ACA -Vs- Temporary -Vs- Defined Benefit Plan

[Luck_Club]

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Originally Posted by Sarah S I think you may be underestimating the costs of prevetive care a tad. I just looked and my physical full price bill was 350. This did not include gyn. Is your wife going to skip periodic gyn? Mammograms? Colonoscopies for both of you? Immunizations? Will it make a psychological difference to you in following recommended screening whether you have to pay? You commented in one of your early thread about having a concern about family genetics impacting your quality of life after 70. The groundwork for minimizing the effects of most genetics predispositions is best started years earlier. Lifestyle is key but good screening and counseling helps

No we have no intention of not getting our screenings. For the past 6 months I've been investigating this actually signed up for a health ministry for about a month. During that time I went to find out the cost of a self pay colonoscopy, and I was surprised at it's relative low cost under a grand IIRC. Doctors visits are under $100 each. Labs are unknown but can't be that much since Mediweightloss does a full work up for under $200 IIRC when you start the program.

The driving force here is to cover bills @10's and 100's of thousands $$$.

You are correct (great recall) I do fear a diminished quality of life after 70's mostly due to stroke risks and arthritis. Though there are steps to prevent the strokes, arthritis is a crap shoot beyond controlling my weight. In other words no genetic predisposition towards cancer, hyper tension, diabetes or other long term health issues, that can be managed through medicine.

Stroke prevention steps: I've had a full work up stroke prevention screen 2 years ago, and will probably do one every 3-5 years through those pink flyers for $500.

[arno]

Hi,
New user to the forums. Retired, healthy, ages 55 and 53.

This is an extremely complex topic, especially if you travel extensively or have homes in more than one state. In our home state, we cannot buy an ACA plan that covers us outside of our immediate area. In our case, we spend winters in another state, and we have no coverage except emergency room (and pray you aren’t admitted to the hospital cause then you have zero coverage). So, ACA has issues at any price. Furthermore, if you get sick - really sick - and you are in-state with one of our ACA plans, the network is incredibly narrow. Forget about going to MD Anderson or Cleveland Clinic. So, even on ACA, you may be exposed to the tail of the curve if you want the best care.

Personally, I don’t think the short term plans or the fixed indemnity plans are that crazy - especially as the system is set up now. First off, you get a wide network of doctors including the places you’d want to go if you were really, really sick. So, let’s look at the two cases:
A) Short term plan - assuming you are healthy and you can purchase a policy for a year (or 6x2 with precondition lookback set at beginning of first policy). Where is your exposure? Best case, you’ve saved some money. Worst case, you can go to the wide network doctors for a year then go on ACA next year. You aren’t going to run up $1M in medical bills in a year (but easily could over a few years). Yes, this is gaming the system but I’m past that - given our wide network PPO policy was yanked away from us and we are having to pay 3.5x for an ACA policy that doesn’t even cover us when we are out of state or for when we need to see the best in the business. The case about Dawn Jones (the woman denied by Golden Rule) is much more complicated than stated in the article. She had an inconclusive mammogram which her doctor said she should check out further. Then she bought the insurance, then she found out she had cancer on the next mammogram. I’m not trying to defend the insurance company - only saying that the facts are more complicated than presented in the posted article.

B) Fixed Indemnity Plan. Again, you usually get a wide network here for “discounts” - i.e. better than charge master pricing without negotiating. This is first dollar “insurance” so really the only way this helps with the tail of the curve is making it less tall because the pricing is better. You could still be on hook for lots of dollars until you go back on ACA. My best guess is that if you had $800K of charge master bills, this would be $400K, which the fixed indemnity plan might cover $100K. Might be way too much exposure, YMMV.

Another option is to combine the two. In our case, you can buy a STM plan that has a $25K deductible(each, every 6 months!) for $320/month for the two of us or a $5K deductible at $600. $1M in coverage, look back for preexisting is before the first of two policies goes into effect (we live in a state with rules limiting policies to six months and this is the workaround). Our alternative is $1600/month with a $6K deductible each and no coverage for 1/3 the year except for emergency room - and forget about MD Anderson or Mayo Clinic. Can combine the STM crazy high deductible plan with a fixed indemnity plan to help with the first dollar costs, still about 1/2 price of ACA and much, much wider network - like before ACA.

Of course, this only works if you are healthy.

[MBSC]

For the record, I agreed with the OP that option #2 (STM) appeared to be a good choice based on the information provided.

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Originally Posted by MBSC Even with this caveat, I agree with your assessment.

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Originally Posted by arno In our home state, we cannot buy an ACA plan that covers us outside of our immediate area. In our case, we spend winters in another state, and we have no coverage except emergency room (and pray you aren’t admitted to the hospital cause then you have zero coverage). So, ACA has issues at any price.

Great first post. I also agree with looking at pairing STM with an indemnity plan. I just wanted to add that if the snowbirding involves two homes then a person can switch ACA plans for the season. The deductible and OOP does reset to $0 met at each plan change and the start of each calendar year.

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FAQs on the Marketplace Residency Requirement and the Special Enrollment Period Q11. If an individual travels between homes in different Exchange services areas throughout the year, where is an individual’s residence for the purposes of Marketplace coverage? If an individual leaves his or her primary home to visit a secondary home for a short duration, the departure will be considered a temporary absence, and the individual will remain a resident of the service area of the primary home. During that time, the individual will not have an “intent to reside” in the location of the secondary home and will not meet the Marketplace residency standard for that location. In contrast, if an individual has two primary homes where he or she spends time for an entire season or other long period of time, then the individual may live and intend to reside in both locations. In such situations, the individual may establish Marketplace residency in both locations. Reference: https://www.regtap.info/uploads/libr...5CR_011916.pdf

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What about people with more than one residence? A person who has homes in more than one location is allowed to switch back and forth between QHPs in each area. HHS notes that brief trips away from one’s primary home do not count, but spending “an entire season or other long period of time” at a second residence would make the person eligible to enroll in a new QHP while living there. This scenario might apply to an early retiree – not yet eligible for Medicare – who lives half the year in one state, and half in another. The best option in this case might be a single plan with a nationwide network that the enrollee can maintain year-round in order to have a single out-of-pocket maximum that applies for the full year. But such plans are not available in all areas, and enrollees might find that the plan they have in one state doesn’t offer out-of-network coverage and provides little value at their second home. The option to switch to a different plan with each move is thus valuable, although enrollees should be aware that each plan change will reset their annual out-of-pocket costs back to zero. Reference: https://www.healthinsurance.org/spec...rigger-an-sep/

[arno]

I’ve seen that HHS information before regarding changing states or even choosing the state to enroll. In our case, state #2 does explicit “residency” checks - and, yes I am aware of the subtleties between residency and domicile as well as the differences of residency for ACA vs. state taxes. Would you win a lawsuit because this seems in conflict with HHS rule? Maybe. Maybe even probably. Personally not looking for that kind of fight.

[ivinsfan]

Unfortunately the way it's rules are written today this will still be an issue when you go on Medicare. Advantage plans are very network specific with much higher OOP and a higher OOP cap if you go out of network. You also lost the benefit of medicare pricing and are dependent on the adjusted price your Advantage plan uses in an OFN facility.


I ended up buying more coverage then I really wanted to because of this detail.

[audreyh1]

I noticed that BCBSTX offers this option for current ACA plans which are all HMO.

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THE AWAY FROM HOME CARE® PROGRAM Access for Extended Stays (Temporarily Residing Away From Home) BCBSTX members who have HMO plans may become guests of an affiliated HMO when they are away from home for at least 90 days. The Away From Home Care Program is ideal for members who: Have a child attending school out of state Have family members who live in different service areas Have a long-term work assignment in another state This program allows ongoing access to contracting hospitals and doctors. If you are already a BCBSTX member, log in to Blue Access for Members to get more information about Away From Home Care. Call the customer service number on the back of your member ID card to find out where the program is available.

[saydiver]

I was in the health insurance business for 28+ years of my working career and have seen way too many high dollar claims to even consider 2, 3, or 4 so for us we chose #1.

Also FL Blue is one of the few insurance companies in the US to still offer a PPO plan with a nationwide network if you're traveling or living elsewhere part of the year. Their non-HMO plans are both an EPO and a PPO plan. In state they're an EPO plan and when you're out of state the plan is a PPO. Blue Options plans have a larger network in state than Blue Select plans. There's also a difference in some ancillary services between the two plans.

[bmcgonig]

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Originally Posted by saydiver I was in the health insurance business for 28+ years of my working career and have seen way too many high dollar claims to even consider 2, 3, or 4 so for us we chose #1. Also FL Blue is one of the few insurance companies in the US to still offer a PPO plan with a nationwide network if you're traveling or living elsewhere part of the year. Their non-HMO plans are both an EPO and a PPO plan. In state they're an EPO plan and when you're out of state the plan is a PPO. Blue Options plans have a larger network in state than Blue Select plans. There's also a difference in some ancillary services between the two plans.

I just got a notification from Blue Shield CA stating that they will no longer cover out of state except for emergencies.

[Dreaming of Freedom]

This information is very useful to me. My husband is 60 and I am 42, so there may never be a time when we will both be alive, retired, and safely on Medicare. He has had 3 skin cancer surgeries in the past year, so he has pre-existing conditions.

The plan right now is for me to work at my full time job for 3.5 years until we can go on my COBRA ($20,000/yr) until he is safely in Medicare. Like most Americans, we only have small network, crappy ACA plans available to us. I will still be on my own for health insurance in 5 years though, and I am scared to death. How much is a good amount of cushion for unforseen out of network or balance billing expenses? $250,000? $500,000?

My other idea is to go back to school for another undergrad degree and go on a PPO student healthcare plan, if those are even around by then. Or maybe I can talk my husband into retiring to Mexico where we can obtain insurance for most health problems, and self insure for the pre-existing conditions.

I wonder, if one has had 2 A1c readings in the prediabetic range, but current A1c readings have been good, would they even offer me a plan? Combining Options 2&3 sound like they could work for me if I could buy the policies in the first place. I have done enough research to know that option 4 is too risky and not for me.

Thanks for all this great information!

[arno]

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Originally Posted by audreyh1 I noticed that BCBSTX offers this option for current ACA plans which are all HMO.

Audreyh1 - We were unaware of this option from BCBS. It isn’t available in every state but in our particular situation would work well based on talking to Anthem and looking at the coverage. It still may not be for everyone.

In our case what happens is that when you are “away from home” for 90-180 days you can be hosted by another BCBS plan. It is almost as if you have another plan in the other state - in fact, you have different rules/copayment/deductibles and they don’t carry over to your native plan. For example, we will have an HDHP HSA plan in our state and a relatively low out of pocket max w/10% copay on everything in the host state. Even if we hit the out of pocket max in the host state, we start from zero in our native state when we return.

In our case, this isn’t as good as the PPO we once were able to purchase but is so much better than the alternative. Thanks audreyh1!

[Pluperfect]

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Originally Posted by MBSC Quote: Originally Posted by ivinsfan Do you have personal knowledge of STM"s denying people coverage under these circumstances? This is a big deal if there is hard evidence to back it up. See below. Quote: Despite showing evidence she was unaware of the cancer when she bought the policy, the insurer didn’t pay for Jones’s treatment, leaving her with a $400,000 medical bill. But the judge sided with Golden Rule and dismissed the case in August, finding the policy agreement clearly stated that preexisting conditions wouldn’t be covered, even if the customer was unaware of the condition. Jones wasn’t diagnosed until after she bought her policy. Reference: http://www.post-gazette.com/business...s/201710160252 See also: https://www.protectourcare.org/fact-...rm-junk-plans/

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Originally Posted by arno The case about Dawn Jones (the woman denied by Golden Rule) is much more complicated than stated in the article. She had an inconclusive mammogram which her doctor said she should check out further. Then she bought the insurance, then she found out she had cancer on the next mammogram. I’m not trying to defend the insurance company - only saying that the facts are more complicated than presented in the posted article.

Actually, she didn't know the results of the "inconclusive" mammogram when she bought her Golden Rule policy. She had requested the results from her doctor, but no report was forthcoming. She applied with Golden Rule about two months after the mammogram, and got the report a couple of weeks after that (by going in person to the doctor's office).

Also, and more important, the judge's decision was reversed on August 23, 2018. And not only reversed, but the appellate court granted summary judgment to Dawn Jones even though she didn't ask for summary judgment at either the district court level or the appellate court level--an unusual move that cut off any further fact-finding. It was strongly criticized in the dissent.

So Dawn Jones won big (assuming no further appeal). Of course, she had to spend a ton of money to get there, but this is not an example of insurance companies getting away with denying coverage based on determining cancer was already inside someone when she applied for coverage.

For one, that's not really what they did, but regardless of the details, the insurance company got slapped down hard.

The appellate decision is here:
http://media.ca11.uscourts.gov/opini.../201713952.pdf