Health Insurance Questions

brij2006

Okay, so I'm asking here because it's not in the "open" yet and I wanted to see if anyone here knows and is reading what I am.

We are 90% sure I'm putting in my notice at work within the next 2 weeks.
However, the only reason I was holding off on quitting and becoming a stay at home mom was because of my health insurance through my employer and I'm due in June with child #2.
So worst case scenario with my current health insurance, our out of pocket expense would be $4,000 total.  If I were to quit and get onto my husband's plan, worst case scenario, our out of pocket expense would be $12,500. Best case scenario on my plan would be $3,000 and on my husbands plan would be about $6-7,000. 

But then I got thinking.  There are no pre-existing conditions with ACA and both quitting a job and having a baby are life events to be able to make an insurance change.
So here's what I'm thinking.
I've priced out an independent plan for myself that has a low deductible and maxOOP.  It's $471/month for $1,750 deductible and $3,300 maxOOP.  It's $400/month to add me to H's employers plan with a $4,000 deductible and $6,250 max OOP.  That would save us about $3,000 just on the max OOP for me for the birth of baby.  Then another $2,250 if we meet the deductible for baby (hopefully won't).
So we'd pay $284 (4 months, March-June) more total for this plan vs my H's plan, but save $5,250 in deductibles/maxOOP for the birth of baby.

Then since having a baby is considered a qualified life event, and according to what I've found in my searching, I have 60 days after baby is born to make insurance changes.  So baby and I could then go on my H's plan and his would switch to a family plan.
Otherwise his open enrollment period is in October.  So worst case scenario I'd have to wait until then to get myself added to his plan.

Any thoughts on this?  Or am I completely off my rocker?  Is there something I'm missing in all of this?
Either way, we'll have enough in medical expenses this year to be able to write off the birth of baby as well as this premium paid out of pocket.  So the fact that the premium would be paid post tax rather than pre-tax on H's plan, doesn't matter as much.

smerka

First of all only the medical expenses that exceed 10% of your income are deductible. So if you make $50,000, the first $5,000 is not deductible. 

Second, make sure your husband's plan allows you to join his plan after a job change.  That might not be a qualifying condition and you might have to wait for you to join until his next open enrollment period. The baby should not be a problem. 

hoffse

How is your daughter insured?

I would recommend trying to get the cheaper insurance set up ASAP, just in case there is some difficulty with it.  You do NOT want to lose that window to switch to your H"s insurance if for some reason it doesn't pan out or the actual cost is much higher than the quotes.

The other thing I would consider is what other health needs you guys are likely to have this year?  Keep in mind that if you go straight to your H's plan then most likely your deductible will be met for the entire family for the rest of the year as soon as you give birth.  Whereas if you switch to his insurance post-birth, you won't necessarily hit that limit.  It would be significantly more expensive in the second half of the year if one of you suddenly had a health issue.

brij2006

@smerka So you can't deduct that $5,000?  Only anything beyond that $5,000?

@hoffse DD is currently under H's employers plan.  So this would just be affecting me.
The only part where I'm not sure about is once me or the baby is added to his plan, he's switched to a family plan to where the premium doesn't increase for adding that 4th person.  So if I did the separate plan and then added baby to it for a month or 2 till we switched to H's plan, we would have that extra cost for a couple months' premium. Granted once I had baby on my employers plan I would have needed to pay them for that premium anyways. 
That's a good point about any other care throughout the year.  If I'm remembering correctly, if you're switching from Blue Cross to a Blue Cross policy (all of these are with Blue Cross), your deductible/maxoop carries over to the next policy to apply to it.  So if anything happened after we got onto H's plan, we would just pay that difference in the deductible and maxOOP.
Best case scenario, if everything is good with me and baby, we would just have well visits for the rest of the year.

Xstatic3333

In addition to @hoffse's thoughts, I would also take a careful look at the recent executive orders regarding the ACA and how much teeth they do or do not have. I've read varying things and it's so hard to find unbiased information, but my understanding is that the recent orders take some "teeth" away from the ability of agencies to make sure certain ACA provisions to be enforced.  My concern would be making sure that you and the kids all get onto your husband's plan before anything happens that could be considered a preexisting condition and before the law changes. I think it's very likely that most ACA rules will still be enforced for the duration of your pregnancy, but at the same time everything feels so scary and uncertain right now. Of course since you work in the industry I probably don't have to tell you that

smerka

You can only deduct what is in excess of 10%. So yes the first $5,000 isn't deductible. 

Also no one knows what is going to happen with the repeal of Obamacare. Pregnancy might become a preexisting condition again. So I would switch sooner rather than later. 

And keep in mind that once you pay your deductible, most people only pay 20% coinsurance until they hit the OOP max. You may not even hit the max if you have a cheap delivery. 

brij2006

Unfortunately I'm pretty sure we'll hit that max OOP for me.  With DD's birth it was unmedicated and I labored at home till 45 minutes before she was born.  We still hit my $4,000 maxOOP at that time.  That was 2 years ago and we're going through the same midwife and hospital we did with her.  So over $35,000 was billed between her and I and it was as plain of a delivery as you could get.  We did only meet the $1,000 deductible for her though.  I'd have to look, but her total charges were under $2,000.
I swear, if only my H would get on board with me delivering with the Mennonite midwife that's just a few miles outside our town.  It would save us so much money! ;-)

cupcait927

brij2006 said:

That's a good point about any other care throughout the year.  If I'm remembering correctly, if you're switching from Blue Cross to a Blue Cross policy (all of these are with Blue Cross), your deductible/maxoop carries over to the next policy to apply to it.  So if anything happened after we got onto H's plan, we would just pay that difference in the deductible and maxOOP.
Best case scenario, if everything is good with me and baby, we would just have well visits for the rest of the year.

Granted I am in a different state, but working in health insurance on an employer level and with a Blue Cross carrier, I've never heard of anyone being able to apply what they've met on their current deductible to a new deductible between Blue Cross plans. The rare occasions that I have seen it allowed is when a company aquires another and they get an exception to have this happen. This is something that you'll need to make very sure of if you're hinging on this to make a change.

Also, you have 30 days from the qualifying event date to make any changes with employer-based insurance. Not sure if the rules are the same on your individual market but also keep that in mind if you need to make a switch to your H's plan.

LillibetteV

smerka said:

First of all only the medical expenses that exceed 10% of your income are deductible. So if you make $50,000, the first $5,000 is not deductible. 

Second, make sure your husband's plan allows you to join his plan after a job change.  That might not be a qualifying condition and you might have to wait for you to join until his next open enrollment period. The baby should not be a problem. 

Also check your state regulations re. the bolded. My husband's employer (our state government...) had the most incompetent HR department I've ever dealt with in my life. They tried to say that my changing jobs wasn't a qualifying event even though according to our state's regulations it 100% is a qualifying event. We even gave them a copy of the regulation and it still took them a month to figure it out. 

brij2006

The repeal of ACA does and doesn't concern me much. 
The main thing being is that no policy is going to immediately have that policy verbiage removed from it.  So the current ACA plans will fizzle out as they renew.  Just as the ones that were grandfathered in before ACA have now mostly been replaced with an ACA policy.
So in this case, I'd be added to H's policy mid-term and after the pre-existing condition of the pregnancy is over. 

brij2006

LillibetteV said:

smerka said:

First of all only the medical expenses that exceed 10% of your income are deductible. So if you make $50,000, the first $5,000 is not deductible. 

Second, make sure your husband's plan allows you to join his plan after a job change.  That might not be a qualifying condition and you might have to wait for you to join until his next open enrollment period. The baby should not be a problem. 

Also check your state regulations re. the bolded. My husband's employer (our state government...) had the most incompetent HR department I've ever dealt with in my life. They tried to say that my changing jobs wasn't a qualifying event even though according to our state's regulations it 100% is a qualifying event. We even gave them a copy of the regulation and it still took them a month to figure it out. 

Oh goodness.
I know my job loss as well as the baby being born is a qualifying event.  It's in their handbook and H e-mailed HR to confirm it.

brij2006

cupcait927 said:

brij2006 said:

That's a good point about any other care throughout the year.  If I'm remembering correctly, if you're switching from Blue Cross to a Blue Cross policy (all of these are with Blue Cross), your deductible/maxoop carries over to the next policy to apply to it.  So if anything happened after we got onto H's plan, we would just pay that difference in the deductible and maxOOP.
Best case scenario, if everything is good with me and baby, we would just have well visits for the rest of the year.

Granted I am in a different state, but working in health insurance on an employer level and with a Blue Cross carrier, I've never heard of anyone being able to apply what they've met on their current deductible to a new deductible between Blue Cross plans. The rare occasions that I have seen it allowed is when a company aquires another and they get an exception to have this happen. This is something that you'll need to make very sure of if you're hinging on this to make a change.

Also, you have 30 days from the qualifying event date to make any changes with employer-based insurance. Not sure if the rules are the same on your individual market but also keep that in mind if you need to make a switch to your H's plan.

I will definitely have him check into that to see what their rules are.
What I'm finding for an individual policy is 60 days after the birth of a child.  All of the other qualifying events are saying 30 days to make coverage changes.

If the carry over doesn't work (I'd have to talk directly with Blue Cross on this), then we would definitely be taking a gamble that we wouldn't need anything major done the rest of the year.

I honestly would probably wait and see how things are going with both baby and I.  If after baby is born, there are complications with either of us, then we'd probably keep the individual plan until H's open enrollment period in October.

vlagrl35

didn't read all the responses but I can't imagine paying $400 a month for a health insurance premium.  That seems so high.  Could you get an ACA plan just for yourself and after baby is born you both get on your husbands plan or add baby to ACA plan until your DH has open enrollment?

brij2006

@vlagrl35 Unfortunately we don't qualify for any assistance since 2017 will still have some of my income and it bumps our family of 4 over the income threshold.  At least from what I've put into the marketplace.  I've worked all the way through it.  The only thing it says we may qualify for is that our kids "might" qualify for CHIP program. 

vlagrl35

I doubt your kids would qualify for chip especially since you have assets @brij2006 well that's too bad.

brij2006

Haha so I played around with the marketplace @vlagrl35
If I'm reading correctly I should be putting in our AGI.  So I changed it to have what our 2017 should be with only 2 months of my income.
Well, it says me and the 2 kids qualify for some assistance.  However, the premium is $1,515 a month for the best plan ($5,200 family deductible), or $1,000/month for the highest deductible plan ($7,150).

Ummm, sorry.  Affordable Care Act?  Where's that? 
That premium is WITH the assistance. 
My quote for a plan outside the marketplace was cheaper.

Granted I'd put baby on this plan with me right away and DD would stay on H's plan where she is now.  But still.  That premium is outrageous. 

vlagrl35

wow your subsidy must not be much - I know ours is around $700 and we are on a plan that is $1000 so that leaves us with $267 a month of a premium we are responsible.  oh I agree with you that its not affordable.  And yes go by AGI.  Thats what we do. 2018 scares me to think about health insurance - might end up on that christian health plan thing.

jtmh2012

I tried pricing out my wife and I on our separate employer plans.  It just wasn't worth it.  Her plan was good, but mine was better.  And it was only a few dollars different.  Didn't think it was worth the hassle of managing two different sets of benefits, providers, etc.  Especially knowing that my wife would probably be changing jobs more often that I would be.

Also looked at the fact that as a family we'd have multiple deductibles to meet.

LillibetteV

$1500/month for a family plan?? I guess it makes sense since you don't have the employer contribution which is usually significant, but still that's brutal. I really don't understand how the rest of the country can't figure this out. I live in Massachusetts and we were basically the model for the ACA and our premiums are nowhere near that and we don't have a high deductible plan. 

brij2006

jtmh2012 said:

I tried pricing out my wife and I on our separate employer plans.  It just wasn't worth it.  Her plan was good, but mine was better.  And it was only a few dollars different.  Didn't think it was worth the hassle of managing two different sets of benefits, providers, etc.  Especially knowing that my wife would probably be changing jobs more often that I would be.

Also looked at the fact that as a family we'd have multiple deductibles to meet.

It stinks, but even now we're on 2 separate plans. I'm on my employers plan and H and DD are on his. We did have DD on mine for the first year until my premium for her skyrocketed.  Now we have her on my H's higher deductible plan and we cross our fingers she doesn't get sick or hurt.

I seriously don't understand where our health insurance is going.  Even on my H's plan, we'd be paying almost $800/month for 4 of us and with a $4,000 individual deductible, $6,250 max OOP for individuals.  I believe the family deductible is $9,000 and max OOP is $12,500.

How do people afford this? Even if you can afford the premium, you can't afford the deductible or max OOP if anything were to happen.
My H doesn't make a ton of money, but he doesn't do horribly, and we'll be supporting a family of 4 off of his income.  Our month to month isn't pretty by the time we pull out $800 for health insurance for the 4 of us, put into retirement, and taxes.  Let alone if I get on his plan and have #2 on it and God forbid something were to happen to baby and I to where we meet that family max OOP.  There goes a ton of his takehome pay.  Just in 1 calendar year.....and we have zero debts.  I don't understand how the typical American family is supposed to cushion a medical event, even WITH insurance.  Besides going into thousands of debt with the hospitals.

short+sassy

brij2006 said:

jtmh2012 said:

I tried pricing out my wife and I on our separate employer plans.  It just wasn't worth it.  Her plan was good, but mine was better.  And it was only a few dollars different.  Didn't think it was worth the hassle of managing two different sets of benefits, providers, etc.  Especially knowing that my wife would probably be changing jobs more often that I would be.

Also looked at the fact that as a family we'd have multiple deductibles to meet.

It stinks, but even now we're on 2 separate plans. I'm on my employers plan and H and DD are on his. We did have DD on mine for the first year until my premium for her skyrocketed.  Now we have her on my H's higher deductible plan and we cross our fingers she doesn't get sick or hurt.

I seriously don't understand where our health insurance is going.  Even on my H's plan, we'd be paying almost $800/month for 4 of us and with a $4,000 individual deductible, $6,250 max OOP for individuals.  I believe the family deductible is $9,000 and max OOP is $12,500.

How do people afford this? Even if you can afford the premium, you can't afford the deductible or max OOP if anything were to happen.
My H doesn't make a ton of money, but he doesn't do horribly, and we'll be supporting a family of 4 off of his income.  Our month to month isn't pretty by the time we pull out $800 for health insurance for the 4 of us, put into retirement, and taxes.  Let alone if I get on his plan and have #2 on it and God forbid something were to happen to baby and I to where we meet that family max OOP.  There goes a ton of his takehome pay.  Just in 1 calendar year.....and we have zero debts.  I don't understand how the typical American family is supposed to cushion a medical event, even WITH insurance.  Besides going into thousands of debt with the hospitals.

Yes, x1000.

My HD plan with my employer is $6800/individual and $13,800 max OOP.  That's not even a family plan.  Just me and my H.  My portion of the insurance is $110/month (not bad), but I also spend about $300/month out of pocket.

So, almost $5K/year for our medical care.  Which is over 10% of my gross salary (f/t job only).  And I just barely crossed the 50% mark of my deductible.  The OOP Max ALONE is more than one third of my net pay (f/t job only).

And that's to marginally take care of myself.  There are MUCH better treatments available...but those are $17K/year (retail).  Maybe someday.

smerka

We switched to a HDHP with an HSA. Best move ever. The first year was rough because we had to pay the $5,200 deductible/OOP max by February. And we had to put aside a bunch of money into the HSA. I have two kids in speech therapy and OT. But this year that deductible money is already in our HSA and next year's will get put aside over the course of 2017. 

vlagrl35

anything more than $300 for health insurance is too much for us.  $1500 and we would not be able to eat.

jtmh2012

brij2006 said:

How do people afford this? Even if you can afford the premium, you can't afford the deductible or max OOP if anything were to happen.

I know in our case, the HDHP has an HSA attached to it.  The idea being that you contribute tax free dollars to it over time.  But, the plan also really designed for people that are relatively healthy.

I looked up our plans.  The HDHP+HSA plan is $322.36/month.
$4,000 in-network family deductible. $6,000 in-network MaxOOP.
$8,000 out-of-network deductible.  $12,000 out-of-network MaxOOP.

The traditional PPO is $617.92/month.
$1,500 in-network family deductible. $6,000 in-network MaxOOP.
$3,000 out-of-network deductible.  $9,000 out-of-network MaxOOP.

We pretty much have the OOPs taken care of at this point.  That's without going into other emergency funds.

Xstatic3333

I don't think the typical family can afford it, TBH. HDHPs can be a great tool for people like those of us around here who like to have lots of savings vehicles and have some cushion, but I know a lot of people have gotten pushed onto them recently without time to prepare and it can be completely devastating. I'm lucky to have a MA healthcare plan from the same employer as @LillibetteV so I'm not too worried for myself, yet, but I'm another one who's definitely scared for 2018 in general. My friends with chronic health problems are downright terrified. 

hoffse

jtmh2012 said:

brij2006 said:

How do people afford this? Even if you can afford the premium, you can't afford the deductible or max OOP if anything were to happen.

I know in our case, the HDHP has an HSA attached to it.  The idea being that you contribute tax free dollars to it over time.  But, the plan also really designed for people that are relatively healthy.

I looked up our plans.  The HDHP+HSA plan is $322.36/month.
$4,000 in-network family deductible. $6,000 in-network MaxOOP.
$8,000 out-of-network deductible.  $12,000 out-of-network MaxOOP.

The traditional PPO is $617.92/month.
$1,500 in-network family deductible. $6,000 in-network MaxOOP.
$3,000 out-of-network deductible.  $9,000 out-of-network MaxOOP.

We pretty much have the OOPs taken care of at this point.  That's without going into other emergency funds.

Yeah, it's the HSA.

I've been on a HDHP plan for 3 full years, starting my fourth.  I've max out my HSA each year and have never pulled $$ from it because I'm pretty healthy and everything that I have paid for over the last several years could be cash flowed or budgeted.  My HSA now has over $10K in it, which will cover two years' worth of deductibles for us.  We are TTC and I actually plan to stay on the HDHP plan during that time.  And with 9+ months to prepare, we won't dip into the HSA to pay for it.  I view that money as an extension of our emergency fund.

The cost for the HDHP is pretty reasonable - about $200 per month.  The cost for the PPO for us is outrageous, closing in on $600 per month, and that's subsidized.  Our partners pay something like $1500/month for the PPO because theirs is unsubsidized.  

We would need to consume a LOT of healthcare in order for a PPO to ever make sense.  With the HDHP I tend to consume about 1/3 of my deductible over the course of the year anyway just through my prescription for birth control (I am on an expensive kind when I use it).  But that's a known expense for us, so it's something we budget for.   

Honestly, money aside, I have to be pretty sick or significantly injured to go to the doctor more than once a year.  It becomes a multi-hour experience every single time, and the waiting drives me crazy.  They tell you to get there early, and then they don't see you until it's an hour+ late.  Also, my doctor only sees patients during regular business hours, and that eats into billable time for me, which directly affects how much vacation time I get and whether I advance to the next level and make bonus.   

LillibetteV

@Xstatic3333 I've complained about our insurance because NHP outsources prescription benefits management to CVS Caremark which is spectacularly incompetent (call 4 times get 4 different, yet extremely specific answers...) but at the end of the day I have to remind myself that it's still very good compared to the rest of the US. For $314/month my husband and I are on a family plan (which won't increase when the baby comes) with a $900 deductible and $10k OOP. This plan year we had fertility testing, IUI, IVF, prenatal visits, and 2 specialists (with procedures) and PT for my husband. We consumed a LOT of medical care and we've only spent about $3,500 out of pocket. 

short+sassy

Xstatic3333 said:

I don't think the typical family can afford it, TBH. HDHPs can be a great tool for people like those of us around here who like to have lots of savings vehicles and have some cushion, but I know a lot of people have gotten pushed onto them recently without time to prepare and it can be completely devastating. I'm lucky to have a MA healthcare plan from the same employer as @LillibetteV so I'm not too worried for myself, yet, but I'm another one who's definitely scared for 2018 in general. My friends with chronic health problems are downright terrified. 

Yeessss.  Up until this year, my workplace had two plans to choose from.  And HDHP and a more typical health plan (lower deductible/copays/etc.).  The employee portion for the "typical" health plan was substantially more so, even considering my OOP expenses, I would still choose the HDHP.

This year's deductible on the HDHP plan is almost double what it was last year.  This is the first year it would have made sense for me to switch to the "typical" health plan.  Except my workplace isn't offering that plan anymore.  Now it is only the HDHP plan, which is really no better than a catastrophic plan.  Yet, is extraordinarily expensive (if you look at the total cost) for not much.

As for HSA, which I do love, that needs to catch up to what is now happening in the medical insurance industry.  There are limits to how much a person/family can have deducted each year.  For me and for many, that limit doesn't even cover one year's deductible.  And it doesn't even come close to many people's OOP Max.

AprilZ81

short+sassy said:

Xstatic3333 said:

I don't think the typical family can afford it, TBH. HDHPs can be a great tool for people like those of us around here who like to have lots of savings vehicles and have some cushion, but I know a lot of people have gotten pushed onto them recently without time to prepare and it can be completely devastating. I'm lucky to have a MA healthcare plan from the same employer as @LillibetteV so I'm not too worried for myself, yet, but I'm another one who's definitely scared for 2018 in general. My friends with chronic health problems are downright terrified. 

Yeessss.  Up until this year, my workplace had two plans to choose from.  And HDHP and a more typical health plan (lower deductible/copays/etc.).  The employee portion for the "typical" health plan was substantially more so, even considering my OOP expenses, I would still choose the HDHP.

This year's deductible on the HDHP plan is almost double what it was last year.  This is the first year it would have made sense for me to switch to the "typical" health plan.  Except my workplace isn't offering that plan anymore.  Now it is only the HDHP plan, which is really no better than a catastrophic plan.  Yet, is extraordinarily expensive (if you look at the total cost) for not much.

As for HSA, which I do love, that needs to catch up to what is now happening in the medical insurance industry.  There are limits to how much a person/family can have deducted each year.  For me and for many, that limit doesn't even cover one year's deductible.  And it doesn't even come close to many people's OOP Max.

Yeah, the HDHP are pretty much catastrophic plans.  Mine isn't as bad as some ($1,500 deductible, $5,500 OOP Max) but we maxed mine out last year.  My employer has us earn funds for our HRA, and that really annoys me.  To get funds we are required to do a health survey and get biometric screening ($150) once we do that we can earn additional funds by doing other health related activities.  The kicker is that you only have a small number of choices if you don't already smoke, have diabetes or are pregnant.  Plus some of the choices are a one time only deal, so if you have already completed it you can't get that credit again.  We can earn a max of $500 which is a drop in the bucket.

I really think that health care (care =/= insurance) would be cheaper without the insurance companies.  They add a ton of middleman expenses and even more regulations.  Let the patients determine care with their doctors.  If you cut the middleman out it will lower the cost and most likely improve care.

Xstatic3333

I complain too @LillibetteV, particularly about how strict the referral process is (otherwise my stats are the same as yours, just through Tufts) but we truly are very lucky. It's a big reason my H wants to make his career with the State. We're lucky they let us live in RI; if that policy ever changes we'll need to move back. 

brij2006

Unfortunately with my H's plan it isn't considered a HDHP to qualify for us to contribute to an HSA or FSA.  I looked into it because I thought that maybe we could at least funnel some funds through that knowing we will be using it this year.  Nope.
Which to me is so stupid.  We pay the first $4,000, on his base salary of $40,000.  Thankfully he has overtime that is pretty much guaranteed.  But if we were to go off his base salary, that's $3,333 gross monthly.  Minus $800 for health insurance, minus 10% into his 401k ($333), 10% tithe to church ($333), then 15% tax bracket ($500).
Leaves us with $1,367 a month to put food on the table, gas in the car, keep the lights and water on, and support 2 children.
That is the average household income in our county.  So 1 year of hitting the family maxOOP of $12,500 will put us at $367/month to support our family and pay the medical expense.  WTF?
Now, thankfully that isn't my H's income since he has overtime, but his overtime isn't guaranteed.  It can go away at any minute.  Well if there is a medical event to the extent that we meet the maxOOP, I can guarantee he wouldn't be working the insane hours and would be with the family members who are needing this medical care. 

I'm going to get political here, but I'm just ranting.  I'm not for Trump nor was I for Hillary.  But I'm just sitting here looking at all of this stuff thinking, "go ahead Trump.  Pull ACA.  Get that bullshit program out of our country.  It obviously isn't working."
This obviously isn't a program that's working as it was supposed to.  Not going to lie for one second and say there aren't great points in it.  Breastpumps covered, laws that protect a breastfeeding woman pumping at work, making it so the maxOOP truly is the max amount you pay, etc.  But the main point of it was to make healthcare affordable.  For who?  At least in Illinois, what I'm finding through the marketplace, the lowest deductible/maxOOP plan is the one I looked into.  If you want to purchase a plan independently, the deductibles start at $5,000.