Please help me buy my first private health insurance plan
January 8, 2024 1:03 PM Subscribe
After decades of poverty, Medicaid, and sometimes being uninsured, I’m about to buy my first-ever private healthcare plan. Please walk me through this process and help me sort out how to make sure everything I need is covered. I've never done this before, and I am chronically ill and need consistent care, but the process is confusing.
So, I’m in my early 40s and am now making too much for Medicaid or a state-subsidized Essential Plan (NY) and will be buying my own health insurance on the state exchange. I am trying to find a good plan that will cover my major needs (neurology/multiple sclerosis care, and mental health). I’ve been poor most of my life, and spent a lot of it either on Medicaid or uninsured. Afterwards, I’ve had a mix of state Essential Plan coverage and from 2020- Medicaid again with HMO. I’m now working and making enough to buy a plan. Just me, living alone, working for a foreign-owned company as a salaried independent contractor.
Deductibles- I am trying to cover all of most of this with the annual MRIs I need to monitor my MS. So I’m not sure how it will work. If the MRI costs more than my deductible, how much do I actually pay? The deductible limit and the co-pay or do I pay the full amount?
Is it worth it to go for a lower deductible and higher co-pay costs or would saving money on co-pays make more sense? I think the mid-level deductible and slightly higher co-pays makes sense, but I have a few variables up in the air right now.
Right now, I have two psychotherapy sessions a week. I have depression, anxiety, and PTSD and we’re sorting through decades of difficult stuff, including some more recent abuse. I’ve been working with my therapist for 5 years. This is incredibly important to me to keep up. I also have periodic appointments with a doctor or psych NP for med reviews and new prescriptions.
I have blood work several times a year, and quarterly neurology visits, in addition to two Ocrevus (treatment) infusions. I have been with BCBS under state plans and Medicaid before and my hospital takes them, but the plan I was looking at doesn’t seem to cover the mental health clinic (I will call them for more info, as they do offer sliding scale and are nonprofit). It also would make me switch my PCP.
But, given my history with BCBS, it might be easier to secure prior authorization for my medication, since I know some won’t cover it specifically on their formularies since it’s still a specialty biologic. My neurologist had to request an exception to cover a few years ago and got it. BCBS has handled those smoothly for several years. So I’m leaning towards a BCBS silver plan but only if I can figure out something for my mental health.
(But this leaves therapy, which I need to find out more info about. I don’t want to find a new PCP, as mine is great, but that I’d be okay with if everything else worked. ) I also need dermatology, GYN services, monitoring mammogram, but those are secondary and tertiary concerns. Radiology and neurology are the same hospital network.
For priority, I start with what will cover neurology/MS care first, then mental health, then everything else. I keep looking through the plan documents and provider networks online but some are different between plans, and some cover part of what I need and not all. Sometimes one company's plan will cover but another plan from the same company won't. It's hard.
Please tell me if there’s anything else I should know, as I don’t know what I might be missing, or what I need to beware of, since this is my first time and healthcare is so important to me, considering my various illnesses.
So, I’m in my early 40s and am now making too much for Medicaid or a state-subsidized Essential Plan (NY) and will be buying my own health insurance on the state exchange. I am trying to find a good plan that will cover my major needs (neurology/multiple sclerosis care, and mental health). I’ve been poor most of my life, and spent a lot of it either on Medicaid or uninsured. Afterwards, I’ve had a mix of state Essential Plan coverage and from 2020- Medicaid again with HMO. I’m now working and making enough to buy a plan. Just me, living alone, working for a foreign-owned company as a salaried independent contractor.
Deductibles- I am trying to cover all of most of this with the annual MRIs I need to monitor my MS. So I’m not sure how it will work. If the MRI costs more than my deductible, how much do I actually pay? The deductible limit and the co-pay or do I pay the full amount?
Is it worth it to go for a lower deductible and higher co-pay costs or would saving money on co-pays make more sense? I think the mid-level deductible and slightly higher co-pays makes sense, but I have a few variables up in the air right now.
Right now, I have two psychotherapy sessions a week. I have depression, anxiety, and PTSD and we’re sorting through decades of difficult stuff, including some more recent abuse. I’ve been working with my therapist for 5 years. This is incredibly important to me to keep up. I also have periodic appointments with a doctor or psych NP for med reviews and new prescriptions.
I have blood work several times a year, and quarterly neurology visits, in addition to two Ocrevus (treatment) infusions. I have been with BCBS under state plans and Medicaid before and my hospital takes them, but the plan I was looking at doesn’t seem to cover the mental health clinic (I will call them for more info, as they do offer sliding scale and are nonprofit). It also would make me switch my PCP.
But, given my history with BCBS, it might be easier to secure prior authorization for my medication, since I know some won’t cover it specifically on their formularies since it’s still a specialty biologic. My neurologist had to request an exception to cover a few years ago and got it. BCBS has handled those smoothly for several years. So I’m leaning towards a BCBS silver plan but only if I can figure out something for my mental health.
(But this leaves therapy, which I need to find out more info about. I don’t want to find a new PCP, as mine is great, but that I’d be okay with if everything else worked. ) I also need dermatology, GYN services, monitoring mammogram, but those are secondary and tertiary concerns. Radiology and neurology are the same hospital network.
For priority, I start with what will cover neurology/MS care first, then mental health, then everything else. I keep looking through the plan documents and provider networks online but some are different between plans, and some cover part of what I need and not all. Sometimes one company's plan will cover but another plan from the same company won't. It's hard.
Please tell me if there’s anything else I should know, as I don’t know what I might be missing, or what I need to beware of, since this is my first time and healthcare is so important to me, considering my various illnesses.
If there is a specific _provider_ (maybe your therapist) whom you really, really don't want to replace, find out which plans and insurers they work with, and choose one of those.
If this provider will recommend an insurer that is better than average, that will help too.
Don't focus only on costs - start with the non-numeric factors.
posted by amtho at 1:17 PM on January 8 [4 favorites]
If this provider will recommend an insurer that is better than average, that will help too.
Don't focus only on costs - start with the non-numeric factors.
posted by amtho at 1:17 PM on January 8 [4 favorites]
I'll second that you should ask the existing providers you wish to keep about specific product lines you are considering to confirm that it's in their network.
posted by ThePinkSuperhero at 1:21 PM on January 8 [3 favorites]
posted by ThePinkSuperhero at 1:21 PM on January 8 [3 favorites]
I wish you luck!! Health insurance in the US is so messed up but we all know that. Each plan can be different so this BCBS plan is definitely going to be different, in some good but mostly bad ways.
My employer has a few options, all of which suck in various ways but are better than nothing. When we switched a few years ago -- got rid of BCBS -- I compared to see which one would cover the most doctors I was currently seeing. For me, the most important were my psychiatrist and OBGYN even though I only see the former once a month and the latter once a year (unless something is wrong, which they are amazing about fwiw and is why I have stuck to them!) My co-pays went from $25 to $40 and now I have to also pay like $330 at the beginning of the year (I have a version of Cigna, yuck.) They told us "oh, you will save $25/month on your premium" but ofc we had to pay more than that for other things. My therapist isn't covered so I rarely see her anymore; fortunately I'm doing quite well and only see her a few times a year. Even with my coverage that most Americans would consider to be pretty good, an ER visit last year was almost $800 out-of-pocket.
I don't want to say this to be scary or negative but rather realistic. You can look up providers online as you are already; you call each insurance company and walk through options with their representatives. I hope you can find something that works OK or even well for you!!
posted by smorgasbord at 1:29 PM on January 8
My employer has a few options, all of which suck in various ways but are better than nothing. When we switched a few years ago -- got rid of BCBS -- I compared to see which one would cover the most doctors I was currently seeing. For me, the most important were my psychiatrist and OBGYN even though I only see the former once a month and the latter once a year (unless something is wrong, which they are amazing about fwiw and is why I have stuck to them!) My co-pays went from $25 to $40 and now I have to also pay like $330 at the beginning of the year (I have a version of Cigna, yuck.) They told us "oh, you will save $25/month on your premium" but ofc we had to pay more than that for other things. My therapist isn't covered so I rarely see her anymore; fortunately I'm doing quite well and only see her a few times a year. Even with my coverage that most Americans would consider to be pretty good, an ER visit last year was almost $800 out-of-pocket.
I don't want to say this to be scary or negative but rather realistic. You can look up providers online as you are already; you call each insurance company and walk through options with their representatives. I hope you can find something that works OK or even well for you!!
posted by smorgasbord at 1:29 PM on January 8
Healthcare navigators exist for exactly this purpose and are free. Here is information on New York's healthcare navigator program. My husband and I have used NY navigators twice. You don't need to be disadvantaged, or meet any other criteria to use the service. They can explain what each plan covers, help you enroll, answer all the questions about taxes, subsidies, etc
The advice about checking with your doctors about coverage is solid. By the time you've triangulated which doctors take what insurance... you'll probably have narrowed your choices down to just a couple of plans.
posted by kimdog at 1:31 PM on January 8 [10 favorites]
The advice about checking with your doctors about coverage is solid. By the time you've triangulated which doctors take what insurance... you'll probably have narrowed your choices down to just a couple of plans.
posted by kimdog at 1:31 PM on January 8 [10 favorites]
Is it worth it to go for a lower deductible and higher co-pay costs or would saving money on co-pays make more sense? I think the mid-level deductible and slightly higher co-pays makes sense, but I have a few variables up in the air right now.
Don't worry too much about deductibles and copays. Given that you have high-cost medical needs, the most important number for you to look at is the maximum annual out of pocket expense. This is the maximum amount you will pay on top of your premiums.
You can pretty safely assume that your medical costs for the year are going to be the cost of your premiums PLUS that out-of-pocket max, exactly. You might spend most of the out-of-pocket max in copays or you might spend the out-of-pocket max on deductible expenses, but either way, you're going to spend the out-of-pocket max. Once you're over your out-of-pocket max, when your provider asks you to pay, you say, "Oh, I'm over my out-of-pocket max, please just bill the insurance."
posted by mskyle at 1:50 PM on January 8 [10 favorites]
Don't worry too much about deductibles and copays. Given that you have high-cost medical needs, the most important number for you to look at is the maximum annual out of pocket expense. This is the maximum amount you will pay on top of your premiums.
You can pretty safely assume that your medical costs for the year are going to be the cost of your premiums PLUS that out-of-pocket max, exactly. You might spend most of the out-of-pocket max in copays or you might spend the out-of-pocket max on deductible expenses, but either way, you're going to spend the out-of-pocket max. Once you're over your out-of-pocket max, when your provider asks you to pay, you say, "Oh, I'm over my out-of-pocket max, please just bill the insurance."
posted by mskyle at 1:50 PM on January 8 [10 favorites]
When you have known big expenses like MRIs, the "out of pocket max" becomes hugely relevant. It can very much be worth it to pay a high premium for a low OOPM, because after you hit it, everything that's covered is literally free. This is especially likely to be the case for you if you qualify for the tax credits. I'm in that situation and generally choose "silver" plans that have a deductible equal to the OOPM, which means I pay everything up to the deductible and then don't have any additional healthcare costs for the rest of the year as long as I keep up on the premiums. That means my total annual cost follows the very predictable equation premium*12+OOPM, and I feel gloriously free to pursue any care that seems appropriate without worrying about costs. With the level of healthcare use you're describing, I'd definitely recommend it if you can afford it.
posted by teremala at 1:50 PM on January 8 [3 favorites]
posted by teremala at 1:50 PM on January 8 [3 favorites]
Strongly seconding "Contact a navigator. That's what they're for." The navigators in your state know the marketplace plans and will be able to give you better answers than anyone's theoretical answers here.
posted by hydropsyche at 2:48 PM on January 8
posted by hydropsyche at 2:48 PM on January 8
I have been summoned.
Everyone here has given really excellent advice, most important of which is to yes please call your state's navigator.
One thing that hasn't been mentioned here yet is coinsurance. This is the magic missing piece between the deductable and "then what?" So in your MRI example, if your MRI costs more than your deductible, you pay your deductible, then you also pay your coinsurance until you reach your out of pocket match.
So if you're someone who is using a lot of healthcare, your most important numbers are premium+out of pocket max. And crucially, you need to make sure that ALL of your providers are in network. Out of network coverage will often have a much higher deductible and much higher (financially ruinous) out of pocket max.
posted by phunniemee at 3:01 PM on January 8 [5 favorites]
Everyone here has given really excellent advice, most important of which is to yes please call your state's navigator.
One thing that hasn't been mentioned here yet is coinsurance. This is the magic missing piece between the deductable and "then what?" So in your MRI example, if your MRI costs more than your deductible, you pay your deductible, then you also pay your coinsurance until you reach your out of pocket match.
So if you're someone who is using a lot of healthcare, your most important numbers are premium+out of pocket max. And crucially, you need to make sure that ALL of your providers are in network. Out of network coverage will often have a much higher deductible and much higher (financially ruinous) out of pocket max.
posted by phunniemee at 3:01 PM on January 8 [5 favorites]
You almost certainly qualify for and should absolutely apply for Ocrevus' copay assistance program -- where the drug manufacturer will cover the cost of your drugs and infusions, up to the out-of-pocket maximum for your insurance plan. Ocrevus is expensive enough that you will likely meet that maximum amount. Check the plans for that figure and choose one that has a lower out-of-pocket maximum -- Once you meet it, then you don't need to pay anything for covered drugs or in-network medical visits.
As a result, the most important thing is to make sure that your neurologist, infusion center and other health care providers are in-network. You may want to schedule your annual infusion early in the year, if possible, so that your out-of-pocket maximum is met and you won't need to worry for the rest of the year.
Luckily, it looks like New York is one of the 19 states that banned a practice known as a "copay accumulator" where the insurance company might not count the co-pay assistance program's payments towards your deductible/out-of-pocket maximum. Just mentioning as something to check if you ever move.
posted by Theiform at 4:52 PM on January 8 [1 favorite]
As a result, the most important thing is to make sure that your neurologist, infusion center and other health care providers are in-network. You may want to schedule your annual infusion early in the year, if possible, so that your out-of-pocket maximum is met and you won't need to worry for the rest of the year.
Luckily, it looks like New York is one of the 19 states that banned a practice known as a "copay accumulator" where the insurance company might not count the co-pay assistance program's payments towards your deductible/out-of-pocket maximum. Just mentioning as something to check if you ever move.
posted by Theiform at 4:52 PM on January 8 [1 favorite]
Also, in NY you have until the end of the month to apply for a Marketplace plan; otherwise, you'll need to qualify for a "special enrollment period" based on some life circumstance. Better to apply for coverage this month if possible.
posted by Theiform at 5:01 PM on January 8 [1 favorite]
posted by Theiform at 5:01 PM on January 8 [1 favorite]
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