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Old 11-06-2015, 08:08 AM   #21
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Originally Posted by ivinsfan View Post
My first year for the exchange and I didn't really understand a thing you just wrote, I think I going to follow brewer's lead and go to a broker...I feel completely over my head....
Apparently I didn't understand what I wrote either! Or the source I used didn't understand, or they changed the rules. It looks like the embedded deductible for one family member is 50% of the family plan deductible - which OMG, makes sense.

Ran into another gotcha that caught me by surprise. When selecting my 2015 plan, the oncology specialist I see 2x a year was on the in-network list of providers. He retired at 2014 year-end, and the 19-member practice he was from gave me two choices for a replacement, and a quick check of the first name showed up as in-network so that was who I picked. First appt was on me as I had not yet hit the deductible, but EOB came through normally with in-network discount applied. By the second appt I had met deductible & OOP, now the EOB came though saying not in network, and no discount. Called insurance co. and oh, even thoguh that doc is in-network at three nearby locations, because I saw him at the satellite location nearest me, he was not. They 'educated' me on in-network being specific to a provider's location, not the provider themselves.

I shall have my revenge though. Doctor was busy with another patient that day, so I actually saw a practitioner instead. And that practitioner is listed as in-network at that location. I called practice business office and they told me standard procedure is to submit claim under the name of the supervising MD at a location for that day. But, they could submit under the (in-network) practitioner's name - when I explained the situation they said they'd be happy to do that. Apparently the MD not being in-network at that particular location, for my insurance company, had fallen off their radar screen.
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Old 11-06-2015, 09:26 AM   #22
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... the EOB came though saying not in network, and no discount. Called insurance co. and oh, even thoguh that doc is in-network at three nearby locations, because I saw him at the satellite location nearest me, he was not.
I'm not one to call for legislation very often, but this is yet another trick in their shell game that needs to be tamed; the providers and insurance companies hold all the cards and we're left to navigate the rocky shoals without a map.

As to the OP, as others have said, they now released a "clarification" to require an embedded deductible and max OOP. This hits close to home for me because the BCBSNC rep told me I was getting an embedded deductibles plan when buying my policy for 2014. Then it turned out that wasn't the case and I was $5,500 poorer as the result of that rep's misrepresentation. Then they "lost" the transcript/recording of my call. Yeah, right. But under an embedded scenario, though, even though you have one policy, you don't have to hit the family numbers before they start paying. What this means is that it's more advantageous to get a single policy since, if something bad happens to one person (they cause the policy to hit the family max OOP), the healthy person(s) would get free medical. Under the split scenario, both would have to hit individual numbers. In the case where no body on the policy has a high likelihood of hitting the max OOP, we are probably talking about a miniscule increase in expected value (chance of hitting family OOP by one member times the expected health expenditure of the healthy one). So split would only mean a bit more overhead in billing.
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Old 11-06-2015, 09:44 AM   #23
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Originally Posted by sengsational View Post
I'm not one to call for legislation very often, but this is yet another trick in their shell game that needs to be tamed; the providers and insurance companies hold all the cards and we're left to navigate the rocky shoals without a map.

As to the OP, as others have said, they now released a "clarification" to require an embedded deductible and max OOP. This hits close to home for me because the BCBSNC rep told me I was getting an embedded deductibles plan when buying my policy for 2014. Then it turned out that wasn't the case and I was $5,500 poorer as the result of that rep's misrepresentation. Then they "lost" the transcript/recording of my call. Yeah, right. But under an embedded scenario, though, even though you have one policy, you don't have to hit the family numbers before they start paying. What this means is that it's more advantageous to get a single policy since, if something bad happens to one person (they cause the policy to hit the family max OOP), the healthy person(s) would get free medical. Under the split scenario, both would have to hit individual numbers. In the case where no body on the policy has a high likelihood of hitting the max OOP, we are probably talking about a miniscule increase in expected value (chance of hitting family OOP by one member times the expected health expenditure of the healthy one). So split would only mean a bit more overhead in billing.
You have me a bit lost here. You talk about under an embedded case that one person hits the individual deductible but then (being real sick) runs expenses up to the family max OOP. See link
From the link I'm guessing in 2016 that max OOP should be embedded too. If both deductible and max OOP are embedded, I'm not sure the advantage of individual policies are for two people unless they want different plans.
Or am I just not understanding your point?
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Old 11-06-2015, 09:54 AM   #24
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Originally Posted by bingybear View Post
You have me a bit lost here. You talk about under an embedded case that one person hits the individual deductible but then (being real sick) runs expenses up to the family max OOP. See link
From the link I'm guessing in 2016 that max OOP should be embedded too. If both deductible and max OOP are embedded, I'm not sure the advantage of individual policies are for two people unless they want different plans.
Or am I just not understanding your point?
I think it is that both deductible and max OOP are embedded. In the HDHP's I look at, the deductible and max OOP are so close as to make them one thing, from a modeling perspective.

There is no advantage to individual policies, as far as I can tell. What I was trying to say was that there was a slight disadvantage. It was slight because a lot of negative stars had to align to make it any different at all from the family policy.
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Old 11-06-2015, 11:36 AM   #25
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There is no advantage to individual policies, as far as I can tell. What I was trying to say was that there was a slight disadvantage. It was slight because a lot of negative stars had to align to make it any different at all from the family policy.
It's an unusual case, but American Indians below 300% of the household poverty line and no "affordable" employer group coverage available to them can purchase an Exchange plan -- *any* plan, even the cheapest bronze HMO -- and have *no* cost sharing whatsoever, at any provider. So if you are in a situation where one spouse is AI/AN and the other isn't, you need separate policies in order to avoid cost sharing on one of them. If you were in a family plan together, you would both be subject to the deductibles and OOP costs.
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