ACA costs

[Onda]

The Federal law is there, state laws may add additional protections.

In Massachusetts you can have income of (5*FPL) 98600 + ROTH distributions + Cash and qualify for very low Health care cost and out of packet. With large Roth account one live on 200k a year and enjoy cheap high quality healthcare.

Insurance for 255 USD per person, Out of pocket 3000 for family.


https://www.mahealthconnector.org/learn/plan-information/connectorcare-plans

 

[MBSC]

Balance billing was addressed Federally with the No Surprises Act.

https://www.cms.gov/nosurprises

That site covers Medicare and Medicaid. Not ACA.

The ACA did not create a new "Department of Affordable Care". ACA administration is assigned to already existing agencies, mainly HHS and IRS, with some HHS responsibilities being delegated to CMS.

In July, 2021, the U.S. Departments of Health and Human Services, Labor, and the Treasury (the Departments) released the “Requirements Related to Surprise Billing; Part I,” to restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.

https://www.cms.gov/nosurprises/policies-and-resources/overview-of-rules-fact-sheets

The 'No Surprises Act' only applies to ACA-compliant group and individual plans. It does not apply to original Medicare or Medicare Advantage because they already have more comprehensive protections in place.

 

[GenXguy]

The 'No Surprises Act' only applies to ACA-compliant group and individual plans. It does not apply to original Medicare or Medicare Advantage because they already have more comprehensive protections in place.

But notice the quote:

In July, 2021, the U.S. Departments of Health and Human Services, Labor, and the Treasury (the Departments) released the “Requirements Related to Surprise Billing; Part I,” to restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.

You might need service at out-of-network facilities.

Balance billing was addressed Federally with the No Surprises Act.

https://www.cms.gov/nosurprises

That will offer some protection, but we know out of network charges still occur and with a much higher deductible and out of pocket max.

 

[GenXguy]

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.

Yeah, this can happen with HMO and PPO. But for a specialist, the HMO requires a referral, though.

The plan docs for the PPO we intend to utilize specifically mentions balance billing as uncovered.

Yes, the same for my POS plan, which is a combination HMO and indemnity plan.

 

[TickTock]

jim584672 and MichaelB,

Thanks for the links! This is new to me (the No Surprises Act).

I just did a search on "no+surprises+act" and prior to this thread the next instances are in May and February of 2023 and September of 2022.

Going into research mode now...

 

[GenXguy]

Speaking of surprises, I got a surprise last night refilling a couple prescriptions. The combined price went up about $1.40 for the 30 day supply to over $9 total. There were no changes with my health care coverage, medication, or pharmacy. Even the retail prices on the printout hadn't changed.

 

[gauss]

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.

+1 I tend to agree especially if you are in a decent size market (not necessarily NYC, but my rust-belt metro area would be included) and buy from a firmly entrenched insurer (ie the Blues). This also assume that you don't have chronic medical conditions.

I think balance billing may be the new "identity theft" that folks are afraid of and there is a market in fanning those fears.

Old school identity theft has been resolved ~20 years ago, IMHO, once folks were allowed to place and remove federally legislated security freezes on their credit reports. I guess the folks at LifeLock never got the memo.

-gauss

 

[GenXguy]

+1 I tend to agree especially if you are in a decent size market (not necessarily NYC, but my rust-belt metro area would be included) and buy from a firmly entrenched insurer (ie the Blues). This also assume that you don't have chronic medical conditions.

What does "chronic" have to do with it? It's possible that a chronic medical condition can be handled in or out of network like many other conditions, and you never know when you might have a chronic condition as you age. So, you always need to be prepared for out of network charges and balance billing, which would likely be very expensive. You should be able to see what the out of coverage is on your plans, but that won't cover balance billing.

I have Health Alliance POS. The only other option was Blue Cross PPO. The Health alliance coverage looked better in the plans, but I don't know if it would cover some facility that I might be referred to in the future, same thing with Blue Cross.

 

[gauss]

The idea was that if you have chronic/uncontrolled medical conditions and/or cancers that are causing you to hit the OOP max more years than not, then that could get pricey. If you are hitting the OOP max once only every 5-10 years, then that is more manageable especially if in-network and subject to the ~10,000 limit per person.

Now granted, I say all this from a perspective of having a high 5 figure HSA account (I started funding in the mid 2000's when MegaCorp finally starting offering High Deductible Health plans as an option).

-gauss

 

[gauss]

Speaking of surprises, I got a surprise last night refilling a couple prescriptions. The combined price went up about $1.40 for the 30 day supply to over $9 total. There were no changes with my health care coverage, medication, or pharmacy. Even the retail prices on the printout hadn't changed.

I'll readily admit that is a huge % increase.

My DW has experienced several ups and downs of similar magnitudes with her generic high blood pressure meds.

 

[qwerty3656]

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.

I live in Michigan, but right on the boarder and am basically a suburb of Toledo OH. ALL the close hospitals, medical facilities, specialists are in Toledo. Toledo is considered out of network for Michigan ACA purposes.

 

[gauss]

I live in Michigan, but right on the boarder and am basically a suburb of Toledo OH. ALL the close hospitals, medical facilities, specialists are in Toledo. Toledo is considered out of network for Michigan ACA purposes.

Thank you for this info.

I have a Michigan Blue Cross PPO plan so I did a quick check on two hospitals in Toledo.
1) ProMedica - which I could not find in the directory

2) The University of Toledo Medical Center - Which showed up as a National network but not the "best" PPO network

I thought I had a decent plan for coverage, but perhaps my out of state coverage is lacking (yikes). I purposely avoided the lower cost plans offered by them that were "Michigan" based, so I am not really sure what is going on here.

Thanks again for the info. It's good to find this out before you need it.

-gauss

 

[GenXguy]

The idea was that if you have chronic/uncontrolled medical conditions and/or cancers that are causing you to hit the OOP max more years than not, then that could get pricey. If you are hitting the OOP max once only every 5-10 years, then that is more manageable especially if in-network and subject to the ~10,000 limit per person.

I certainly don't disagree with that. And with medical costs, it doesn't take much to run up the bill. But since you were responding to Jim's comment about not needing out of network coverage, that's what threw me, since chronic conditions could still be in network.

 

[jim584672]

Speaking of surprises, I got a surprise last night refilling a couple prescriptions. The combined price went up about $1.40 for the 30 day supply to over $9 total. There were no changes with my health care coverage, medication, or pharmacy. Even the retail prices on the printout hadn't changed.

That doesn't make sense, usually plans have a set cost for a given Tier drug and that doesn't change.

 

[Rianne]

Speaking of surprises, I got a surprise last night refilling a couple prescriptions. The combined price went up about $1.40 for the 30 day supply to over $9 total. There were no changes with my health care coverage, medication, or pharmacy. Even the retail prices on the printout hadn't changed.

Does it depend on the pharmacy, drug, or perscription length? I got 2 refills yesterday. One for 90 days. $0. One for 30 days $2. I have Wellcare.

 

[TickTock]

I think balance billing may be the new "identity theft" that folks are afraid of and there is a market in fanning those fears.

I don't know about that, but I will note this - when I go to healthcare.gov and look at the plan docs for our HMO and PPO options, HMO says OON is not covered and PPO says balance billing applies and there is no OOP max for OON services. No mention of the NSA.

 

[MichaelB]

I don't know about that, but I will note this - when I go to healthcare.gov and look at the plan docs for our HMO and PPO options, HMO says OON is not covered and PPO says balance billing applies and there is no OOP max for OON services. No mention of the NSA.

Balance billing is a practice where policyholders receive services from out of network providers without their knowledge or prior approval and are billed the entire amount. In an emergency room setting, for example, this can cost $$ thousands The No Surprises Act no longer allows that.

You are still liable for out of network services if you are informed beforehand agree to pay. That’s what the PPO insurer is saying.

 

[TickTock]

MichaelB,

That's good to know. The PPO insurer is, IMO, deliberately obfuscating that. And if I'm reading this correctly, the acceptance has to be in writing.

Are OON services in HMOs covered, contrary to what the docs I'm seeing in their plan are saying?

 

[TickTock]

From the PPO Summary of Benefits:

What is the out-of-pocket limit for this plan?
Individual: Participating $9,450; Non-Participating Unlimited. Family: Participating $18,900; Non-Participating Unlimited. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?
Premiums, balance billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit.

 

[MichaelB]

MichaelB,
Are OON services in HMOs covered, contrary to what the docs I'm seeing in their plan are saying?

Typically HMOs do not cover out of network services. The exception to this is emergency care.

 

[TickTock]

From the HMO Summary of Benefits:

What is not included in the out-of-pocket limit?
Premiums, balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

And everything OON, except for Emergency Room Care and Emergency Medical Transportation, are listed as Not Covered.

 

[MichaelB]

MichaelB,

That's good to know. The PPO insurer is, IMO, deliberately obfuscating that. And if I'm reading this correctly, the acceptance has to be in writing.

From the PPO Summary of Benefits:

What is the out-of-pocket limit for this plan?
Individual: Participating $9,450; Non-Participating Unlimited. Family: Participating $18,900; Non-Participating Unlimited. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?
Premiums, balance billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Balance billing is still allowed, but under very specific circumstances. You have to be informed beforehand a service is not covered and you also need to agree in writing.

Here’s a summary by CMS that’s pretty clear https://www.cms.gov/newsroom/fact-s...nd-your-rights-against-surprise-medical-bills

Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).

Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.

Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.

Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

 

[GenXguy]

That doesn't make sense, usually plans have a set cost for a given Tier drug and that doesn't change.

Doesn't make sense?? This is how it's been with 3 straight insurance providers over the last few years. The last two insurance providers through my work (BCBS, UHC) and my ACA marketplace insurance provider (HA). It has NEVER been a set cost for these lowest tier meds.

All my prescriptions are the lowest tier of drugs, but my cost has varied from $0 to $10 per 30-day prescription over the last few years. On BCBS, I had one prescription that suddenly went from about $10 to free a few months into the year and stayed free monthly the rest of the year while another cost me several dollars when I would refill it during that time. My current plan's coverage details shows $10 (and no deductible) for the lowest two tiers of drugs, but the most expensive one on this plan has cost me $6.19 (which shows about $25 retail cost on the printout). Here are my out of pocket prescription charges in 2024: $2.54 $2.71 $1.58 $5.30, $3.22, $6.19, all lowest tier drugs from the same pharmacy for monthly prescriptions under the same insurance. These costs also show when I login to my insurance website to view where I am with out of pocket costs. So, I don't see how that "$10 tier 1" listed in my plan info has any relevance. And those prices aren't retail, either. The $6.19 one is about $25 retail, and the $3.22 one is $4.04 retail, just as it was in the previous months. I also didn't use coupons in any of these instances.

Does it depend on the pharmacy, drug, or perscription length? I got 2 refills yesterday. One for 90 days. $0. One for 30 days $2. I have Wellcare.

These prescriptions were all monthly, and they were the same drug, same number of doses, same mg dosage, same pharmacy, and the retail price was still the same as previous refill. It was just my out of pocket that went up some in March compare to January and Feburary. It's small potatoes, but it make me wonder why.

 

[PappaChris]

Plan w/ HSA compatibility

If looking for a deduction.

Live in Ohio and the ACA plan we have (both 63) is HSA compatible. Funded the last two years. For 2024 planning $8300 + $1000 (me) + $1000 (spouse) = $10300

If not already established you'll have to set up a separate HSA for your spouse.

 

[TickTock]

Sent the first ACA monthly payment. Ouch!

Still, (in our situation) ACA > COBRA > megacorp retiree health insurance.