Bronze, Silver and Coinsurance/Copay

[GLM]

One thing I'm probably doing wrong is that the deductable and out of pocket max are for one person, and the prices are for a policy on a couple and 18yo. I don't know how the family/individual deductable and oopm works. If one person needed big-time care and blew through $5,500, I need to see if the insurance company would start paying, or if we'd need to hit the family deductable/oopm.

[/code]

I learned about this when we switched from mega corp coverage to the individual market. Unlike most employer coverage, individual coverage (which is what is in the ACA market place) generally have plans that pay only after the full family deductible is reached . That is if one spouse requires a lot of care the full family OOM must be reached for coverage to kick in .

Seems like I was reading that a lot of folks would be shocked by this in the ACA marketplace. (as well as by the high OOPM)

 

[47]

I learned about this when we switched from mega corp coverage to the individual market. Unlike most employer coverage, individual coverage (which is what is in the ACA market place) generally have plans that pay only after the full family deductible is reached . That is if one spouse requires a lot of care the full family OOM must be reached for coverage to kick in .

Seems like I was reading that a lot of folks would be shocked by this in the ACA marketplace. (as well as by the high OOPM)

That is incorrect.

Individual deductible works like you expect it to work. If only one in the family runs up the bills they would have to satisfy only the individual deductible before insurance starts paying.

Family deductible actually works in your favor. If you have a family of four, each member may be below their deductible but the family deductible may be reached and after that insurance will start paying for all the family members.

Similarly there is a separate out of pocket max counter for the individual as well the family. Typically if two people max it out the whole family would be fully covered thereafter.

 

[MichaelB]

For individual vs family deductible, this post is helpful http://www.early-retirement.org/forums/f38/aca-federal-marketplace-updates-67141-6.html#post1370758

For those of you wondering about individual vs family deductible, here's what I learned from our current insurer last week when I called to ask about their Marketplace plans. There are 2 kinds of deductibles, embedded and aggregate (non-embedded ).

The HSA plans I was asking about have the aggregate deductible which means that if there is more than one person on the plan the entire deductible has to be met before any benefits are paid, for us that's 2 times the $6000 = 12000 for example. For a family of more than 2 it may be limited to 2. Not certain about that.

For the non-HSA plans the deductible is embedded and applies per person. If person A meets the deductible of $6000 then after that benefits are paid to person A even if person B had not met the deductible. Talking to my insurer their HDHP with HSAs are all aggregate and their non-HSA plans are all embedded deductible. I don't know if all insurers treat HDHPs with HSAs vs regular insurance the same way.

Something to consider when shopping for plans and none of it is explained very well at Healthcare.gov. Like that's a surprise.....

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.

 

[audreyh1]

For individual vs family deductible, this post is helpful http://www.early-retirement.org/forums/f38/aca-federal-marketplace-updates-67141-6.html#post1370758



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.

Another reason to have two separate policies if there are just two of you?

Are people considering "family" policies for couples? There is no price break in our case, and we are planning on signing up individually.

I find the family total deductible and max OOP applying to just one individual hard to believe.

 

[MichaelB]

Another reason to have two separate policies if there are just two of you?

Are people considering "family" policies for couples? There is no price break in our case, and we are planning on signing up individually.

I find the family total deductible and max OOP applying to just one individual hard to believe.

+1

It seems to me even using the term "individual deductible " on one of these policies is misleading. We took separate policies years ago for this reason. I can think of one situation where an aggregate deduction would be a smart choice, which is a platinum level policy with very low deductibles and a family where one member has some kind of chronic condition and the entire OOP is met in the first month. Not the case of most people here. With a high deductible policy, aggregate deductible is painful.

 

[rbmrtn]

Another reason to have two separate policies if there are just two of you?

Are people considering "family" policies for couples? There is no price break in our case, and we are planning on signing up individually.

I find the family total deductible and max OOP applying to just one individual hard to believe.

I'm not sure you have a choice, at least in regards to subsidies. Couples have to file a joint return and the household income is taken for subsidy calculation. But there may be cases where the subsidy is less beneficial than having individual deductibles

 

[bizlady]

Another reason to have two separate policies if there are just two of you?

Are people considering "family" policies for couples? There is no price break in our case, and we are planning on signing up individually.

I find the family total deductible and max OOP applying to just one individual hard to believe.

I think that if the plans have two separate administrators, they are NOT required to combine these to create the family max deductible until at least 2015.

However, where it is just a couple, $6250 max each (plus premiums) is the max out of pocket anyway.

 

[Animorph]

It seems like I'm using the spreadsheet correctly, but I'm getting some "interesting" results.

I kind of expected that plans with the lowest premium cost would be cheapest overall to "operate" as long as your medical utilization was low, but the higher premium plans would have an advantage if you needed more services. But that doesn't seem to be true, based on what I've seen in the spreadsheet (if I'm doing this right). It seems like coinsurance isn't really worth very much in a lot of cases.

Blue Value Bronze 5500 is in the sheet, rows 9 through 12, as ($1,065, $5,500, 0%, $5,500). That one has a deductable the same as out of pocket max, so there really is no coinsurance. I expected that one to "win" if my expenditures were low, but lose if expenditures were high, but it wins hands-down (which makes me wonder if I'm doing this right). The second best one appears to be Blue Value Silver, which I have in there as ($1,167, $3,000, 30%, $6,350).

One thing I'm probably doing wrong is that the deductable and out of pocket max are for one person, and the prices are for a policy on a couple and 18yo. I don't know how the family/individual deductable and oopm works. If one person needed big-time care and blew through $5,500, I need to see if the insurance company would start paying, or if we'd need to hit the family deductable/oopm.

I entered your numbers and looked at the results. What I'm seeing is the cheaper policy is better with low medical expenses, as expected. The pricier plan is very slightly better for $6000 in expenses. The cheaper plan is better after that.

The reason is that the cheaper plan has slightly lower premiums and has the advantage for the first dollar of medical expenses. Then the lower deductible kicks in for the pricier plan and it is briefly able to pull ahead as you pay only 30% of medical expenses instead of 100%. Then you hit the OOP, which is smaller for the cheap plan than for the pricier plan. The cheaper plan is again better in that case. Given the small chance that your medical expenses will be close to $6000 for any given year, the cheaper plan seems better.

Hopefully the deductible/OOP discussion will help with what to enter for those numbers.

By the way, if you don't populate the spreadsheet with a full nine plans, you can enter 1000000 for monthly premium costs to make them look really bad and keep them out of the comparisons.

 

[47]

Another reason to have two separate policies if there are just two of you?

Are people considering "family" policies for couples? There is no price break in our case, and we are planning on signing up individually.

I find the family total deductible and max OOP applying to just one individual hard to believe.

Same here. I am not sure if the family HSA policies make sense for even with one or two kids. The real price break comes in to play when there are more than two kids. Otherwise, the individual premiums are just added up.

Typically the family dedcutibles quoted are double the amount of individual deductibles. Even with three people (a couple and one kid) , I don't see the combined family deductible working in our favor unless all three people have huge medical bills like being in a car accident together.

So why would anyone bother getting a family plan? Read the para under "embedded warning" in the following link:
Embedded vs. Non-Embedded Deductible | Medical Claims Consulting

The Blue Cross plan I am looking at in the exchange has the following:
Key benefitsBronze 60 Health Savings Account
Individual Deductible $4500
Family Deductible $9,000
No details as to whether this "embedded" or not. am I to assume, the plan won't pay anything unless we hit the $9000 figure combined?

I wouldn't think there would be even an individual deductible to speak of in a non-embedded family plan. I think as far as nomenclature goes it should then be:
individual policy deductibe, and family policy deductible to be less confusing.

 

[GLM]

I learned about this when we switched from mega corp coverage to the individual market. Unlike most employer coverage, individual coverage (which is what is in the ACA market place) generally have plans that pay only after the full family deductible is reached . That is if one spouse requires a lot of care the full family OOM must be reached for coverage to kick in .

Seems like I was reading that a lot of folks would be shocked by this in the ACA marketplace. (as well as by the high OOPM)

47 Percent - Glad to hear am wrong , thanks for the catch. I thought I put enough qualifiers (generally, most ) on it as I was only speaking from my experience. It was late and I should have added that qualifier too.

Earlier this year I was shocked that I could not find lower, individual (embedded? ) deductibles in the individual market. I even went to an insurance broker for help and she told me what I was looking for did not exist . She explained that while employers may offer that plans you buy on your own don't have that . My experience in looking for myself bore that out . Perhaps because I want an HSA eligible plan it is a rare thing . It took awhile to emotionally learn to live with a 10k deductible . We have been fortunate to never go over 2K in costs OOP.

Anyhow, I went looking today for individual deductibles in the individual market . On eHealth as I still can't get verified for the exchange. I found some and choice is a good thing. ( If you click through the links at eHealth you can get more detailed deductible information. ) Unfortunately in my market they don't appear with HSA plans that also use my Doctors.

As a disclaimer I would say don't trust eHealth, me or anyone . Read the SOB for the legal specifics.

Aggh getting so tired of this . Just found out we have the option to keep our plan through 2014. Very tempting . Catch is , we won't know if they will raise our rates until we are well into 2014 . I called to ask and the person on the phone said we might get the normal inflation adjusted type increase but that they were not changing the plan until the end of 2014. ( I took this to mean brace yourself for 2015. ) Our plan is currently basically like a bronze ACA compliant except that we had to underwrite when we bought it last March. We pay $512/mo now and the closest plan I see for 2014 on eHealth ( without subsidy) is $957 /mo !

Does anyone know if a rate increase constitutes a qualifying event to sign up between March 2014 and the next enrollment period ?

 

[47]

Aggh getting so tired of this . Just found out we have the option to keep our plan through 2014. Very tempting . Catch is , we won't know if they will raise our rates until we are well into 2014 . I called to ask and the person on the phone said we might get the normal inflation adjusted type increase but that they were not changing the plan until the end of 2014. ( I took this to mean brace yourself for 2015. ) Our plan is currently basically like a bronze ACA compliant except that we had to underwrite when we bought it last March. We pay $512/mo now and the closest plan I see for 2014 on eHealth ( without subsidy) is $957 /mo !

Does anyone know if a rate increase constitutes a qualifying event to sign up between March 2014 and the next enrollment period ?

Any rate they offer as a renewal rate should hold for a full year -- Unless one of the people covered in the policy is moving to different age band (typically 40-45-50-55-60 etc) the rate should not change in the middle of the year. If that is the case, they can hike the price immediately after that birthday. Even then it should be consistent for the policy as a group, and cannot come-up with some random amount just for you. I have to add a disclaimer here that the above is true is a normal state where the insurance regulation works and is allowed to work normally. I am not sure how it works in those states where they shoot first and ask questions later.

There is no bracing for 2015. If your policy is non-ACA compliant grandfathering is only for one year. If it is already ACA compliant, the market forces will overtake and overwhelm any pricing pattern that is unique to that policy. Either way, 2015 is a whole new ball game.

Rate increase does not constitute a qualifying event.

 

[bizlady]

Does anyone know if a rate increase constitutes a qualifying event to sign up between March 2014 and the next enrollment period ?

A rate increase is not a qualifying event. However, if the premium for ONE person exceeds 9.5% of family income, then you can make the switch.

 

[sengsational]

For individual vs family deductible, this post is helpful http://www.early-retirement.org/forums/f38/aca-federal-marketplace-updates-67141-6.html#post1370758



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.

 

[Bestwifeever]

Here's the spreadsheet I created to compare a few health plans. It simply compares the costs of several plans for a given level of medical charges for the year, assuming you pay premiums, a deductible, and then coinsurance amounts, with a maximum out of pocket amount that includes both the deductible and coinsurance. Not a lot of detail. You enter the plan data and it creates a table that shows you costs for various levels of medical charges. It's pre-loaded with real plans I was looking at directly from BCBS.

You can see one plan is best with low medical charges, one is best with high charges, one or two are best within a particular range of charges, and one was actually not too far off from the best at all charge levels.

Thank you so much for this spreadsheet! Yesterday we learned that COBRA just for me through DH's megacorp retireee HI will be $915 a month, a little more than what we had been paying for both DH and me on his megacorp retiree HI plan (which he leaves next month to start Medicare). I was happy to get back on the exchange this morning and get through the application process to see that the most expensive Gold plan would be less than that, and a Bronze PPO Blue Choice plan with our doctors is $350 a month. These are all without any subsidy.

You can be sure I will be filling out Animorph's spread sheet with several plans including my COBRA coverage (which also has deductibles and OOP to consider), before deciding on the $350/month plan .

 

[Sue J]

Here's the spreadsheet I created to compare a few health plans. It simply compares the costs of several plans for a given level of medical charges for the year, assuming you pay premiums, a deductible, and then coinsurance amounts, with a maximum out of pocket amount that includes both the deductible and coinsurance. Not a lot of detail. You enter the plan data and it creates a table that shows you costs for various levels of medical charges. It's pre-loaded with real plans I was looking at directly from BCBS.

You can see one plan is best with low medical charges, one is best with high charges, one or two are best within a particular range of charges, and one was actually not too far off from the best at all charge levels.

Another THANKS for the spreadsheet. I had made something similar for myself but yours is nicer.

We've already picked a plan and enrolled and even paid the first bill. But I still like playing with the options. The tough part for me was comparing 2 Bronze HDHPs with HSA that have the combined (aggregate) deductible of $8000 or $12000 vs Silver plans with co-pays and co-insurance where the deductible is per person. So I compared the 2 Bronzes to each other and the 2 Silvers to each other. The monthly premium cost difference between the Bronzes and the Silvers was large so the first step was deciding what our idea of health insurance needs to be and we decided to go for a low cost Bronze with an HSA.

 

[sengsational]

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.

 

[audreyh1]

Well, drum roll....., I'm getting ready to sign up online - probably tomorrow. Definitely this week.

Here is my analysis for my personal case. I'm most likely to go with the Bronze PPO plan in the first column.

DH and I are signing up separately. Once I sign up, he'll probably sign up next week.

 

[donheff]

Well, drum roll....., I'm getting ready to sign up online - probably tomorrow. Definitely this week.

Here is my analysis for my personal case. I'm most likely to go with the Bronze PPO plan in the first column.

DH and I are signing up separately. Once I sign up, he'll probably sign up next week.

Sounds like you have a lot of company. I read this morning that mid Nov numbers show California on target for enrollments and a couple of states ahead. The Federal exchange still lags of course but it will be fixed in two weeks.

 

[jowi]

Wow, that's a great comparison! Nobody could accuse you of not choosing your plan thoughtfully!

 

[audreyh1]

Wow, that's a great comparison! Nobody could accuse you of not choosing your plan thoughtfully!

Thank you!

 

[MichaelB]

Well, drum roll....., I'm getting ready to sign up online - probably tomorrow. Definitely this week.

Here is my analysis for my personal case. I'm most likely to go with the Bronze PPO plan in the first column.

DH and I are signing up separately. Once I sign up, he'll probably sign up next week.

Signing up separately is a good idea. I'll follow suit, less chance of getting stuck in one family policy with aggregate deductibles.

Thanks for posting the worksheet. I'm surprised at the pricing, such differences between Texas and Florida. Your BCBS is a PPO and costs less than Humana. For me BCBS only offers an EPO, which isn't as good, while Humana has an (apparently) wider network at a much lower premium. Even after having worked in corporate pricing, I am always surprised at how businesses position their products and use pricing to drive demand toward (or away from) from specific offerings.

 

[rbmrtn]

Thank you!

Your examples show similar results to what I was calculating. An interesting thing to me is after reaching a certain level of expenses the total annual costs tend to level out, there is not a lot of total cost difference between bronze to gold.

The only thing the higher metal plans give you is spreading the cost sharing between the deductible and the expenses where the OOPM is hit. So if you have low expenses, bronze wins and if you have really high expenses ( $10k+), bronze wins. At least that's what I see.

 

[audreyh1]

Signing up separately is a good idea. I'll follow suit, less chance of getting stuck in one family policy with aggregate deductibles.

Thanks for posting the worksheet. I'm surprised at the pricing, such differences between Texas and Florida. Your BCBS is a PPO and costs less than Humana. For me BCBS only offers an EPO, which isn't as good, while Humana has an (apparently) wider network at a much lower premium. Even after having worked in corporate pricing, I am always surprised at how businesses position their products and use pricing to drive demand toward (or away from) from specific offerings.

I believe that BCBS has the dominant network in TX by far. Sounds like Humana has the better network in FL.

I get the impression that BCBS operates somewhat independently in each state - they certainly aren't consistent in their approach from state to state.

No, I wouldn't touch an EPO either - too restrictive.

Pretty much we'll probably always go with whoever has the more extensive network, even if we have to pay a bit more. Access and negotiated prices are the most important to us. (Plus the actual insurance to limit OOP expenses)

Another reason we are staying separate is that keeps our insurance decisions separate. Either one of us can change policies without affecting the other.

And our starting point is different. I don't have insurance next year, and DH does but is switching policies. Our sign up process may be slightly different.

 

[ziggy29]

The only thing the higher metal plans give you is spreading the cost sharing between the deductible and the expenses where the OOPM is hit. So if you have low expenses, bronze wins and if you have really high expenses ( $10k+), bronze wins. At least that's what I see.

I could construct situations where silver barely wins, even without eligibility for cost sharing. But those were rather uncommon cases, and in almost all situations, bronze would still win. And I don't see how Gold or Platinum would ever "win", at least not based on the plans available to me -- and even less so since they are not HSA-eligible like the Bronze and Silver plans can be (which also lets you reduce your MAGI and potentially increase your tax credits).

Of course, if you have income below 250% of FPL and cost sharing kicks in, Silver looks better.

 

[audreyh1]

Your examples show similar results to what I was calculating. An interesting thing to me is after reaching a certain level of expenses the total annual costs tend to level out, there is not a lot of total cost difference between bronze to gold.

The only thing the higher metal plans give you is spreading the cost sharing between the deductible and the expenses where the OOPM is hit. So if you have low expenses, bronze wins and if you have really high expenses ( $10k+), bronze wins. At least that's what I see.

Yep - pretty much.

And in the occasional intermediate cases, which are perhaps more common than the extreme, the difference can be very small amount if you choose a Bronze plan with a lower deductible.

I suspect TX requires 20% copays or less and that helps the Bronze cases. In other states Bronze has higher copays. Still....