Help me think about health insurance options
November 29, 2017 4:27 PM   Subscribe

I'm going to be needing some medical care in the coming months, but I don't yet know exactly what kind and how much it'll cost. I'm trying to figure out whether to keep my current insurance, which is paid for up front but only pays 75% of costs, or buy new insurance, and if the latter, what a good option would be. Because of the uncertainty about the types of services I'll be needing, I'm not sure how to go about making this decision. Help? Details inside.

Details about (a) medical situation and (b) insurance situation:

(a) I have a swollen lymph node in my neck which has been there for about 4 months now, cause unknown. I've had a CT scan and a biopsy; latter came back negative for cancer cells. Doc says the next step is to see an ENT doctor, and that most likely the lymph node will have to be removed since the swelling doesn't seem to be resolving by itself, and that it would have to be biopsied after removal in case cancer cells were missed the first time around. So at a minimum I'm looking at an ENT consultation with ultrasound (which would run to about $1500 out of pocket); plus whatever further steps are recommended, probably including removal of the lymph node.

(b) Up to now these procedures happened under my old insurance plan, but that has now expired and I can't renew it (I'm no longer eligible for benefits through my employer because I now work part time). I do have this low-cost plan with a $500 deductible, but it only pays 75% of costs. That leaves me footing the bill for the remaining 25%, but since I don't know what procedures will be necessary, I don't know how to estimate what that would come to. It seems like it would probably be better to pay for a plan that covers 100%, but I would have a lot of trouble affording a low-deductible plan, and if most of the costs end up falling within the deductible then there's not much point doing that. In fact my finances are so tight right now that I'm not sure how I'm going to pay for any of this whatever I end up doing. (I'm in California but don't qualify for government assistance because I'm here on a work visa.)

Given the unknown total costs, how should I approach this decision? If I stay with my current plan, 25% of the total will come to $X where X is presumably at least a four-digit number, but without an estimate of the total I don't know whether I can get a lower X with a different plan and if so, what kind of deductible vs. premium calculation I should be making.

So my main question is how to think about that. But assuming I need a different plan, I could also use tips on specific choices. Finally, I've been looking into low-cost clinics here in the SF bay area which might be able to provide ENT or other relevant services, but haven't found anything promising so far, so ideas there would be great too.
posted by zeri to Health & Fitness (6 answers total) 2 users marked this as a favorite
Do the plans have an out-of-pocket maximum? What is it?

Note that if you stay in network you will pay coinsurance/deductible on the approved amount, which will be less than the list price. You could try to estimate costs by asking your insurance company, but nothing about that will be binding. At least it’d get you a ballpark estimate.

What is your open enrollment timeframe? How much time do you have left to make this decision?
posted by Huffy Puffy at 4:36 PM on November 29, 2017 [1 favorite]

My current plan (the one that pays 75%) has a $100,000 overall maximum.

I'm not sure about timeframe -- what would affect that? Can't you buy private insurance at any time? As I said I'm not eligible for any US government programs. My current plan is valid until next June. Obviously I want to start taking care of this as soon as I can given that I don't know how long of a process it'll be.
posted by zeri at 4:44 PM on November 29, 2017

I would contact an insurance broker who can guide you through the options. One very important consideration is whether a new individual policy would have exclusions for pre-existing conditions.

You may not be able to find a plan with 100% coverage that kicks in after a low deductible - it tends to be either one or the other - but there are plans with only 10% co-insurance instead of 25%. Another consideration is whether the plan includes a out-of-pocket maximum (it pays 100% above a certain amount.)

Once you know the options, I would do an two or three estimates - low, medium, high and compare the impact of each plan on each option. Remember this is all of your medical expenses for the year, not just this particular procedure. So the high estimate should include unexpected accident or injury and/or a major cancer diagnosis. It may not be likely but you want to think through how you will deal with it if it happens.
posted by metahawk at 6:30 PM on November 29, 2017 [2 favorites]

Make sure you understand that visitor medical plans are very stringent about what is considered a pre existing condition. ( for example any symptom in the last three years). If you have a high bill you can set up a payment plan four part of it, especially if your ncome is low. However If you do end up having an expensive to treat or prolonged illness your best bet would be to go back to your home country.
posted by SyraCarol at 6:43 PM on November 29, 2017 [2 favorites]

These visitor plans reject just about every claim and are sometimes borderline scammy. Your best bets are to either receive treatment in your home country or purchase the lowest priced ACA compliant plan you can find. MAybe start with blue california to see if there are any plans you can afford.
posted by WeekendJen at 9:55 AM on November 30, 2017

Were you offered coverage under COBRA when you became ineligible under your Employer's group plan?
posted by namret at 2:22 PM on November 30, 2017

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