Health Insurance Nightmares

[BrianGSDTexoma]

I got talked into carry this plan from Manhattan Life to go with my ACA since I have high OOP this year. Not sure how good it is but with the two plans combined I paying about same as I was last year so I just went with it.

 

[chef k-dude]

Thats kinda good news bad news. I did hit the max OOP this year, which was $9200. Not something I wanted to achieve and came with a lot of pain. But $9200 is far better that the $200K in bills I ran up getting there. Doesnt take much.

Monthly premiums for me have bounced around over the last 5 years. 2026 will be the most.

If I were younger and healthier I might consider catastrophic coverage. The last year has scared that idea away. Looking into next year I will be having a few cardiac tests, I have a pile of meds, and likely some imaging all coming - that I know of. I dont see any option but to stay insured.

Another consideration is preventatives are free on all ACA plans. This also become more important as you get older.

I had hernia surgery last year and still didn't reach my max OOP of $7,500! ($8,000 this year, $8,500 next year if I stick with the same plan)

You are right on preventative. I waited until I was back on insurance to get a colonoscopy for exactly that reason. Cardiologist would like to see a dye contrast CT scan on me which will net out at roughly $1,800 OP but that STILL wont get me to max OOP this year, so even rushing that by the end of the year wont help. When I told her how much the estimate was she said "that is outrageous, lets hold on any more tests right now and up your med a little".

I wish we could go right to the best test, like that dye contrast, but no, insurance requires going step by step so I've had to spend 1K in other tests to even get to approval of the dye contrast which will be another $1,8000! Could have saved me $1,000 if we just went straight to dye contrast. My common sense doesn't fly with them though...I dont understand why we cant just do a catheterization which would tell the whole story...and be done with it.

 

[DougE]

I'll just drop this here:

Provider FAQs | CarePayment

Want to learn more about CarePayment patient financing? Get answers to provider FAQs such as what is CarePayment, how we make money, and more.

www.carepayment.com

I got jammed with a pretty big out of pocket payment from radiation treatments ...... seems about all the insurance plans only cover 80% for cancer treatments.

Anyhow, all my providers are in the same network (St. Joseph), and they participate in carepayment.

What it does for me is provide monthly payments I can manage with zero interest so long as I make regular payments. I can pay off this out of pocket without paying any interest at all.

 

[BrianGSDTexoma]

I'll just drop this here:

Provider FAQs | CarePayment

Want to learn more about CarePayment patient financing? Get answers to provider FAQs such as what is CarePayment, how we make money, and more.

www.carepayment.com

I got jammed with a pretty big out of pocket payment from radiation treatments ...... seems about all the insurance plans only cover 80% for cancer treatments.

Anyhow, all my providers are in the same network (St. Joseph), and they participate in carepayment.

What it does for me is provide monthly payments I can manage with zero interest so long as I make regular payments. I can pay off this out of pocket without paying any interest at all.

I was wondering once you hit your out of pocket do you still have to pay that 20%?

 

[jcam222]

I was wondering once you hit your out of pocket do you still have to pay that 20%?

In plans with an out of pocket max I would sure hope not.

 

[ifitsdeadsmokeit]

Sounding like I will be working until I hit 65 just to maintain insurance. Due to kids still on my plans until graduate college in 4+ years I will have to stay full time. Will have to reevaluate at that time. No telling what will happen between now and then with our wonderful political dicotamy and not even able to discuss anything. They spend way more on nonsense than what it would take to provide subsidies to those in need.

 

[sandyut]

I was wondering once you hit your out of pocket do you still have to pay that 20%?

In plans with an out of pocket max I would sure hope not.

No, at least I didnt. Once I hit the OOP max in March this year, I paid for nothing unless I went out of network or skipped a preapproval...which I didnt. This is on ACA. And I suppose its all in the benefit summary.

 

[jcam222]

No, at least I didnt. Once I hit the OOP max in March this year, I paid for nothing unless I went out of network or skipped a preapproval...which I didnt. This is on ACA. And I suppose its all in the benefit summary.

I opted for an Anthem PPO that includes an out of network max out of pocket too. I think it's around $7K in and $9K in/out combined. The advantage plan costs me $51 a,month but I felt the flexibility made it worth it.

 

[DougE]

I was wondering once you hit your out of pocket do you still have to pay that 20%?

I don't expect so. Once you reach your plans out of pocket limit, they should cover 100% from there on.

I also don't expect it matters if you are paying said out of pocket expense through CarePayment, or what have you. The payment terms are between you and your provider. As far as the insurance plan, you have met your out of pocket max.

 

[sandyut]

Just renewed for 2026. went from $150 to $435. I had to upgrade my plan to cover new meds and expected testing. But my deductible is going to be $2050. My meds will eat up that deductible real fast. My consultant agreed that with the higher premium would come out ahead rather than paying lower premium with 6K deductible. Can not wait to get on Medicare!

 

[DougE]

Can not wait to get on Medicare!

Pretty much the same BS as with private insurance.

When I said I got only got 80% of my radiation treatments covered, it was through Medicare. None of the Medicare plans cover more than that.

On the plus side, my new plan gives me $350.00 towards corrective lenses next year .......

 

[sandyut]

Pretty much the same BS as with private insurance.

Seems like its all a bunch of BS.

Sadly twice in 3 years I needed to use a lot of the ins. and maxed out OOP...they sent me letters saying they suspected I was sharing my coverage. I blew a gasket. Sent them a very nasty reply. Never heard back....huh.

 

[Gonna Smoke]

When I said I got only got 80% of my radiation treatments covered, it was through Medicare. None of the Medicare plans cover more than that.

Doug, I didn't know this...

 

[Fueling Around]

Medigap insurance has jumped significantly for 2026.

Sounding like I will be working until I hit 65 just to maintain insurance. Due to kids still on my plans until graduate college in 4+ years I will have to stay full time. Will have to reevaluate at that time.
...

That was part of the Obamacare plan was that those on an employer covered plan will work until medicare age.

Pretty much the same BS as with private insurance.

When I said I got only got 80% of my radiation treatments covered, it was through Medicare. None of the Medicare plans cover more than that.

On the plus side, my new plan gives me $350.00 towards corrective lenses next year .......

Did you mean Medicaid?

 

[Winterrider]

On Medicare, but spouses premiums went up from $345 to $776 with no tax credits available for 2026 . Oop went up $800 to $10k. What a rip off. Another yr before medicare for her.

 

[DougE]

Doug, I didn't know this...

I didn't either, but I did a review of my medicare coverage, and what changes I should make. The agent said I would have gotten jammed with 20% of the cancer treatment costs no matter which carrier I chose.

I did update my coverage and will get more money per year for corrective lenses and got $0 copay for primary care, and my copay for specialists went down for next year.

 

[chef k-dude]

When you live on the economy, this is what it's like. My high deductible bronze plan went from $650 to $850 a month in 2026. $8,500 MOOP. Our reward for bieng solidly middle class. We get no help, but we get the joy of helping others through our taxes...You're welcome whoever that applies to! Just doing our part...

 

[pineywoods]

Insurance is the main reason my wife still works. She works from home now but still works. With my health I need good insurance seems I'm in the hospital once or twice every year anymore. Medicine costs are crazy without a company plan like the wife has and I'm on some high priced drugs. We pay a lot for the insurance but it actually went down a few dollars this year. They now have a plan for employee and spouse instead of having to have the family plan like it's been for years.

 

[Gonna Smoke]

They now have a plan for employee and spouse instead of having to have the family plan like it's been for years.

When I worked, our insurance was the same. Either employee only or family plan. Made no sense why I should have to pay the same for just the 2 of us as someone else who had children...

 

[sandyut]

Insurance is the main reason my wife still works. She works from home now but still works. With my health I need good insurance seems I'm in the hospital once or twice every year anymore. Medicine costs are crazy without a company plan like the wife has and I'm on some high priced drugs. We pay a lot for the insurance but it actually went down a few dollars this year. They now have a plan for employee and spouse instead of having to have the family plan like it's been for years.

I hear ya. This a big part of decision process in retiring early. My wife was only on ACA for 2 year. I am 10 years younger so I am still not that close to Medicare. Till 2026 my monthly premiums were palatable. Next year will have a higher monthly, but it will likely pay off with the cost of meds and specialists. 2 years during retirement I maxed OOP from accidents/surgeries. While unexpected, I am still active and thus there are things that can happen. 7 years to go.