Health insurance confusion
 

Hello,

I just found out about this forum, and wish I had joined before.

I’m really confused about health insurance options and would appreciate any information, clarifications, advice, etc. To cut a long story short, currently, my wife and I are receiving healthcare coverage via New Jersey Family Care (Medicaid, as far as I understand it?). Dreadful! I know people complain about NHS waiting times etc., but I’ve never had any problems with the NHS. However, I’m sick of spending four hours in a PCP waiting room in NJ, regarding some of my wife’s health concerns, to be referred to another place for tests, and having to then return to the PCP for the results, and losing another four hours in their waiting room, to repeat the whole process again a couple of months later. And feeling like we’re getting nowhere, as if everyone in the system is just leeching money from the state of New Jersey but not actually providing healthcare. I feel like my wife’s issues are being totally neglected. Fortunately, our financial circumstances are improving, except the uncertainty of covid-19 and the economy etc. I’m going to be eligible for health insurance through work in a couple of months, but unfortunately while for one individual the rates are very good, the “family” (+spouse) coverage costs are about one quarter of my monthly income. I’ve been advised to enrol my wife via the Affordable Care Act (ACA / Obamacare). It’s all so complicated. Two systems, two insurances, probably PCPs and dentists etc. in two places, two bills, two sets of paperwork. I know Obamacare is under threat, but assuming for a moment that it will still be here in 2021, how does it work? A few specific questions:

1. As far as I understand it, there is a deadline for annual enrolment. Is that correct? So we can’t just enrol at any time, like now, we have to wait until the enrolment period? (Maybe I misunderstood, but if I understand correctly, so much for the “marketplace” that is mostly closed!)
2. How much can we expect to pay Obamacare for one person? Or what percentage of our household salary should we expect to pay?
3. Is it correct that they take taxes into consideration – e.g. last year’s tax return? (Even though for many people, their income level in one year might be totally unrepresentative of their financial situation in the subsequent year!)
4. If I’m correct in understanding that you sign up to a health insurance company via the “marketplace” for one year, what happens if one’s work / financial situation drastically changes within the year (hours are reduced, or you get laid off) and you can’t afford to pay the monthly costs?
5. It seems one can get lost in days of enquiries, trying to choose the right insurance company, and checking with local PCPs etc. Please can anyone recommend how to navigate this hellish system efficiently and effectively?
6. Is IVF possible via health insurance under Obamacare? Would both of us need the same health insurance?

Sorry for so many questions. Anyway information or advice would be greatly appreciated.

Thank you!

Re: Health insurance confusion
 

I would suggest googling for an insurance broker local to you who specializes in health insurance. As you say, the options are indeed complicated and working with a professional (at no cost to you) is the best way to find the right plan and to have the workings of the system explained.

Re: Health insurance confusion
 

I would suggest investigating QHDP (Qualified High Deductible Plan) and PPO (Preferred Provider Organization) style plans versus an HMO (Health Management Organization) plan. See https://www.medmutual.com/For-Indivi...Insurance.aspx for more information on the differences. The former are usually more expensive but you can typically self-refer to specialists without any PCP having to get involved. This prevents the frustrating back and forth referral loop you are stuck in. This isn't often true for HMO plans, sadly, where every interaction with a specialist is usually via a PCP.

Two other options are EPO plans, where you can sometimes self-refer but are locked in a single network like HMO, and health share schemes. Some health share schemes seem to operate like a PPO plan where you can go straight to a specialist without having to go via a PCP.

Some of my friends have had a lot of success with getting healthcare coverage via a health share scheme like Liberty Healthshare: https://libertyhealthshare.org. When I last checked, the premiums for a single person were very reasonable ($150 /month) with a low deductible ($500 /year). I'm not sure about their coverage for preexisting conditions though... but perhaps your wife doesn't have a preexisting condition as you can't currently get it diagnosed. Also, I don't know if any cover IVF. You could do some research on the health share websites and make some calls to find that out.

Re: Health insurance confusion
 

Whereas I've always had excellent healthcare in the US, the access to it - as you've discovered - is pretty much a total mess. So many disparate systems with differing rules etc that it's very difficult not to trip up when you need to transition between them.

Very briefly, the ACA aka "Obamacare" provides subsidies based on income. You receive a subsidy of varying levels if your family modified adjusted gross income is less than four times the federal poverty level. Beyond that there is a cliff and no subsidy at all. When you apply, you are effectively making an estimate of what your yearly income will be and the subsidy will be provided based on that estimate. But, as you point out, your income (say for 2020) may be more or less than the estimate. This is reconciled when you file your taxes (by April 2021, for 2020). If your income ended up less than the estimate, you are "owed" more subsidy; if your income is more, you "owe". So if you owe, you have to pay more taxes when you file for 2020 to reconcile the difference. Be very careful if your estimated income is close to the subsidy cliff..

Also, if you live in a state that extended Medicaid (for people of low income) you would qualify if your income is less than 133% of the federal poverty level. I presume New Jersey did extend.

I am in the middle of this mess right now. I will be moving to Medicare (over 65) and my wife will need an ACA policy. Of course, there are completely different rules: the ACA reconciles using current year income; Medicare part B does no reconciliation and simply uses the last tax return filed to determine that premium. Go figure...

Re: Health insurance confusion
 

On your question 1, you normally can only sign up during open enrollment in Nov/Dec unless you have a qualifying event (loss of employer-provided insurance etc). However, some states have opened a special enrollment period now due to covid-19. You'd have to check whether New Jersey did.

https://www.healthcare.gov/glossary/...ng-life-event/

Re: Health insurance confusion
 

In my experience, the mistake that a lot of people arriving from the UK make, is to try to replicate the "all you can eat buffet" model of health care that the NHS provides. This is expensive, and for most people, wholly unnecessary. I compare "traditional" US health insurance to being like paying for car insurance that covered new wipers, oil changes, tyres, etc. .... it would be hellishly expensive!

Therefore my recommendation would be to look carefully at "high deductible" insurance, which, to continue the car insurance analogy, means that you pay for "minor repairs and maintenance out of pocket, but if you have a major medical incident, you're still covered after you have paid the deductible, which for HD insurance is typically around $3k/person/year. Note: All insurance, whether ACA or through your employment, is required to cover an annual check-up, health screenings (mammogram, colonoscopy, etc.), and vaccinations.

Another thing to look out for when comparing traditional health insurance with high deductible insurance, is that the deductible on traditional insurance might be as much as $1,000/person/yr (it was for us), so if you only make two visits to your GP during the year, and get billed, say, $250 for each, plus $10 each for antibiotics, then you will have to pay all of that either way, whether you have high deductible insurance or traditional insurance, so looking back you would have paid the substantially high premiums for traditional insurance and got zero benefit for paying the higher premims unover lower HD insurance premiums. It was this realization that caused us to switch to HD insurance.

If you sign up for high deductible insurance you are allowed to open a "Heath Saving Account", which you can fund with upto about $6,800/yr/couple (or /family) of tax free money, like an ISA for out of pocket healthcare expenses. After a few months of funding your HSA with payroll deductions, you will have enough money to pay any likely "deductible" (excess) if you need to claim on your insurance.

FWIW my wife and I have insurance through our jobs, but the aggregate cost for us, including our daughter, is about $200/mth, plus about $430/mth that goes into our HSAs, and another $800 each per year, is chipped-in through our employment benefits package, to max out our contributions. We don't need to use our HSA funds much and now have accumulated balances far into five figures, that should leave us in a good place with respect to meeting health expenses all the way upto when we retire, and beyond. :thumbsup:

Re: Health insurance confusion
 

Go onto the New Jersey sit for Affordable Care Act, input info and you'll be able to find out costs and plan details

Alternatively, if NJ does not have its own ACA site then do onto https://www.healthcare.gov/ input your info and again, you'll get details of what plans are available for you.

Based on what you have said - that you have been on a Medicaid type of plan - then you will probably qualify for subsidies based on your income for an ACA plan.

To answer your questions specifically:

4. If you cannot pay the premiums for any plan you sign up for you will, eventually, be kicked off.
6. IVF is a complex subject and some states have laws regulating that insurance policies cover OR offer the treatment. (offering usually means you pay more premiums to obtain the treatment. Some states do not cover it)......... it is very expensive and therefore you would need to investigate whether whatever plan you end up with covers or offers it; together with maternity cover also.

Re: Health insurance confusion
 

I think it may typically be more than this. In my area (CA) it's over $6k.

Re: Health insurance confusion
 

Here are the applicable limits:

https://www.healthcare.gov/glossary/...e-health-plan/

Re: Health insurance confusion
 

Hmm, maybe. Our family policy deductible is around $8k, but the individual IIRC is $3k, which doesn't help us much (never has done to date), but would be more relevant the larger your family is. .... But either way, if the deductible on traditional insurance is $1k, and you only incur costs of less than $1k, then with traditional insurance you would have paid for something that you got zero benefit from.

Re: Health insurance confusion
 

Your health insurance is not going to pay for IVF in most situations.

Some excellent responses above from Pulaski on the 'buffet' issue. You should not try to get care the way that you get it from the NHS back home, it doesn't work that way here.

Frankly what you describe about having to wait or go elsewhere for tests seems fairly typical for the US to me.

Full disclosure - I am a healthcare finance professional.

Re: Health insurance confusion
 

Full disclosure - I am a healthcare finance professional.[/QUOTE]

Hi Civilservant,

what would you recommend for a family of 6, all healthy, well l have type 1 diabetes...

High deductible or normal plan..??

this has always been a big concern about our move..

thanks

Re: Health insurance confusion
 

Your question is almost impossible to answer on an internet forum, as it's highly market and situation dependent.

I agree you should obtain the services of a health insurance broker who will be aware of all the options in your area.

Re: Health insurance confusion
 

No problem, thanks for responding

Re: Health insurance confusion
 

Great thread thanks.

Could you ellaborate on Health Insuracne Broker?
Above someone stated this service is free. Does the broker get paid by insurance company? Is the broker likely incentivised by certain companies/policies? Would the broker inform on ACA?

thx