Health Insurance Question

[Mosaud1998]

I recently lost health insurance (well got kicked off my dad's health insurance plan) and have been looking around for health insurance. I just started a new job and can't enroll in the employer's health insurance until I have been employed with the company for 3 months. I had an organ transplant a couple of years back so not having health insurance is kind of a big issue since I've got about 6 different medications I take and have to get my blood drawn every month.

Out-of-pocket cost for just those two things is out of wack. Anyway, I went on Health.gov to see if I could get enrolled in a health insurance plan there. I picked out a plan from Blue Cross Blue Shield of IL. The total premium was $335/month. The deductible was $2000~ if I am not mistaken.

Anyway to get to the point, I had a question regarding the copay for medications so I called Blue Cross. The rep handed me over to a "sales rep". The sales rep somehow got my premium down to $22/month, $0 deductible, and no out-of-pocket expense for medications, lab work, etc. I'm like, "how tf did he do that?" He said I qualify for a "Premium Tax Credit". Not sure how that works. But, it seems too good to be true. I don't want to move forward with paying the premium and then get bent over backwards by the state.

[BMWCCA1]

I thought transplant recipients qualified for Medicare?
Maybe they jammed you into some sort of Part C coverage through Medicare?

[Mosaud1998]

Originally Posted by BMWCCA1

I thought transplant recipients qualified for Medicare?
Maybe they jammed you into some sort of Part C coverage through Medicare?

Apparently, I made too much last year to qualify for Medicare. Funny, I made 10k less in 2023 than in 2022. In 2022, I got medicade. But, I think that's because IL extended the insurance plan.

[chassis]

PTC (subsidy) is income based.

If you have less than $68k or so in income you qualify for a PTC subsidy. $68k = 4x the Federal poverty limit for a household of one person.

Is your income less than $68k?

[dreamingat30fps]

Originally Posted by Mosaud1998

Apparently, I made too much last year to qualify for Medicare. Funny, I made 10k less in 2023 than 2022. In 2022, I got medicare. But, I think that's because IL extended the insurance plan.

You can get a discount on the cost through the market place. If your income was $0 you actually wouldn't qualify for the discount and they would tell you to apply for medicare or medicaid. So I believe there is a minimum AND maximum incomes for the discount.

So my guess is based on your income you qualified for a discount. However I'm not sure how that would remove the deductible. Unless the discount was big enough that he moved you to a $0 deductible plan.

[ZL9M2]

Originally Posted by chassis

PTC (subsidy) is income based.

If you have less than $68k or so in income you qualify for a PTC subsidy. $68k = 4x the Federal poverty limit for a household of one person.

Is your income less than $68k?

this is exactly it.

[Mosaud1998]

Originally Posted by chassis

PTC (subsidy) is income based.

If you have less than $68k or so in income you qualify for a PTC subsidy. $68k = 4x the Federal poverty limit for a household of one person.

Is your income less than $68k?

Yes, income last year was under $68k.

[thebmw]

Not to burst your bubble, but every single plan is different and NOBODY actually knows what is covered and not covered until it is too late (ie, when you need that service or medication). You can thank Obamacare, the biggest kickback to insurance companies in the history of humanity (multi-trillion dollar kickback). It forced us all to buy insurance but here is the scam...insurance companies are not required to actually cover or pay for services!

So yes, you literally are buying a worthless piece of paper saying your are "covered". On top of that, deductibles and copays have increased all while physician reimbursement are at all time relative lows (literally cut every year, despite inflation). The F'ing BMW dealership oil change dude charges 2x what Medicare reimburses the physician's office that is saving your life should be paid. Yes, it is that bad. BCBS pays slightly more than Medicare typically.

Point is, you will be disappointed if you actually need healthcare because BCBS (which is still better than United) will likely find some way to deny all or partial coverage.

Welcome to the real world kid...it's glorious LOL. BTW, how the heck did someone of your age (around 30, right) almost get Medicare? Did you mean MedicAID?

[Mosaud1998]

Originally Posted by thebmw

Not to burst your bubble, but every single plan is different and NOBODY actually knows what is covered and not covered until it is too late (ie, when you need that service or medication). You can thank Obamacare, the biggest kickback to insurance companies in the history of humanity (multi-trillion dollar kickback). It forced us all to buy insurance but here is the scam...insurance companies are not required to actually cover or pay for services!

So yes, you literally are buying a worthless piece of paper saying your are "covered". On top of that, deductibles and copays have increased all while physician reimbursement are at all time relative lows (literally cut every year, despite inflation). The F'ing BMW dealership oil change dude charges 2x what Medicare reimburses the physician's office that is saving your life should be paid. Yes, it is that bad. BCBS pays slightly more than Medicare typically.



Point is, you will be disappointed if you actually need healthcare because BCBS (which is still better than United) will likely find some way to deny all or partial coverage.

Welcome to the real world kid...it's glorious LOL. BTW, how the heck did someone of your age (around 30, right) almost get Medicare? Did you mean MedicAID?

Oh wait, yeah Medicaid

I think I am just going to go ahead with that BlueCross Blue Shield plan for $22/month. I can pay my premium with a credit card. So, if anything seems fishy, I can get my money reimbursed.

[thebmw]

Originally Posted by Mosaud1998

Oh wait, yeah Medicaid

I think I am just going to go ahead with that BlueCross Blue Shield plan for $22/month. I can pay my premium with a credit card. So, if anything seems fishy, I can get my money reimbursed.

I would buy that plan because it is cheap. But don't expect it to actually do anything for you. Maybe it will be there for catastrophic claims and hopefully you'll never need that. It's extortion money and a tax, even though the Supreme Court said that it's not a tax. You have to have medical coverage by law even though that coverage doesn't cover you for anything.

[Mosaud1998]

Originally Posted by thebmw

I would buy that plan because it is cheap. But don't expect it to actually do anything for you. Maybe it will be there for catastrophic claims and hopefully you'll never need that. It's extortion money and a tax, even though the Supreme Court said that it's not a tax. You have to have medical coverage by law even though that coverage doesn't cover you for anything.

So, I'd still have to pay for medications etc?

[ZL9M2]

Call the provider and ask them. You can find out prior to any procedure if and how it is covered. Same with specific medications. But with your income you can select a more comprehensive plan - with lower deductibles - and pay no more per month in premiums.

[Mosaud1998]

If anyone is interested, I attached the plans that "HealthGuys Collaborations, Inc" gave me. I was originally going to go with the Blue Cross Blue Shield of Illinois Blue Precision Gold HMO plan ($423/month premium etc). I had a question about the deductible for medications(before I spoke to the agency, I think it was a 25% deductible for medications). Hence why I called Blue Cross. Then got sent over a "licensed agent" and homeboy "hooked" me up

[thebmw]

Originally Posted by Mosaud1998

So, I'd still have to pay for medications etc?

It's not as simple as asking a question like that. First off, yes, you will have to pay for all medications because your deductible will not be met. Second, once your deductible is met, some medications will be covered but you may still have to pay some type of copay. Some medications won't be covered, especially brand name medications. The insurance will try to direct you to the cheapest form of generic medication possible, which most of those are counterfeit as they are not manufactured the same as the brand.

In many situations, the medications may be cheaper out of pocket with a good PBM discount card then they would with insurance no matter what. This will then lead you to ask "what good is insurance". That will then lead you to the conclusion that I'm pointing out in these posts.

If you are healthy, get the cheapest plan as it's going to be useless for the most part. If you do have medical issues, then it will pay to get a much more comprehensive plan, even though you will still incur out of pocket costs.

[thebmw]

Originally Posted by ZL9M2

Call the provider and ask them. You can find out prior to any procedure if and how it is covered. Same with specific medications. But with your income you can select a more comprehensive plan - with lower deductibles - and pay no more per month in premiums.

This is not true. Providers are not the insurance company and they cannot tell you exctly what a patient's out of pocket will be. Obviously, provider offices try to be transparent but many times it backfires and patients blame the providers for lying. That is simply because when an insurance says a specific service is covered, that is not a guarantee of payment and that is listed on every approval. That is how the insurance companies are able to do a bait and switch and avoid lawsuits because it is in the fine print that approval or coverage has no connection with payments and patient responsibility.

[Mosaud1998]

Originally Posted by thebmw

It's not as simple as asking a question like that. First off, yes, you will have to pay for all medications because your deductible will not be met. Second, once your deductible is met, some medications will be covered but you may still have to pay some type of copay. Some medications won't be covered, especially brand name medications. The insurance will try to direct you to the cheapest form of generic medication possible, which most of those are counterfeit as they are not manufactured the same as the brand.

In many situations, the medications may be cheaper out of pocket with a good PBM discount card then they would with insurance no matter what. This will then lead you to ask "what good is insurance". That will then lead you to the conclusion that I'm pointing out in these posts.

If you are healthy, get the cheapest plan as it's going to be useless for the most part. If you do have medical issues, then it will pay to get a much more comprehensive plan, even though you will still incur out of pocket costs.

Man, this health insurance bs seems like such a scam smh. I can get all 6-7 of my medications from Costplus for $56 with shipping. The only thing that would realistically hurt my pockets is when I go get labs done and visit the doctor at NorthWestern. Of course, if the doctor writes me up for an EKG or somehow I have another rejection, I am screwed then.

[Maynard]

There is some seriously defective advice going on above here making it sound like insurance is a total waste of money. While it is true that there are a ton of loopholes that leave you with some things not being covered, it is not a con job (especially with a better policy from a reputable carrier). BCBS forked out the $550k for my heart surgery during the first year I was on their policy; I paid about a grand in meds and copays. The bit about 'if you are healthy...' is also bunk. Young healthies won't likely need insurance for a liver transplant, but if you get in a car accident or fall down some stairs you can easily ring up over $20k just with the trip to the hospital for that overnight in the ED or observation unit. Many car accidents will be over $100k if you need surgery, easily 20-30k just for the evals to know you don't. Nowadays you really do need some insurance for that kind of thing. And our OP has made it clear that he DOES have pre-existing medical issues that do have the potential to ring up some big bills.

[thebmw]

Originally Posted by Maynard

There is some seriously defective advice going on above here making it sound like insurance is a total waste of money. While it is true that there are a ton of loopholes that leave you with some things not being covered, it is not a con job (especially with a better policy from a reputable carrier). BCBS forked out the $550k for my heart surgery during the first year I was on their policy; I paid about a grand in meds and copays. The bit about 'if you are healthy...' is also bunk. Young healthies won't likely need insurance for a liver transplant, but if you get in a car accident or fall down some stairs you can easily ring up over $20k just with the trip to the hospital for that overnight in the ED or observation unit. Many car accidents will be over $100k if you need surgery, easily 20-30k just for the evals to know you don't. Nowadays you really do need some insurance for that kind of thing. And our OP has made it clear that he DOES have pre-existing medical issues that do have the potential to ring up some big bills.

What you're describing is a personal experience. What I am describing is how the industry works. That said, you're describing a catastrophic event, which I described previously. Catastrophic events are typically covered. However maintenance and usual conditions have a lot of issues with coverage for procedures and medications.

In addition, you are you're incorrect about car accidents. That would be the auto insurance that would cover that, not your health insurance. If the health insurance did cover it, they would subrogate those costs to the auto company and/or hold the patient responsible because insurance will ask for their money back. Usually the provider will get screwed in that situation, which is why a lot of providers want nothing to do with car accidents. Or they will go after the patient or lien the case. That's how the real world works unfortunately.

[UncleWede]

Originally Posted by thebmw

In many situations, the medications may be cheaper out of pocket with a good PBM discount card then they would with insurance no matter what.

Originally Posted by Mosaud1998

I can get all 6-7 of my medications from Costplus for $56 with shipping.

BUT, then the medications don't get applied to your deductible. Either way, pick a plan knowing you are going to pay the annual out of pocket first. Adulting simply sucks these days, especially if you hung on to age 26 with a parental coverage.

Medical benefits can be the real deal-closer for employers. . .

[spazzyfry123]

Young, healthy guy with young, healthy wife and two healthy toddlers here. Employer covers the brunt for the whole family, so I don't feel my annual cost is that bad all things considered. Includes medical, vision, dental, etc. It's a far cry from $22/mo, though.

I, too, was in the "well we're healthy, so why go nuts with it" camp. Beginning of this year, I had to unexpectedly take my wife to the ER after which she was admitted for a period of time. While still a hefty bill to cover deductibles and such, woo boy we'd be in a different spot without insurance or some lesser quality stuff.

Same with previous incidents. ACL snapped while playing sports. Torn meniscus. Spinal fusion...list goes on. Some of mine may be extreme examples, but bottom line is sh*t happens unless you live in a bubble. There's been years that I did nothing but check-ups. Others that things hit the fan no one could predict. I certainly think that things could be improved for the common guy, but I dunno why you wouldn't want it.

[Mosaud1998]

Originally Posted by spazzyfry123

Young, healthy guy with young, healthy wife and two healthy toddlers here. Employer covers the brunt for the whole family, so I don't feel my annual cost is that bad all things considered. Includes medical, vision, dental, etc. It's a far cry from $22/mo, though.

I, too, was in the "well we're healthy, so why go nuts with it" camp. Beginning of this year, I had to unexpectedly take my wife to the ER after which she was admitted for a period of time. While still a hefty bill to cover deductibles and such, woo boy we'd be in a different spot without insurance or some lesser quality stuff.

Same with previous incidents. ACL snapped while playing sports. Torn meniscus. Spinal fusion...list goes on. Some of mine may be extreme examples, but bottom line is sh*t happens unless you live in a bubble. There's been years that I did nothing but check-ups. Others that things hit the fan no one could predict. I certainly think that things could be improved for the common guy, but I dunno why you wouldn't want it.

Yeah, I mean with my health condition, anything can happen. I can get another kidney rejection and end up needing another transplant (god forbid that happens). I wouldn't be able to afford the cost of that out of pocket.

I just don't want to get finessed with that $22/month plan. In the end, it's just $22/month I guess

[dreamingat30fps]

Originally Posted by thebmw

What you're describing is a personal experience. What I am describing is how the industry works. That said, you're describing a catastrophic event, which I described previously. Catastrophic events are typically covered. However maintenance and usual conditions have a lot of issues with coverage for procedures and medications.

In addition, you are you're incorrect about car accidents. That would be the auto insurance that would cover that, not your health insurance. If the health insurance did cover it, they would subrogate those costs to the auto company and/or hold the patient responsible because insurance will ask for their money back. Usually the provider will get screwed in that situation, which is why a lot of providers want nothing to do with car accidents. Or they will go after the patient or lien the case. That's how the real world works unfortunately.

That's kind of the point of insurance... to insure in case of catastrophic events. Like I'm someone who never buys extended warranties and such because I can self insure most all of that. A week in the hospital on the other hand.

Is the system fucked up? No doubt, but it sounds to me like the OP should definitely have health insurance, especially given the fact he has an organ transplant. I don't know much about that, but my guess is the likelihood of catastrophic event rises significantly.