Need new 2015 ACA plan: Help!

[tizlo]

I posted part of this as a reply in another thread, but please allow me to make a new thread with a request for suggestions for our situation. If you have already read the first part below then skip on down to the new part with more info. Thank you.

My wife and I bought a high deductible PPO plan ($6000/each, $12,700/family) on healthcare.gov in December 2013. We had been buying private health insurance since 1999. Recently we got a letter saying that assuming nothing had changed (same plan, same income) then we were going to have our premium increased by 68% on 1/1. Our income has gone up a bit since 12/2013 though (a little more in dividends and interest) so it is going to be more than a 68% increase. When I plugged in my expected 2015 income (just 7% more than what I estimated our 2014 income would be) healthcare.gov says our premium is going up 98%.

Right after we got that letter my sister told me that my nephew who also bought a plan on healthcare.gov received a similar letter. His premium is going up 105%! His income is slightly up since 2013 too though so he is looking at a more than 105% increase.

My wife and I are trying to figure out what to do now. We already have the cheapest PPO plan available. We spend lots of time out of state, after all we are FIRE, so it seems like an HMO, which is about the same price in 2015 as the PPO was in 2014, would be pretty much pointless.

New info: For the last 14 years we have lived a somewhat nomadic life. We live part time in various states and countries. As an example, in 2014 we only spent 3 months in the U.S. In 2013 we spent 6 months in the U.S., but only 3 months in our state of residence. In 2012 we spent 6 months in the U.S., but only 1 month in our state of residence. With our PPO insurance we can make use of it in other parts of the U.S. (at least get negotiated rates since our deductible is so high), but when we are out of the country the premiums are mostly just money thrown away.

Now we are faced with keeping the high deductible PPO at the new much higher 2015 cost so that when we are in the U.S. from time to time we have some coverage (and also to comply with the law). Or for 2015 get the cost back down to the 2014 cost, but with an HMO that would be almost totally useless for us. In other words, just pay the premiums and think of it as a high tax that we get nothing for. And then in December 2015 we will probably find that even that is no good any longer when we get the next 68% or 77% or 112% increase.

I see that this year healthcare.gov is showing a few POS and EPO plans that are more than HMO plans, but less than PPO plans. I am still investigating to see if they have any advantages compared to HMO for our unique case. We have until 12/15 to decide, but we are traveling to to another country for a month on 12/10 so this needs to be taken care of before then, within the next 3 days.

All of our choices seem horrible, but I wonder if some of the very knowledgeable people here might have some ideas we haven't thought of?

[papadad111]

Similar discussion here. http://www.early-retirement.org/foru...ad.php?t=74606

Similar situation - we are planning to be global nomads once FIREd. Unsure where we will be or for how long. Which city/state/country ...who knows!!

Lots of considerations - if we get sick, are we willing to stay in the medical care system of ( pick country here). If not, then having access to usa medical care ( and insurance) will be essential.

We are viewing this like you - as a tax to have access to usa medical care.

That implies a domestic usa and an international cover with medivac policies. One international and one usa policy through different insurance carriers.

The global coverage policies that I've seen usually offer to cover up to 60 days in usa but they require that you be a resident of another country .. And don't help if you want,say, cardiac bypass or cancer treatment in a usa hospital. Not sure where we will be resident (usa or abroad) yet so those won't work. Estimate at least 50 percent of fire time outside usa in early post FIRE stage.


I am considering to buy a non-ACA compliant policy bypassing healthcare.gov given cost savings and just pay the penalty. However that prevents any subsidy from being awarded. (Hope i don't need maternity care...). Then purchase a global policy for top quality coverage for use outside USA.
And, Reassess annually as circumstances change. Need to price this all out

Have not found a true global policy that covers world wide and is ACA compliant although when surveying people I know, seems they are all covered through mega corp using Aetna Global and that provides coverage world wide - maybe it's also available through an insurance broker. I am searching and have a couple brokers on it too.

We usa nomadic gypsies are a rare breed apparently and not a big enough segment to target insurance products. My euro friends have much easier time with global insurance ... It's more a part of their retirement culture I guess.


Will be following this thread too ...

[Fermion]

Also going to be doing the nomad thing, but for now limited to Alaska, Canada, and the lower 48. In Texas the Blue Cross Blue Shield PPO plan seems to have some support for out of network coverage (and also has a fairly big network) so we are likely to call Texas home.

When we buy a sailboat and start world sailing, I see problems. That is five or six years in the future though...

[pb4uski]

Wouldn't an HMO plan cover someone while traveling? We had one 20+ years ago, but i would think there would be coverage while traveling.

[Fermion]

Quote:

Originally Posted by pb4uski Wouldn't an HMO plan cover someone while traveling? We had one 20+ years ago, but i would think there would be coverage while traveling.

It is the out of network treatment that will get you. If you are abroad and get seriously injured to the point where you can not be safely medevac to your home town hospital I could see tens of thousands of out of pocket costs.

Obviously if I am traveling in Europe and get diagnosed with some very expensive to treat disease that is not yet affecting my mobility, I can rather easily fly back home to start the treatment at my HMO.

[pb4uski]

I guess I was thinking of someone traveling in the US. Even if an HMO wouldn't their total exposure be their ~$6k deductible?

I understand that if you leave the confines of the US it is a whole different ball game.

[Fermion]

Quote:

Originally Posted by pb4uski I guess I was thinking of someone traveling in the US. Even if an HMO wouldn't their total exposure be their ~$6k deductible?

No, that is not correct. Search for the phrase "out of network" and "maximum out of pocket"

Even in the USA out of network has separate deductibles, some as much as $12,600 per person. The max out of pocket for out of network on some plans is unlimited. Unlimited is a nasty number.

There have been a few cases already where a person in the USA on vacation with insurance was treated at a facility that was out of network....bills in the 100k range.

[MichaelB]

Healthcare while traveling outside the US really needs a separate discussion from how to choose a policy for coverage while in the US.

Quote:

I see that this year healthcare.gov is showing a few POS and EPO plans that are more than HMO plans, but less than PPO plans. I am still investigating to see if they have any advantages compared to HMO for our unique case. We have until 12/15 to decide, but we are traveling to to another country for a month on 12/10 so this needs to be taken care of before then, within the next 3 days.

Not very much background to go on, so it will be challenging to help find a viable option in 3 days. Still, when comparing HMO, PPO, POS, EPO, it helps to keep in mind that if they are ACA compliant, what the policy covers is probably the same. Essential health benefits have helped standardize this.

There would be two major differences among them. One is the size and reach of the network. You need to investigate each policy offering to determine if the network satisfies your need. The other difference is what prerequisites must be met. With the HMO, POS and EPO you need some level of authorization prior to a service being provided or it will suffer some (or all) loss of coverage. You need to see the detail of each policy to determine exactly what level of pre-authorization is needed, whether you can live with that, and what the penalty is if missed.

Perhaps you can look at the policies and, if you still have specific questions, ask them while providing more detail.

Edit to add: when a service is out of network, the total cost one will be expected to pay is unpredictable, but it is safe to say it will be costly. The only exception to this is when the state insurance regulatory agency specifically protects the consumer from this. Not many do.

[sheehs1]

Quote:

Originally Posted by Fermion No, that is not correct. Search for the phrase "out of network" and "maximum out of pocket" Even in the USA out of network has separate deductibles, some as much as $12,600 per person. The max out of pocket for out of network on some plans is unlimited. Unlimited is a nasty number. There have been a few cases already where a person in the USA on vacation with insurance was treated at a facility that was out of network....bills in the 100k range.

That is correct and it is not divulged in the details. One has to ask what the out of network deductibles are. "Some" however will cover you anywhere provided it is an emergency, although I can imagine how this goes. They get to decide if it is an emergency or not.
As mentioned, it may hard to control the "out of network" thing. One never knows if an "out of network" doctor, nurse or practitioner has been called in to assist. The most I suspect that one can do to protect themselves is to put in writing, that no one out of network is to be called in during a procedure or surgery and hope for the best.

[pb4uski]

I can see a need for legislation to standardize out of network/emergency coverage as a consumer protection measure like homeowner, auto, in-network and other typies of coverage are standardized. Consumers shouldn't have to wade through a myriad of fine print to figure out the "got-cha"s in a health insurance policy.

I'd like to see some onus place on providers to confirm coverage and disclose to patients a reasonable range of what their financial responsibility will be so the patient can make an informed decision before proceeding with non-emergency services.

[sheehs1]

Agreed pb4uski! It is difficult to make a decision without the detail. Ex: I looked into a Humana policy that I was very interested in due to lower premiums, deductibles, etc. They at least offer a place to download their restrictions and limitations. After reading it, I decided against it as the network was restricted and they had some very strange restrictions such as (1) no coverage if admitted the same day of surgery (2) no coverage if admitted on a Friday or Saturday (unless of course an emergency), absolutely no coverage at all for ANY out of network, etc.

I have a friend whose daughter went for a Humana policy, went into labor unexpectedly and low and behold, Humana is not covering because they said she could have driven to the in network hospital an hour away. The baby was born within 40 minutes. She would not have made it. Obviously they are fighting this.

It is the details that make me nervous going forward as this is the first year for me with this type of policy, having been fortunate that Anthem BC/BS extended my policy last year. Anthem BC/BS doesn't have a link to their exceptions or limitations. I called them to verify that. I don't get that until they mail me the policy and I have (I think) 30 days to review and accept. Of course…I may be out of the enrollment period before I get it…as it has not arrived in my mail yet. I enrolled a couple of weeks ago.

[pb4uski]

Quote:

Originally Posted by sheehs1 ....I have a friend whose daughter went for a Humana policy, went into labor unexpectedly and low and behold, Humana is not covering because they said she could have driven to the in network hospital an hour away. The baby was born within 40 minutes. She would not have made it. ...

While I'm all in favor of insurers forcing consumers to avoid some of the stupid things they do like going to the ER for a bad cough or other minor illnesses when a clinic is available to them, the above is utterly ridiculous.

[MBSC]

Quote:

Originally Posted by pb4uski I can see a need for legislation to standardize out of network/emergency coverage as a consumer protection measure like homeowner, auto, in-network and other typies of coverage are standardized.

The ACA already includes some emergency non-network standards. An emergency admission to a non-network hospital is to be paid as in-network until such time as the insurer (not necessarily the hospital) determines the member can be transferred to an in-network facility.

A visit to the Emergency Department of a non-network hospital for an emergency without admission is to be paid as in-network, however, the member may be "balance billed" the difference between the amount paid by insurance and the actual charges when a state's insurance regulations allow for balance billing. As another poster mentioned before, a layman's definition of emergency may differ from the insurer's.

Getting back on the topic of world travel, if one is willing to adjust their estimated tax payments every year so no refund is due, one could purchase a world health insurance policy and incur the ACA penalty for having a non-compliant policy. Since their is no refund to collect the ACA penalty, it rolls over with interest. Each year's penalty keeps rolling over as long as you never have a refund due.

ACA penalty Link: IRS hamstrung on collecting health law penalties

ACA penalty Link: Obamacare Penalty: 4 Things You Don’t Know | The Fiscal Times

[tizlo]

I am sorry if I confused people. I thought I was clear, but maybe not. I am not looking for insurance that will cover us when we are out of the country. We have that covered in other ways. We are also not talking about short trips within the U.S. and possibly going to an emergency room. We spend extended time away from our home state. Months at a time, sometimes more than a year. When we are in another state, and staying there for months there are the occasional times which are more serious than the stuff that can wait for 6-18 months until we are back in our home state, but less serious than an ambulance to the emergency room. When you are basically living in a place for months sometimes you may need to see a doctor.

For the last 15 years we have had private PPO insurance. Even when staying in another state for a long period we could go see a doctor and if it was within the network (BCBS) then just pay the $25 co-payment for the office visit and anything else we would have to pay out of pocket since our deductible was high -- BUT we would pay the negotiated rate which is almost always much, much lower than what the doctor, lab, hospital charges. For 2014 we have new ACA PPO insurance. High deductible and no co-payments, since now we have to pay for everything up to the deductible, but at least we still get the negotiated rate.

Now the premium for the 2014 plan will be up 98% starting on 1/1. Sheesh. Over the last 15 years we have paid a lot for private health insurance, rarely used it, and have been out of the country a significant amount of time where it is useless for us. Now we must decide what to do. Accept the 98% premium increase knowing that much of the time we are out of the country where the insurance is of no use to us, but in the future (no plans right now) when we again spend time in the U.S. but not our home state we can see doctors as we have done for the last 15 years. Or change to some much more restrictive HMO plan (or POS, EPO) that will have a lower premium but is in addition to being useless out of the country is also useless out of the our home city?

By the way, an HMO requires one to see doctors in your area, right? So, even in the same state if you need to see a doctor (except for an emergency) in another city then that means no coverage, right? Basically, an HMO is for people who never wonder more than say 25 miles from home, right?

No matter what we do now we expect that a year from now to get another huge, huge premium increase. It seems to be baked into ACA.

[photoguy]

Quote:

Originally Posted by tizlo For 2014 we have new ACA PPO insurance. High deductible and no co-payments, since now we have to pay for everything up to the deductible, but at least we still get the negotiated rate. Now the premium for the 2014 plan will be up 98% starting on 1/1.

To clarify in 2014 you are on a ACA PPO exchange plan and the premium will be up 98% in 2015?

This seems really high. I think in CA the vast majority of plans (including PPO) see less than a 10% increase. My PPO was 6% including age adjustment.

Is the absolute cost of your premiums in-line with what others are reporting based on similar ages?

Quote:

No matter what we do now we expect that a year from now to get another huge, huge premium increase. It seems to be baked into ACA.

Your increase from 2014 to 2015 is unusually large. Is this due to subsidy changing? The full rate adjustment for most plans is much smaller and seems to be within historical norms.

Quote:

Originally Posted by tizlo My wife and I are trying to figure out what to do now. We already have the cheapest PPO plan available. We spend lots of time out of state, after all we are FIRE, so it seems like an HMO, which is about the same price in 2015 as the PPO was in 2014, would be pretty much pointless.

Agree I think that an HMO would not work as you would keep having to see your primary physician to get referrals to specialist.

However, if you are truly traveling that much have you considered changing your state of residence to one where there are better PPO options?

Quote:

We have until 12/15 to decide, but we are traveling to to another country for a month on 12/10 so this needs to be taken care of before then, within the next 3 days.

If you are willing to change state of residence, this is a qualifying event for new enrollment. So you could signup for your current PPO (with the 100% increase in premium) and then switch a few months later.

[sheehs1]

Photoguy, my increases from 2014 to Jan 1 2015 are substantial as well. My premium is up 68% and my deductible is up 58%. The increases are actually higher as last year I had dental and vision in those prices. I have dropped them due to just the medical coverage. If I find that is a mistake I can always add it back in a year from now.

This is what is happening to those of us who do not have access to employer sponsored plans and do not qualify for a subsidy. It may be happening to others as well. There is no benefit to going to the health care website. Insurers are closely matching the prices.

[sheehs1]

Tizlo, have you checked into Anthems Blue Card Access? I meant to ask about this but didn't so I am going to call them tomorrow.

What is the BlueCard Program?

[photoguy]

Sheehs1 -- the reason I thought the OP may not be comparing like to like because of all the reported data shows much smaller increases (and even decreases) in premiums:

ACA state exchanges

Analysis of 2015 Premium Changes in the Affordable Care Act’s Health Insurance Marketplaces | The Henry J. Kaiser Family Foundation

http://www.nytimes.com/2014/11/15/us...2015.html?_r=0

I think these analyses are based on averages or a benchmark silver plan. So if an specific plan has a large increase it might have only a small impact on the above analyses. But it does suggest that 50-100% premium increases from 2014 to 2015 (for the same ACA plan, unsubsidized) are anomalous and not representative. If my plan had such an increase i would choose a different plan in open enrollment unless the actual dollar amount change is not large.

As another option for the OP: use the HMO with the cheapest rate. When he/she moves to another state, enroll in that state's low cost plan and terminate the old plan.

[MBSC]

Quote:

Originally Posted by tizlo Or change to some much more restrictive HMO plan (or POS, EPO) that will have a lower premium but is in addition to being useless out of the country is also useless out of the our home city? By the way, an HMO requires one to see doctors in your area, right? So, even in the same state if you need to see a doctor (except for an emergency) in another city then that means no coverage, right? Basically, an HMO is for people who never wonder more than say 25 miles from home, right?

Most of the marketplace plans offered in my state are not HMO but EPO, which is a hybrid. With EPO, you have to stay in-network for non-emergency care (like an HMO) but you do not have to choose a primary physician and do not have to obtain a referral to see a specialist (like a PPO).

With my single state EPO policy, I can go to ANY primary care physician or specialist within the state that is in-network and accepting patients. You may want to research multi-state EPO policies.

EPO definition link: EPO, PPO, HMO: The Alphabet Soup That Tells...

[rbmrtn]

Quote:

Originally Posted by tizlo Over the last 15 years we have paid a lot for private health insurance, rarely used it, and have been out of the country a significant amount of time where it is useless for us. By the way, an HMO requires one to see doctors in your area, right? So, even in the same state if you need to see a doctor (except for an emergency) in another city then that means no coverage, right? Basically, an HMO is for people who never wonder more than say 25 miles from home, right?

I've paid a lot for all kinds of insurance ( renters/home/auto) over the years and never used them. That's what insurance is, helps cover a disaster that I hope never happens.

HMO requirements vary. Mine covers almost all of my state. It does want you to use a selected PCP ( don't most people do that anyway ? ). It does not require a referral to see a specialist ( in network ). Preapproval required for procedures/test ( I think many PPOs do that also )