Health Insurance Marketplace - can I choose to buy a plan in another state?

short+sassy · December 2016

With my upcoming lay-off, I've been checking out the health insurance marketplace. The plans in Louisiana are as bad as it gets. The plan that would make the most sense for me is completely useless, unless me or my H had a really major medical event. It's a $13,000+ OOP max and the ded. isn't much better. After that, it covers 60%.

Then I had a potentially brilliant idea. Look at plans in neighboring states. Low and behold, plans on the market place are WAY, WAY better in MS. Which is less than one hour away from me. Cheaper monthly cost for a $1400 OOP max/ded. AND dr. visits/Rx have a co-pay that can be used, even before the ded. is met. Sure, I'd have to go to doctors in MS or pay out of pocket here. If I needed to go to the ER, I'd be "out of network" and pay more. But, geez, I'd have to pay totally out of pocket for dr. visits anyway and pay 100% for an ER visit with a LA plan!!!

I'm just not seeing a down side, unless I can only buy a plan if I am a MS resident. Does anyone know/have a good guess? Can I choose to buy a plan on the marketplace in a different state? I searched online and on the gov site for the marketplace, but couldn't find much.

vlagrl35 · December 2016

No you can't sorry. We've been on it for 4 years and are allowed only plans in Missouri. I'm just greatful blue cross is still an option for us. I heard they already pulled out in KS. It's getting bad - companies are pulling out and those that are left are sky rocketing premiums. I hope they open across state lines soon because if not we will probably go on the christian ministry health insurance.

brij2006 · December 2016

vlagrl35 said:

No you can't sorry. We've been on it for 4 years and are allowed only plans in Missouri. I'm just greatful blue cross is still an option for us. I heard they already pulled out in KS. It's getting bad - companies are pulling out and those that are left are sky rocketing premiums. I hope they open across state lines soon because if not we will probably go on the christian ministry health insurance.

It's getting bad in Illinois too. We're down to 2 companies through the marketplace.
What's sad is BCBS no longer wants to pay insurance agents to sell nor service the policies, but the average person knows nothing about health insurance or their options. So the agency we outsource our health insurance to, they charge an annual fee of $200 to handle the health insurance. They hate doing this, but otherwise they're doing it all for free and can't afford to pay their staff. Yet their health insurance clients have built by 75%. Not because they're forced to get insurance but because people are so confused on their options and don't even know where they can buy insurance anymore.

julieanne912 · December 2016

I think this is one of the changes that Trump or whoever gives him his ideas wants to make to the ACA... make it so you can buy insurance across state lines.

I'm glad to be here in CO, where they opted to create their own exchange instead of going on the federal one.

short+sassy · December 2016

Thanks for the responses. It's silly for a lot of reasons it wouldn't be open across state lines.

There are a lot of places in our country where major areas are split by a state line. People live in one state and work in another. For someone who works a daytime office job, it can be a lot easier for your doctor to be near your workplace. Not your "out of state" home.

I'll have to see how things play out but, seriously? I'm seeing such a big difference, I'm tempted to buy my next investment property in MS to show "residence" and then buy in their marketplace.

I'm usually very well versed in the idiosyncracy's and minor "fine print" minutia of health insurance plans and options, but it has all been very confusing.

If medical insurance companies aren't in the marketplace, who are they selling to? Private individuals? If a person is a private individual who buys a plan NOT in the marketplace, are they still meeting the ACA requirement to have insurance?

And apparently I mistakenly thought that, if a company wants to sell medical insurance, they have to be part of the marketplace and follow all those requirements. If that isn't the case, of course it turns into a disaster.

It's right back to the same original problem. If you've "coughed twice" in the last year, no one will sell you insurance.

julieanne912 · December 2016

From my understanding, at least here, you can still go and buy a plan direct with the company. But again, things are different here because they elected not to participate in the federal exchange. They do still have to comply with the requirements of ACA though.

However, I do believe if you want the subsidies, you have to go through the exchange.

lbonga1 · December 2016

Health insurance options are so terrible right now. The plan I have through my employer just got worse too; they cover the premium 100%, but the deductible & OOP went up by $350 to $6850, and the copay to see a specialist doubled to $150. I have a friend that works in insurance, and she pointed out to me that because FI and I are not yet married and he doesn't work, he qualifies for Medi-Cal. That has honestly saved us because he has some ongoing medical problems that we're still trying to figure out the cause, and all the testing would be extremely expensive otherwise.

vlagrl35 · December 2016

You can buy it privately but it's just as expensive but without subsidy. Our plan for 2017 for the 3 of us without subsidy is $1085!! With subsidy we pay $269. We only pay $90 right now. It's quite the jump for us. I asked what the off exchage plan rates are and he said about $20 more but you don't get subsidy. He says a lot has changed and it's made everything more expensive. I remember 7 years ago looking at plans comparable to what we have with a price around $400. IMO it's gotten worse in some aspects but hey at least pregnancy is covered now.

short+sassy · December 2016

Thanks for the feedback, everyone. I would definitely need to go through the marketplace. Both for the subsidy, no WAY I could afford the normal price, and no one will sell me insurance outside of it due to my Type I Diabetes*.

Which is why I really can't fault the ACA, though it needs a major overall. Before it, I couldn't even buy a catastrophic plan...at any price.

*Never mind that, in my entire life, I have only spent one day in the hospital on two different occasions. And both of those were over 20 years ago.

brij2006 · December 2016

I know at least in Illinois a majority of the health insurance companies are pulling out or getting bought out by other companies and consolidating. The other half of them are bankrupting.
I know ACA was supposed to fix health insurance industries from being a monopoly, but it has begun to turn toward monopolizing even more. Now there are only a few companies offered through the exchange and only a couple more offered outside it.
My parents are self-employed and do not qualify for any subsidies. So they pay their premium out of pocket. They had the option between 2 companies this year. 2! Their premium is $1,400/month for just the 2 of them and that's with a $6,850 deductible & $13k family maxOOP. It's not even a co-pay plan, it's a HDHP so they pay that first $6,850 before anything is paid out. On top of their $1,400/month in premiums. Thankfully they have a business so they can write it off on their taxes, but last year my mom had a hysterectomy and my dad had an angiogram. Their family max OOP is $13,000. Sure enough they met that, plus the $16,800 they paid in annual premium. Their healthcare for the year 2016 cost them right under $30,000 and that's WITH insurance. How the heck do people afford this?

I'll happily take reforming ACA.
But really, think about it in the health insurance side of things. So the companies are now forced to accept anyone and everyone, regardless of conditions. Everyone is supposed to be purchasing it, which is what is supposed to make it cheaper. Yet you have healthy people who just pay the penalty every year because that's cheaper than paying the premium on the outrageous health insurance.
That's like the government stepping in and telling life insurance companies they have to insure everyone no matter what and not charge a different premium for if they're perfectly healthy or have stage 4 cancer. 1 person the likelihood of them filing a claim soon is slim, the other the company knows they'll be paying the death benefit soon.
How are they supposed to stay in business or have affordable rates? They won't. The sick will buy the insurance because they finally can get coverage, but the healthy won't because it's now too expensive to afford.

Not saying healthcare didn't need some sort of reform. It most definitely did. They'd decline people if they had a cold within the last 5 years. Although I feel like this is on both ends. Not just the insurance side needed reformed, so does the healthcare industry. When I had DD I labored at home for all but 45 minutes before she was born. Had zero meds except ibuprofen afterward, and she was a perfectly healthy baby. Just the normal routine tests and first shots. Yet they billed my insurance over $30,000 between the both of us.
I've joked with H that next time I'm having the Amish 2 miles out of town do a home delivery for me. They charge $3,000 for the whole thing and that includes after birth lactation assistance for the first 2 weeks. That's cheaper than just paying my deductible!

smerka · December 2016

Your insurance company didn't pay $30,000. That's just the list price. The insurance company and the hospital have a set price. That's the part I hate. The providers jack up their list prices but that's very rarely what they actually get.

smerka · December 2016

What I also hate is you can never get providers to tell you how much anything will cost. My son had kidney surgery. I asked if I could get a ballpark number so I could budget for it. No one could tell me if the surgery would be $10,000 or $50,000 or $100,000. That's absurd. No where else in our economy do you get a service where you have no idea what you're going to pay going in.

jtmh2012 · December 2016

smerka said:
Your insurance company didn't pay $30,000. That's just the list price. The insurance company and the hospital have a set price. That's the part I hate. The providers jack up their list prices but that's very rarely what they actually get.

When we had our son, the hospital billed $36,000 for a normal uncomplicated delivery. The insurance discount got it knocked down to about $16-18k (I forget which). They paid it down to our remaining deductible which left $3400 for us to pay (high deductible health plan). I'm sorry, but even the $16k or so is way too much considering we camped out in a room by ourselves for most of the time we were there. I've taken cruises for less and had way more attention paid to us.

jtmh2012 · December 2016

smerka said:

What I also hate is you can never get providers to tell you how much anything will cost. My son had kidney surgery. I asked if I could get a ballpark number so I could budget for it. No one could tell me if the surgery would be $10,000 or $50,000 or $100,000. That's absurd. No where else in our economy do you get a service where you have no idea what you're going to pay going in.

Same thing with pregnancy. We tried calling the hospital, her OB, the insurance company. Nope.

julieanne912 · December 2016

The best was, before ACA, insurance would charge me more because I have a plate and pins in my upper arm/shoulder from when I broke it.... so not even a real health condition. Otherwise I go to the doctor maybe once a year for the usual checkup, and was not on any prescriptions. So that makes me "higher risk". So ridiculous.

But yeah, the idea of ACA was great, the implementation, not so much. Anybody who thought insurance companies wouldn't take advantage of it by raising prices were crazy.

als1982 · December 2016

smerka said:

What I also hate is you can never get providers to tell you how much anything will cost. My son had kidney surgery. I asked if I could get a ballpark number so I could budget for it. No one could tell me if the surgery would be $10,000 or $50,000 or $100,000. That's absurd. No where else in our economy do you get a service where you have no idea what you're going to pay going in.

Part of that is the unpredictability associated with illness and injury. A doctor isn't going to know if your family will be required to stay overnight for observation because of a reaction to medication or anesthesia or if you'll be released to go home that day, so it's impossible to quote an exact number. If providers started doing that, they'd be facing lawsuits from people who were told one number initially but billed another in the end.

LillibetteV · December 2016

This thread is absolutely fascinating. I live in Massachusetts (always have) and all of this is totally foreign to me. I don't understand how it works so well here and is so broken everywhere else. Our premiums are reasonable ($314/month for a family plan that won't change when the baby comes), the deductible is about $900 I think, and our OOP maximum is pretty high, but you'd need a LOT of copays to hit it and we've never come close even with IVF. My fertility clinic went over every cost detail before we started IVF in the event my insurance denied coverage (which it didn't, because MA law requires they cover it except in specific circumstances that didn't apply to us) so that we'd be able to decide what we wanted to do BEFORE treatment started and we were stuck with some huge bill. Between some deductible charges and co-pays our IUI and IVF cycles cost us $1500 or so over the course of many months which I think is very reasonable considering how much care my husband and I have received. And not for nothing, but Boston hospitals are amazing so it's not like we're getting cut rate service for this price.

als1982 · December 2016

brij2006 said:

I know at least in Illinois a majority of the health insurance companies are pulling out or getting bought out by other companies and consolidating. The other half of them are bankrupting.
I know ACA was supposed to fix health insurance industries from being a monopoly, but it has begun to turn toward monopolizing even more. Now there are only a few companies offered through the exchange and only a couple more offered outside it.
My parents are self-employed and do not qualify for any subsidies. So they pay their premium out of pocket. They had the option between 2 companies this year. 2! Their premium is $1,400/month for just the 2 of them and that's with a $6,850 deductible & $13k family maxOOP. It's not even a co-pay plan, it's a HDHP so they pay that first $6,850 before anything is paid out. On top of their $1,400/month in premiums. Thankfully they have a business so they can write it off on their taxes, but last year my mom had a hysterectomy and my dad had an angiogram. Their family max OOP is $13,000. Sure enough they met that, plus the $16,800 they paid in annual premium. Their healthcare for the year 2016 cost them right under $30,000 and that's WITH insurance. How the heck do people afford this?

I'll happily take reforming ACA.
But really, think about it in the health insurance side of things. So the companies are now forced to accept anyone and everyone, regardless of conditions. Everyone is supposed to be purchasing it, which is what is supposed to make it cheaper. Yet you have healthy people who just pay the penalty every year because that's cheaper than paying the premium on the outrageous health insurance.
That's like the government stepping in and telling life insurance companies they have to insure everyone no matter what and not charge a different premium for if they're perfectly healthy or have stage 4 cancer. 1 person the likelihood of them filing a claim soon is slim, the other the company knows they'll be paying the death benefit soon.
How are they supposed to stay in business or have affordable rates? They won't. The sick will buy the insurance because they finally can get coverage, but the healthy won't because it's now too expensive to afford.

Not saying healthcare didn't need some sort of reform. It most definitely did. They'd decline people if they had a cold within the last 5 years. Although I feel like this is on both ends. Not just the insurance side needed reformed, so does the healthcare industry. When I had DD I labored at home for all but 45 minutes before she was born. Had zero meds except ibuprofen afterward, and she was a perfectly healthy baby. Just the normal routine tests and first shots. Yet they billed my insurance over $30,000 between the both of us.
I've joked with H that next time I'm having the Amish 2 miles out of town do a home delivery for me. They charge $3,000 for the whole thing and that includes after birth lactation assistance for the first 2 weeks. That's cheaper than just paying my deductible!

How many days were you in the hospital? I did some quick math and came up with a minimum of $1,435.20 for just the cost of one nurse and one doctor's time per day (24 hours of nursing care at $32 per hour and MD/OD at $90 plus benefits, divided by 2 patients in their care at a time). That doesn't include the salary costs of any additional staff like pharmacists, anesthesiologists, environmental services, lactation consultants, etc. Those professionals also need paid.

Also, people forget to factor in the costs of equipment. Have a child in the NICU? That bed they're laying in costs a staggering $80,000. Need an MRI or other radiological equipment (obviously not in the case of pregnancy but your dad's angio) that MRI machine costs a staggering $5M plus the expense to outfit a lead encased room and order specialized medical equipment and air tanks that can't be magnetized to be used in that room. Also, even if you didn't use it, there has to be a scrubbed OR ready and waiting should you need it for a c-section.

And hospitals are like college campuses. The amenities people now demand (spa-like private rooms with birthing tubs, queen sized beds, etc.) are EXPENSIVE.

brij2006 · December 2016

jtmh2012 said:

smerka said:
Your insurance company didn't pay $30,000. That's just the list price. The insurance company and the hospital have a set price. That's the part I hate. The providers jack up their list prices but that's very rarely what they actually get.

When we had our son, the hospital billed $36,000 for a normal uncomplicated delivery. The insurance discount got it knocked down to about $16-18k (I forget which). They paid it down to our remaining deductible which left $3400 for us to pay (high deductible health plan). I'm sorry, but even the $16k or so is way too much considering we camped out in a room by ourselves for most of the time we were there. I've taken cruises for less and had way more attention paid to us.

Yes. It's insane! We live in a LCOL area too, you would think having a baby would be cheaper here.
I also called and fought our bill because they charged us $3,000 for triage. Um, I was wheeled in a wheelchair at 9.5 centimeters dilated. They got me to the door of triage and I was screeching and wailing. Instantly a bunch of nurses said she's in transition, no need for triage and rushed me to a room. Yet they tacked that $3,000 onto our bill. I called and told the lady over the phone that they didn't even open the door to that room when I got there, so there should be no charge for the triage room I never even stepped foot in. They removed the charge, but it still made me mad that they added it in the first place. My armband was scanned for every single thing I was charged, including my room. There was a barcode in my room they scanned then scanned my band. I didn't even get into triage for them to scan the barcode in there.

H has been having physical therapy sessions for his feet. Now, his options are to do physical therapy 3 days/week for a month or have surgery which will put him out of work for 8 weeks and cost thousands of dollars. We're choosing to try the physical therapy first.
We're actually better off being cash paying customers for it because by the time the company bills insurance, insurance does their adjusted price, then we pay our portion due to physical therapy being a "specialty" service and costing $150 each session. It is actually cheaper if we take the cash discount with the physical therapy place. It's saving us $30 each session by not using insurance. Well when you're talking about 12 sessions in a month, that's a $360 savings for us. Um yeah, I'll be a cash paying customer please.
Yet we still pay an insane amount for this shitty health insurance for him......

Let's just all go to a healthcare sharing practice and become cash paying customers for services. Now that would be one way to drive the cost down.

vlagrl35 · December 2016

you really should check out the christian ministry insurance - my chiro has it for his family and they've been on it for 4 years. It paid for 100% of his 2nd childs birth and they could keep all their doctors. You would have to go to church weekly I believe though.

short+sassy · December 2016

LillibetteV said:

This thread is absolutely fascinating. I live in Massachusetts (always have) and all of this is totally foreign to me. I don't understand how it works so well here and is so broken everywhere else. Our premiums are reasonable ($314/month for a family plan that won't change when the baby comes), the deductible is about $900 I think, and our OOP maximum is pretty high, but you'd need a LOT of copays to hit it and we've never come close even with IVF. My fertility clinic went over every cost detail before we started IVF in the event my insurance denied coverage (which it didn't, because MA law requires they cover it except in specific circumstances that didn't apply to us) so that we'd be able to decide what we wanted to do BEFORE treatment started and we were stuck with some huge bill. Between some deductible charges and co-pays our IUI and IVF cycles cost us $1500 or so over the course of many months which I think is very reasonable considering how much care my husband and I have received. And not for nothing, but Boston hospitals are amazing so it's not like we're getting cut rate service for this price.

I've heard the same thing about Hawaii. In fact, I think Mass. and Hawaii have both been looked at (at various times) for how to do something similar, but on either a federal level and/or through the ACA.

Alas, no dice yet.

To me, the biggest problem with the ACA is it didn't address at all the underlying problem that many of you have alluded to. The astronomical (largely inflated) and continually escalating cost of healthcare. Ever increasing premiums for worse coverage has been going on for years. Long before the ACA was even a glimmer in a gov't. bureaucrat's eye.

I've mentioned this before, but I buy some of my insulin through an online Canadian pharmacy. Exact same brand and medication and quantity. In the U.S., it is $500+. Through my online pharmacy, it is $150. I can only assume the U.S. pharmaceutical company charges different prices to retailers, depending on what country it is going to. And apparently by a large amount, at least for this particular one. Disgusting.

LillibetteV · December 2016

short+sassy said:

LillibetteV said:

This thread is absolutely fascinating. I live in Massachusetts (always have) and all of this is totally foreign to me. I don't understand how it works so well here and is so broken everywhere else. Our premiums are reasonable ($314/month for a family plan that won't change when the baby comes), the deductible is about $900 I think, and our OOP maximum is pretty high, but you'd need a LOT of copays to hit it and we've never come close even with IVF. My fertility clinic went over every cost detail before we started IVF in the event my insurance denied coverage (which it didn't, because MA law requires they cover it except in specific circumstances that didn't apply to us) so that we'd be able to decide what we wanted to do BEFORE treatment started and we were stuck with some huge bill. Between some deductible charges and co-pays our IUI and IVF cycles cost us $1500 or so over the course of many months which I think is very reasonable considering how much care my husband and I have received. And not for nothing, but Boston hospitals are amazing so it's not like we're getting cut rate service for this price.

I've heard the same thing about Hawaii. In fact, I think Mass. and Hawaii have both been looked at (at various times) for how to do something similar, but on either a federal level and/or through the ACA.
Alas, no dice yet.
To me, the biggest problem with the ACA is it didn't address at all the underlying problem that many of you have alluded to. The astronomical (largely inflated) and continually escalating cost of healthcare. Ever increasing premiums for worse coverage has been going on for years. Long before the ACA was even a glimmer in a gov't. bureaucrat's eye.
I've mentioned this before, but I buy some of my insulin through an online Canadian pharmacy. Exact same brand and medication and quantity. In the U.S., it is $500+. Through my online pharmacy, it is $150. I can only assume the U.S. pharmaceutical company charges different prices to retailers, depending on what country it is going to. And apparently by a large amount, at least for this particular one. Disgusting.

They absolutely do - look at the recent EpiPen scandal. A large part of it goes back to executive compensation. I was practically giddy watching Congress rip into Heather Bresch. Unchecked capitalism = greedy people without any compassion or morals.

als1982 · December 2016

short+sassy said:

LillibetteV said:

This thread is absolutely fascinating. I live in Massachusetts (always have) and all of this is totally foreign to me. I don't understand how it works so well here and is so broken everywhere else. Our premiums are reasonable ($314/month for a family plan that won't change when the baby comes), the deductible is about $900 I think, and our OOP maximum is pretty high, but you'd need a LOT of copays to hit it and we've never come close even with IVF. My fertility clinic went over every cost detail before we started IVF in the event my insurance denied coverage (which it didn't, because MA law requires they cover it except in specific circumstances that didn't apply to us) so that we'd be able to decide what we wanted to do BEFORE treatment started and we were stuck with some huge bill. Between some deductible charges and co-pays our IUI and IVF cycles cost us $1500 or so over the course of many months which I think is very reasonable considering how much care my husband and I have received. And not for nothing, but Boston hospitals are amazing so it's not like we're getting cut rate service for this price.

I've heard the same thing about Hawaii. In fact, I think Mass. and Hawaii have both been looked at (at various times) for how to do something similar, but on either a federal level and/or through the ACA.
Alas, no dice yet.
To me, the biggest problem with the ACA is it didn't address at all the underlying problem that many of you have alluded to. The astronomical (largely inflated) and continually escalating cost of healthcare. Ever increasing premiums for worse coverage has been going on for years. Long before the ACA was even a glimmer in a gov't. bureaucrat's eye.
I've mentioned this before, but I buy some of my insulin through an online Canadian pharmacy. Exact same brand and medication and quantity. In the U.S., it is $500+. Through my online pharmacy, it is $150. I can only assume the U.S. pharmaceutical company charges different prices to retailers, depending on what country it is going to. And apparently by a large amount, at least for this particular one. Disgusting.

I'm not saying it's right or wrong, but the cost of that medication is likely being used to subsidize funding for research related to other drugs being developed by the pharmaceutical company. It's unfair to compare US and Canada when it comes to anything health care
or pharmaceutical industry related since their government is shelling out so much more money for research and they have universal health care. Canadians are still paying the same price, theirs is just paid via taxes. For what's it worth, I'm pro single payor.

vlagrl35 · December 2016

my blood test today I bought from my chiro w/o insurance for $193. If it went thru insurance it wouldn't have been covered and would have cost us well over $1k. really? the cost is insane!

vlagrl35 · December 2016

@LillibetteV - you are so lucky your IVF is covered. We have zero coverage so I'm really hoping we don't need IUI or IVF to conceive because we really don't have the money for it. The only reason my HSG test is covered is because the doctor will code it as irregular period. If it was coded as fertility they wouldn't pay out. However Cigna does cover all fertility treatments I found out but hardly any doctors accept them because they don't pay out much in claims. So we could go with cigna but loose half our doctors and hospital but hey fertility treatment would be covered - but that assumption would be based solely on something that we don't even know if we will use or not. So we stayed with BCBS because they have the best coverage and it only took them 24 hours to let me doc know our HSG was covered. Even she admitted that was really fast turnaround.

LillibetteV · December 2016

als1982 said:

short+sassy said:

LillibetteV said:

This thread is absolutely fascinating. I live in Massachusetts (always have) and all of this is totally foreign to me. I don't understand how it works so well here and is so broken everywhere else. Our premiums are reasonable ($314/month for a family plan that won't change when the baby comes), the deductible is about $900 I think, and our OOP maximum is pretty high, but you'd need a LOT of copays to hit it and we've never come close even with IVF. My fertility clinic went over every cost detail before we started IVF in the event my insurance denied coverage (which it didn't, because MA law requires they cover it except in specific circumstances that didn't apply to us) so that we'd be able to decide what we wanted to do BEFORE treatment started and we were stuck with some huge bill. Between some deductible charges and co-pays our IUI and IVF cycles cost us $1500 or so over the course of many months which I think is very reasonable considering how much care my husband and I have received. And not for nothing, but Boston hospitals are amazing so it's not like we're getting cut rate service for this price.

I've heard the same thing about Hawaii. In fact, I think Mass. and Hawaii have both been looked at (at various times) for how to do something similar, but on either a federal level and/or through the ACA.
Alas, no dice yet.
To me, the biggest problem with the ACA is it didn't address at all the underlying problem that many of you have alluded to. The astronomical (largely inflated) and continually escalating cost of healthcare. Ever increasing premiums for worse coverage has been going on for years. Long before the ACA was even a glimmer in a gov't. bureaucrat's eye.
I've mentioned this before, but I buy some of my insulin through an online Canadian pharmacy. Exact same brand and medication and quantity. In the U.S., it is $500+. Through my online pharmacy, it is $150. I can only assume the U.S. pharmaceutical company charges different prices to retailers, depending on what country it is going to. And apparently by a large amount, at least for this particular one. Disgusting.

I'm not saying it's right or wrong, but the cost of that medication is likely being used to subsidize funding for research related to other drugs being developed by the pharmaceutical company. It's unfair to compare US and Canada when it comes to anything health care
or pharmaceutical industry related since their government is shelling out so much more money for research and they have universal health care. Canadians are still paying the same price, theirs is just paid via taxes. For what's it worth, I'm pro single payor.

I want to believe that...but when CEOs make $19 MILLION a year I have to call bull!@#$. And for drugs like insulin and epi that haven't changed in years for the prices to suddenly skyrocket is very suspect. These are things that people NEED to in order to stay alive and yet the sellers of these drugs have more money than they can spend?

als1982 · December 2016

LillibetteV said:

als1982 said:

short+sassy said:

LillibetteV said:

This thread is absolutely fascinating. I live in Massachusetts (always have) and all of this is totally foreign to me. I don't understand how it works so well here and is so broken everywhere else. Our premiums are reasonable ($314/month for a family plan that won't change when the baby comes), the deductible is about $900 I think, and our OOP maximum is pretty high, but you'd need a LOT of copays to hit it and we've never come close even with IVF. My fertility clinic went over every cost detail before we started IVF in the event my insurance denied coverage (which it didn't, because MA law requires they cover it except in specific circumstances that didn't apply to us) so that we'd be able to decide what we wanted to do BEFORE treatment started and we were stuck with some huge bill. Between some deductible charges and co-pays our IUI and IVF cycles cost us $1500 or so over the course of many months which I think is very reasonable considering how much care my husband and I have received. And not for nothing, but Boston hospitals are amazing so it's not like we're getting cut rate service for this price.

I've heard the same thing about Hawaii. In fact, I think Mass. and Hawaii have both been looked at (at various times) for how to do something similar, but on either a federal level and/or through the ACA.
Alas, no dice yet.
To me, the biggest problem with the ACA is it didn't address at all the underlying problem that many of you have alluded to. The astronomical (largely inflated) and continually escalating cost of healthcare. Ever increasing premiums for worse coverage has been going on for years. Long before the ACA was even a glimmer in a gov't. bureaucrat's eye.
I've mentioned this before, but I buy some of my insulin through an online Canadian pharmacy. Exact same brand and medication and quantity. In the U.S., it is $500+. Through my online pharmacy, it is $150. I can only assume the U.S. pharmaceutical company charges different prices to retailers, depending on what country it is going to. And apparently by a large amount, at least for this particular one. Disgusting.

I'm not saying it's right or wrong, but the cost of that medication is likely being used to subsidize funding for research related to other drugs being developed by the pharmaceutical company. It's unfair to compare US and Canada when it comes to anything health care
or pharmaceutical industry related since their government is shelling out so much more money for research and they have universal health care. Canadians are still paying the same price, theirs is just paid via taxes. For what's it worth, I'm pro single payor.

I want to believe that...but when CEOs make $19 MILLION a year I have to call bull!@#$. And for drugs like insulin and epi that haven't changed in years for the prices to suddenly skyrocket is very suspect. These are things that people NEED to in order to stay alive and yet the sellers of these drugs have more money than they can spend?

I don't disagree that CEO compensation is crazy but most pharmaceutical companies research, test and market more than one drug. And I think that people tend to forget when they're complaining about the cost of pharmaceuticals that behind every single drug is a team of researchers who work for years to come up with that single drug, and then it takes even more manpower to test and receive FDA approval of a single drug. It takes money to save lives, and with paltry NIH funding, that cost is unfortunately on the backs of those who require prescriptions.

brij2006 · December 2016

LillibetteV said:

als1982 said:

short+sassy said:

LillibetteV said:

This thread is absolutely fascinating. I live in Massachusetts (always have) and all of this is totally foreign to me. I don't understand how it works so well here and is so broken everywhere else. Our premiums are reasonable ($314/month for a family plan that won't change when the baby comes), the deductible is about $900 I think, and our OOP maximum is pretty high, but you'd need a LOT of copays to hit it and we've never come close even with IVF. My fertility clinic went over every cost detail before we started IVF in the event my insurance denied coverage (which it didn't, because MA law requires they cover it except in specific circumstances that didn't apply to us) so that we'd be able to decide what we wanted to do BEFORE treatment started and we were stuck with some huge bill. Between some deductible charges and co-pays our IUI and IVF cycles cost us $1500 or so over the course of many months which I think is very reasonable considering how much care my husband and I have received. And not for nothing, but Boston hospitals are amazing so it's not like we're getting cut rate service for this price.

I've heard the same thing about Hawaii. In fact, I think Mass. and Hawaii have both been looked at (at various times) for how to do something similar, but on either a federal level and/or through the ACA.
Alas, no dice yet.
To me, the biggest problem with the ACA is it didn't address at all the underlying problem that many of you have alluded to. The astronomical (largely inflated) and continually escalating cost of healthcare. Ever increasing premiums for worse coverage has been going on for years. Long before the ACA was even a glimmer in a gov't. bureaucrat's eye.
I've mentioned this before, but I buy some of my insulin through an online Canadian pharmacy. Exact same brand and medication and quantity. In the U.S., it is $500+. Through my online pharmacy, it is $150. I can only assume the U.S. pharmaceutical company charges different prices to retailers, depending on what country it is going to. And apparently by a large amount, at least for this particular one. Disgusting.

I'm not saying it's right or wrong, but the cost of that medication is likely being used to subsidize funding for research related to other drugs being developed by the pharmaceutical company. It's unfair to compare US and Canada when it comes to anything health care
or pharmaceutical industry related since their government is shelling out so much more money for research and they have universal health care. Canadians are still paying the same price, theirs is just paid via taxes. For what's it worth, I'm pro single payor.

I want to believe that...but when CEOs make $19 MILLION a year I have to call bull!@#$. And for drugs like insulin and epi that haven't changed in years for the prices to suddenly skyrocket is very suspect. These are things that people NEED to in order to stay alive and yet the sellers of these drugs have more money than they can spend?

Meanwhile, a friend just showed me the other day that their employers group plan now covers gender transition surgery.....
I'm just sitting over here going WTF?
So I test positive for BRCA, meaning I have the gene that carries breast cancer and my grandmother has had breast cancer. So once I'm done having kids, I've been recommended by 3 doctors to have a double mastectomy since I also have a lump in each breast (non-cancerous, yet). My insurance won't even cover for me to get implants put in so I actually have boobs and look like a normal woman.
Yet a man could walk in and say he wants to be a woman and have boobs and my friends' insurance plan will cover that.
It's all so crazy to me. My H and I have been saving up for years knowing that we'll most likely have to pay out of pocket so I can have boobs after the double mastectomy that has been recommended by 3 different doctors! But my insurance says they will only cover the mastectomy itself. If I would like nipples placed they will cover that, but they will not cover the cost of the implants so I can have boobs like a normal woman.
Where is this okay? It is a surgery that will save them hundreds of thousands of dollars they aren't paying out to treat cancer someday. This is a preventative surgery that I have fought for years about them covering and have had 3 different doctors run the same tests poking and prodding at my boobs to reconfirm to insurance that the other doctors' recommendation is true and they recommend the same. Yet my friend could walk in and ask for boobs and get them with no problem.

LillibetteV · December 2016

@brij2006 I think it's terrible that your insurance doesn't cover reconstructive surgery - feeling comfortable in your own body is important to one's mental health. But I don't think it's really fair to say "well some guy can go get boobs because he feels like it". Someone with gender dysphoria is also trying to feel comfortable in their own body and take care of their mental health. It's great that person is lucky enough to have an insurer who recognizes the importance of treating them properly for something that still has such a social stigma in many parts of the country. However, I would be surprised if their insurer didn't require a recommendation from a mental health professional before covering the surgery, unless they also cover elective plastic surgery.

cbee817 · December 2016

LillibetteV said:

This thread is absolutely fascinating. I live in Massachusetts (always have) and all of this is totally foreign to me. I don't understand how it works so well here and is so broken everywhere else. Our premiums are reasonable ($314/month for a family plan that won't change when the baby comes), the deductible is about $900 I think, and our OOP maximum is pretty high, but you'd need a LOT of copays to hit it and we've never come close even with IVF. My fertility clinic went over every cost detail before we started IVF in the event my insurance denied coverage (which it didn't, because MA law requires they cover it except in specific circumstances that didn't apply to us) so that we'd be able to decide what we wanted to do BEFORE treatment started and we were stuck with some huge bill. Between some deductible charges and co-pays our IUI and IVF cycles cost us $1500 or so over the course of many months which I think is very reasonable considering how much care my husband and I have received. And not for nothing, but Boston hospitals are amazing so it's not like we're getting cut rate service for this price.

Kind of in the same boat as you on this- we're in NY, which is usually 2nd to MA in terms of health insurance/mandates/pre-existing/etc.

Xstatic3333 · December 2016

You're definitely right, @LillibetteV; years of treatment and other therapies are required before gender reassignment surgery. It is still also completely unfair that @brij2006's reconstruction wouldn't be covered.

I'm also with you on MA. Insurance works so well there and is totally uncontroversial. The system was even put in place by a Republican! And yet, the rest of the country just isn't having it. Many states seem to be actively sabotaging the ACA (which I admit needs some help) by gutting their exchanges and declining the Medicaid expansion. I just think that in a country as wealthy as ours, nobody should go uncovered because of preexisting condition they have no control over, even if it means that I personally pay more. I could be in their shoes someday in a hot second. Then again, I have cushy MA insurance so I'm being shielded from the worst effects the ACA has had. I kind of feel stuck to this part of the country given what insurance is doing outside of New England, particularly if we go for more kids.

@als1982 your perspective on these issues as a medical industry pro is very interesting! Thanks for sharing.

Health Insurance Marketplace - can I choose to buy a plan in another state?

Re: Health Insurance Marketplace - can I choose to buy a plan in another state?

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