Out of Pocket Limit?

[Youngster]

Not good. Thanks.

 

[MichaelB]

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.

 

[ziggy29]

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.

 

[2017ish]

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.

 

[Youngster]

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.

 

[sengsational]

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.

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.

 

[Katsmeow]

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.

 

[MichaelB]

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.

 

[sengsational]

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.

 

[MBSC]

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.

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-2015-02-27/pdf/2015-03751.pdf

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/article/20150915/NEWS/150919927

 

[Youngster]

Will someone please expalin the term "embedded" as has been used various times in this thread?

 

[ziggy29]

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.

 

[Youngster]

Thanks for the explanation, ziggy29.

 

[audreyh1]

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.

 

[Katsmeow]

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....

 

[MBSC]

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.

Please refer to the more accurate description below. The embedded MOOP is $6850 for 2016 unless the plan specifically states it is using the individual plan's MOOP.

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.

Example provided by HHS:

Example: Assume that a family of four individuals is enrolled in family coverage under a group health plan in 2016 with an aggregate annual limitation on cost sharing for all four enrollees of $13,000 (note that a plan is permitted to set an annual limitation below the maximum established under section 1302(c)(1), which is an aggregate $13,700 limitation for coverage other than self-only for 2016). Assume that individual #1 incurs claims associated with $10,000 in cost sharing, and that individuals #2, #3, and #4 each incur claims associated with $3,000 in cost sharing (in each case, absent the application of any annual limitation on cost sharing). In this case, because, under the clarification discussed above, the self-only maximum annual limitation on cost sharing ($6,850 in 2016) applies to each individual, cost sharing for individual #1 for 2016 is limited to $6,850, and the plan is required to bear the difference between the $10,000 in cost sharing for individual #1 and the maximum annual limitation for that individual, or $3,150. With respect to cost sharing incurred by all four individuals under the policy, the aggregate $15,850 ($6,850 + $3,000 + $3,000 + $3,000) in cost sharing that would otherwise be incurred by the four individuals together is limited to $13,000, the annual aggregate limitation under the plan, under the assumptions in this example, and the plan must bear the difference between the $15,850 and the $13,000 annual limitation, or $2,850.

 

[bingybear]

So I take this to mean that when spending 5k to 10k (or more) for insurance that you should understand what you are buying. Last year I ended up calling the insurance company for plans (including ACA plans that I was considering) to figure out which one I was going to buy.
I do sometimes think that some of the insurance companies are trying to make this more confusing on purpose.
Last year I noticed the difference in embedded and aggregate... and for a bit did not remember which name went with which mechanism.
How many people here buy a car without learning at least the basics about the car? I do agree that insurance is a bit more complicated than it likely should be.