seven day a week, 24 hour a day advice nurses by phone and seven day a week 24 hour a day urgent care (can keep you up to 24 hours). The urgent care facility can (in my non-medical opinion) handle about 99% of anything you would go to an ER for - at a fraction of the cost to you (details depend on your plan).

In our experience, about half of the last 40 years, Kaiser offers excellent care and well qualified physicians.
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Postmon
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by Postmon »

Rupert wrote: Sat Nov 18, 2017 7:02 am OP, if I were you, I'd go with the HMO, probably Kaiser, and not one of those non-ACA options. You're in northern Virginia, not rural North Dakota. So you'll likely have good care under an HMO.
I would agree for routine care. However, I looked at the facilities included in the HMO and EPO. Surprisingly, neither includes the largest healthcare system in my area, INOVA. Although INOVA isn't the only game in town, there can be a huge difference between network capabilities. I recently had a not so uncommon procedure that typically requires a 2-week hospital stay with pain and a long recovery. However, one of the INOVA facilities is the only one in the area that has a certain robotic machine --- it allowed for a 2-day stay, no pain, lower risk, and I was walking immediately after! If I were in the HMO or EPO, I won't have had access to it. Given the rapid introduction of new technologies, I'd hate for my family not to have access to everything that's available because I chose the wrong network.
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dm200
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by dm200 »

Postmon wrote: Sat Nov 18, 2017 9:01 am
Rupert wrote: Sat Nov 18, 2017 7:02 am OP, if I were you, I'd go with the HMO, probably Kaiser, and not one of those non-ACA options. You're in northern Virginia, not rural North Dakota. So you'll likely have good care under an HMO.
I would agree for routine care. However, I looked at the facilities included in the HMO and EPO. Surprisingly, neither includes the largest healthcare system in my area, INOVA. Although INOVA isn't the only game in town, there can be a huge difference between network capabilities. I recently had a not so uncommon procedure that typically requires a 2-week hospital stay with pain and a long recovery. However, one of the INOVA facilities is the only one in the area that has a certain robotic machine --- it allowed for a 2-day stay, no pain, lower risk, and I was walking immediately after! If I were in the HMO or EPO, I won't have had access to it. Given the rapid introduction of new technologies, I'd hate for my family not to have access to everything that's available because I chose the wrong network.
A few years ago, except for the ER, Kaiser dropped INOVA Fairfax (and other INOVA hospitals) and focused on Virginia Hospital Center (Arlington Hospital), where they have their own Hospitalists on staff and Kaiser only patient wings. My wife was there for 3 days two years ago - very good care. Of all the things that concern me about my health, not being able to use INOVA is at the bottom of my list. Kaiser also has relationships with hospitals in DC and Maryland.
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Postmon
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by Postmon »

pintail07 wrote: Sat Nov 18, 2017 8:33 am FYI, the US Health Plans have dramatically changed, no longer a discount plan but a PPO 3-5000 deductible, 80/20 to max out of pocket of 5-7000, Cigna network.
The US Health Group plan is still in the back of my mind. I spoke to a couple of local insurance brokers. They said to stay away but they may not be neutral. Comments found from googling are not good but not exactly a reliable source.

How would I go about evaluating whether this company/plan is a viable alternative?
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dm200
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Re: Risks of Non-ACA Compliant Health Insurance?

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I ran a Kaiser family (of 4) Bronze plan in Northern VA and got 1232/mo

Kaiser Silver plans in the $1,400 -$1,600/mo ranges

Gold in $1600+ range

Platinum in $1,800/mo range
I just don't get why you would take serious risks of a non ACA plan for a family of four when you can get a fully ACA compliant Kaiser plan - zero risk of pre-existing condition exclusion, ready access to all types of excellent Physicians, urgent care facilities, centralized records, and so on.

Your rates will vary depending on your age.

If you, for any reason, do not like your Kaiser Primary Care Physician, you can switch at any time for any reason.

In the last few years, depending on the Center you choose, there are always many (my center has over a dozen) Primary care physicians you can select from. I am very happy with mine (7 years), but I know several friends and acquaintances who are with Kaiser and have switched Primary care physicians (two switched to the one I use and two did not like mine and switched away). My wife has a different Primary care physician that she likes very much.
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Postmon
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by Postmon »

dm200 wrote: Sat Nov 18, 2017 9:49 am I just don't get why you would take serious risks of a non ACA plan for a family of four when you can get a fully ACA compliant Kaiser plan
I look at healthcare as two parts: routine and non-routine. For routine, I'd be okay with the Kaiser HMO or an EPO. However, when we get into non-routine I believe HMOs and EPOs pose a risk because you *may* be limited in your ability to get the best possible care. There are just so many things that can happen, so many ways of treating them, and every day there are new technologies introduced and not everyone has access to them (e.g. the robot I mentioned earlier). So, when it comes to the unexpected and non-routine, I find it risky to be limited to a single network.

As far as the risk of a non-ACA plan, that's what I'm trying to get my arms around. What are the risks? If it's legit and will provide the coverage that it appears to, it seems to me that it's less risky than an HMO.
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dm200
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Re: Risks of Non-ACA Compliant Health Insurance?

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Postmon wrote: Sat Nov 18, 2017 10:42 am
dm200 wrote: Sat Nov 18, 2017 9:49 am I just don't get why you would take serious risks of a non ACA plan for a family of four when you can get a fully ACA compliant Kaiser plan
I look at healthcare as two parts: routine and non-routine. For routine, I'd be okay with the Kaiser HMO or an EPO. However, when we get into non-routine I believe HMOs and EPOs pose a risk because you *may* be limited in your ability to get the best possible care. There are just so many things that can happen, so many ways of treating them, and every day there are new technologies introduced and not everyone has access to them (e.g. the robot I mentioned earlier). So, when it comes to the unexpected and non-routine, I find it risky to be limited to a single network.
As far as the risk of a non-ACA plan, that's what I'm trying to get my arms around. What are the risks? If it's legit and will provide the coverage that it appears to, it seems to me that it's less risky than an HMO.
No knowledge or experience, but non-ACA compliant plans would (or might) restrict pre-existing conditions or have annual or lifetime limits.

I don't know what you consider "routine", but my wife and I have each had surgeries with Kaiser, hospitalizations, urgent care, etc. I see (or have seen) multiple specialists (cardiology, urology, ophthalmology, ENT, general surgery, neurology, endocrinology) - all without any delay or difficulty being referred. From the discussion, as well as my understanding, I believe all of the non-ACA choices pose much higher risk than the available Kaiser choices - and at a reasonable (in today's world) monthly premium. As I understand, for all (or almost) all Physician types, there are many more qualified applicants than available positions with Kaiser. I am also convinced that Kaiser successfully weeds out the kooks and quacks. I worry more about the risk of a kooky doctor than getting the most expert in a field. I have actually run into such kooky Physicians (not at Kaiser) over the years.

My wife and I would never have left Kaiser over the decades (in and out) if not for job insurance changes. We regard Kaiser in this area as very, very LOW risk. Kaiser has regular requirements that Physicians keep up to date (often no such requirements of other outside physicians) and all must keep certifications and affiliations with applicable hospitals (I know a longtime, now retired Kaiser specialist personally). Kaiser also prohibits the drug company reps from pitching their expensive drugs and "charming" the office staff.

As I think I have posted before, one interesting aspect of Kaiser in the last few years is that Kaiser nearly eliminated Nurse Practioners, Nurses and Physicians assistants from adult primary care. The ONLY medical professional I see when I have an appointment with Primary care is my Physician (Internal medicine, MD). A technician takes blood pressure, weight, temperature, tells me to get undressed or not, etc. - but that is all. My doctor, herself - not an assistant - also responds to my emails.

Sign up and try it for a year -- take full advantage of the Kaiser system - and see what you experience. I think you are placing your and your family's health at risk by even considering a non-ACA plan and rejecting Kaiser the way you do.
Tanelorn
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by Tanelorn »

dm200 wrote: Sat Nov 18, 2017 9:49 am I just don't get why you would take serious risks of a non ACA plan for a family of four when you can get a fully ACA compliant Kaiser plan - zero risk of pre-existing condition exclusion, ready access to all types of excellent Physicians, urgent care facilities, centralized records, and so on.
I get you like Kaiser, but I'm not sure what risk of a preexisting exclusion you're talking about - they tell you up front based on your medical application to these short term policies. I also would argue that having access to "all types of excellent physicians" is something you'll get a lot more of under a nationwide PPO from these short term providers than you will from a local HMO. OP only has a single very expensive ACA PPO plan, while there are several choices of short term PPO policies which cost about 1/3 of that.
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by Tanelorn »

BruDude wrote: Fri Nov 17, 2017 4:24 pm The Petersen and National General policies allow for guaranteed renewal and pre-ex conditions developed in a prior coverage period are covered, but pre-ex conditions from before the first policy were bought are not covered. Ex: Buy policy that starts January 1, have heart attack January 30, renew policy on April 1, heart attack/complications still covered. Pivot/Companion Life also has one of these type of policies available. Options vary depending on what state you're in.
Thank you so much for your pointers to these partially renewable short term policies. For those looking to learn more about these options, here are the links for them:

https://www.pivothealth.com/short-term- ... insurance/
https://www.piu.org/health-insurance/sh ... or-medical
https://www.agilehealthinsurance.com/te ... al-general

Pivot has no network - you see whoever you want. Petersen and NG are nationwide PPOs. The fine print exclusions seemed reasonable on the first two to me - excluding stuff most of these types do - preexisting, lots of "voluntary stuff" (drug abuse, fertility treatments, sex change, risky sports, weight loss), eyeglasses / hearing aids, etc. the National General one excluded a lot more, including things like organ transplants and joint replacements that seem more medically reasonable to me.
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dm200
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Re: Risks of Non-ACA Compliant Health Insurance?

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Tanelorn wrote: Sat Nov 18, 2017 11:19 am
dm200 wrote: Sat Nov 18, 2017 9:49 am I just don't get why you would take serious risks of a non ACA plan for a family of four when you can get a fully ACA compliant Kaiser plan - zero risk of pre-existing condition exclusion, ready access to all types of excellent Physicians, urgent care facilities, centralized records, and so on.
I get you like Kaiser, but I'm not sure what risk of a preexisting exclusion you're talking about - they tell you up front based on your medical application to these short term policies. I also would argue that having access to "all types of excellent physicians" is something you'll get a lot more of under a nationwide PPO from these short term providers than you will from a local HMO. OP only has a single very expensive ACA PPO plan, while there are several choices of short term PPO policies which cost about 1/3 of that.
OK - do what you want. I just hope you do not take risks of the health and well being of your family with one of these "bargain" plans. How can a good plan, such as these, be 1/3 the cost? It is absolutely absurd and very ill-informed to call a Kaiser plan in this area (Northern Virginia suburbs of Washington DC) anything but "low risk". Even if all, now, have, good health - that can change quickly.
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by Tanelorn »

dm200 wrote: Sat Nov 18, 2017 11:32 am I just hope you do not take risks of the health and well being of your family with one of these "bargain" plans. How can a good plan, such as these, be 1/3 the cost?
Before the ACA, individual health insurance for a reasonable healthy person costed about 1/3 of the current, unsubsidized ACA Silver plans. The reason these short term plans can be just as good as an ACA one (or maybe better) at that price is because they aren't billing you triple to make up for lots of other sick people who aren't paying their actuarially expected cost as part of the ACA's subsidy mechanism.
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dm200
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Re: Risks of Non-ACA Compliant Health Insurance?

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Tanelorn wrote: Sat Nov 18, 2017 11:43 am
dm200 wrote: Sat Nov 18, 2017 11:32 am I just hope you do not take risks of the health and well being of your family with one of these "bargain" plans. How can a good plan, such as these, be 1/3 the cost?
Before the ACA, individual health insurance for a reasonable healthy person costed about 1/3 of the current, unsubsidized ACA Silver plans. The reason these short term plans can be just as good as an ACA one (or maybe better) at that price is because they aren't billing you triple to make up for lots of other sick people who aren't paying their actuarially expected cost as part of the ACA's subsidy mechanism.
I think you probably mean "YOUNG" reasonably healthy person. There is another very significant reason as well, for some. Before the ACA, in most states, health insurance policies were much, much more expensive for much older insured. My wife, for example, when in her early 60's - before ACA - paid about 5 times the rate as someone (healthy) in their early 20's. The ACA, in most states including ours, capped that at 3 times.

It is certainly up to you, but if this were my family, I would certainly consult and get concurrence with my wife.
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by randomguy »

Tanelorn wrote: Sat Nov 18, 2017 11:43 am
dm200 wrote: Sat Nov 18, 2017 11:32 am I just hope you do not take risks of the health and well being of your family with one of these "bargain" plans. How can a good plan, such as these, be 1/3 the cost?
Before the ACA, individual health insurance for a reasonable healthy person costed about 1/3 of the current, unsubsidized ACA Silver plans. The reason these short term plans can be just as good as an ACA one (or maybe better) at that price is because they aren't billing you triple to make up for lots of other sick people who aren't paying their actuarially expected cost as part of the ACA's subsidy mechanism.
Not really. There were plans that cost 1/3 yes, but they also covered less. My apples to apples plan cost the same and the rate of increase in premiums wasn't any different under ACA than before (i.e. it went up 10% or so/year). What is different this year is that Silver plans are being priced really high this year (there are gold plans that are cheaper than the equivalent silver ones) because of uncertainty about some payments. It is a mess.

From an actionable point of view, I am suspect that you are better off from a health point of view with any of the listed alternatives. You just sort of have to accept that you can't afford a PPO in this market and hope the HMO works out.
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dm200
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by dm200 »

From an actionable point of view, I am suspect that you are better off from a health point of view with any of the listed alternatives. You just sort of have to accept that you can't afford a PPO in this market and hope the HMO works out.
My view as well.
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by Tanelorn »

dm200 wrote: Sat Nov 18, 2017 11:58 am
Tanelorn wrote: Sat Nov 18, 2017 11:43 am Before the ACA, individual health insurance for a reasonable healthy person costed about 1/3 of the current, unsubsidized ACA Silver plans.
I think you probably mean "YOUNG" reasonably healthy person... Before the ACA, in most states, health insurance policies were much, much more expensive for much older insured. My wife, for example, when in her early 60's - before ACA - paid about 5 times the rate as someone (healthy) in their early 20's. The ACA, in most states including ours, capped that at 3 times.
Yes, you're right about being younger. An older person is likely to find the ACA pricing much more favorable due to the price caps you mention, and hence the non-ACA alternatives not worthwhile. I think I saw somewhere that the actuarial difference in cost between an early 20s person and an early 60s one for their expected healthcare use was around the 5-6x difference you mention. So with the 3x rule preventing charging the older applicants their expected costs, the ACA premiums have risen to an average rate which gives older people a better deal and younger ones a worse one.
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Re: Risks of Non-ACA Compliant Health Insurance?

Post by Tanelorn »

randomguy wrote:You just sort of have to accept that you can't afford a PPO in this market and hope the HMO works out.
I'm not OP, but I refuse to settle for a poor HMO and "hope it works out". Kaiser isn't available where I am and the few HMOs that are have very limited and often poor networks (first hand experience from using them in prior years before I knew better). For me the out-of-network risk is what I want from my health insurance, both for reasons like surprise uncovered hospital charges (like when a specialist or additional surgeon sees you unexpectedly and isn't in your HMO network), and for cases like wanting to go to a top cancer treatment center (which are increasingly not covered by ACA plan networks). With limited to no OON coverage for most ACA plans, I view those possible costs in such scenarios the largest financial risks and hence what I would like coverage for.

Sadly in my case, the ACA killed all the PPO plans in my area so I can't even pay $3000+/month like OP even if I wanted to get out of network coverage. Likewise, none of the short tem policies mentioned above are available in my state either, so that's another dead end that I had hoped might give access to a nationwide PPO. My next step will be investigating creating a company and joining one of those employee benefits aggregators to get access to a good national group plan and leave the individual market entirely.
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