Can I get better insurance than employer offers?

April 7, 2014 9:18 PM

My husband's new job only offers one plan: a high deductible plan with $5,000 and $10,000 deductibles. We both have chronic illnesses with lots of medications and several doctors. We cannot afford to pay out of pocket for everything. What can I do?

Ok, so my husband has switched jobs because his company shut down the local plant. He found a new job with a small family owned local company that is really good in a lot of ways. They even waved the 90 day waiting period for insurance coverage just for him.

Except I JUST today (coverage started April 1st) got written details of the plan. It's the only plan available to employees, everyone has the same. It's Texas Blue Cross Blue Shield PPO and the deductibles are $5000 individual/ $10,000 family. According to the paperwork all services are covered at 100% only after the deductible has been met. Including prescriptions.

We are going to call tomorrow to check on the details. But as of right now, this pretty much means we DON'T have any insurance as far as I'm concerned. I am disabled (but not receiving benefits, long story) and I run a small business (very small but it pays a few bills.) I have a chronic back condition and I take several meds, most of them not THAT expensive except my antidepressant. My husband on the other hand has ulcerative colitis and it's well controlled but his meds cost hundreds of dollars a month. Each.

We have finally gotten our finances on track and are paying off debt, but we can't afford to add several hundred dollars a month to our bills. We're already paying several hundred dollars a month in medical expenses.

So I really really need some advice. Is there anything I can do to get other insurance? Additional insurance? BETTER freaking insurance?

As far as affording the medications, I know there are patient assistance programs available, but they seem to only be open to the uninsured. What about the FUNCTIONALLY uninsured?

I'm really scared right now.

posted by threeturtles to Health & Fitness (19 answers total)

The plan as it stands costs you $833/month (max out the deductible). Are your current meds more or less expensive than this? Secondly, you can shop around for private insurance but $800 a month including deductibles for a family with pre existing conditions does not seem crazy high. Have you looked at your states ObamaCare exchanges?
posted by saradarlin at 9:50 PM on April 7, 2014 [2 favorites]

Response by poster: That's a third of our income. Plus you're not taking into account what we are already paying in premiums for this plan, just the deductible.

I haven't done the math on exactly how much our medications cost with no insurance yet, but it's probably approaching that. Plus paying 100% for all doctor visits (I have three doctors, two which want to see me every 3 months) and all tests and labwork and procedures.

So does this insurance plan save us some money every year? Probably, a bit in December. Does that mean we can afford to pay for both it and all our expenses? No.
posted by threeturtles at 10:01 PM on April 7, 2014

Be sure to check your eligibility for subsidies for the Obamacare plans. See this article for a summary. There are complicated rules about the cost of the plan, or you might qualify by yourself. Or, if you could qualify for SSI (aka Social Security disability) in many states you would be eligible for Medicaid, if your doctors would accept it. Or, you might qualify for Medicaid just based on income. The exchange would help you with the latter possibility. I'm sorry this is difficult; the U.S. healthcare system is really complicated.
posted by wnissen at 10:10 PM on April 7, 2014 [4 favorites]

With a high deductible plan you might also benefit from an HSA or other tax-reduction scheme for medical expenses.
posted by nat at 11:00 PM on April 7, 2014

Also, call your insurance company and the drug companies about getting help to pay for Rx.

I got a $2,500/month prescription paid in full and another reduced from $100/month to $20. Also helped a friend get his very expensive heart medications covered in full.

No one seems to believe it's this easy. But it is. My only regret is that it took me a year to track down a way to pay for the $100 med. I called my insurance company and said "this is too expensive." My dr made one call and it was done. No paperwork even.

Call them.
posted by crankyrogalsky at 11:39 PM on April 7, 2014

If $833/month is a third of your income, then you guys are making well below 400% of federal poverty guidelines. If the insurance plan offered by his employer is not 'qualified' or is not 'affordable' then you can buy possibly better insurance through the exchange and have the premium be capped to 9.5% of your income.

- 'qualified' means something like it covers three doctors visits a year and 60% of medical costs for an average person. Your employer should be able to tell you specifically whether the plan they offer is 'qualified' or not.

- 'affordable' means the premium is less than 9.5% of your income (~$230/month for an annual income of $30,000).

So, ask the employer specifically if their plan is 'qualified', and contact the exchange in Texas to get details of plans available to you.
posted by the agents of KAOS at 12:05 AM on April 8, 2014 [14 favorites]

You should probably contact a Texas-based navigator (enter your city/zip here) to assist you in reviewing your options under the ACA.
posted by dhartung at 12:18 AM on April 8, 2014 [11 favorites]

A bit unrelated but you should be aware of this, as I understand it, under ERISA, an employer can't "waive the 90 day waiting period for insurance coverage just for him.. Be aware that the insurance company could deny (PDF file) ALL claims during that 90 day period.
posted by HuronBob at 3:29 AM on April 8, 2014 [2 favorites]

Use dhartung's link ASAP.
posted by Lesser Shrew at 4:25 AM on April 8, 2014 [2 favorites]

For you, at least, maybe you need to take the "long story" to a lawyer who can help you secure your benefits. If you are disabled, you should be Medicaid-eligible even in Texas.

Another answer, though no doubt difficult to implement, is to move to a state which has expanded its Medicaid program under the ACA.
posted by yclipse at 4:48 AM on April 8, 2014

I live in a different state. I have chronic medical conditions and so does my wife. My deductible on my BCBS plan (also a PPO) does not mean I pay everything out of pocket until I hit my deductible. It means that I pay my copayments. I haven't had to pay a full bill for anything. Even with 4 therapy appointments a month, and 2 doctor appointments a month I pay 150 out of pocket plus copay for meds (which are also 25 per med generally). So you may not actually reach your deductible.
posted by AlexiaSky at 4:54 AM on April 8, 2014 [2 favorites]

And word to the wise make sure with your small business you pay your medicare taxes each year. There is a huge difference in coverage for someone who is disabled and qualifies for Medicare vs someone who qualifies for medicaid. This generally based on work credits which is calculated by work you paid taxes on. Check with the SSA website to see your personal credits. In addition waiting to long to apply can decrease your overall benefit.
posted by AlexiaSky at 5:01 AM on April 8, 2014 [1 favorite]

My partner and I are in a very similar position. You may want to look into Cobra coverage from his last job. It is expensive but maybe less so.
posted by southern_sky at 5:41 AM on April 8, 2014

I had what sounds like a very similar plan in another state for several years (BCBS PPO but in a different state). I suggest you to take AlexiaSky's advice and make sure you get the exact details of what is actually subject to the deductible.

When I was on that BCBS plan (and I think this is fairly common across a lot of insurance plans), all of my doctors visits had copayments that were not subject to the deductible. The same was true for my prescriptions. The deductible did apply to things like hospital visits, lab work, etc. Make sure you also are clear on the difference between the deductible and the out of pocket maximum. I believe my particular BCBS PPO plan had a deductible that was $2500/$5000 (for individual/family) and an OOP maximum of $5,000/$10,000.

This is definitely YMMV territory, especially since this was in a different state, but as someone who had a fair amount of prescriptions and doctors visits, I really loved that insurance plan. It gave me a lot of flexibility about what doctors I saw, and it was really great about covering things. This may not be relevant to you, but it also had above average mental health coverage. If it were an option, I would go back on this plan in a heartbeat.

With all of that being said, You should call the insurance company directly and ask all of these questions. They will be best equipped to give you accurate answers.

I can't speak to whether or not you would be covered under ADA, and you should probably also speak to someone on the phone about this, but I recommend spending some time looking through the available plans if you haven't already. Again, this was in a different state, but I was recently shopping for plans through the health care exchange, and the options really were not very good, so I would make sure you understand all the fine print before making a decision.
posted by litera scripta manet at 6:20 AM on April 8, 2014

Sounds like you got one of those old fashioned "junk" plans. That's unPossible. With the new rules of the ACA these things simply cannot exist, like dinosaurs after the comet.

Now to some reality. You and or your husband had a "life-changing event": a new job. You could have applied for a plan through your state exchange. You may still be able to. Check it out, get online and apply specifying a life-changing event. You do not have to wait for open enrollment to do this.
posted by Gungho at 7:09 AM on April 8, 2014 [6 favorites]

Definitely check whether you're eligible and can do better under the ACA as described above, and the details of what you'd be responsible under your insurance, but also see if you can find out what just having Blue Cross will do to your payments. I just got Blue Cross in Michigan this year, thanks to the ACA, and am shocked at what they pay v. what gets waived just because it's Blue Cross. My last prescription was billed to Blue Cross for $70. They paid $3, and the rest just went away. I had some surgery earlier this year, my bill was about $15,000, Blue Cross paid something like $6,000 of it, and again, the rest just vanished. I paid under $200.

And if you do look into ACA plans, be sure to find out about the cost sharing options, as well as the subsidies. That makes a huge difference, and doesn't seem to be well publicized.

Good luck.
posted by still_wears_a_hat at 2:01 PM on April 8, 2014

Response by poster: For the record, I checked and yes, I have zero coverage until we meet the deductibles. I was told the prescription deductible is $3700, which seems really random, especially since the paperwork said $5000. I honestly don't know how they are allowed to call this health insurance, since it's only catastropic coverage. Plus I'm paying $400/month in premiums to get nothing.

I've completed an application for ACA and been told I qualify to buy through the marketplace, but I have to get info from my husband's employer before I know more.
posted by threeturtles at 3:12 PM on April 8, 2014

Wow, that's insane.

Can you talk to the HR/benefits person and find out what the next level up plans are and if you could pay the difference in premiums? My company will pay 100% of premiums for a basic plan (pretty good coverage but less than I would personally want), and then there were two more comprehensive options above that employees could pay the difference for.
posted by radioamy at 3:14 PM on April 8, 2014

Response by poster: I don't know. I'm sending my husband to get more info (it's a fun game of telephone) so I'll tell him to ask. But from what I understand all employees have the same group plan. There are only about 50 employees. But yeah, if we could just pay the difference to upgrade or something, that would make sense.
posted by threeturtles at 3:34 PM on April 8, 2014