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Calculations/figuring out which ACA plan to buy?
Old 12-08-2014, 10:01 PM   #1
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Calculations/figuring out which ACA plan to buy?

I'm confused about how to figure out whether to get a 0% co-insurance PPO, or a 20% co-insurance PPO.

(Below is in-network only, for simplicity. I'm looking a subsidized silver PPO plans.)

The 0% co-ins plan has deductible/OOPmax of 1500/1500. The 20% co-ins plan has a deductible/OOPmax of 500/1500.

So am I correct in assuming that, if I choose the 20% co-ins plan (which has a higher premium) I am gambling that, after a 500 deductible, my medical expenses will not exceed 5000? After that point, my OOP is 1500, so I"m on the same footing as if I had the 0% co-ins plan?


Next question: reading the fine print of BCBS-TX, it states that co-pays do not count toward deductibles. But do they count toward the OOPmax? The fine print says that premiums and balance-billed charges do not count toward OOPmax, but there is no montion of co-pays.

I also have to choose between a multi-state plan and a non-multistate plan. The multistate plan has lower premiums than the non-multistate plan; the co-pays are higher. The networks are the same. It is a toss-up?
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Old 12-09-2014, 07:31 AM   #2
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For covered in-network services, the most you would be responsible for is $1500 under either plan. The difference is how you reach the $1500 maximum OOP. Under the 0% plan, you have reached the $1500 OOP max when you meet the $1500 deductible. Under the 20% plan, you pay the first $500 (deductible), then for medical services in the $500.01-5500.00 range you pay 20%. This $1000 in co-insurance is added to the $500 deductible to reach your $1500 max OOP.

Keep in mind the $5500 in medical services is based on the insurer's allowed amount, which may be less than the provider's billed charges. For example, a provider bills $8750, the insurer's allowed amount based on the contract negotiated with the provider is $5500, and your responsibility is $1500.

Co-pays, such as for an office visit, are not applied to the deductible. They do count toward the OOP max.

The choice between single or multi-state would be a personal decision based on how much time you spend in the other states, how often you expect to incur the co-pay fee, and if the lower co-pay offsets the higher premium.
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Old 12-09-2014, 07:42 AM   #3
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Quote:
Originally Posted by BarbWire View Post
I'm confused about how to figure out whether to get a 0% co-insurance PPO, or a 20% co-insurance PPO.

(Below is in-network only, for simplicity. I'm looking a subsidized silver PPO plans.)

The 0% co-ins plan has deductible/OOPmax of 1500/1500. The 20% co-ins plan has a deductible/OOPmax of 500/1500.

So am I correct in assuming that, if I choose the 20% co-ins plan (which has a higher premium) I am gambling that, after a 500 deductible, my medical expenses will not exceed 5000? After that point, my OOP is 1500, so I"m on the same footing as if I had the 0% co-ins plan?
See post 85 in this thread for a very helpful excel spreadsheet by Animorph that allows you to plug in the premiums and cost sharing for different plans and compare the total cost. Bronze, Silver and Coinsurance/Copay

Quote:
Originally Posted by BarbWire View Post
Next question: reading the fine print of BCBS-TX, it states that co-pays do not count toward deductibles. But do they count toward the OOPmax? The fine print says that premiums and balance-billed charges do not count toward OOPmax, but there is no montion of co-pays.
Yes, copays count toward total out of pocket.
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Old 12-09-2014, 08:58 AM   #4
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Thank you for the replies; I will look at the spreadsheet in short order.

My next point of confusion -- and one for which I get conflicting answers from the BCBS-TX reps -- is "balance billing." Does this occur only when one uses out-of-network providers, or is there the potential for it with in-network providers?

That is, suppose I go to in-network provider Smith, and they bill BCBS-TX $3000 for their services. The agreed amount is $1800. Will Smith then charge me the $1200 balance (which won't apply to my OOPmax)? Or is that, by definition, something that won't happen with an in-network provider?

I have asked three BCBS-TX phone reps this, and the answers have been "yes, they can balance-bill even if they are in-network,", "no, in-network providers agree not to balance-bill," and "we can't tell you without an actual claim in hand".

It's the balance-billing that scares me: everything else I can pretty much estimate.

Thanks.
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Old 12-09-2014, 09:07 AM   #5
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What I do is look at my total for premiums, deductible and co-pays under three scenarios for each policy being considered. First, we don't have any medical issues, in which case the only cost is the premiums paid. Second, we have a serious illness, in which case the total cost is the premiums and maximum out of pocket costs (deductibles and co-pays) and third, our likely medical costs based on recent history and current health.

Then I make a judgement call based on those results. I personally put the most weight on the third scenario but consider the others. IIRC the spreadsheet, it take a similar approach.

In our case, the pricing of catastrophic coverage is quite favorable because our state does not age-rate and the coverage is not that different from bronze level coverage so that is our best alternative. Having only two carriers to chose from also makes it easier in my case.
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Old 12-09-2014, 09:28 AM   #6
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Balance billing varies by state, here's a table from kaiser with state data. Looks like the only state with no restrictions on balance billing in-network is Alaska

State Restriction Against Providers Balance Billing Managed Care Enrollees | The Henry J. Kaiser Family Foundation

Here's a presentation with some balance billing info near the end. ACA made some changes regarding emergency treatment balance billing but mostly still a state issue.

http://www.nhpf.org/uploads/Handouts...s_12-06-13.pdf
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Old 12-09-2014, 03:30 PM   #7
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In my experience, if a doctor has signed onto the network, then has also agreed to accept the negotiated rate as payment in full. One of the main reasons I buy insurance is to have access to those prices. If I couldn't be guaranteed those prices, health insurance would be a hard sell!
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Old 12-09-2014, 04:23 PM   #8
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Thanks for the links; they have clarified the balance-billing issue.

It boggles my mind that the BSBC phone reps have so little grasp of the policies, terms, etc. On the other hand, I suspect that most of the phone reps are temps who have been hired for the open enrollment period and really don't know anything about health insurance....

Once again, this forum to the rescue!
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Old 12-11-2014, 12:38 PM   #9
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OK, after using the excellent plan comparison spreadsheet provided last year by Audrey1, reading for hours, and recalculating my 2015 MAGI correctly (duh, with capital gains in addition to dividends and interest it will be about $30K ) I have reached the following conclusions:

  1. It is highly unlikely that I will qualify for cost sharing, and if so it will be very little. Given that,
  2. Running the numbers at $30K income for Bronze and Silver PPO BCBS-TX really points towards a Bronze plan (I'm not a big consumer of medical care, but I know that in 2015 I'll need a foot injury addressed)
  3. There are two Bronze PPO plans:
  • Bronze PPO 005: $305/month, 20% co-ins, $5000/$6600, not HSA eligible
  • Bronze PPO 006: $284/month, 0% co-ins, $6000/$6000, HSA eligible
My inclination is to take the Bronze PPO 006: OOPMax = Deductible, is HSA eligible, and has the lower premiums. And then see how this year goes, and if PPO 005 would have been a better choice.

Does that make sense?

And I can pay my expenses up to OOP Max using the HSA money, right?

I want to pull the trigger on this tonight, and stop obsessing over it.


Cheers.
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Old 12-11-2014, 04:30 PM   #10
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I agree with your choice of the Bronze PPO 006. It looks to me like the only benefit to the 005 plan is that between $5000 and $6600 you pay 20% until you get to $6600. So you still get to the $6600 level it just slows down between 5K and 6.6K. The 006 plan having the HSA eligibility is very nice. Look into the triple tax benefits of that.
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Old 12-11-2014, 05:38 PM   #11
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Thank you, Sue J. Having the affirmation is good.

As someone said in another thread, when you've boiled it down to a couple of plans, you can't go too far wrong. But I worry (unnecessarily) about the difference between "not wrong" and "right" -- especially when my grasp of the subject is so tenuous.
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Old 12-11-2014, 06:57 PM   #12
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Quote:
Originally Posted by BarbWire View Post
Thank you, Sue J. Having the affirmation is good.

As someone said in another thread, when you've boiled it down to a couple of plans, you can't go too far wrong. But I worry (unnecessarily) about the difference between "not wrong" and "right" -- especially when my grasp of the subject is so tenuous.
You can look at it as "worse case scenario" as if you met MOOP on either plan-

Bronze 005 $305x12 months = $3660+6600=$10260
Bronze 006 $284x12 months = $3408+6000=$9408

Also consider the tax deduction for the HSA. You don't say if you are single (3350) or married (6650) or over age 55 (additional $1000) but that gets you lower taxes. Also, if you are getting an ACA subsidy then your lower income means your subsidy should have been larger and that gets reconciled when you file your 2015 taxes in 2016.

We funded our HSA for 2014 with $7550, not all at once but in chunks throughout the year. I am not a genius investor but it has grown by over $350, invested in Vanguard funds. The tax deduction for the $7550 lowers our taxes by $755. Our now smaller MAGI means that our ACA subsidy was smaller than it should have been and that will be adjusted by almost $800 in our favor. Our now smaller Federal AGI carries over to our state return and that will reduce our state income tax by about another $250.
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Old 12-11-2014, 08:33 PM   #13
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Guess I need to find a HSA account administrator -- my balance (2014 which I haven't paid yet) and 2015 will be $4350*2, so fees will be a factor....
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