How premiums work
Up until now, I have only purchased privately an HMO policy that has no deductible. So I am unfamiliar with how these deductibles work. Looking at the available exchange policies in my state, they are all HMO's as far as I can see. Average deductible around $4,000 which states medical and drug deductable. And most have Total max at around $6,000 a yr. Now as they state that deductible is for both medical and drugs, it says to me that if you had some expensive drugs you needed to take each month or if you were a diabetic as an example and needed insulin shots (have no idea how expensive these are) I would assume you would have to spend $4,000 in addition to your premiums every year, making insurance for a single person pretty expensive every year, as those medications are re-occurring. (It could be heart medications as well. Just using an example)
First, am I correct in these assumptions? Second, they state various costs (co-pays) for things like seeing a GP or a Specialist at say $40 & $80, as well as stating different costs for different things like X-rays, Cat Scans, etc. So do I assume that these co-pays come into play only after you spend $4,000? You have to pay all your doctor bills in full and your medications in full until you reach that $4,000 mark. You would have to have an awful lot of doctor visits to use up that deductible, so doctor visits would probably not get you there, but medications could if you had some kind of chronic illness.
From what I can gather, the plans that have low deductibles but higher cost plans, have very restrictive doctors you can see. That was my experience with my son's previous HMO with BCBS. Even though the cost for the policy was not cheap for an HMO for a 32 yr. old. ($420 a month) He just had co-pays which were reasonable $25 for GP, and I think $40 for Specialist.
In trying to select a plan, I am concerned with two things (not having a $4,000 deductible that includes medications in that deductible, and opening up the availability of doctors to at least have a few choices. I don't care if the co-pays are higher, as long as there was a cap on the Total out of pocket costs should something serious happen. Seems like the two don't go together. (cover medications and some choice of doctors even with higher premiums)
Anyone have any experience with this? His income is very low, so he qualifies for a subsidy, but no PPO's are available on it.