I’m guessing you disqualified for the tax credit for some reason or another. Otherwise it is supposed to be < 10% income IIRC.
~Max
Yeah, 10% of my income would suck. We’re paying a lot less.
Now keep in mind, we’re public employees so our benefits are really good.
Well, that’s at just under 400% FPL. If you’re at or near FPL it is supposed to be near zero.
~Max
We’ve had wildly varying coverage of our proton pump inhibitors - which again, supposedly, are mandated by the employer who purchases the group policy. When I was still covered through my own job, there was a memo saying they would no longer cover ANY PPIs as there are so many inexpensive ones over the counter.
Didn’t immediately affect me, as that was the year we switched to cover me under my husband’s policy. Those folks have jerked me araound on coverage of Dexilant (a newer PPI which works better, and can be taken with food which makes compliance a lot easier). I claim they’d rather I just hurried up and died of Barrett’s esophagus / cancer. Doc actually filed an appeal, and basically their response was “yeah, that’s what she should be on, but too bad”. I’d say joke’s on them, as cancer care would be a LOT more than the Dexilant… but I turn 65 this year so it wouldn’t be on their dime.
It’s been a while since I’ve dealt with ExpressScripts, if ever. We have to use OptumRx (I call them Dropped’em) for any long-term meds, though they have switched to allowing me to get a 90-day fill at Walgreens instead if needed. I actually haven’t had issues with them in a while, though there were a few times (like the time my MIL’s cancer meds nearly did not arrive in time, due to their screwup). My insurance coverage had a similar mandate, but our mail-order was Caremark and we could get the meds at CVS.
Luckily for us, the Walgreens is almost as close as the CVS.
So I think if your employer plan meets certain requirements, premium <10% income being one of them likely met by a public employer, you are ineligible for the tax credit. So in that case you wouldn’t have a choice in the marketplace unless you’re willing to pay the full premium out of pocket, in my area $350+ / mo.
But the coverage that disqualifies you for marketplace credit has to meet certain minimum standards (which your wife’s probably does). I think it has to cover more than half of the costs for example, which puts OP’s $500/$100 split out the window.
~Max
Yeah, we are public employees represented by unions that negotiate good terms, and since we work for two completely different governments (one state and one county) and can be covered by either, we went with the better one. We are fortunate in that way.
I do recall working for an employer years ago (medical software company) that had terrible benefits. I got a decent health plan for myself but they didn’t cover my wife at all for anything. She had to be covered by private insurance and was unemployed. It was pricey, even with tax credit. I mean, I wasn’t making a lot of money at the time, so any extra burden was hard.
I don’t even remember what insurance I ended up getting, but it cost enough each month it really strained us. When people aren’t making a lot of money, every dollar you spend hurts. I’m pretty sure I got whatever the cheapest option was I could find.
Max proving time and again that he gets all his ideas from “think tanks”
How much choice a person has almost entirely depends on the employer- I have health insurance from a union/government employer through a program that insures over a million state and government workers. Eighteen choices are listed in their booklet - but only two are open to people who live in my county/city. If the employee lives in a different state (which is common) , there is only one option. Other counties have as many as five choices. My husband’s employer offers only a single option.
But you could pay $28,000 a year and get your own insurance!
Choice!
Whether insurance meets marketplace standards isn’t the only thing that matters to people - for example, I want to be able to see my current doctors rather than finding new ones. I don’t see how marketplace policies could be guaranteed to cover half the costs unless you can only use participating doctors. Because if my insurance pays $100 for service A, there is no way they can stop my non-network doctor from charging me $500.
I can’t speak for other areas, but here all the major networks are on the marketplace. Maybe not Cigna but I’m not aware of Cigna exclusive HMOs here.
~Max
You could switch to any of the hundreds of PCPs on your area that are taking new patients.
Your choice to use your own doctor, or any doctor. Why not Nurse Practitioners or Physician Assistants.
“Hundreds?” Is that sarcasm I hear?
I don’t know if you understand what I mean - where I live there is no such thing as “major networks” . Maybe you mean “major insurance companies”? Different insurance companies have their own networks ( sometimes multiple ones for different policies through the same company ) and it’s possible that there is no one network that all my doctors participate in. Happened to me a few years ago - my PCP’s office stopped participating in my insurance although they continued to participate in others. I used the out-of-network coverage for my PCP visits but since he didn’t participate in my insurance, my insurance company couldn’t control what they charged me.
We seem to be talking about the same networks. Yes, it’s possible no one network covers all of your doctors if you have more than two or three doctors (i.e. independent gp, ped, obgyn). And that is a consideration when shopping for plans. There are PPOs but they tend to be bronze, roughly 60/40 split with you paying 40% of the cost for OON. As opposed to most plans which have a fixed <$40 copay for in-network visits. My plan for example is an EPO with $0 for network PCP and I think $5 for urgent care or specialist visits, 70/30 split for diagnostic testing.
Still does not come close to paying $500 for an office visit.
~Max
Really - who tells my non-participating doctor he can’t charge me $500 for an office visit even if my insurance will reimburse me much less? Had a dermatology visit a couple of weeks ago - the NP charged $700, the insurance paid around $200. If she had been out of network, it would have cost me around $500.
Okay, looking back on this specifically. The OON doctor is free to balance bill for the remainder. Health insurance only covers a percentage of the patient’s bill up to its own in-network rates for the service, because as you say they have no contract with OON doctor.
~Max
ETA: ninja’d
Not necessarily - when I ran our office regular practice was to put a very large number on the invoices, send to insurer, the insurer writes back (or rather sends electronic remittance) with the adjustments according to contracted fees and their payment. We write off the difference between our initial bill and the contracted fee, then bill the patient for the difference between the fee and insurance payment.
If it turned out the insurer rejected the service as non-covered, that does not necessarily mean the patient is stuck with the entire initial amount. That initial amount is so high because we did not have the resources to keep track of 150+ fee schedules changing on an annual basis for 150+ insurers, in and out of state, for each individual service code we ever wanted to use. We had less than 10 employees as I said before, we outsourced billing but they were a small local operation, too. The reason the initial bill is high is because if we ever accidentally sent a bill lower than the contracted amount, the insurer would never adjust the bill upward. It does not reflect the going rates for uninsured.
So I would have to manually look at the contract with this patient’s insurance and see what the provisions say about out of network. As you note some insurers have multiple networks and as a condition for taking one network we might be required to bill within X% of the rate for a patient from the same insurer on a different network. Multi-Plan/PHCS was one of those aggregate insurers with this kind of policy going on, BCBS is also a fragmented coalition with special provisions for out of state billing since we only contracted with the Florida entity.
Additionally some plans had variations where certain benefits were not covered for certain patients. As a provider we dealt with the one network and the one fee schedule, which we are locked to, but the insurer by virtue of carve outs in the patient’s contract, simply would force the patient to pay 100% of the contracted rate. Nothing we could do in those situations.
But if the contracts did not mandate otherwise, I fixed our self-pay rate as 115% of Medicare pricing. Far less than the number appearing on all our initial bills to insurers. Sometimes this meant balance billing the patient. Sometimes it had the paradoxical effect of the patient paying less than if we were in-network.
~Max
How in hell was she supposed to even know this? Are patients supposed to quiz every person working for an in-network hospital, down to the cleaner and parking attendant? What’s next, “oh sorry, the dude who cleans toilets is out of network. Here is your toilet cleaning bill for $6,734.67”
What a stupid system.
You just don’t understand how things work. Max will explain it to you. It’s quite logical and all your fault, I’m sure you will agree, after reading 60,000 words on the issue.
Max’s employer assures him he is doing God’s work.