None of the plans in NY have an out of network option. You can switch plans within 90 days for the Essential Plan and Medicaid. Each plan has a slightly different Provider network.
ACA costs
- Thread starter TickTock
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It takes a qualifying event or open enrollment to change marketplace plans here. We don't have the essential plan like NY does, and I'm way above the Medicaid thresholds.
Fermion
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
A change in income that puts you above Medicaid threshold is a qualifying event.
Of course. Any qualifying event is a qualifying event. But I said "change marketplace plans" and as I mentioned, my income is well above the Medicaid threshold. It always has been. In fact, I am having trouble keeping my income low enough for better ACA subsidies, as I went into more detail about in previous posts in this thread. I can't change plans until open enrollment, but I'm not looking to change since I went with the best option when I signed up. It's just not as good of a deal as those NY plans.
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Move your $$ from money market funds or savings accounts paying 5% to non-interest bearing accounts?
I don't have much at all in money market accounts, and nothing in saving accounts. That wouldn't move the needle. As per previous posts, the income is from CD interest, dividends, capital gains distributions from mutual funds & ETFs. If we hadn't had such high inflation and high interest rates it would never have been an issue, but you have to try to maintain some buying power when prices are soaring as they were.
Of course, with inflation, that's also not good to have money sitting out there not earning anything, anyway.
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You could break the CD's and put into non interest accounts. If you're on the cusp of losing the tax credits, it could be worth it.
Tax credits aren't the problem. I was talking about the CSR thresholds, which could mean $4000 or more possible out of pocket, however, without knowing the amount I'll use, it's not certain of those higher costs, while giving up years of 5% CD interest income is a certain loss. For maturing CDs, I am looking into alternative like MYGA or BRK.B.
Earlyretirementology
Confused about dryer sheets
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My wife and I have purchased our healthcare on the ACA Texas Marketplace the last 4 years. Our lowest out-of-pocket annual total (Premiums+Deductible/Co-Pays+Stuff they decided not to cover very much of) for the 2 of us (ages 59 and 61 now) was 37K and the highest year was 51K. We have a 100% track record of using in-network doctors and facilities. The ACA plans seem to be fine for normal stuff e.g. colonoscopies et al, but if you have anything weird, look out. I received less than 2K of benefit on 16K of complex cataract surgery, and if you need anything even slightly special for drugs - well, hope Mark Cuban's drug company starts offering them. My cancer drug went from 11K/month thru my ACA provider to $37/month (no typos in that sentence) when his company started selling it. You hit the OOP really fast 
Virtually overnight he caused the market price to disintegrate... but the insurance companies bled it at list price for 7 years after it went generic! I wish you well, the fact that you are talking about a PPO on ACA indicates you are somewhere other than TX as there are no PPOs on ACA here. Having to do the ongoing referrals is a nightmare. My numbers above do include contacts and glasses but that is only about $1000 per year of the total.
Virtually overnight he caused the market price to disintegrate... but the insurance companies bled it at list price for 7 years after it went generic! I wish you well, the fact that you are talking about a PPO on ACA indicates you are somewhere other than TX as there are no PPOs on ACA here. Having to do the ongoing referrals is a nightmare. My numbers above do include contacts and glasses but that is only about $1000 per year of the total.
gauss
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Just so we are clear here...
For any ACA compliant plan, the max per person OOP Max for in-network services can be no more than $9,450 in 2024. This, of course, is in addition to the premium cost.
An even lower OOP Max will apply to an HSA compliant ACA plan.
Here is a reference
https://www.cigna.com/employers/insights/informed-on-reform/cost-sharing
I learned this when DW had serious brain surgery a few years ago and I was expecting a large OOP contribution. NOPE! I think it was limited to about $7,500 at the time. ( I think the family OOP max was $15,000 which I expected to pay, but the per person limit applies -- even in family plans).
-gauss
p.s. I purposely purchase insurance from the largest legacy PPO insurer in my area to ensure a broad network and very favorable negotiated "in-network" rates.
For any ACA compliant plan, the max per person OOP Max for in-network services can be no more than $9,450 in 2024. This, of course, is in addition to the premium cost.
An even lower OOP Max will apply to an HSA compliant ACA plan.
Here is a reference
https://www.cigna.com/employers/insights/informed-on-reform/cost-sharing
I learned this when DW had serious brain surgery a few years ago and I was expecting a large OOP contribution. NOPE! I think it was limited to about $7,500 at the time. ( I think the family OOP max was $15,000 which I expected to pay, but the per person limit applies -- even in family plans).
-gauss
p.s. I purposely purchase insurance from the largest legacy PPO insurer in my area to ensure a broad network and very favorable negotiated "in-network" rates.
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Well, of course the per person limit applies to one person, regardless of the family limit. That's how it's always been on my work insurance also.
Sometimes plan will decline to cover care, and that does not credit your out of pocket max. And if you have out of network care, that can have a much higher out of pocket max or even unlimited!
I use an alternative called POS that looked to have as good of in-network coverage as the PPO plan, plus better out of network coverage.
RetiredHappy
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My wife and I have purchased our healthcare on the ACA Texas Marketplace the last 4 years. Our lowest out-of-pocket annual total (Premiums+Deductible/Co-Pays+Stuff they decided not to cover very much of) for the 2 of us (ages 59 and 61 now) was 37K and the highest year was 51K. We have a 100% track record of using in-network doctors and facilities. The ACA plans seem to be fine for normal stuff e.g. colonoscopies et al, but if you have anything weird, look out. I received less than 2K of benefit on 16K of complex cataract surgery, and if you need anything even slightly special for drugs - well, hope Mark Cuban's drug company starts offering them. My cancer drug went from 11K/month thru my ACA provider to $37/month (no typos in that sentence) when his company started selling it. You hit the OOP really fast
It is not a problem with ACA but rather, costs before Medicare age. I have an off-exchange private individual insurance which is superior to any of the ACA plans offered here in Nevada. I had an accident in 2022 and I hit my maximum out of pocket. Premiums + Max OOP cost about $25K in 2022. Last year was a normal year, and my premiums + OOP came out to about $18K. I cannot wait to get old!
Now, if you don't make as much, you get premium and out of pocket costs subsidies through ACA. Unfortunately we make "too much".
Earlyretirementology
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Again, things that the insurance company chooses not to cover do not count toward the OOP. They are simply on top. For example, in my cataract situation, I was not a good candidate for the standard lenses. Insurance would ONLY cover standard lenses, so the entire incremental amount for a better outcome (14k) I not only paid out of pocket, but it did not count toward my ACA out of pocket max as it was considered a non-covered expense. I encourage everyone to factor an extra slush fund in their retirement hc budget for these situations.
That's what I just said above, but also, out of network has a different OOP max, which can be unlimited, but other times it's just very much higher than the in-network OOP.
I guess you can come up with super rare edge case examples if you want. But realistically if you don't live in the middle of nowhere you are not going to have the need for out of network providers and I think these examples are not useful at all.
It's not uncommon. In fact, I've heard of people going to in-network providers, and they were treated by an out of network doctor, and then they received some large uncovered bills as well as balance billing. It's not a matter of where you live, although there are many millions who do not live in NYC.
Balance billing was addressed Federally with the No Surprises Act.
https://www.cms.gov/nosurprises
Many states also have state laws against surprise billing. For example:
https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills
Super rare? Do you have any data to back that up?
I don't have data, but anecdotally I've heard of several cases where people went in for a major procedure and one or more of the sub-providers (anesthesiologist, rad-tech, specialist, etc.) were not in-network, and it blew away savings from HMO vs. PPO.
Also, if you travel and have a medical event that requires immediate attention there will likely be no in-network providers.
As I've posted before, DW and I view insurance as protection from catastrophic costs, not trying to figure the lowest yearly cost for the most likely outcome. (Once that goal is met, we do try to figure the lowest likely cost and go with that option.)
That site covers Medicare and Medicaid. Not ACA.
The plan docs for the PPO we intend to utilize specifically mentions balance billing as uncovered.
The Act covers the ACA as well.
I like this and would like to see it applied federally rather than on a state-by-state basis!
The Federal law is there, state laws may add additional protections.
Would you please link to where the website says that? It was not apparent to me. The top of the page says:
CMS.gov Centers for Medicare & Medicaid Services
Just because the site is from CMS doesn't mean the law only applies to Medicare/Medicaid.
https://www.consumerfinance.gov/ask...ld-i-know-about-the-no-surprises-act-en-2123/
The No Surprises Act was implemented in 2022 and covers all health care in the United States. Here’s a summary from Kaiser Health Foundation https://www.kff.org/affordable-care...es-act-implementation-what-to-expect-in-2022/
Balance billing can only happen now if the patient is informed a service or provider is not covered before the service is carried out, and the patient has to acknowledge and agree in writing.
