Advice on Choosing Affordable Health Plan

[BrianGSDTexoma]

I like the plan I been on but it went up quite a bit this year and my agent wants me to switch plans. I really like keeping low deductibles and out of pocket as you never know what is going to happen. I have the Silver 205 that will be $244 a month , was $65, and he wants me to go with the Gold 206 which would have no premiums which would save me $3000 a year.

 

[BigW.]

Medicare Advantage agents need to switch your plan every few years to continue getting paid. Your choice is do you want to pay a monthly prem and have lower out of pocket limit or no monthly premium and really high deductible. I'd be iffy on switching unless you are a marathon runner, no health issues and good amount in your checking account. Most folks do not have those 3 qualities.

 

[Winterrider]

May need to jump through whoops on that referral issue if emergency arises. Otherwise, it is usually thru your physician .

 

[BrianGSDTexoma]

Medicare Advantage agents need to switch your plan every few years to continue getting paid. Your choice is do you want to pay a monthly prem and have lower out of pocket limit or no monthly premium and really high deductible. I'd be iffy on switching unless you are a marathon runner, no health issues and good amount in your checking account. Most folks do not have those 3 qualities.

Thats probably why he pushing me though he been suggesting this plan since I been using him. Tells me he is on it and had couple surgeries one year and never came close to his out of pocket.

May need to jump through whoops on that referral issue if emergency arises. Otherwise, it is usually thru your physician .

Yeah the referral thing been a pain a couple times but HMO's is all I can afford. Next year going to have to figure out the Medicare thing. I been just using my SS to keep my income where I can get these plans. Once I get on Medicare I can start using my IRA's.

 

[BigW.]

Ah, I assumed you were on Medicare already since "Advantage" was part of a plan name. You will certainly like Medicare and Supplement world more than current plan options.

 

[noworries]

Talk to your health care consultant and tax advisor about the impact of Marketplace plans and your income on your potential tax liability from ACA subsidy claw backs, and how different Marketplace plans compare based on total expected medical costs (existing conditions +/-).

For the ACA/Marketplace, your income level matters none, a little, a lot, or massively in the future. If you make more than 400% of the Modified Adjusted Gross income based on the Federal Poverty Level (FPL) income in your area, pay particular attention to your 2025 income, and what congress does or does not next year about health care (ACA or successor) going forward. See for FPL lmiits (2024) https://www.medicaidplanningassistance.org/federal-poverty-guidelines/

For 2025, do the math and visit your state's Marketplace website to compare plans to see your "Estimated Total Cost" (premiums + drugs you take + copays + deductibles) based on your medical/drug needs.

As a low consumer of medical care, I found that a Bronze HSA plan had modest premiums and a maximum out of pocket that, if I maxed it out, together were about equal to the total annual premiums for an arguably "better" plan having a lower deductible. Why prepay in premiums for care I likely won't use?

If I continued not to need much care I could put the lower premium difference into an HSA or into my pocket, but if I did need care, I would be capped at the maximum out of pocket. Then I'd use my banked HSA or pocketed funds in whole or in part. And, you can put pre-tax money into an HSA for future medical expenses.

To summarize, or clarify: If I had the higher premium silver or gold plan, I was guaranteed to pay something approaching the maximum out of pocket in premiums alone. YMMV. I went with the Bronze HSA.

Now a bit about taxes and the ACA/Marketplace. An exemption to required repayment of the substantial ACA subsidy (that could approach $20,000) was implemented during the pandemic. Thank you to then congress/President.

That exemption was later extended/modified to limit health care premiums to no more than 8.5% of income for "incomes" above 400% of the Federal Poverty Level. Thank you again then congress/President. This extension expires after 2025 unless congress/Pesident finally now comes up with a "better" system than the ACA, or again extends the extension. Otherwise, you may be in for a rude tax awakening if you make more than 400% of the FPL. I heard about a "concept" of a better plan than the ACA. We'll see.

Also see: https://www.healthinsurance.org/obamacare/beware-obamacares-subsidy-cliff/

I'm now on a Medicare Supplement "Plan G" and could not be happier. But that's another discussion.

 

[JckDanls 07]

BrianGSDTexoma

I'm coming up on all that crap too... 2 more years .. and I am clueless... LOL

 

[chopsaw]

I have Medicare and an advantage plan through the Carpenters . Nice thing is I can call any of the gals at the hall and they help me with questions .

 

[jcam222]

Thats probably why he pushing me though he been suggesting this plan since I been using him. Tells me he is on it and had couple surgeries one year and never came close to his out of pocket.

Yeah the referral thing been a pain a couple times but HMO's is all I can afford. Next year going to have to figure out the Medicare thing. I been just using my SS to keep my income where I can get these plans. Once I get on Medicare I can start using my IRA's.

Brian are these plans on the .gov marketplace?Biggest issue I'm having is finding one that has a decent amount of providers in my area. Really narrows it down to Molina for me.

 

[Fueling Around]

Thanks N noworries for the run down.
ACA has so many holes and flaws that are coming to the surface. Gawd I wish our politicians would actually read something (and comprehend it) before they push to pass it. Oh yeah, "we have to pass it to find out what is in it" is their mentality.
As you pointed out, they passed it and now we are finding what isn't in it.

I was on ACA for a short time last year after my wife was forced to retire and we lost her healthcare insurance. I am also a basic non medical user so my BCBS through MNSure was very little cost. I would have preferred to stay on that plan as it was much less than what I have to pay for my basic Medicare coverage. I have avoided a supplemental to this point and will NEVER go on an Advantage plan.
Got about 8 months before I can officially retire and start drawing from my IRAs and 401k plans without the income penalty as I still work part time and it surpasses the damn near poverty level levels for SSI.

Brian, you are in a different boat from me. You have some medical issues so the ACA coverage really limits you. My ACA through BCBS was a high deductible but not tied to a HMO plan.
My advice, talk to 2 or 3 other insurance agents on your options for your last year of ACA and transition into Medicare. Once you hit 65 and go on Medicare it gets multiplied for the amount of options and plans. If a HMO works for you an Advantage plan may be your option. My wife is on a low deductible BCBS supplement that is pretty much universal but it comes with a cost.

 

[BrianGSDTexoma]

Brian are these plans on the .gov marketplace?Biggest issue I'm having is finding one that has a decent amount of providers in my area. Really narrows it down to Molina for me.

I go directly to BCBSTX here to look at the plans. Look and see who covers your state. The same plan using the Gov site shows alot different prices. I let a agent which is free do the leg work. I got lucky and a friends daughter worked for a doctor and she got me in. Most the doctors that accept the plan are not taking new patients.

 

[BrianGSDTexoma]

alk to your health care consultant and tax advisor about the impact of Marketplace plans and your income on your potential tax liability from ACA subsidy claw backs, and how different Marketplace plans compare based on total expected medical costs (existing conditions +/-).

Thanks for that write up. One think I did before starting is I kept changing my income to find the sweet spot. For me $25,000 was it. That plan I been on does not even show if the income got much higher.

 

[BrianGSDTexoma]

My advice, talk to 2 or 3 other insurance agents on your options for your last year of ACA and transition into Medicare.

I was planning on doing that next year when I try to figure out how to make the transition.

 

[Chasdev]

I've been on medicare for a few years along with my wife and we had been buying suplimental coverage to the tune of around $300 a month to cover what medicare did not pay for and for drug coverage.
I switched to Humana PPO and was able to drop the supplimental insurance coverages, which save us around $3600 a year.
My drug costs are 99% covered with the exception of tier 3 drugs like Mounjaro, for which I paid roughly $1000 a year (this is going down in 2025 thanks to congress lowering drug costs).
I've read all the warnings about how PPO's are bad news and I guess if you live in an area where there are few hospitals/doctors to choose from, it could be a problem, but for me, living in a large city, my healthcare provider choices abound and frankly I wish I had joined a PPO a long time ago.

 

[jcam222]

I go directly to BCBSTX here to look at the plans. Look and see who covers your state. The same plan using the Gov site shows alot different prices. I let a agent which is free do the leg work. I got lucky and a friends daughter worked for a doctor and she got me in. Most the doctors that accept the plan are not taking new patients.

So do you find that the plans are cheaper and / or more comprehensive via an agent?

 

[sandyut]

You may check with a different broker. I use a broker for marketplace ins. but I also shop it up before talking with them to make sure I have confidence in their advice. If you like you plan, I would keep it. I've been on the same plan 2 years, going on three. I like it. My wife is on a Medicare advantage plan with United and they have issues paying for dental claims, crowns in particular. she real pissed at them and likely changing because of it.

 

[BrianGSDTexoma]

So do you find that the plans are cheaper and / or more comprehensive via an agent?

I pretty much found the plan I wanted and told him. He will give suggestions but mine always wants me to go with a high deductible plan with $0 premium. I was just using the agent to make sure everything was done correctly. The hard part is keeping income down and finding a doctor that will take you and the plan.

 

[chef k-dude]

I was stunned at the low cost of Medicare when my wife turned of age. We had not been carrying insurance prior to that because the cost of any plan premiums was equivalent to the catastrophic financial impact of a sudden medical issue (and neither of us have serious ongoing medical issues). If you dont qualify for subsidy, the cost of insurance in my area was outrageous.

Its more affordable now that somehow the number of insurers has increased in this area. I finally got insurance for 2014 and its a higher deductible plan of $7,500 max out of pocket and runs $650 a month in 2024. My employer doesn't provide insurance but does provide a $300 a month stipend for employee's health insurance and will deduct and pay my premium directly from my paycheck before taxes...AND its an HSA plan which will save us some money.

Talk to your health care consultant and tax advisor about the impact of Marketplace plans and your income on your potential tax liability from ACA subsidy claw backs, and how different Marketplace plans compare based on total expected medical costs (existing conditions +/-).

For the ACA/Marketplace, your income level matters none, a little, a lot, or massively in the future. If you make more than 400% of the Modified Adjusted Gross income based on the Federal Poverty Level (FPL) income in your area, pay particular attention to your 2025 income, and what congress does or does not next year about health care (ACA or successor) going forward. See for FPL lmiits (2024) https://www.medicaidplanningassistance.org/federal-poverty-guidelines/

For 2025, do the math and visit your state's Marketplace website to compare plans to see your "Estimated Total Cost" (premiums + drugs you take + copays + deductibles) based on your medical/drug needs.

As a low consumer of medical care, I found that a Bronze HSA plan had modest premiums and a maximum out of pocket that, if I maxed it out, together were about equal to the total annual premiums for an arguably "better" plan having a lower deductible. Why prepay in premiums for care I likely won't use?

If I continued not to need much care I could put the lower premium difference into an HSA or into my pocket, but if I did need care, I would be capped at the maximum out of pocket. Then I'd use my banked HSA or pocketed funds in whole or in part. And, you can put pre-tax money into an HSA for future medical expenses.

To summarize, or clarify: If I had the higher premium silver or gold plan, I was guaranteed to pay something approaching the maximum out of pocket in premiums alone. YMMV. I went with the Bronze HSA.

Now a bit about taxes and the ACA/Marketplace. An exemption to required repayment of the substantial ACA subsidy (that could approach $20,000) was implemented during the pandemic. Thank you to then congress/President.

That exemption was later extended/modified to limit health care premiums to no more than 8.5% of income for "incomes" above 400% of the Federal Poverty Level. Thank you again then congress/President. This extension expires after 2025 unless congress/Pesident finally now comes up with a "better" system than the ACA, or again extends the extension. Otherwise, you may be in for a rude tax awakening if you make more than 400% of the FPL. I heard about a "concept" of a better plan than the ACA. We'll see.

Also see: https://www.healthinsurance.org/obamacare/beware-obamacares-subsidy-cliff/

I'm now on a Medicare Supplement "Plan G" and could not be happier. But that's another discussion.

I've been dealing with this kind of strategy too. The cost of a gold plan is roughly equivalent to the premium plus max out of pocket of a bronze plan. A gold plan is "pre-paying" for medical care you may never need and you never get that money back. A reasonably healthy person should keep this in mind.

I got insurance this year because it finally became fairly affordable plus I wanted to have a hernia repaired. I knew the most if could cost me is the maximum $7,500 out of pocket and figured the surgery and related charges JUST HAD to be more than that.

Well, I found out the added benefit of insurance...they are your advocate (actually their own advocate but its power you dont have on your own) for keeping the charges down. I watched as the hospital and insurance company battled back and forth to settle on the costs. I watched as $20,000 of charges were whittled down by the insurance company to the point where even with a few visits earlier in the year where I paid towards deductible I'm still only out of pocket about $6,500 this year after the surgery. Might be more if they have to snip anything during an upcoming colonoscopy, but thats another reason I scheduled that by the end of the year, so if there is any added charges, they will fall within my max OP.

So I may STILL not reach my max OP even with surgery. We have the money saved so its actually better than expected. BUT...going to look at paying the bill, they have an option to finance it for 3 or more years at zero %! if you want. So the old stories of hospitals coming after your home for medical debt may not be as dramatic as the lore. All I know is they are offering me a payment plan and I didn't even ask for it.

 

[sandyut]

So do you find that the plans are cheaper and / or more comprehensive via an agent?

the brokers can help sort out a plan that will cover your meds, your doctor is in network etc. you can do all this yourself, but its a PITA. brokers are free and the complete the enrollment for you-to me that is a huge benefit. Colorado uses their own marketplace website and it seem to a nightmare.

I dont run any of my meds through my insurance. I use the Kroger health saving plan (i think thats the name) $36 a year and everything is real cheap and they cover all my meds. My ins wont cover one of mine at all and its a spendy one. removing the medication piece makes it much easier to pic a plan. its pretty much down to providers/provider networks, deductibles, cost and such.

 

[sandyut]

I like the plan I been on but it went up quite a bit this year and my agent wants me to switch plans. I really like keeping low deductibles and out of pocket as you never know what is going to happen. I have the Silver 205 that will be $244 a month , was $65, and he wants me to go with the Gold 206 which would have no premiums which would save me $3000 a year.

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JSYK, this plan you posted is amazing! Sh*t man, my deductible is $6000, max out of pocket is $9500. those prices are far better than what I get...I pay about 200 +/- a little for mine plan and its about as low as I can go with still having copays for everything, no copay plans are more expensive and have higher deductibles.