Health Insurance Options, Advice and Opinion

This post comes from personal and professional experience. There is a large lack of knowledge about health care/insurance, how to get it, and the differences, etc.

I've been semi-active in this sub and it’s honestly frustrating to see that most of the time, the only advice people have for others is that they should look at healthcare .gov. Although it can be a good option for low-income and people who need the subsidy to cover their medical costs, it can cause more issues than it solves and can be expensive for those who make too much to qualify for a subsidy. Another one I see is that they should do their COBRA plan after losing or leaving a job, which costs so much it can put people into debt or leave them unable to afford coverage.

So I'd like to put my 2 cents, advice, and expertise out there, hoping that people can use it to go about finding coverage in a better way. This is a long post, but I hope it helps at least a few people. I have bolded topics to make it easier to skip to a part you care more about reading than others as well.

Terms/Abbreviations –
Network: Doctors, health care providers, and hospitals that a plan contracts with to provide medical care to its members. In-Network gives you better savings and coverage costs(or lack thereof) than Out-of-Network
Coverage: Health care services that are paid for in full or in part by insurance, allows the patient to pay a reduced price (lower out-of-pocket expenses/deductible)
Deductible: The cost you pay on health care before the health plan starts covering expenses, whether fully or through co-insurance.
Out of Pocket Max: The amount spent on eligible healthcare expenses through copays, coinsurance, or deductibles before the health insurance company covers all expenses.
Co-pay: A fixed amount paid by you toward the cost of medical expenses, usually in advance of an appointment/treatment. The fixed amount is different per doctor type (PCP vs Specialist), procedure, in/out of network. Low premiums are more likely to have higher copays.
Co-Insurance: An individual's share of costs for services, expressed as a percentage. If you have an 80/20 coinsurance policy, it means that, when you have a medical bill, you are responsible for paying 20% of it.
Premium: The amount you pay every month to have coverage for a company’s health insurance plan.
Group Plan: Offered by an employer or employee organization. Provides health coverage to employees and their families. Can be direct or through insurance, reimbursement, or other means(payroll deduction) of payment towards your plan.
Having just yourself on one of these plans is typically cheap and the best option, but sometimes, adding a spouse and dependents is expensive and not all employers pay for those on the coverage that don’t actually work for them. If this is the case, a long-term private plan is the best option for the spouse and dependents, or an ACA plan if affordability is a large concern and a subsidy is needed to pay for coverage.

PCP(Primary Care Physician)
PPO(Preferred Provider Organization)
HMO(Health Maintenance Organization)
EPO(Exclusive Provider Organization)
POS(Point of Service)
HDHP(High Deductible Health Plan)
HSA(Health Savings Account)
OOP(Out of Pocket)
ACA(Affordable Care Act)
OEP(Open Enrollment Period)
SQE(Special Qualifying Event)
COBRA(Consolidated Omnibus Budget Reconciliation Act)

Private vs ACA Marketplace vs Group Plans – The different places you get coverage from can vary depending on what you qualify for (income, medically, job).
1-A. ACA marketplace plans are based on income which is why subsidies can be given when you don’t make enough to equal the percentage requirements the government has that should be spent on health coverage. A majority of ACA plans are HMO, some EPO and POS, and a few are PPO.
1-B. Private plans are typically medically underwritten (you have to qualify by having good health, not having an illness that the company deems as too big of a liability, etc). More Private plans are PPO than ACA plans, but there are HMO private plans, make sure you know what's what and which one the plan you're looking into is.
1-C. Group Plans or "Employer Coverage" are coverage that you can opt into (or may have to have) when working for someone/a company. Many times employers will pay towards the whole amount or part of your monthly premium. These can also be PPO, HMO, etc, depending on what your employer has chosen for their employees. If you do not like/want to have their provided plan, you can get a plan from somewhere else, if it is cheaper or same price, some employers will pay towards it in a percentage or fixed amount, so be sure to ask if you find something else you want to have. Group plans through an employer tend to be the cheapest when it is an option, but not always the best network or coverage.

PPO vs HMO (and Others). This is a big topic that matters and I've found many people don't know the difference.
2-A. PPO – Doctors, hospitals, and providers who agree to provide care at a certain rate (think of it as getting a bigger discount by going to someone in network). Doesn't limit you to only seeing in-network providers. Copay or OOP costs for out-of-network visits may be higher (you don't get as big a discount). Gives increased flexibility, no need to maintain a PCP, can see doctors/specialists as you choose, you can receive care wherever you are traveling. Lab work providers are also more readily available and you can choose the convenient option while still being covered
2-B. HMO – Doctors, hospitals, and providers who agree to provide care at a reduced rate. May require you to have a primary care physician, who refers you to specialists when needed. Most HMOs will not cover specialist visits unless you are referred by a PCP. It only pays for care from providers in network, except for emergency care. Lab work is also limited to a provider in network and is usually only 1 provider. If you go out of network without a referral, they won't cover it at all, even if they would per a referral to that doctor.
2-C. POS – Similar to HMO. May require you to get a referral from your PCP to see a specialist. Higher premiums than an HMO, does cover out-of-network doctors (but you’ll pay more), helpful if you have a previous condition to manage and one or more of your doctors are not in network.
2-D. EPO – Typically lesser known. Like HMOs, EPOs cover only in-network care, but the networks are larger. It may or may not require referrals from a PCP for specialists. Premiums are higher than HMOs, but lower than PPOs.
2-E. HDHP – Low premiums but higher OOP costs. Often paired with an HSA to help cover some or all of the deductible. Pre-tax dollars can be deposited into an HSA to cover medical expenses, which can save money (only able to use money in HSA for medical costs though). Depending on age, may cover services like mammograms, colonoscopies, annual well visits, and vaccines at no extra charge, even if you haven’t met your deductible. A HDHP can be an HMO, POS, PPO or EPO. It can save people money in the long run who are managing a health condition but on a tight budget.

Healthcare .gov can be useful. HOWEVER. A lot of times when you fill out an application it sends your info out to just about every company that can sell a health policy in your area. The calls and texts can be excessive and make it almost impossible to just use your phone normally or keep your ringer on, considering the amount of calls and texts can be 20-50 a day. Also if you make too much for a subsidy, you can end up paying way too much for coverage that is an HMO and sucks.
3-A. My advice to bypass this is to contact a local agent/broker who can look at all of your options for you and tell you the best one. This avoids the excessive calls and texts and actually lets you speak to someone 1-on-1 who likely cares about you more than the normal ACA marketplace callers.
3-B. If you do get calls and texts, the more reputable of those use their picture, business card, and business name in texts. You can look it up and even ask for their agent license number and look that up and see if they are who they say they are and that they in fact are licensed to help you and sell policies. And you can ask about their social media/facebook etc. If they are real they probably won't have a problem giving you those details. These are the people to talk to, not the ones that put a vague link in their text or don't answer your questions and just want you to answer theirs. You can also try to have a normal conversation with them and see how they respond. This weeds out bots.
3-C. The private companies and the big call centers/scammers (unfortunately) get sent people's contact info the same way sometimes, so if you were scammed and get to the point of talking to them on the phone, they usually have sympathy for that situation and have no problem taking you off their call list and not contacting you again. They may have a text that is automated to send out to a new lead (possible client), but this is why asking them the questions above and vetting the text/caller can be important. NO ONE should ask for your SSN in the first 5 minutes of a call either, big red flag there.

Long-term PPO Plans and Private Plans that cover just as much, if not more than marketplace plans do exist. It is not just private short-term plans that exist. But they do not go through healthcare .gov, so you won't see them when looking there. That is another reason to speak to someone local and ask them what type of plans they have/sell. If someone tells you private plans are just short term, they are wrong and just don't want you to go talk to someone else or are not educated in the different types of coverage out there.
4-A. Private long-term plans that cover major medical situations and don't kick you off after experiencing one also do exist. This is why learning about a plan before you buy it matters. Private plans can also allow you to get coverage outside of open enrollment and special qualifying events because they don't have to follow the ACA OEP and SQE guidelines.
4-B. A lot of these are medically underwritten and not based on your income. Because of this, you may not end up qualifying, but the agent who you talk to should be able to tell you yes or no. So if they are asking about your previous medical history, that is why and they are actually trying to not waste your time by going through everything just to find out at the end that you don't qualify for their coverage. This also means that they can be cheaper than an ACA plan, especially if you make too much to qualify for a subsidy.
4-C. Because private plans don’t go through the ACA, subsidies through the government that pay for part of the ACA plan premiums can’t be used to pay for private plan premiums, so if you had a subsidy for coverage, it will no longer apply. The same goes for HDHP paired with an HSA. Most Private plans do not allow use of an HSA, they will let you use what’s left in it to pay towards care, but you can no longer contribute money to that HSA for the pre-tax benefits.
You can however use it as a tax write off as long as you are the one paying for it – if an employer pays for all or part of it you can not write off the portion they pay for.

COBRA is temporary health coverage after a job loss or a SQE that may be available to get to continue having the same coverage previously had through your employer. It is not the best option after a job loss for many though because it is expensive, and is a hassle to do and keep up with. It also doesn't cover supplemental coverage, such as disability, life insurance, hospital care insurance, or other types of voluntary coverage. Those who opt into COBRA may be required to pay the entire premium for coverage and up to 102% of the cost to the plan. (Usually the whole premium amount plus an additional 2% for “administration fees”). So employer coverage that costs $800 a month that the employer may have paid for, and the employee wasn’t having to spend that money, ends up having to pay ~$816 a month for coverage without an income to support them. It leaves many with debt, or no medical coverage because they can’t continue to pay for it without an income.
5-A. Some better options than COBRA can be a private plan, ACA marketplace plan or supplemental plan until a new job is found or better coverage options.
5-B. Keep in mind you only have 60 days from a SQE to get ACA coverage, and your projected income is used to determine what you get a subsidy for (which may be $0 as of job loss, but wasn’t from the last paychecks they see, which can cause issues). This can end up being just as expensive or more than COBRA if you don’t qualify for a subsidy.
Private insurance currently gives coverage to over half the US population, This is why…
5-C. A private short-term plan allows you to (more often than not) get the same benefits or more than previous employer coverage for a lower price than COBRA (depending on if you qualify, typically based on your health not income). Coverage for preventive care, doctor visits, urgent care, and emergency care. May also cover prescriptions Good option for being in between jobs, but can be as short as 1 month before you have to find something else. As of right now (June 2024) can last up to 3 years per federal guidelines, but after September 1st 2024, those rules will limit short-term plans to a maximum of four months, including renewals. Some states also already have regulations on length, so be sure to check your state's information.
5-D. A private long-term plan allows you to (more often than not) get the same benefits or more than previous coverage. Plans can vary significantly in terms of coverage. From just covering medical illnesses and preventive care. To covering that plus accidents, hospital services, stays, surgeries, treatment in a hospital, prescriptions, dental, and vision. They can be PPO or HMO, but choosing a PPO option over HMO is better to do because it actually makes having the same plan for a while or forever (until 65 and eligible for Medicare, when most of these stop) a reality and an HMO may only work for your state, which in my opinion makes it not a great long-term plan, because if you move, it can’t go with you. There are long-term plans that once you qualify, won’t/can’t kick you off for any illness or disease that is new (if it was a previous condition and they find out, they can kick you off). The only way you’d lose coverage is if you stop paying. Based on your medical history and age, it can be significantly cheaper than other options, especially when you can have it until 65.
The younger and healthier you are the cheaper it is.

That’s about it for what I have right now. If you have any questions I will respond to comments as soon as I see them.

submitted by /u/LHoneysuckle
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