Texas (Dallas Area) and Affordable Care Act Plans

[tbis]

So as I consider early retirement, I started looking more closely at the various affordable care act plans available to me here in Texas (Dallas / Ft. Worth area). While there are a number of plans, I am simply not seeing the majority of my doctors in these plans! Indeed, a while back I researched orthopedic surgeons (knee issues) and I only see ONE of the multiple docs I looked at (generally the better rated docs) on any of the plans I have surveyed so far.

In addition, it seems virtually all of the plans are HMO style with no opportunity to go out-of-network - yuck!

For my fellow Texans, what am I missing here? Are we just getting shafted in terms of the docs taking these plans? Any plans you've had good luck with?

I'm more than a little bummed since while I had seen "unfamiliar" brand names in the marketplace, I had also spotted bigger names like United Health and Blue Cross/Blue Shield...but the doc selection is underwhelming.

Any feedback is greatly appreciated!

 

[TripleLindy]

Hello fellow DFWer! I retired 5 years ago and still have another 5 years to go before I’m Medicare eligible, so I rely on the ACA for healthcare coverage. As you note, virtually all of the plans are HMOs with the requisite “mother may I” approach where a referral is needed for anything beyond care provided by your PCP.

My wife and I are both relatively healthy, so we have the insurance for 3 primary reasons: cancer, some kind of accident causing serious injury, and orthopedic issues. The latter has been our only real use of the insurance and last year, after 2 ortho surgeries, was the only year out of 5 that I met my individual deductible.

We had BCBS HMO for the 1st 4 years and switched to Friday Health Plan for ‘22. The reason we switched was because my ortho doc quit accepting BCBS HMO, but accepted Friday. He did this during the middle of the year, so we had no recourse and I had to find another surgeon for my shoulder. Now, with yet another knee issue, my ortho doc has decided to no longer accept Friday. It’s very frustrating because the doc, practice, and associated surgery center all show up in the provider search on the insurer’s website. Why providers are allowed to move in and out of insurance plans while patients are only allowed to do so once per year is something that needs to be addressed, but I digress.

Open enrollment starts 11/1, so I’ll see what is available once I can start the process. I received an email from Friday recently saying that they will no longer offer coverage in Texas, so they’re out.

You’ll find coverage to be VERY expensive if you don’t qualify for the subsidy, but there is a cap on premiums through 2025 based on your income - 8.5%. Without any subsidy or premium cap, coverage is in the $20k+/year range for the least expensive Bronze plan, and that comes with a deductible in the $7k-$8k range, so you’re spending almost $30k before you get a penny of coverage. The U.S. Healthcare system is a complete racket.

As you probably know, the DFW healthcare market is dominated by 2 organizations: Baylor Scott and White, and Texas Health Resources. BSW tends to have more of a presence east and south while THR is in the west. We live right in the middle, so their markets overlap in our area, with our preferred PCP practice being BSW, but our local hospital being THR. If you can find a plan that includes one or both of those health systems, you should have access to very good, comprehensive care. Friday doesn’t include either one, but has (had) our ortho practice. Interestingly, while Friday is an HMO, no referral is required to see a specialist. I never found a PCP while enrolled in Friday and at this point of the year, looks like I won’t have a need to.

Thanks for starting this thread. I’ll be watching it once open enrollment starts to see what others may contribute. Good luck with your early retirement!

 

[tbis]

Thanks for the REAL-WORLD feedback TripleLindy - all 100% pertinent to my situation! Which Ortho WERE you originally using and then which one did you go with - you can PM me that if you aren't comfortable sharing that here...or just not share it at all - Were you at least happy with the outcome or ?

I began to question whether the websites were accurate in terms of which docs were in their plans as well - especially when I started seeing some docs in a practice listed as in and others out. Indeed, I also notice the info reported on the various exchange sites would conflict with the actual insurance vendors' sites. I tended to "trust" the latter more, but only so far.

Right now BCBS and Ambetter APPEAR to have the best physician inclusion, but that assumes the data is correct (and as you note, can easily change). Ambetter does seem to do a halfway decent job of having BSW coverage. Of course, my PCP is in THC!

I do have one advantage...my wife is 8 1/2 years older (she loves it when I point that out)...and eligible for Medicare next year!

Like you though, it will be a long ride on ACA for me.

 

[TripleLindy]

My first ortho practice was/is Orthopedic Associates in Flower Mound. Dr. Cantrell has been my ortho doc for 25 years, but have also seen Dr. Singhal. My shoulder surgery was performed by Dr. Scott Hrnack in Keller. He’s great, but his surgery center isn’t on Friday even though he accepts it. I’d recommend any of the three if you’re in this area.

I’ve considered Ambetter in the past. It will probably come down to them or BCBS. Given the premium cap based on income, every plan (up to 2nd cheapest Silver Plan, I think) will be the same price, so I hope there’s more selection with an expanded criteria. I didn’t know about the cap last year or I might have found something other than Friday. I actually learned about it on this forum.

The challenge with insurance provider searches is that the docs who show up in the search are under contract, but apparently they can just decide not to accept the insurance, regardless of the contract. The patient is left holding the bag.

 

[tbis]

Thanks TripleLindy. It looks like BOTH Friday AND Bright are pulling out of Texas next year. Bright appears to be on its last legs overall.

I can't help but wonder if all these "unfamiliar name" entities got into the health insurance game with the belief they could undercut the traditional insurance companies and are now discovering the reality is quite different. In the end the ACA may be left with more of the big guys (United, BCBS, etc.)...or worse...MARGINAL insurance players!

On the subject of the CAP, am I correct that it is essentially 8.5% of for adjusted gross income (i.e. an AGI of $70K puts you at a max of 70,000*8.5% - $5950 or $495.83/mo)?

 

[PaunchyPirate]

On the subject of the CAP, am I correct that it is essentially 8.5% of for adjusted gross income (i.e. an AGI of $70K puts you at a max of 70,000*8.5% - $5950 or $495.83/mo)?

It’s actually your Modified Adjusted Gross Income. You should review the healthcare.gov definition of this. One thing that gets added in is tax exempt interest earned, for example.

As for the calculation, first identify the monthly premium of the Second Lowest Cost Silver Plan (SLCSP) available to you. Then identify 8.5% of your MAGI and divide that by 12 to determine your max monthly premium. If the SLCSP costs more than your max premium, your monthly subsidy will be the difference. Let’s say that subsidy for the SLCSP is $549 per month. That amount will not change. However, you can use that $549 to pay for a lower cost plan (A Bronze plan, for example) which might make it free to you or much less than the price of the SLCSP. Alternatively, you may choose to use your $549 to pay for a top of the line Gold plan that costs $1200 per month. You would only pay the portion of that $1200 above the $549 subsidy, so $651 for a Gold plan.

 

[orchid55]

I'm in Georgia and we have the same situation with only narrow network HMOs available.

I don't know if you have followed some of the other insurance posts but one important thing to do is to get separate policies for you and your wife. Doing so will make it easy to drop her ACA coverage when she goes on Medicare. Buying a joint/family policy will add a lot of stress to the transition period. Also don't put her ACA policy on any kind of auto-pay to avoid difficulties in ending the ACA policy.

 

[TripleLindy]

It’s actually your Modified Adjusted Gross Income. You should review the healthcare.gov definition of this. One thing that gets added in is tax exempt interest earned, for example.

As for the calculation, first identify the monthly premium of the Second Lowest Cost Silver Plan (SLCSP) available to you. Then identify 8.5% of your MAGI and divide that by 12 to determine your max monthly premium. If the SLCSP costs more than your max premium, your monthly subsidy will be the difference. Let’s say that subsidy for the SLCSP is $549 per month. That amount will not change. However, you can use that $549 to pay for a lower cost plan (A Bronze plan, for example) which might make it free to you or much less than the price of the SLCSP. Alternatively, you may choose to use your $549 to pay for a top of the line Gold plan that costs $1200 per month. You would only pay the portion of that $1200 above the $549 subsidy, so $651 for a Gold plan.

The MAGI calculation got me a couple of years. I had a tax exempt bond fund that wasn’t included in AGI, but just barely put me over the MAGI limit, which cost me almost $15k when filing, as I had estimated income based on AGI and had taken the subsidy.

Your explanation of the subsidy and premium cap is interesting - thank you. If I understood correctly, if income is $70k, the max premium would be $5950. If SLCSP is $20,950, then I’ll have a $15k subsidy? I can then choose any plan up to $15k and pay $0? And if I choose the SLCSP, I pay $5950? If I choose a Gold Plan that costs $30k, do I pay $15k (Gold premium minus subsidy)?

 

[PaunchyPirate]

The MAGI calculation got me a couple of years. I had a tax exempt bond fund that wasn’t included in AGI, but just barely put me over the MAGI limit, which cost me almost $15k when filing, as I had estimated income based on AGI and had taken the subsidy.

Your explanation of the subsidy and premium cap is interesting - thank you. If I understood correctly, if income is $70k, the max premium would be $5950. If SLCSP is $20,950, then I’ll have a $15k subsidy? I can then choose any plan up to $15k and pay $0? And if I choose the SLCSP, I pay $5950? If I choose a Gold Plan that costs $30k, do I pay $15k (Gold premium minus subsidy)?

Yes, I believe your math is correct. I choose to pay for a gold plan to get better benefits. I pay $303 per month and have a $719 subsidy. The gold premium is $1022 before the subsidy. My subsidy is high enough that I could have free insurance if I only wanted the inferior bronze coverage. It came down to doing the math on expected medical services needed for the year to pick my plan.

FYI, you should be able to verify all this by pretending to buy insurance starting December 1st on your exchange. At least on most exchanges you can get these estimates without creating an account.

 

[SecondCor521]

In my state Open Enrollment has already started for 2023. It started on 10/15.

I thought the rest of the country would also open 10/15 this year, but maybe not.

 

[PaunchyPirate]

In my state Open Enrollment has already started for 2023. It started on 10/15.

I thought the rest of the country would also open 10/15 this year, but maybe not.

Nope. Still November 1st here in PA and the federal exchange.

 

[Geld ist Freiheit]

Thanks for starting this topic.

I too am a Texan looking at health plans with an eye towards retiring next year.

I really like my PCP but of the 147 plans BCBS offers in the area, my doc takes exactly ZERO of them.

I guess I need to look into Ambetter, Friday, Molina, Oscar etc…to see if he takes any of those. I’ve kind of dismissed them as I’ve never even heard of these companies before.

As an aside, would there be any interest is having a DFW GTG? If so, we could start a topic for it. Would be nice to meet with like-minded people. Most of my circle can’t seem to relate when it comes to finances. The FIRE folks are cut from a different cloth.

 

[TripleLindy]

Yes, I believe your math is correct. I choose to pay for a gold plan to get better benefits. I pay $303 per month and have a $719 subsidy. The gold premium is $1022 before the subsidy. My subsidy is high enough that I could have free insurance if I only wanted the inferior bronze coverage. It came down to doing the math on expected medical services needed for the year to pick my plan.

FYI, you should be able to verify all this by pretending to buy insurance starting December 1st on your exchange. At least on most exchanges you can get these estimates without creating an account.

Yes, I have an ACA account and should be able to compare plans/prices once open enrollment starts on 11/1. Premiums in your area are MUCH lower than the DFW area. I think I chose the least expensive Bronze plan with Friday and it was over $1k per month before the subsidy. I don’t think I even looked at any Gold plans, as Silver plans were in the $2k per month range. Given that the premiums cap was in place last year, I don’t know why the system showed my subsidy to be much less than the calculation from the post above. I think I entered either $65k or $70k in the income section. Assuming $70k, I should have been given a much higher subsidy based on the price of the Silver plans. Now that I understand the calculation, I’ll pay much closer attention to it next week.

 

[PaunchyPirate]

Yes, I have an ACA account and should be able to compare plans/prices once open enrollment starts on 11/1. Premiums in your area are MUCH lower than the DFW area. I think I chose the least expensive Bronze plan with Friday and it was over $1k per month before the subsidy. I don’t think I even looked at any Gold plans, as Silver plans were in the $2k per month range. Given that the premiums cap was in place last year, I don’t know why the system showed my subsidy to be much less than the calculation from the post above. I think I entered either $65k or $70k in the income section. Assuming $70k, I should have been given a much higher subsidy based on the price of the Silver plans. Now that I understand the calculation, I’ll pay much closer attention to it next week.

Are your numbers for one person? Mine are. I also control my income to keep it in the $45k range, which increases my subsidy. But that doesn’t effect the base premiums. I live in Pennsylvania. Our state has embraced the ACA from the start and the state Insurance Department is actively involved in working with the insurance companies to set rates each year. We also set up our own exchange which supposedly saves 3-5% in rates each year. From my many years of living in Texas (also DFW area), I’m pretty confident in saying that Texas has made decisions that help to increase your medical costs.

 

[TripleLindy]

Are your numbers for one person? Mine are. I also control my income to keep it in the $45k range, which increases my subsidy. But that doesn’t effect the base premiums. I live in Pennsylvania. Our state has embraced the ACA from the start and the state Insurance Department is actively involved in working with the insurance companies to set rates each year. We also set up our own exchange which supposedly saves 3-5% in rates each year. From my many years of living in Texas (also DFW area), I’m pretty confident in saying that Texas has made decisions that help to increase your medical costs.

Good point - my numbers are for two people. And yes, Texas has fought just about every federal healthcare-related initiative, including federal funds to expand Medicaid, so our uninsured population is higher than most states. That obviously contributed to higher costs here.

 

[tbis]

Quick question. Are these plans restricted based on your county? I was talking to a friend of mine (who lives in the area, but in adjacent DALLAS county) and he mentioned the BSW Health (Baylor, Scott and White - a large hospital system) plan, which I did not see. When I changed my county to Dallas (even though I am in Tarrant county) the BSW Health options shows up. Note that when I enter my zip code it presents both Dallas and Tarrant counties as choices since a tiny piece of my zip code (not mine) is actually in Dallas county it appears.

 

[TripleLindy]

Quick question. Are these plans restricted based on your county? I was talking to a friend of mine (who lives in the area, but in adjacent DALLAS county) and he mentioned the BSW Health (Baylor, Scott and White - a large hospital system) plan, which I did not see. When I changed my county to Dallas (even though I am in Tarrant county) the BSW Health options shows up. Note that when I enter my zip code it presents both Dallas and Tarrant counties as choices since a tiny piece of my zip code (not mine) is actually in Dallas county it appears.

Not sure what system you are using to search. I haven’t been on the ACA site since last year, so I don’t recall the search parameters when looking for docs/hospitals, but I do recall that you could enter them and search for plans where they were in-network. I would be surprised if it was county specific, but understanding that premiums vary based on geography, it’s possible. If searching on the insurer website, there’s usually a distance parameter, like within 25 miles, but I’ve never seen a county parameter.

 

[orchid55]

In Georgia the plans are highly dependent on county both for networks and for premiums.

 

[PaunchyPirate]

Quick question. Are these plans restricted based on your county? I was talking to a friend of mine (who lives in the area, but in adjacent DALLAS county) and he mentioned the BSW Health (Baylor, Scott and White - a large hospital system) plan, which I did not see. When I changed my county to Dallas (even though I am in Tarrant county) the BSW Health options shows up. Note that when I enter my zip code it presents both Dallas and Tarrant counties as choices since a tiny piece of my zip code (not mine) is actually in Dallas county it appears.

Yes. ACA plans are defined at the zip code level and insurers are free to sell a plan in one zip code but not another. Generally, the insurers choose to sell at the county level, by offering a plan in all zip codes in that county. But they do not have too.

 

[TripleLindy]

I see now. I thought that the question was about searching for an in-network provider, specifically BSW, but now I see that it was about searching for the BSW health plan, which would be geography specific.

As an aside, a health plan tied to a system like BSW is usually a very narrow network of only that system’s providers and facilities. If you want a specialist that’s not employed by the system, he/she most likely will be out of network. It may not be important to some, but personally, I’d rather find a plan that includes the system, as well as other docs. For example, my ortho practice is an independent practice, not owned by a large system.

 

[TripleLindy]

FYI, plans, pricing and subsidy calculation are available on healthcare.gov, even though open enrollment doesn’t begin until 11/1 in Texas. You don’t even have to log in. Just enter some basic info, like zip code, age of everyone to be covered, and income. You can filter the plans based on any physician or facilities that you want included as in-network. Filtering will eliminate plans that don’t have them, so if you still want to see other plans, just add them under the Medical Providers section of any plan. Then they’ll show up with either a red X (not in-network) or a green check mark (in network).

 

[TripleLindy]

Looks like we’ll be back to BCBS HMO. None of the other plans include our preferred PCPs or hospitals. Our preferred ortho practice isn’t on a single ACA plan in our area, but there’s an ortho doc we’re comfortable with who is on the BCBS plans. The least expensive BCBS plan is ~$100/month after the subsidy, but I’m going to go with the one that is ~$200/month. For the extra $1200/year, our individual deductible/out of pocket max drops from $9100 to $7000. If either of us needs anything significant, that’s a $2100 savings. If we both need something, we’d save over $4k, less the $1200 additional premium. Given that both of us have current ortho issues, I’m going with the higher premium/lower deductible option. It also qualifies for an HSA whereas the cheaper plan does not.

 

[Echard]

It’s actually your Modified Adjusted Gross Income. You should review the healthcare.gov definition of this. One thing that gets added in is tax exempt interest earned, for example.

As for the calculation, first identify the monthly premium of the Second Lowest Cost Silver Plan (SLCSP) available to you. Then identify 8.5% of your MAGI and divide that by 12 to determine your max monthly premium. If the SLCSP costs more than your max premium, your monthly subsidy will be the difference. Let’s say that subsidy for the SLCSP is $549 per month. That amount will not change. However, you can use that $549 to pay for a lower cost plan (A Bronze plan, for example) which might make it free to you or much less than the price of the SLCSP. Alternatively, you may choose to use your $549 to pay for a top of the line Gold plan that costs $1200 per month. You would only pay the portion of that $1200 above the $549 subsidy, so $651 for a Gold plan.

how is the $549 calculated? I can't quite follow your description

 

[PaunchyPirate]

how is the $549 calculated? I can't quite follow your description

Let's say the Second Lowest Cost Silver Plan (SLCSP) available to you has a monthly selling price of $1080 per month.

If your MAGI is $75,000 then 8.5% of your MAGI is $6,375. This is the total amount per year you are expected to pay for the SLCSP. Divided by 12 gives you $531 per month. You are expected to contribute $531 toward the price of the SLCSP, if you were to buy that one. Regardless of which plan you actually buy, your subsidy is calculated based upon what the SLSCP would cost you. The Subsidy will not change after that calculation.

Since the SLCSP costs $1080 and you are only expected to contribute $531, this means your calculated subsidy (or actually, your advance tax credit) is $1080 minus $531 = $549. This $549 per month is the subsidy you will be given if you buy the SLCSP.

If you choose to buy a lower cost plan, you still get the $549 subsidy. If you choose to buy a higher cost plan, you still get the $549 subsidy.

So if you really want to buy a bronze plan that sells for $600 per month, you can do that and it will only cost you $600 - $549 = $51 per month.

If you want to buy a gold plan that sells for $1400, you can do that and it will cost you $1400 - $549 = $851 per month.

Hopefully I got all those numbers correct. Does that help explain how it works?

Note: That 8.5% is the maximum you would pay. It may actually be less. It is a graduated scale that increases up to 8.5% as income rises. I don't really know at what income it actually become the full 8.5%.

 

[Echard]

Ah got it. Thanks.