[Martina]

Question about ACA marketplace health insurance for those that are FI. I’m used to company sponsored Aetna PPO plan, which i have found frustrating, but ok enough.

I assumed i could get a similar plan on the marketplace when the time comes, i’ll just pay through the nose for it, but i’m starting to realize i may end up paying 15x in premiums for what will be much worse coverage.

I’m in NY and a) there are no PPO options on the marketplace, b) there are no plans that have out-of-network coverage, and c) there is only one “name brand” insurer which is United. Uhm, what?

I have a HDHP and have basically treated insurance as my own form of “catastrophic” insurance based on the annual out of pocket max since i never hit my deductible anyway and am essentially paying cash for all my medical needs as a result.

But if i’m truly in a catastrophic situation, do i really want to be limited to a closed network HMO (my understanding of HMOs is limited to the horror stories from the 1990s) and what if there’s an emergency?

Am i to make sure the ambulance takes me to an in-network hospital to make sure i don’t end up with a hospital bill in the 5-6 digits?

Do i need to get travel insurance every time i leave the state just in case??

How are others dealing with this (especially curious to hear from those in NY), or am i just misunderstanding how this all works?

All input much appreciated — i’m really starting to think i should work longer just to keep my “good” insurance…

[Melissa]

Hello Martina, I am an individual broker that sell plans on the Marketplace but I do not sell in the state of New York. I can recommend someone that can help you go over your options if you like.

Individual brokers services are free. We get paid by the insurance companies.

One of the main reasons folks may have to pay back to the IRS is if they give the wrong amount for their estimated yearly gross income.

[Charlotte]

15x in premiums? Will you still have a high income even though you will be retired?

[Megan]

NYer doing ACA, my region of NY (NYC) has zero PPO type plans, all HMO and EPO with no out of network.

So, I definitely would not assume.

[Polly]

I’ve in PA- been on ACA insurance for 8 years. I’ve always been able to find a PPO with good in-network coverage. This year I found a good HSA too.

My family has several exoensive illnesses so I go for a plan that includes our drs and meds.

We hit our max out of pocket every spring. So, I budget for hitting the Max and for the monthly premiums.

Family of 5. About 30-40k per year with premiums and max out if pocket. But, like I said, we hit max out of pocket in the spring due to meds and infusions.

[Modupe]

I actually have had 3 meetings with a healthcare Navigator here in Maryland. I am self employed so my company pays for my health insurance and because I made more last year the cost of coverage now is so much higher.

She advised me to call the healthcare companies directly and to buy directly since there were no cost efficient plans on the Maryland Marketplace.

I will calling around this week to see what is out there. She suggested Kaiser.

[Shaunna]

An emergency admission will be paid as in network. If it’s ‘reasonable’ that a non medical person thinks it’s an emergency (chest pain, trauma, etc) then it’s covered as in network.

If you go rolling in to the ED for a hangnail you may have issues.

The word of caution on that is if you are given the option and go out of network for a catastrophic issue (paid in network) and need follow up (such as cardiologist for example) the provider may not be in network for outpatient follow up.

While it’s technically possible to run into that at an in network facility, it’s less likely to occur.

[Rachel]

I’ve been hearing this a lot lately.
I’d reach out to individual brokers who sell marketplace plans.

[Daphne]

Start by calling your state office and requesting an ACA counselor – they are free and can answer questions.

I haven’t used one but a friend in TX did and was very pleased with the assistance received.

[Robin]

Also something to think about if your income changes .. you will have to repay any “free money” government allots for you/your family…

this healthcare really can hurt people who don’t have stable income …

[Natalie]

In my experience, HMOs have come a long way. We have an HMO plan now as the VA marketplace no longer offers any PPO plans either.

The last 3 years, we’ve not had any issues getting coverage anywhere.

There definitely seems to be a monopoly starting with one insurance provider cornering the market. There used to be two that would compete, but one bought out all the local hospitals, so it doesn’t make $$ sense to choose the other provider.

Until we qualify for Medicare or become expats it works just fine. FYI we do choose a PPO dental plan.

[Marcia]

We do a healthshare. Not for everyone but works for us and we save a ton.

[Kristin]

I had a good “test run” of the ACA this year due to taking having a few months out of the work place. Glad I did. I went with the lowest level bronze plan to keep expenses down, good for emergencies and knowing I would most likely have an employer plan in the new year.

It was very eye opening. Definitely couldn’t keep my doctor, doctors accepting new patients that took the insurance had 1.5 month waiting period before being able to schedule an appt for a sinus infection, plan didn’t contract with CVS, so we had to switch pharmacies, ect.

I will be adjusting my FI number to budget for better health insurance plans to fit our needs in the future.

It’s an adjustment for sure going from employer subsidized decent plans to ACA subsidized plans.

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