Should I look into alternative health insurance to my jobs'?
July 14, 2018 3:08 PM   Subscribe

There's a big gap in my company's health insurance. I don't think I can lobby them to change plans or anything, and I don't want to switch jobs. If I refuse my work's coverage and buy my own on the market to get an expensive surgery, will that work out?

I'm a software engineer in Boston (Jr level, $100K/yr), and my job has me on a low deductible PPO, but it covers lab tests poorly, and its drug plan isn't great. Otherwise, I'm pretty happy with the low copays for specialists and routine appointments. Most of all, I'm hoping to get a $27,000 surgery that my company's insurance specifically excludes.

I'm told Massachusetts has other plans that would cover the surgery. The idea of going without a plan that's taken care of and paid for with a cut of my salary concerns me. I'm worried I'd screw up the switch between companies and lack major coverage, or find myself unable to switch back to my work plan. I'm also scared of pre-existing conditions, which well could become a thing again in this political climate. I'm also aware that more than half of my premium is paid for by my company, which especially annoys me that I'm looking outside.

Is this as risky as I'm thinking? Would it have to take place during open enrollment? Would I be better off just taking out a loan for the ~$27,000 surgery? I have good credit, so that shouldn't be hard to secure, and only annoying to pay off since I have few recurring expenses, rather than crippling.
posted by ikea_femme to Work & Money (9 answers total) 1 user marked this as a favorite
Can you wait until open enrollment at the end of the year? (That is, can the surgery wait until next year?) Right now enrollment is closed, so you'd have to qualify for special enrollment:
Types of Qualifying Events for Special Enrollment Period (SEP)

A Special Enrollment Period is a time outside of the open enrollment period that you and your family have a right to sign up for health coverage through the Health Connector. You may qualify for a special enrollment period 60 days following certain qualifying events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage.

Qualifying Events

Getting married.
Change in household dependents. Birth or adoption of a child, receiving a child into foster care, placing a child for adoption or foster care, or court-ordered care of a child.
Qualifying for ConnectorCare, after not applying or qualifying for it in the past
Losing minimum essential coverage. You may qualify for a special enrollment period if you lose health coverage for a reason other than not paying premiums or because of fraud. This includes:
loss of MassHealth coverage.
loss of your insurance from a job.
your COBRA coverage ending. Note: Not paying your COBRA premium is not considered loss of coverage.
no longer living or working in your health insurance carrier’s service area.
no longer qualifying for student health coverage.
the end of your dependent status on someone else’s plan.
turning 26 years old and no longer qualifying as a dependent in a family plan.
turning 19 years old and no longer qualifying for a child-only plan.
primary subscriber of your health insurance plan becomes eligible for Medicare.
having a claim that would meet or exceed a lifetime limit on all benefits;
death of a primary subscriber
Change in residency, such as a permanent move to Massachusetts, gains access to new plans as a result of a permanent move within the state, or release from jail or prison.
Is an American Indian or Alaska Native, as defined by section 4 of the Indian Self-Determination and Education Assistance Act. Such an individual may enroll in a health or dental plan or change from one plan to another once a month even if the open enrollment period is over.
Becomes a lawfully present individual but you were not lawfully present in the U.S. before.
Was mistakenly enrolled or not enrolled in a Health Connector health or dental plan due to an error, misrepresentation, or inaction on the part of the Health Connector or the Department of Health and Human Services, or its instrumentalities, as determined by the Health Connector.
Other exceptional circumstances
I am failing at getting confirmation of whether voluntarily giving up your employer-sponsored insurance would be a qualifying event, but my assumption is that it would fall under "not paying premiums" and so would not qualify.

You can talk to a Massachusetts Health Connector at 877-623-6765 to get a more official answer.

If you do switch, you'd likewise have to wait until your employer-sponsored Open Enrollment period to switch back.
posted by lazuli at 3:34 PM on July 14, 2018 [1 favorite]

My understanding is that you'd decline coverage during open enrollment and need to stick with the alternate plan for the year until open enrollment rolls round again. (Now, precisely what happens if your work's open enrollment doesn't line up with the marketplace open enrollment, I don't know. I think you end up being double-covered for a few months, which is annoying because the plans will fight with each other over who pays, but not the end of the world. You can purchase insurance at any time if you don't go through the marketplace.)

Another risk to weigh is whether your current insurance would refuse to cover any care from complications because the original procedure was excluded.

However, I'm taking a guess that you're trans. Massachusetts has a ban on trans exclusions, so you first want to understand whether the exclusion in your plan is enforceable (sometimes they were never removed). There are a few reasons it may be. For a start, your plan may not be regulated by the state of Massachusetts (this is the "self-insured" vs "fully-insured" distinction, or your plan may just originate in another state). Also, a blanket exclusion on transition-related care may not be enforceable, but an exclusion for specific procedures may be. Remember also that exclusions, coverage rates and networks are plan-specific and not company-specific, but the discussion in the trans community is often at the company level, which is misleading.
posted by hoyland at 3:37 PM on July 14, 2018

Response by poster: I wasn't going to talk about it, but fine. It's facial feminization surgery. Seems to be pretty clearly excluded although my plan covers several other procedures related to transition.
posted by ikea_femme at 3:40 PM on July 14, 2018

Sorry! I was trying to be procedure-agnostic when speaking about transition-related coverage so you wouldn't feel obliged to give details.
posted by hoyland at 3:46 PM on July 14, 2018

(Now, precisely what happens if your work's open enrollment doesn't line up with the marketplace open enrollment, I don't know. I think you end up being double-covered for a few months, which is annoying because the plans will fight with each other over who pays, but not the end of the world. You can purchase insurance at any time if you don't go through the marketplace.)

You can cancel insurance at any time, just not start it at any time. So once you'd re-enrolled with your work insurance during their open enrollment period, you could cancel the marketplace plan. (You might have a month or something before the cancellation went into effect, but it wouldn't be a long period.)
posted by lazuli at 4:07 PM on July 14, 2018

Does the surgeon take insurance or do you have to reimburse it?
posted by nikaspark at 4:49 PM on July 14, 2018

The reason I’m asking is that if the surgeon does take insurance then you can work to get it all preapproved, but if you have to pay up front then get reimbursed the complication factor rises considerably.

I know of trans people who had reimbursement claims denied after surgery, it can be tricky. It’s one of the reasons I went to Mayo Clinic because their insurance department is total pro and my trans care liaison with Premera confirmed that Mayo had their shit together. I’ve spent many hours talking with my trans care liaison about reimbursement for trans surgeries and she’s said it’s a pretty sad state of affairs out there among trans surgeons and insurance companies playing nicely together when it comes to getting care reimbursed.

Given my own experiences and knowing the experiences of others I would say if you’re filing for reimbursement consider it a crapshoot if it will be actually paid out, and if the surgeon takes insurance you’ll know what’s covered when the surgeon attempts to get prior authorization.

All this hassle is why I’m going to do all my trans related surgeries at mayo even though I feel like there are more experienced people out there.
posted by nikaspark at 5:15 PM on July 14, 2018 [1 favorite]

Response by poster: Well, I'm not even booked with the ffs person, and honestly a bit on the fence about it, but I'm leaning towards it now. I can't produce enough cash for the 30% deposit without a loan. Hence the loan and insurance chat. And my insurance explicitly excludes ffs.

I'm consulting and finally scheduling grs this Monday, with a surgeon I intend to pay out of pocket and then bill my insurance. I'm not thrilled that it's her arrangement, but she's got an excellent reputation and is close to me and good with revisions. But that $17,000 is money I'm prepared to lose entirely, although I imagine that I can get them to pay me the $11,000 minimum they'll owe me. ($6,000 yearly out of network cap)

For a broader picture of my financial situation, I don't have any savings yet outside of a few thousand in emergency money, and about $7,000 that will be enough for grs in less than a year at the rate I'm envelope budgeting for it. I'm on good terms with my family for emergency money, and have excellent credit but low credit card limits (they haven't gotten wind of my new job, perhaps the name change is confusing them). I still owe $2000 in credit card debt at 13.7 apy (which I'm paying off $200 of per month) and $5,000 in student loans (which I'm paying minimum payments off of until I snowball away the credit card).

So, I can afford this stuff within tight limits, but I worry about what a loan and a hardship could do.
posted by ikea_femme at 7:24 PM on July 14, 2018

Response by poster: As for the FFS surgeon, if I stick with him, he only is in network with one plan in the state. But there's plans with good out of network trans coverage as well. Of course, I also worry about the gamble of taking on higher, unsubsidized premiums in a tumultuous climate for health care and trans rights.
posted by ikea_femme at 7:33 PM on July 14, 2018

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