Tips for Exchange Insurance Buying

December 8, 2022 10:03 AM

Hello, all! Thanks to the resolution of the "family glitch", getting my wife insurance through the ACA rather than taken out of my check through my employer could save us many thousands of dollars a year. I'm not very familiar with the ACA, so looking for any hive mind tips.

This is in Minnesota, so MNSure, and we have availed of a program which gets us help from an actual insurance agent to get set up (per the tip in the first comment here), so thus far we think we've found a good plan for her (similar but higher deductible than my work plan, but saves 4-5x the higher deductible in premiums a year). It is a "lower" deductible plan so doesn't qualify for a HSA.

Signing up for insurance is always fraught with possible failure to catch something important, potentially costing massive amounts of money if you aren't paying attention, so even though the insurance agent seems to agree that the plan that we found (but haven't signed up for yet) should be about as good as what I get through my insurance, I wonder if anyone who has actually had ACA health insurance -- any state is fine -- has tips or pitfalls they've learned from their experience.

Also, if there are any other helpful but poorly documented benefits from the ACA, aside from the insurance premium assistance, I should look into that would be helpful too. Thanks!

posted by AzraelBrown to Health & Fitness (12 answers total)

If your employer's health benefit is "self-funded", then it is regulated by a Federal statute called ERISA, which completely preempts your state from regulating it. Self-funded plans are not required to comply with any state coverage mandates. I'm not familiar with Minnesota law, but here is a list of mandates which ACA plans are required to cover in Minnesota but which ERISA plans are not required to cover. (To be sure, both ERISA and ACA plans must meet the requirements of the ACA; I'm talking about the benefits under "Minnesota Additional Mandated Benefits" on that page.)

Your HR can tell you if you have a self-funded plan or not.
posted by gauche at 10:15 AM on December 8, 2022

Response by poster: This is just insurance for my wife, because covering her as a dependent through my employer is super expensive. My small group BCBS coverage is paid 100% by my employer and is not changing. I am looking for any tips on getting my wife her own coverage through the ACA that is maximized in our favor.
posted by AzraelBrown at 10:45 AM on December 8, 2022

Best answer: The biggest thing in family members experience with exchange plans is remembering that you have to actively make a choice every single open enrollment period, because available plans change every year. If you don’t do this, they will switch you to whatever is “most similar” which may be significantly more expensive than you were paying before.
posted by rockindata at 10:56 AM on December 8, 2022 [4 favorites]

The agent helping you can search for plans based on any practitioners your wife uses.
posted by leslies at 10:57 AM on December 8, 2022

If deductibles and copays are lining up, the other big factor in insurance is provider network. If she has doctors that are important to her are they in network? Are the hospitals closest to you or that you are most likely to use in an emergency in network?

One way insurers reduce costs is by creating a “narrow network” that sharply limits which providers are in network. These are usually labeled as such but it’s worth asking about.
posted by jeoc at 11:36 AM on December 8, 2022

Best answer: All plans under the ACA are required to provide coverage (at least of some kind) for these "essential health benefits":

Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Emergency services
Hospitalization (like surgery and overnight stays)
Pregnancy, maternity, and newborn care (both before and after birth)
Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
Prescription drugs
Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Depending on your income (i.e. if your estimated Adjusted Gross Income for the year is between 100% and 250% of the federal poverty level), you may qualify for "cost-sharing reductions", which are lower deductibles and co-pays -- but only if you sign up for a "Silver" metal tier plan.

In addition to thinking about the cost of the premium, you should see what a plan's deductible is, as well as the cost for copays and co-insurance once you have met your deductible. This should be available in the plan's "Summary of Benefits" available on the MNSure website or through the plan itself. If you think you might need a lot of care then you should also see what the plan's "out of pocket maximum" is. Definitely check to see if your doctors are covered under the new plan as well.
posted by Theiform at 11:38 AM on December 8, 2022 [1 favorite]

I emphasize jeoc's mention of networks. You want to be sure all your wife's doctors are in network, and it would be surprising, but not too impossible to imagine, if the local hospital is out of network. But do you use other services? Physical therapist? Psychologist? Dermatologists?

Of course, sometimes you have to take the hit and change providers.
posted by SemiSalt at 1:32 PM on December 8, 2022 [1 favorite]

I always recommend that folks delving into the ACA exchanges talk to a healthcare navigator. They are free, and have a wealth of information about the variations in plans, subsidies, and other implications. Here is Minnesota's healthcare navigator directory. They are paid for by federal grants, so have no ulterior motives in directing you to one plan or another.
posted by kimdog at 1:52 PM on December 8, 2022 [3 favorites]

Check the plan's formulary-- i.e. the list of prescription drugs covered under that plan-- for anything your wife's currently taking. That is my hottest tip. (You may well have rights on top of what the plan explicitly says it covers for out-of-network coverage for medically necessary medication but it'll certainly be more of a hassle if so!)
posted by peppercorn at 4:23 PM on December 8, 2022

I found it super helpful to ask on my city's subreddit for people's experience with the plans they'd bought on the exchange.
posted by Jacqueline at 10:25 PM on December 8, 2022

I explored getting an ACA plan for my family in Minnesota earlier this year and was ineligible due to having access to an employer-provided plan. I was even willing to pay about twice what my employer plan costs because I hate them so much. But having access to a plan stopped things cold The question is at the very end of the application process. I would make absolutely sure you can do this especially before you decline employer coverage if you are in open enrollment.
posted by peanut_mcgillicuty at 3:04 AM on December 9, 2022 [1 favorite]

Think long and carefully before you sign up for a high deductible plan. I did that on the ACA figuring that I rarely get sick and I could pay out of pocket for routine visits. Ha ha, that was the year my gall bladder flipped out and I needed an ER visit and surgery. The $6000 ER visit was not covered at all and the surgery would barely have been covered. I did not have $6000 and it got ugly. Granted this was mostly my fault for basically refusing to deal with it and fight with the hospital and the insurance provider. You have to be prepared to do that and I was not.

I ended up getting laid off due to Covid and it literally saved me: I was able to go on Medicaid and that paid for the surgery. I still got sued for the $6000 and needed a lawyer and it was horrible. I will never go with a high deductible plan again: even if the monthly premiums are outrageous, they're better than being hit by thousands of dollars all at once.
posted by mygothlaundry at 12:13 PM on December 9, 2022