"Premium" insurance vs "second-lowest cost silver"
March 31, 2023 2:18 PM Subscribe
I currently have a "good" high-deductible Blue Cross plan through work--"good" being a relative term in the US of A. By "good" I mean that there is no difference in cost between in-network and out-of-network providers and anyone I want to see takes my insurance. I'm considering switching to part-time at an income low enough that I would qualify for a subsidized ACA "second-lowest cost silver" plan. The main thing hanging me up is that I've heard that a lot of providers don't take ACA plans. Is this true? Have you experienced the difference for yourself? I'm kind of a power user of medical services so it matters to me a lot.
I have a subsidized Silver ACA plan and have had no problems with it being accepted within my (very large) medical group. I’ve had surgery and take multiple prescriptions and have never had difficulties. Obviously, YMMV.
posted by bookmammal at 2:29 PM on March 31, 2023
posted by bookmammal at 2:29 PM on March 31, 2023
My knowledge of ACA plans is that you're not really getting an "ACA" plan. You're buying a plan for XYZ insurance through the ACA marketplace. The providers just see the insurance carrier. Maybe your group ID number indicates ACA, but that's not super important. There may very well be Blue Cross plans available on the marketplace.
posted by hydra77 at 2:55 PM on March 31, 2023 [4 favorites]
posted by hydra77 at 2:55 PM on March 31, 2023 [4 favorites]
For the first several years, I purchased a Gold Blue Cross Blue Shield of Tennessee plan (through the federal marketplace, as my state doesn't have its own). Then I switched to the second-lowest silver plan, was amazed at my subsidies and the affordable price...and the fact that there was literally zero difference between the coverage, either in terms of what was covered or what physicians/hospitals/etc. was in-network.
In my county, at least, all BCBST plans participate in the same networks (coded like S for multi-state plans, because I live on a state border, P for in-state only plans, and a few other network codes). So the fact that I picked a BCBST plan via the federal marketplace didn't create a problem, because all BCBST plans had the same networks. The Silver ACA plan was in the same Gold ACA plan, and both were in the same plan I'd been in pre-ACA. They were all network S. I was going from one (non-ACA) BCBST plan to an ACA BCBST plan, so it was easy to compare apples to apples. You'll probably want to make a little chart if you're going to look at non-BCBST plans to compare to your current BCBST plan. But this info is EASY to access.
I suspect that these things vary by the insurance provider, state, and county. Be sure to make a list of all of the doctors, hospitals, and medications you currently use, and then when you're on the ACA.gov site (after your application has been approved, but before you pick a plan) and you can enter in all of the information and filter for doctors, meds, etc. (in whatever combinations you want). You'll have all the info you need before you pick a plan, and you'll be able to see whether all the providers (and meds) you need are covered before you ever pull the lever on purchasing a plan. If it doesn't line up the way you want, you don't have to move forward with picking a plan.
posted by The Wrong Kind of Cheese at 3:44 PM on March 31, 2023 [1 favorite]
In my county, at least, all BCBST plans participate in the same networks (coded like S for multi-state plans, because I live on a state border, P for in-state only plans, and a few other network codes). So the fact that I picked a BCBST plan via the federal marketplace didn't create a problem, because all BCBST plans had the same networks. The Silver ACA plan was in the same Gold ACA plan, and both were in the same plan I'd been in pre-ACA. They were all network S. I was going from one (non-ACA) BCBST plan to an ACA BCBST plan, so it was easy to compare apples to apples. You'll probably want to make a little chart if you're going to look at non-BCBST plans to compare to your current BCBST plan. But this info is EASY to access.
I suspect that these things vary by the insurance provider, state, and county. Be sure to make a list of all of the doctors, hospitals, and medications you currently use, and then when you're on the ACA.gov site (after your application has been approved, but before you pick a plan) and you can enter in all of the information and filter for doctors, meds, etc. (in whatever combinations you want). You'll have all the info you need before you pick a plan, and you'll be able to see whether all the providers (and meds) you need are covered before you ever pull the lever on purchasing a plan. If it doesn't line up the way you want, you don't have to move forward with picking a plan.
posted by The Wrong Kind of Cheese at 3:44 PM on March 31, 2023 [1 favorite]
If you switch to part-time work, would you no longer qualify for insurance from your employer? You can't get subsidies for an ACA plan if you're offered insurance from an employer that costs less than 9.16% of your household income.
That aside, the whole purpose of the "Exchange" or "Marketplace" is that insurance companies are selling a range of health insurance plans with different networks of what doctors and facilities are covered. There's also a push now in some states to offer standardized plans with the same copays for services across plans, which may or may not apply in the state you live in.
The best way to find out if your providers would be in network for a plan would be to look at the directory on the insurance company's website or healthcare.gov (or the webpage for the Exchange in your state).
It's great that you know to look at shopping for silver plans -- you don't need to pick the second-lowest-cost one; thats just a term to refer to how much subsidy your premium cost is based on -- which are subsidized to have low copays and coinsurance if your income is less than 250 percent of the federal poverty level. You should also compare their cost with gold plans, which cover even more of the copays, but typically at a higher premium.
posted by Theiform at 4:37 AM on April 1, 2023
That aside, the whole purpose of the "Exchange" or "Marketplace" is that insurance companies are selling a range of health insurance plans with different networks of what doctors and facilities are covered. There's also a push now in some states to offer standardized plans with the same copays for services across plans, which may or may not apply in the state you live in.
The best way to find out if your providers would be in network for a plan would be to look at the directory on the insurance company's website or healthcare.gov (or the webpage for the Exchange in your state).
It's great that you know to look at shopping for silver plans -- you don't need to pick the second-lowest-cost one; thats just a term to refer to how much subsidy your premium cost is based on -- which are subsidized to have low copays and coinsurance if your income is less than 250 percent of the federal poverty level. You should also compare their cost with gold plans, which cover even more of the copays, but typically at a higher premium.
posted by Theiform at 4:37 AM on April 1, 2023
Ah, an issue near and dear to my (frustrated) heart as a self employed person in the US. I think this will vary by state and local market.
My knowledge of ACA plans is that you're not really getting an "ACA" plan. You're buying a plan for XYZ insurance through the ACA marketplace. True, but often the few non-group plans offered (including those on the exchange) have different networks than the networks offered to group/employer plans. My experience has been that hospital systems/physicians groups fall in and out of network frequently on these plans but there’s nothing you can do about it. This pertains to any non-group/non-employer plan wether subsidized (e.g. second lowest silver) or not. You really need to do your research to see if the offered networks will work for you and your doctors.
there is no difference in cost between in-network and out-of-network providers and anyone I want to see takes my insurance. In my experience this is never available on any non-group plan that I’ve seen in the past 10 years where I live. If you’re asking if you can buy the same(ish) plan offered from your employer the answer, in my experience/where I live, is no. You can’t even pay more for it! The past 5 years in one of the largest cities in the US only one PPO plan was offered at all! Most insurance companies only offered HMOs. The one offered PPO plan came in the 3 metals, the difference between being the monthly premium and deductible. Sometime there’s plans offered with special benefits that may appeal to you based on how you consume healthcare. I’ve seen some that offer X number of PCP visits for $40, or plans tailored for diabetics. Still, all three levels had the same $7k out of pocket max with just a different way to get there. If you are a “power user” I assume you will want to be on a PPO. It sucks. Feel free to email me with more questions.
posted by Bunglegirl at 9:59 PM on April 1, 2023 [1 favorite]
My knowledge of ACA plans is that you're not really getting an "ACA" plan. You're buying a plan for XYZ insurance through the ACA marketplace. True, but often the few non-group plans offered (including those on the exchange) have different networks than the networks offered to group/employer plans. My experience has been that hospital systems/physicians groups fall in and out of network frequently on these plans but there’s nothing you can do about it. This pertains to any non-group/non-employer plan wether subsidized (e.g. second lowest silver) or not. You really need to do your research to see if the offered networks will work for you and your doctors.
there is no difference in cost between in-network and out-of-network providers and anyone I want to see takes my insurance. In my experience this is never available on any non-group plan that I’ve seen in the past 10 years where I live. If you’re asking if you can buy the same(ish) plan offered from your employer the answer, in my experience/where I live, is no. You can’t even pay more for it! The past 5 years in one of the largest cities in the US only one PPO plan was offered at all! Most insurance companies only offered HMOs. The one offered PPO plan came in the 3 metals, the difference between being the monthly premium and deductible. Sometime there’s plans offered with special benefits that may appeal to you based on how you consume healthcare. I’ve seen some that offer X number of PCP visits for $40, or plans tailored for diabetics. Still, all three levels had the same $7k out of pocket max with just a different way to get there. If you are a “power user” I assume you will want to be on a PPO. It sucks. Feel free to email me with more questions.
posted by Bunglegirl at 9:59 PM on April 1, 2023 [1 favorite]
Another data point from my specific plan (YMMV)—out of network anything is 0% covered until you meet your deductible. I would look at the specifics of any plan you’re considering for this difference.
posted by Bunglegirl at 10:16 PM on April 1, 2023
posted by Bunglegirl at 10:16 PM on April 1, 2023
Response by poster: Okay, wow. This is good information. I live in a rural area with terrible options and have frequently needed to travel five hours to the nearest big city for specialist care, so that’s a big deal. Thanks!
posted by HotToddy at 9:27 PM on April 2, 2023
posted by HotToddy at 9:27 PM on April 2, 2023
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