Health insurance enrollment questions

"AestheticsInMotion" (aestheticsinmotion) 11/09/2020 at 00:22 • Filed to: None

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I was on my mom’s plan until I hit 19, then switched over to a different plan that was made available to me for free (!!!) through a volunteering opportunity. Many years later, I find myself no longer meeting eligibility requirements with the company I volunteered with, and my benefits will end in about six months. I’ve never shopped around, and if I’m being quite honest I’m pretty ignorant about how health insurance works in the US... I don’t have the slightest idea how to rate a plan, or really know what I should be looking for.

Current company offered health/dental/vision at what seem like reasonable rates. Anyone more experienced than I that could possibly chime in and tell me if I should shop around, or... Idk. Does this look pretty standard?

This seems like as good a time as any to again thank oppo for all the help over the years.

(edit) I’m so lost . Platinum/gold/silver/etc is mentioned in the benefits guide exactly zero times. I can... Pick a network? Look, I just want to be able to go get my body fixed if needed with minimal hassle and no life-altering debt. Maybe even some preventative maintenance!

Chariotoflove > AestheticsInMotion 11/09/2020 at 00:34

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What does your company offer. I usually say go that way. You’ll get better coverage and pay less than buying on your own. Do you have a limited enrollment period?

That said, I’ve always got mine from state-backed university plans. So take my perspective with that grain of salt. 

Dr. Zoidberg - RIP Oppo > AestheticsInMotion 11/09/2020 at 00:35

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Your dental plan looks comparable to mine. I always buy up on dental.

My advice for the medical is... If you want no hassle, buy up and get into a plan that covers out-of-network insurance for those rainy days or if you ever have to be referred to a specialist. I recommend an HSA if you're young, single, and healthy. PPO if you're conservative or have kids. 

BeaterGT > AestheticsInMotion 11/09/2020 at 00:44

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May have to ask your HR dept about the different levels of medical coverage. The dental plan looks pretty decent, just have to make sure your dentist and insurance are on the same page about coverage.

I echo what Zoidberg says about the HSA if it is available. They’re a great option for health-related expenses as well as tax-free investing.

ttyymmnn > Chariotoflove 11/09/2020 at 00:54

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We have been very fortunate that my wife works for a Major Texas University™ and done so for more than  25 years . They have a lot of buying and negotiating power.

AestheticsInMotion > BeaterGT 11/09/2020 at 00:54

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I’ve been interested in an HSA, more for the tax-free investment than anything else. I’ll definitely check to see if that’s an option.

I'm afraid if I ask about HR I'm going to be told that I'm the HR department. 

AestheticsInMotion > Dr. Zoidberg - RIP Oppo 11/09/2020 at 01:02

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Hmm. Looks like this plan would make me eligible to open an HSA on my own if my company doesn’t doesn’t have the option. I do like that idea.

What a pain. 

BeaterGT > AestheticsInMotion 11/09/2020 at 01:09

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Oof. I’ve been in that unfortunate situation where you end up more knowledgeable about what’s being offered than HR. Doesn’t hurt to ask though!

If you already have a doctor that you like, you may have to see whether they accept the n etwork options that are listed on your form so that you are considered in-network and not forced to hand over your wallet come bill time . It seems as though the “Preferred” network in the last image is the same network as “Regence Preferred Network” referenced in the first Employee Medical Benefits image.

ttyymmnn > AestheticsInMotion 11/09/2020 at 01:13

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I wish I could help, but TBH, my wife handles all of that sort of stuff. I find all of it to be utterly  inscrutable.

wafflesnfalafel > AestheticsInMotion 11/09/2020 at 01:15

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and it you end up not using it until you are an old like me, you can always use it to pay for gap medical between the end of your employment and retirement if needed.  

AestheticsInMotion > Dr. Zoidberg - RIP Oppo 11/09/2020 at 01:20

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Also, I love your new avatar. 

Tohru > AestheticsInMotion 11/09/2020 at 01:20

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I hate the idea of HSA’s because if you don’t use the money in it it’s just fuckin’ gone. I don’t make enough to let insurance fuckwads just take it from me because I didn’t spend enough.
What’s important is that with the new plan, if your current providers will be in-network or not. If they’re not, you’re either spending more to visit the people you currently trust or finding different health care providers.

Chariotoflove > ttyymmnn 11/09/2020 at 01:24

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Yup. They also have the final say on what is covered, not the insurance company. Sweet. 

Dr. Zoidberg - RIP Oppo > AestheticsInMotion 11/09/2020 at 01:24

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Yep, this and the TORSELL, and Luna as a unicycle robot dog, are my favorite images every posted on Oppo

BeaterGT > Tohru 11/09/2020 at 01:24

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That’s a FSA, not a  HSA.

Tohru > BeaterGT 11/09/2020 at 01:25

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well, shit.

BeaterGT > Tohru 11/09/2020 at 01:28

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Yeah, FSAs don’t make that much sense unless you know you’re spending X amount of dollars on medical expenses each year and it’s a significant enough amount to lower your taxable income.

ttyymmnn > Chariotoflove 11/09/2020 at 01:30

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My son was taking Dupixent (dupilumab) for his eczema. I was already getting copay support from the manufacturer, but then they raised the copay to $1,000 for a three-month supply. Before I even knew that change was happening, we got a phone call saying that our insurance would cover the increase. He has since stopped taking the injections, though, because it didn’t work for him. 

Chariotoflove > ttyymmnn 11/09/2020 at 01:33

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Score for state government.

Those biologicals are hit and miss. You have to cycle through different ones sometimes without knowing for sure what will work. And then they can work for a while and wear off. My wife went through a lot of that. 

facw > AestheticsInMotion 11/09/2020 at 01:45

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I’d say the medical plan isn’t great (I’ll talk about why in a bit), but the dental plan is a bit better.

It’s very weird they are asking you to choose coverage levels and networks, but then only presenting you with one choice, you’ll want to talk to your benefits coordinator about that.

Anyway, let’s talk about the health plan first. This is a high deductible plan, with a high out-of-pocket maximum. This is not necessarily a bad thing as you will save money on premiums, so it can be the right choice for someone young and healthy. Actually, you may already know these things, but let’s go over some terms first:

Premium: This is the monthly cost. Your employer should be picking up at least part of this, though they may not tell you how much. As a result, buying through your employer will likely be significantly cheaper than buying through the Obamacare exchange (but maybe not, it doesn’t hurt to look at what’s available, and hope Obamacare doesn’t get killed by the Supreme Court).

Deductible: This is the amount you must pay before insurance covers anything. There are some exceptions, but those will differ by plans so you need to look at that.

Out-of-pocket Maximum: This is the most you have to pay out of pocket before the plan will cover everything, regardless of copays or coinsurance. Premiums do not count towards this number.

Co pay: This is a fixed fee for services/prescriptions.

Coinsurance: This is a percentage fee for services

Network: These are the collection of doctors, medical facilities, and hospitals your insurance has negotiated rates for. If at all possible, you want to get service from one of these providers, as out of network rates are much higher, out of network benefits are lower, and out of network spending hits different (higher) limits for out of pocket and deductibles.

Formulary: This is the list of drugs your insurance will cover, and at what level (as you can see on the plan summary different drugs have wildly different costs).

PPO/HMO : Preferred provider organization/Health maintenance organization. These are the two major types of plans (there are some other ones as well, but most will be one of these two). In a PPO you can select your own doctor, and can visit specialists without needing a referral from your primary care physician (PCP), though you would still need approval for major services . In an HMO, your care is “ managed”, they’ll assign you a PCP (though you can usually request a different one, as long as they are in network). Under an HMO, you’ll need to visit your PCP and get a referral to see a specialist. This is less desirable, but HMOs can be much cheaper up front to account for it.

HSA/FSA: Health savings account, Flex savings account. These are accounts where you can deposit pre-tax earnings (you have to pick how much when you sign up) to pay for healthcare costs. The big difference between them is that FSAs are use-it-or-lose- it, if you don’t spend and claim reimbursement by the end of March the next year, that money is gone (I’ve had problems with this). HSAs you can roll over. But HSAs are only available on high-deductible plans.  

Anyway, back to your plans. $3000 is definitely a high-deductible amount, so if you have any serious problems, expect to pay out thousands before the plan contributes meaningfully. The out of pocket maximum is also high. You’d want to consider if you could reasonably come up with that $8,150 if you had a serious injury or condition and needed surgery, or if you had a hospital stay. Of course if you can get a plan with a lower deductible and out of pocket max, the premiums might be high enough to make it more expensive anyway. For example I’m on a plan with I think a $10 00 deductible, but considering both premiums and out-of-pocket costs, a $3000 deductible plan had a worst-case cost that was $300 lower than my current plan, even before considering the tax benefits of the HSA.

Your copays aren’t too terrible. They are roughly $15 more p er visit than what you’d normally see on a high level plan, but in the grand scheme of things that’s not bad. The one exception is the ER visit copay which seems expensive. 70% coinsurance is low, but the normal level for this sort of plan. More expensive plans will have 80-90% coinsurance.

FWIW here’s what the benefits on my plan look like (though keep in mind I’m paying $500+ in premiums):

As for dental, those benefits seem ok. 50% for major services is lower than you’d like, but isn’t out of the norm (I believe my plan covers these at 75%, but the dentist has commented that that’s abnormal).

In any event, in terms of making your choice, I think step one is to find out from you benefits coordinator/HR if you do actually have more options for plans and network. The metals don’t have precise meanings outside of the Obamacare exchanges, but generally speaking yours would be a bronze while mine would probably be a gold ($1000 deductible is a bit high for platinum, though the rest would fit in a platinum plan). For networks they should be able to provide you with links to the insurers’ website so you can check the network for your plan, to make sure any doctors you currently see are included (unless you are willing to switch). Similarly, if you currently take any prescriptions, you can view the insurer’s formulary to make sure they are covered at a level you are happy with. If you decide you aren’t happy with what your employer is offering, you can look at the Obamacare exchanges, though you wouldn’t be getting subsidized by your employer or by the government in that case, so while you’d have more options, your rates might be worse.

In any event, as a young person in good health, you probably shouldn’t be scared about taking a high-deductible plan. It’s often the best option to have a low-cost plan that will protect you from ruinous expenses if you do need hospitalization, surgery, or expensive drugs. Though if you go that route as someone who rides a motorcycle and has what seems to be an active lifestyle, if you go that route, you want to make sure you are putting at least some of the money you’d save on premiums in an HSA (or invested, if you want to go a riskier route), so that if you do need expensive care, you’ll be able to come up with that money.

That’s a lot, (and probably not enough), but if you have questions, let me know, I have a bit of background in this area .

ttyymmnn > Chariotoflove 11/09/2020 at 01:58

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My wife was reading an advert for Dupixent, and the fine print said that it actually worked in some very small percentage of patients (I don’t remember the number, but it was under 50%) . The bad thing for my son is that this is the only biological right now for eczema. There are numerous ones for psoriasis, etc, but not for him. So we’re back to managing symptoms. I did read on some support groups that Dupixent  can help with the itching that keeps you awake, while having no effect on the skin itself. For some people, that was worth the price of admission.

TheRealBicycleBuck > ttyymmnn 11/09/2020 at 07:50

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My best insurance coverage was when I worked for a Major Texas University™. It’s been downhill since then.

notsomethingstructural > facw 11/09/2020 at 08:12

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This is a really good answer. I would add that coinsurance (which usually covers more like procedures) and copays (which usually covers more like visits) still apply after you hit the deductible.

I also don’t agree this is a bronze plan. As I recall this is actually more like a good silver plan near where I live . Bronze plans are basically 50% coinsurance across the board after $5-8k deductible aside from in-network PCP visits, x-rays, and maybe physical therapy . Silver plans are usually $2-4k deductible with more manageable coinsurance rates . Exchange plans near me have zero offerings with a OON component so there’s that too.

To OP, no one is going to be able to divine whether this is a good plan for a good price. It’s probably comparable to the average person - slightly worse than most employer sponsored options, slightly better than most marketplace offerings.

But the only way you’ll know if it’s a good price is to hit the marketplace and cross-shop. I would look at silver plans and their premiums, see if it’s remotely close to the premiums your employer is looking for, and then compare coverage. If your employer wants $120/mo and the marketplace wants $400/mo this isn’t so far removed from a silver plan that it’s worth drilling down to see exact differences, especially if you’re in good health. But unlike years past, even young healthy people DO need insurance for 2021, because * everyone* is just a bad day away from being on a ventilator.

facw > notsomethingstructural 11/09/2020 at 08:37

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Seems you are right on the metal level. $3000 deductible seemed high for a silver plan to me (I think my company is $2000-2500 at that level, but 70% coinsurance is the Obamacare s ilver level, so it’s probably fair to call this a silver  plan)

facw > facw 11/09/2020 at 08:53

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Also, I think it’s clear from context, but I probably should have said directly that coinsurance is listed as the percentage the plan will pay (after the deductible is reached), so with your employer’s plan, they will pay 70% and you will pay 30% (after you’ve paid $3000 out of pocket towards the deductible).

Also to be clear, the deductible isn’t per incident as with car insurance, it’s total for the year, so every bit you spend out of pocket gets you closer to meeting your deductible (and your out of pocket maximum).

Chariotoflove > ttyymmnn 11/09/2020 at 10:43

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The good news is that the field moves pretty quickly. Not quickly enough when you itch like hell though.