Health insurance woes
April 16, 2014 10:05 PM   Subscribe

My last job had health insurance through a certain company I'll call WORST COMPANY, and they capriciously decided to be assholes about pre-certifying a surgery that my husband needs, as per my husband's surgeon (the surgeon is ready to go, he's been treating my husband for this condition for years now, and he says this is what's required. We've done all the conservative measures and they didn't help). We were fighting with them for almost a year and it was a whole big thing including trying to appeal to the state (which didn't work because then we found out my then-employer had a self-insured plan). It's a long story but please take my word for it that it was capricious and not our fault. I just got a new job and thought "Thank god, we'll start over with someone else." Except my two options are a high-deductible plan through OKAY COMPANY and a regular PPO through...........WORST COMPANY.

I don't want the high-deductible plan because even after your deductible is payed off (about $3,000 between my hubby and I) you still have to pay for 10% of your care after that, which could add up. And I don't want the WORST COMPANY plan because I want the surgery to actually, you know, happen. Which is the lesser of two evils? I know WORST COMPANY will carry over our medical histories, but will they continue to dig in their heels or treat it differently because it's a different employer? What should I do?
posted by bleep to Health & Fitness (9 answers total)
Usually, high deductible plans have an out-of-pocket maximum, after which the insurance will cover at 100%. For example, my HDHP has a $1250 deductible and a $5000 out of pocket max, so for the surgery I'm planning for in may, I should have to pay (only?) $6250 max.
posted by leahwrenn at 10:17 PM on April 16, 2014 [2 favorites]

Have you spoken to HR? Or your new co-workers? There's always the possibility that the WORST COMPANY PPO has very different group policies than your husband's old self-insured plan. Ultimately, you have no way of knowing, which is why US health insurance still sucks, but your HR department and the other employees will have the best sense of whether this particular PPO is a familiar kind of suck.
posted by holgate at 10:20 PM on April 16, 2014

Have you confirmed, in writing, that "Okay Company" will cover this procedure?
posted by grouse at 4:30 AM on April 17, 2014 [1 favorite]

Does the new job count as a life event that would allow you to get coverage through the health care exchanges, with a plan that might be better?
posted by needlegrrl at 5:10 AM on April 17, 2014

Remember that WORST COMPANY may only be in name only WORST COMPANY. I have to deal with plenty of pre-authorizations for my job, and the attitudes/benefits between varying "Anthems" is enormous. Most of my pre-auths are for genetic testing, and it's amazing how I can get back an authorization from Anthem of Virginia in a matter of hours, yet Anthem of [another state] will be a knock-down, drag-out fight, replete with peer-to-peer phone calls, faxing of hundreds of pages of journal articles, etc.
posted by kuanes at 5:28 AM on April 17, 2014 [3 favorites]

What Kuanes said. The name is nearly meaningless. BlueCross, for example, has dozens and dozens of different plans and subsidiaries.

Your primary concern should be if the surgeon is a participating provider for the new PPO. Yes they have the same name, but again, that name is basically meaningless. You need to search on both the new PPO and HSA's provider network listings and confirm your surgeon's office participates.

With the knowledge that your surgeon is, or is not in-network you can start to estimate costs with both plans.

To do a real apples to apples comparison you need to ask the HR department for an SBC, Summary of Benefits and Coverage. And if you really want to drink from the firehose, a complete plan document.

Luckily, like nutrition facts labels, SBCs are in a government mandated format so you can actually compare plans. They don't give 100% of every detail, and the "attitude" of an insurer is something harder to quantify. But you can find your share of cost for an outpatient surgery. Of course, if the SPD lists something like "10% coinsurance subject to deductible", you don't know what 10% of [MYSTERY NUMBER] is. Which is annoying. So in that case, assume it will max out your deductible and yearly out-of-pocket.

Considering you're looking at a year with high estimated medical costs I can't imagine the math will work out for you to select the HSA plan.

And Needlegrrl, if you have an employer offered plan that meets the minimum requirements, you are not eligible for an ACA exchange plan.
posted by fontophilic at 6:33 AM on April 17, 2014 [1 favorite]

Also, re out of pocket maximums, that figure INCLUDES the deductible and is not ON TOP OF the deductible. So, for instance, if your deductible is $3000, and your out of pocket maximum is $6000, that means you pay 100% until you hit $3000, then you pay 10% until you've paid another $3000, and then your insurance pays 100% of covered costs. (Obviously plan details will vary.)
posted by devinemissk at 8:51 AM on April 17, 2014

Thanks for your advice - now with a better idea of what to look for, I reviewed the plan details some more and the company website provides some calculators and it seems like we may come out on top with the high deductible plan + health savings account, because we're guaranteed to hit that deductible pretty quickly. According to what I read, With the PPo we'd wind up having paid way more because it has a huge premium whereas the other one has no premium, even accounting for the lower deductible.
posted by bleep at 4:13 PM on April 17, 2014

Full disclosure - I work for a company that sells Health Spending Account (HSA) plans.

People on High Deductible health plans are typically eligible for HSA plans. The plan itself includes a bank account that is entirely yours, and you can contribute to it via payroll deduction or by depositing funds directly into it. One of the beauties of it is that the contributions are not taxed or taxable if you use them for eligible health expenses. So even with a high deductible, you can fund those expenses with pre-tax dollars. HSA plans tend to work best after the first year, particularly if you didnt have many health expenses. Once the balance in the account is high enough, you can invest some of those funds. And the account becomes a "rainy day" account for medical emergencies. And some companies contribute to employee HSA accounts to help defray the high deductibles.

I have even heard of cases in which people have managed to save up a lot of money in their HSAs, keep them growing until retirement, then submit a bunch of medical expenses to receive the funds without tax penalty. There is no time limit on reimbursements - you just need the receipts to prove the expenses qualify. (That may be more of a theoretical case. I dont think HSAs have been around that long.)

I know that some of these benefits may not apply to you, but at a minimum, you could deposit at least some of the deductible amount and get the tax savings.

One of the supposed benefits of HSAs is that they support putting the patience more "in charge" of their health care decisions. But in actual practice I think that means people decide to go to the doctor less often because they dont want to dip into their HSAs.

There are a lot of places where you can research HSA accounts on the web.
posted by Billiken at 10:53 AM on April 18, 2014

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