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Old 07-11-2014, 04:34 PM   #181
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For individual vs family deductible, this post is helpful ACA Federal Marketplace updates

How the deductible is counted (aggregate or embedded) should be spelled out clearly in the summary of benefits. BCBS isn't consistent on this throughout the states.
Thanks for that link to the deductable discussion. I find, though, that the SBC is not clear on the point...it seems to be written to address a policy with only one person. Those PDF links I posted, I presume, are 'official', but don't seem t tell the whole story.
I just got off the phone with BCBS of NC. Spent a minute in the phone menu and got a live person in a couple of seconds on hold (that was nice). I made up a specific example that was as simple as possible...the plan of the example has the deductable and out of pocket both at $5,500. I said what if I racked-up $7,000 and my spouse didn't spend a dime. The rep said that insurance would kick-in for the $1,500. My deductable and the famly deductable would be $5,500. Then I said that before the year was over, my spouse racked-up 5,000. The rep said "You would never pay more than $11,000." So in my example, there was 12k of billing, and I paid 10.5k. So it appears that the way these deductables work is not in a sneaky backhanded way, but rather in a logical way.
The unlikely scenario happened, and one of the family needed more than just routine medical care. Claims came in that exceeded the individual deductible of $5,500, and they didn't pay. They're saying that the deductible is $11,000. I'm working with the state insurance commissioners office now.
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Old 07-11-2014, 04:45 PM   #182
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The unlikely scenario happened, and one of the family needed more than just routine medical care. Claims came in that exceeded the individual deductible of $5,500, and they didn't pay. They're saying that the deductible is $11,000. I'm working with the state insurance commissioners office now.
Bummer. Good luck with the complaint. Is this an HSA policy?
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Old 07-11-2014, 04:49 PM   #183
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The unlikely scenario happened, and one of the family needed more than just routine medical care. Claims came in that exceeded the individual deductible of $5,500, and they didn't pay. They're saying that the deductible is $11,000. I'm working with the state insurance commissioners office now.
Seems strange. Are you sure all of the providers were in your network?
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Old 07-11-2014, 05:00 PM   #184
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It wouldn't surprise me at all if you got wrong info when you called. I've had this happen with state insurance my kids had. In WI (called Badgercare) before this year you could pay the full premium and get your kids into this plan regardless of your income, as long as you didn't have employer-sponsored insurance available. Due to Obamacare, they discontinued that part and you have to meet income guidelines, which we don't meet. In the process of losing that insurance, I talked to about 4 different people and got 4 different stories. 1 person said the kids could still get into it in 2014 (WRONG). 1 person said they could never have been in it because our income was too high (WRONG). Another person said they could still get it through our anniversary date in Nov (WRONG) and only one person got the story straight.

I'm really not sure what is so complicated about it that people who do it for a living can't get it right.

We have a policy that is sold as a "Individual Deductible/Family Deductible" but if you have a family, you have to meet the family deductible even if it's only one person getting care. So if all 4 of us are on it and one person needs to be admitted and has surgery or something that costs $20K, we have to pay our full max OOP which is almost $13K!
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Old 07-12-2014, 09:52 AM   #185
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Bummer. Good luck with the complaint. Is this an HSA policy?
Yes.
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Seems strange. Are you sure all of the providers were in your network?
Yes, the insurance company has it in the in network bucket.

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It wouldn't surprise me at all if you got wrong info when you called.
Thats what I think happened.
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Old 07-12-2014, 10:02 AM   #186
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The brochure has a table where hsa and non hsa policies are displayed together without explaining that the individual deductible is meaningless on hsa policies with more than one person.
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Old 07-12-2014, 10:15 AM   #187
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The brochure has a table where hsa and non hsa policies are displayed together without explaining that the individual deductible is meaningless on hsa policies with more than one person.
This is why DW and I took separate individual policies (which I know you can't do because yours is a family plan). There is no language in any of the materials that clearly spells out if the deductible is aggregate or not. I had specific questions on other aspects of the policy, and telereps gave me answers that were different and also inconsistent.
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Old 07-12-2014, 03:46 PM   #188
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When I was comparison shopping I found that if I downloaded the actual plan brochure PDF that I could figure out the deductible type. Some insurers clearly stated aggregate or embedded. For others you had to read the descriptions and those terms were never used. One didn't make it clear unless you read the examples.

What I figured out was that for all the choices I had, any HDHP with HSA used the aggregate deductible. Any other policies were embedded deductibles. I read and understood and also called and asked questions. If you weren't aware of the 2 deductible types this would be very easy to misunderstand.
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Old 07-12-2014, 10:06 PM   #189
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The unlikely scenario happened, and one of the family needed more than just routine medical care. Claims came in that exceeded the individual deductible of $5,500, and they didn't pay. They're saying that the deductible is $11,000. I'm working with the state insurance commissioners office now.
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This is why DW and I took separate individual policies (which I know you can't do because yours is a family plan). There is no language in any of the materials that clearly spells out if the deductible is aggregate or not. I had specific questions on other aspects of the policy, and telereps gave me answers that were different and also inconsistent.
This is something that I had not paid attention to. The catastrophic policies we just bought for the two of us have individual deductibles of $12,700 and a family deductible of $12.700 on the benefits page when I log onto the carriers website. If I look at the summary of benefits and coverage for that plan on the insurers website it indicates an individual deductible of $6,350 and a family deductible of $12,700. So the info is inconsistent. The premium for two is twice the premium for one.

So I'm calling Monday to get some clarity.
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Old 10-21-2014, 02:00 PM   #190
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The unlikely scenario happened, and one of the family needed more than just routine medical care. Claims came in that exceeded the individual deductible of $5,500, and they didn't pay. They're saying that the deductible is $11,000. I'm working with the state insurance commissioners office now.
The final entry of the saga.....

Today I sued BlueCross BlueShield of NC. But, alas, I lost my case.

In between when I realized the HSA policy I bought would not honor the individual deductible, and the case in small claims court today, they had me running around, wasting a lot of time....

First, they said it would be up to the federal marketplace to fix it. I got a "HICS escalation" that went nowhere. That took a month and a half. Then I got the NC DOI to contact BCBSNC on my behalf, and that also went nowhere.

The state department of insurance (NC DOI) looked promising because I had found a case of a guy in Arizona (also on the federal marketplace) who had the exact same complaint: misled by the insurance company product materials about how the individual deductible would work on an HSA-eligible policy. In that case, the injured party got a remedy: the insurance company honored the individual deductible: Health Net Reviews (search for 'zack of Anywhere') . But I think Wayne Goodwin, Insurance Commissioner in NC, is just a lap dog for BlueCross BlueShield of NC. He rolled-over for the insurance company.

In my case this morning, I showed that the 2014 brochure (linked to from healthcare.gov) lacked disclosure of what they call the "family agregate deductible" on HSA-eligible policies. The 2011, 2012, and 2013 all had the disclosure, but the 2014 brochure did not. There was, in fact, nothing on the healthcare.gov site that called-out the defect in the policy, but there were some instances where the deductible that showed was the family deductible only (and the individual deductible was not showing on that page). I'm not sure the judge understood that even the plans that would honor the individual deductible would still just show only the family deductible on those screens. In other words, just not mentioning the individual deductible doesn't mean that it isn't in effect for that policy.

But it is what it is. I spent $130 bucks to sue them, and it was somewhat satisfying to drag them into the courtroom and make them listen to me harp on this for an hour, hehe! I got my day in court, as they say.

I'm greatful that it's over now, since I've been wasting so much time and gastric juices on this. The good news is that instead of being out $5,500, that figure is now down to $2,500, since my wife and I have racked-up $3,000 worth of "free" medical expenses that otherwise would have been out of pocket. And the year ain't over yet!
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Old 10-21-2014, 03:30 PM   #191
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When I was comparison shopping I found that if I downloaded the actual plan brochure PDF that I could figure out the deductible type. Some insurers clearly stated aggregate or embedded. For others you had to read the descriptions and those terms were never used. One didn't make it clear unless you read the examples.
We weren't sure when we signed up if the deductibles/max OOP were aggregate or not so we have two separate policies. It turns out this information is in the Evidence of Coverage document they sent us (they are embedded) but as far as I can tell, you can't download this from their site (blue shield) ahead of time as it needs a login!
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Old 10-22-2014, 09:19 AM   #192
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We weren't sure when we signed up if the deductibles/max OOP were aggregate or not so we have two separate policies. It turns out this information is in the Evidence of Coverage document they sent us (they are embedded) but as far as I can tell, you can't download this from their site (blue shield) ahead of time as it needs a login!
I don't understand why they get away with obscuring the details of the product until after the sale. What if only 3 companies sold TV's, you were required to go to one portal to buy a TV, and although you were given many of the specs on the shopping portal, you don't know the size of the screen until AFTER you purchased? And if it turns out to be a 38 inch instead of the 50 inch you wanted, you must live with the wrong choice for a year.

I know now...two separate policies is the way to go. If I had only known.
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Old 10-22-2014, 10:28 AM   #193
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I think it's just incompetence. Covered CA also doesn't make it clear that HSA accounts are aggregate limits.
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Old 10-22-2014, 12:11 PM   #194
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Anybody know if it is allowable to have multiple individual HSA Exchange Plans for different family members? Or perhaps, if NOT eligible for subsidy, could husband could buy individual HSA Exchange Plan and spouse could buy open market individual HSA plan? That would seem to solve the aggregate family deductible issue.
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Old 10-22-2014, 12:53 PM   #195
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This is something that I had not paid attention to. The catastrophic policies we just bought for the two of us have individual deductibles of $12,700 and a family deductible of $12.700 on the benefits page when I log onto the carriers website. If I look at the summary of benefits and coverage for that plan on the insurers website it indicates an individual deductible of $6,350 and a family deductible of $12,700. So the info is inconsistent. The premium for two is twice the premium for one.

So I'm calling Monday to get some clarity.
I thought I would write a followup. I called BCBS and they confirmed that the deductible was $12,700 and is an aggregate deductible ($6,350 * 2 people). I then asked if we could instead buy two policies, one for me and one for DW and they said sure, so that is what we did. By having individual policies for each of us we'll get more out of the insurance if we have a health event and the premium for two policies is the same as it would have been for us as a couple so perhaps there is such thing as a free lunch.

I'm sure they make a lot of money on aggregate deductibles vs individual deductibles but for us the simple solution was to simply buy two policies.
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Old 10-22-2014, 03:12 PM   #196
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Anybody know if it is allowable to have multiple individual HSA Exchange Plans for different family members? Or perhaps, if NOT eligible for subsidy, could husband could buy individual HSA Exchange Plan and spouse could buy open market individual HSA plan? That would seem to solve the aggregate family deductible issue.
Yes. From the ACA threads last year discussing policy options, many of us are doing just that. The cost for two separate individual policies is the same as the cost for one family policy for two adults. Not sure about the cost when children are included.

Edit to add: there is no requirement for one single policy to cover multiple members of the same household.
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Old 10-22-2014, 05:25 PM   #197
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Yes. From the ACA threads last year discussing policy options, many of us are doing just that. The cost for two separate individual policies is the same as the cost for one family policy for two adults. Not sure about the cost when children are included.

Edit to add: there is no requirement for one single policy to cover multiple members of the same household.
Does having the separate individual policies impact the subsidy received?
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Old 10-22-2014, 05:27 PM   #198
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Does having the separate individual policies impact the subsidy received?
No. The subsidy is based on household income and household health insurance costs.
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Old 10-22-2014, 08:19 PM   #199
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Last year I asked the insurance company if we could get two individual policies and I was told that if you are married filing jointly you cannot get individual policies and still get the subsidy. If you don't want to get the subsidy you could get individual policies. We needed the subsidy, got a family HDHP with an HSA and the aggregate deductible was $12,000.

If we consider an HDHP with HSA again for 2015 I will definitely ask about this again.

Also, I tried to choose 2 different policies for DH and I from the Marketplace (with subsidy) and it wouldn't work. This was very early in the process when the website was so awful.
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Old 10-22-2014, 09:44 PM   #200
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Here's a KFF FAQ confirming married couples can get separate policies and premium assistance. Health Reform FAQs | The Henry J. Kaiser Family Foundation
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Q: My wife and I qualify for a premium tax credit, but our doctors participate in different health plan networks so we want to sign up for two separate plans. Can we do that?

A: Yes. The Marketplace will allocate the monthly advance payment across the two plans. In most cases the Marketplace will allocate the monthly advance payment in proportion to the premiums for the two plans.

There are many reasons a couple would want or need separate policies. For example, one has a chronic illness and wants a low deductible policy while the other is healthy and wants a much higher deductible. Also, they could each have physicians in different networks. What is clear is the ACA guarantees individual, not joint, access to policies, and premium assistance is based on household income.


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