ACA -Vs- Temporary -Vs- Defined Benefit Plan

[Luck_Club]

What am I missing?
Ages 51 & 52 - So long way to medicare and need to provide insurance. So we don't qualify and wont qualify for subsidies. We have no pre-existing issues, and are relatively healthy. After endless dealing with fake websites, that don't provide quotes, and confusing "agents". We have weaned it down to 3-4 basic options in Florida:

1) ACA high deductible plan @roughly $13,284 per year Max out of pocket approximately $21,184. Max benefit assumed to be about $1-2 million, with typical $25 well visits.

2) United Health Temporary insurance @ $5236 per year Max out of pocket $10,236.26. Max benefit is $2 Million, and you pay for everything from dollar 1 up to $5,000. Needs to be renewed every 12 months.

3) Defined benefit plan (cignet & united health) @ roughly $8760 per year and capped benefits. Some of the caps appear to restrictive, and put the risk for expensive stuff on you. Like heart bypass surgery, strokes and cancer. You know the kind of stuff you really want to insure against. Positive is no new renewal every year.

4) health ministries - approximately $6,000 per year, but I'm cautious due to the fact I like a drink in the evening, so they are off the table in my eyes.

I'm leaning heavily towards the second choice, understanding I will only be able to keep the plan for 34-36 months with some annual frustration to re-enroll. I also understand that should an event happen while on the plan, I will need to go on the ACA the following year, unless new options are available.

Am I missing something or is it obvious given the situation 2 would be the best choice? Anyone out there see a plan that has a high benefit, that doesn't require an annual renewal and risk of being dropped?

 

[pb4uski]

What am I missing?....1) ACA high deductible plan @roughly $13,284 per year Max out of pocket approximately $21,184. Max benefit assumed to be about $1-2 million, with typical $25 well visits.....

Unlimited max benefits for ACA plans as I recall. We went with ACA based on a budget (in 2011) of $900/month. It has ended up being much less, but we are lucky to live in a state that prohibits age rating.

 

[COcheesehead]

I need to make this decision in two years. Leaning toward a high deductible tied to an HSA, but everyone I talk to told me it all changes so fast. So will re-evaluate in two years.
The faith based ones seem cheap, but they are unregulated and have not been around long.
I don’t think I can keep my income under the limits so an ACA policy, if they even exist in two years, is probably out of the question.

 

[ivinsfan]

On number one I'm not sure how you came up with the max benefit amount I thought ACA plans didn't have a cap. Is number one useful for a family HSA? This would lower the cost somewhat.

Number 3 is a no go IMO..it should be cheaper as it basically shifts the cost to you.

Number two could offer a decent short term solution.

Number 4 generates a lot of controversy here but I think if you dig deep you'll find at least one company that doesn't bar drinking. If you have any pre existing it might not be the best choice. You say you don't, so if you are seriously thinking about this plan the sooner you go on the better. Everything should be covered.


Any finally you haven't mentioned if you travel at all or what networks locally these plans use and if you have options for treatment if something big happens.

 

[ivinsfan]

Lets not turning this into a bashing of the number 4 solution please? That won't really help the OP much. That topic is a hot button around here. Now if a poster has an example where they actually got the run around on a plan like that, that's valuable info.

I don't think you'll get much disagreement that regular old insurance companies can be a PITA too when it comes it approving procedures and sorting out bills properly.

 

[MRG]

I'd go 1 or 2, 3 is too risky for me.

There's zero chance of me considering option number 4. Couldn't sleep at night. You have zero recourse if something happens.

 

[Texas Proud]

Please add some info... is your max OOP separate from the premiums? I am thinking your are combining your premiums with what insurance calls max OOP and putting that down as your max...


As someone else mentioned there should be no max benefit from the ACA plan...


Would not know enough about 3 or 4 to give any real insight but it seems you do not like either...


So the question is between 1 and 2 with 1 having no max benefit and 2 having it set at $2 mill... I would guess it would be something really big to get to $2 mill so I might go with #2 as the savings are pretty large...

 

[MBSC]

1) ACA high deductible plan...Max benefit assumed to be about $1-2 million.

ACA compliant plans do not have an annual or lifetime cap. This includes the off-exchange ACA plans bought directly from the insurer.

2) United Health Temporary insurance @ $5236 per year Max out of pocket $10,236.26. Max benefit is $2 Million, and you pay for everything from dollar 1 up to $5,000. Needs to be renewed every 12 months.

I'm leaning heavily towards the second choice, understanding I will only be able to keep the plan for 34-36 months with some annual frustration to re-enroll. I also understand that should an event happen while on the plan, I will need to go on the ACA the following year, unless new options are available.

STMs use national PPO provider networks so traveling isn't an issue. While you will only be able to keep the UHC plan 36 months renewed annually, you can then switch to another reputable carrier such as National General for 36 months then switch back to UHC.

They can be "loose" with the definition of pre-existing condition. For example, six months after enrolling you are diagnosed with cancer and start chemo. Some have been known to say the cancer was already inside you when you enrolled and deny coverage as pre-existing. Even with this caveat, I agree with your assessment.

3) Defined benefit plan (cignet & united health) @ roughly $8760 per year and capped benefits. Some of the caps appear to restrictive, and put the risk for expensive stuff on you. Like heart bypass surgery, strokes and cancer. You know the kind of stuff you really want to insure against. Positive is no new renewal every year.

This is the opposite of insurance. Insurance should be to protect against catastrophic loses and these policies cap payments.

 

[ivinsfan]

ACA compliant plans do not have an annual or lifetime cap. This includes the off-exchange ACA plans bought directly from the insurer.

STMs use national PPO provider networks so traveling isn't an issue. While you will only be able to keep the UHC plan 36 months renewed annually, you can then switch to another reputable carrier such as National General for 36 months then switch back to UHC.

They can be "loose" with the definition of pre-existing condition. For example, six months after enrolling you are diagnosed with cancer and start chemo. Some have been known to say the cancer was already inside you when you enrolled and deny coverage as pre-existing. Even with this caveat, I agree with your assessment.

This is the opposite of insurance. Insurance should be to protect against catastrophic loses and these policies cap payments.

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.

 

[MBSC]

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.

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: Customer feuds, claims denials mar health plans Trump backs | Pittsburgh Post-Gazette

See also: https://www.protectourcare.org/fact-sheet-short-term-junk-plans/

 

[ivinsfan]

See below.

Your first link is interesting and concerning. Oddly enough this is the scenario that people site when they don't like the so called Christian plans.

Your second link calls them short term "junk" plans so appears to be pretty biased.


If you want all the protections of an ACA plan, you are going to have to pay for an ACA plan. I guess that what it boils down to in the end.

 

[travelover]

..........Your second link calls them short term "junk" plans so appears to be pretty biased..........

Based on all the posts I've read here, MBSC knows more about health care insurance than the rest of the forum, combined. just sayin'.

 

[ivinsfan]

Based on all the posts I've read here, MBSC knows more about health care insurance than the rest of the forum, combined. just sayin'.

I don't disagree, I just liked his first link better, it seemed a little more unbiased. I don't think I'd ever buy a short term plan.

We have a lot of good well informed posters here and for better or worse we've all had to increase our study of health insurance options...

Did you ever think that HI would continue to get more confusing and pricey every year? You have to wonder how long this can continue.

 

[MichaelB]

Did you ever think that HI would continue to get more confusing and pricey every year? You have to wonder how long this can continue.

How long can it go on? Two answers, both originally intended for other situations, but may apply here. John Kenneth Galbraith said this:

The market can remain irrational longer than you can remain solvent.

Phil the weatherman shared this

 

[braumeister]

John Kenneth Galbraith said this:

The market can remain irrational longer than you can remain solvent.

A great quote. A similar one I've always liked is this:

Trends often go on for far longer than seems reasonable.

 

[travelover]

.........Did you ever think that HI would continue to get more confusing and pricey every year? You have to wonder how long this can continue.

I'm personally not surprised given all the moving parts and power of entrenched interests. That said, I believe in equilibrium, or as Buffett said, "trees don't grow to the sky". At some point equilibrium is reached.

 

[Luck_Club]

Please add some info... is your max OOP separate from the premiums? I am thinking your are combining your premiums with what insurance calls max OOP and putting that down as your max...


As someone else mentioned there should be no max benefit from the ACA plan...


Would not know enough about 3 or 4 to give any real insight but it seems you do not like either...


So the question is between 1 and 2 with 1 having no max benefit and 2 having it set at $2 mill... I would guess it would be something really big to get to $2 mill so I might go with #2 as the savings are pretty large...

I understand my initial post may have been slightly confusing. The first number was the annual premium, and the second larger number was max out of pocket for a year assuming 1 has a bad year.

So I'm evaluating it as if I have a normal year IE two physicals and blood work. being $50 with option 1 & 3 and probably $500 for option 2. two sick visits for anti-biotics $25 for option 1&3 and free tele-medicine for option 2.

In my eyes it really boils down to $2 million should be enough, so the annual premium and out of pocket costs are the biggest factor.

Situations like MSBC put out about plans calling un-diagnosed condition as pre-existing is pretty frightening, but probably very un-common.
At least I hope they are rare.

 

[Sarah S]

I think you may be underestimating the costs of preventive 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 genetic predispositions is best started years earlier. Lifestyle is key but good screening and counseling helps

 

[Texas Proud]

I understand my initial post may have been slightly confusing. The first number was the annual premium, and the second larger number was max out of pocket for a year assuming 1 has a bad year.
/snip/

What I was asking is YOUR definition of max OOP..... is it premiums PLUS the max you have to pay... or is it the max OOP listed by the insurance which does not include your premiums..

 

[Luck_Club]

What I was asking is YOUR definition of max OOP..... is it premiums PLUS the max you have to pay... or is it the max OOP listed by the insurance which does not include your premiums..

The definition for the various options for Max OOP is: Premium + deductible payments & co-pays =Max out of pocket

 

[Luck_Club]

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]

It is complicated...

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.

Even with this caveat, I agree with your assessment.

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.

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/library/ENR_FAQ_ResidencyPermanentMove_SEP_5CR_011916.pdf

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/special-enrollment-guide/how-your-big-move-can-trigger-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.