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Old 11-14-2015, 08:13 AM   #21
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How would one get 2 spearate plans for husband and wife with the ACA subsidy?
If your state uses Healthcare.gov (the federal exchange) you put in the household income that qualifies for the subsidy... go through the full eligibility, then when that's done - create "groups" - put one person in one group, put another in a different group.

However - I can tell you CoveredCa.com does NOT do this. You cannot get the tax credit in the form of premium subsidies up front and do groups. So we chose to forgo the pre-payment of the tax credit in order to give flexibility on multiple policies for our family. We'll get the money back when we file taxes. Far from optimal but my husband wanted a different carrier than we have for myself and the kids. The group thing works if you aren't doing a subsidy, but doesn't work if you qualify for the subsidy. (So I state an income higher, just to allow groups.)
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Old 11-14-2015, 08:20 AM   #22
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So this would apply to an individual non-marketplace policy bought for 2016? This would be an ACA compliant policy. Wow, I had totally missed this in my consideration of a policy. This could be something important for me to model (we have one family member on the couple who tends to have higher health care needs with two not having high needs).



Well, that depends. If you have one person who alone were to meet the out of pocket max (or deductible) for the two people and then the second person had some claims that wouldn't meet the deductible then it would be better to have both be on the same policy.
Yes that could be true, but if you have one person that always has high expenses you could buy that person a better policy with less out of pocket for a higher premium( this will usually result in somewhat lesser total costs) and the other person a cheaper policy with higher out of pocket and control some costs that way. One policy does means you are locked in the same coverage.
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Old 11-14-2015, 10:20 AM   #23
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Yes, it applies to any 2016 ACA compliant plan. After the ruling was released, group plans requested clarification on if it applied to them also. The link is the response that yes it applies to group plans as well.
Thanks. I re-read the link and I guess I did not read very carefully last night.
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Old 11-14-2015, 10:36 AM   #24
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I have another question. How does the limit work with regard to out of network providers.

For example, the policy I am considering has a limit of $13,100 for single and $26,200 for family for out-of-network providers. Logic would dictate that the same theory would apply. That is, that the limit would be $13,100 for a single person on a family policy. However, when it comes to this kind of thing, logic does not always apply.

The footnote I referenced in an earlier post says in pertinent part that "An individual family member will not exceed $6850 for in-network out-of-pocket expesnes within the calendar year." (emphasis added).

Anyone know the anwer to this question? This is a considerable factor in that sometimes you have no choice over whether your provider is in network, e.g., a hospitalization that requires the services of an anesthesiologist or radiologist who is not in network. Maybe I am over-reacting in that bills for those services may not be terribly significant and under deductible anyways. Also, it is my understanding (I could be wrong) that the two limits, in network and out of network would be combined, so the total exposure could be $26,000 + $6,850 for a total of $32,850, a sum too rich for my blood.
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Old 11-14-2015, 11:11 AM   #25
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ACA doesn't have any rules for out-of-network limits. The insurer can specify whatever they want.
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Old 11-14-2015, 11:25 AM   #26
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Not good. Thanks.
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Old 11-14-2015, 11:35 AM   #27
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Not good. Thanks.
If you are able to enroll in a PPO with a broad, deep network, the out-of-network cost and coverage concern is greatly reduced.
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Old 11-14-2015, 11:39 AM   #28
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If you are able to enroll in a PPO with a broad, deep network, the out-of-network cost and coverage concern is greatly reduced.
Right, which means increasingly that you need a good group employer/retiree health plan. If one is going to the Marketplace, increasingly their networks are getting more and more narrow, and in some areas there are only HMOs available. That would make me nervous as hell.
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Old 11-14-2015, 11:44 AM   #29
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Right, which means increasingly that you need a good group employer/retiree health plan. If one is going to the Marketplace, increasingly their networks are getting more and more narrow, and in some areas there are only HMOs available. That would make me nervous as hell.
Or, look into buying your individual/family policy outside of the marketplace. They have different network structures in at least some states/instances.
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Old 11-14-2015, 12:08 PM   #30
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If you are able to enroll in a PPO with a broad, deep network, the out-of-network cost and coverage concern is greatly reduced.
Thank you. That is what I am considering; however, the premium is $120.00 more per month for the insurer with more in-network providers. I think the extra $120.00 per month might be worth the extra peace of mind. It will only be for 10 months because spouse goes with medicare then.
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Old 11-14-2015, 12:20 PM   #31
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From my experience there were no volume discounts even back before ACA for 2 people. I could be missing something of just my mind is slipping. However, I'm not sure that is true with 3 or more people. From what I've seen in the past the 3 or more did not just keep adding more to the family deductible and max OOP. However, I have not checked this post ACA as we are now a family of two. I just ran a dummy case adding a kid to a ACA price check (bronze plan-HDHP), deductibles and max OOP are the same as with the kid omitted. Try other cases if you like, but I think there is volume discounts... but you need 3 to qualify.
As to pricing, my experience comes with using healthcare.gov to price the same policy for each of 4 people separately using 2014 and 2015 rates. Putting all 4 people on one policy was priced, to the penny, exactly what the 4 separate policy prices were. I only did one policy, one insurance company. No guarantees its universal, but that's what I found using one example.

As to the family deductible, as you say, I'm pretty sure that it stays-put (usually double the individual deductible), even if you add many kids to the policy.

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Or, look into buying your individual/family policy outside of the marketplace. They have different network structures in at least some states/instances.
In my geography, you get the same exact policy on the exchange as you get off exchange. Walking into the doctor's office or hospital, they can't tell and don't care...they both have the same reimbursement rates.
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Old 11-14-2015, 03:07 PM   #32
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The ruling eliminating single aggregate deductibles went into force in 2015 for individual plans and will now apply in 2016 for group and other non-grandfathered plans. Here is an informative link with easy to understand explanations and a good example. Family Plans Must ‘Embed’ Out-of-Pocket Limits in 2016
Actually, it is interesting. After reading this thread last night I went and read up it. It is the out of pocket limit that must be embedded not the deductibles. And the embedding technically only has to be for the max allowed under the law.

Here are a couple of Cigna articles about it:

THE BIG PICTURE NEWSLETTER from Cigna

Embedded Individual Out Of Pocket | Cigna

What is interesting is that for 2016 it is only the OOP of $6850 that has to be embedded. Imagine you had a policy that had an individual deductible of $3000 and a family deductible of $6000 and individual OOP of $6000 and family OOP of $1200. Theoretically as I understand it, the only thing the law requires is that on a family policy the individual's OOP would have to be no more than $6850. The insurer could still say it was using a family deductible of $6000 (and not a deductible of $3000 for an individual) and could say the individual in a family would have an OOP of $6850.

As I understood it, the insurer could embed the individual limits as they would be in an individual policy, but it isn't required to except for an OOP of $6850.

What I'm finding difficult to determine is how the specific policies we are interested in are handling this.
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Old 11-14-2015, 03:24 PM   #33
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Actually, it is interesting. After reading this thread last night I went and read up it. It is the out of pocket limit that must be embedded not the deductibles. And the embedding technically only has to be for the max allowed under the law.
Right. I must have read with my own situation in mind, our HSA plan the deductible and the total OOP are the same. Clearly, it would appear that the case you reference, when the total OOP is greater than the deductible, the aggregate deductible can still be a concern.

Next year we will still get 2 individual policies, despite this change. DW phases into Medicare, and I can't get a firm response to my question, which is when my coverage shifts from family to individual, is it the same policy that continues with the YTD spending counter, or is it a new policy with a reset to all the counters.
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Old 11-14-2015, 03:27 PM   #34
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When I was shopping for a 2014 policy, I was trying to determine how the specific policies I was interested in were handling individual/family limits. I called Blue Cross Blue Shield of NC and was told, in no uncertain terms, that the family policy would start paying as soon as the individual deductible was reached. That was absolutely not true.

Moral of the story, don't believe what the insurance company representative tells you. Or, if you're going to act on what they said, make sure you make an audio recording and be ready to drag them into court.
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Old 11-14-2015, 03:41 PM   #35
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The ruling eliminating single aggregate deductibles OOP limits went into force in 2015 for individual plans and will now apply in 2016 for group and other non-grandfathered plans. Here is an informative link with easy to understand explanations and a good example. Family Plans Must €˜Embed€™ Out-of-Pocket Limits in 2016
The ruling was released February 27, 2015 and is effective 1/1/2016 for both individual and group plans. Your link is the response to a clarification request from group plans.

Quote:
Lastly, in the proposed rule, we proposed clarifying that the annual limitation on cost sharing for self-only coverage applies to all individuals regardless of whether the individual is covered by a self-only plan or is covered by a plan that is other than self-only.

We note that 2016 plans must comply with this policy.

156.130 Cost-sharing requirements.
* * * * *
(c) Special rule for network plans. In the case of a plan using a network of providers, cost sharing paid by, or on behalf of, an enrollee for benefits provided outside of such network is not required to count toward the annual limitation on cost sharing (as defined in paragraph (a) of this section).
Source: http://www.gpo.gov/fdsys/pkg/FR-2015...2015-03751.pdf

Quote:
The federal government finalized its 2016 health insurance marketplace rule in February, which included the clarification to the out-of-pocket maximums for consumers. The rule said all people, regardless of whether they are in a family or individual health plan, will not have to pay more than the individual maximum for cost-sharing.

Those limitations apply to individual, small-group, large-group and self-insured plans.
Source: http://www.modernhealthcare.com/arti...NEWS/150919927
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Old 11-14-2015, 04:07 PM   #36
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Will someone please expalin the term "embedded" as has been used various times in this thread?
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Old 11-14-2015, 04:18 PM   #37
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Will someone please expalin the term "embedded" as has been used various times in this thread?
It means that the OOP expenses for any individual covered by a family plan (or self + 1 plan) can never exceed what the OOP maximum would be in a self-only plan.

Example: You have a plan with a $5000 "individual" OOP maximum and a $10,000 "family OOP maximum. In the past, that could mean a self-only plan had a $5K limit but a family had a $10K limit even if only one of the insureds racked up the entire $10K.

Since the start of this year for "individual" health plans (and required in 2016 for group plans), in this plan the "embedded" individual OOP limit is $5K. Even in a family plan with a $10K OOP maximum, once any specific individual hits $5K in OOP costs, their cost sharing is done. Any additional expenses (in network) are covered 100% with no cost sharing, even if the "family" OOP max has not yet been met.
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Old 11-14-2015, 04:25 PM   #38
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Thanks for the explanation, ziggy29.
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Old 11-14-2015, 04:48 PM   #39
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Or, look into buying your individual/family policy outside of the marketplace. They have different network structures in at least some states/instances.
The same thing is happening even outside healthcare.gov. My county had 3 companies offering PPOs in several flavors in 2014. Now for 2016 it's down to only one company, and only one option which is bronze.
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Old 11-14-2015, 05:10 PM   #40
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The same thing is happening even outside healthcare.gov. My county had 3 companies offering PPOs in several flavors in 2014. Now for 2016 it's down to only one company, and only one option which is bronze.
And in my county there is no PPO option at all. There is no out of network coverage at all (except the emergency care coverage required to to be provided). I would love to have even one PPO option....
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