Last week I detailed how I'd spent eight weeks in health-care purgatory, trying in vain to gain access to healthcare.gov to shop for insurance for my family. Navigating the launch of the Affordable Care Act was a nightmare for me.
Between visits to the website and calls to the toll-free number, I invested hours of my time with no return (http://bit.ly/IDW3MA). Finally, this past week I broke the logjam. The key was using a new feature on the website that allowed me to remove my existing applications, then, using a new e-mail address, I started from scratch.
The process was not intrusive. I provided background information of the name, rank, and serial number variety. And after just 20 minutes, I was looking at 24 offerings from Independence Blue Cross and Aetna.
Not bad, especially considering that Pennsylvania did not set up its own exchange.
For starters, all plans have to offer the same basics for things like doctor visits, prescriptions, hospitalization, maternity and newborn care, and preventive care. Second, there are no longer annual limits on coverage. Third, whether the coverage also includes vision, dental, and medical management of a specific disease or condition is dependent upon your specific plan.
The plans are grouped into four categories depending on the total cost of coverage they offer (Bronze, Silver, Gold, and Platinum). For example, the Bronze plans cover 60 percent of the total cost of care, while the Platinum plans cover 90 percent.
As the website explains: "The category you choose affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or prescriptions. It also affects your total out-of-pocket costs - the total amount you'll spend for the year if you need lots of care. In general, the lower the premium, the higher the out-of-pocket costs when you need care. Premiums are usually higher for plans that pay more of the medical costs. For example, if you have a Gold plan, you'll likely pay a higher premium, but may have lower costs when you go to the doctor or use another medical service."
I need coverage for a family of five - two parents (both 51), and three sons, 13, 15, and 17. (Our daughter will soon turn 26 and leave our insurance.) Healthcare.gov offered me nine choices in the Bronze category, seven in Silver, six in Gold, and two in Platinum. Here are a few details of my most and least expensive options:
Most expensive choice: IBX Platinum (Personal Choice PPO) for $2,108.33 monthly. This has a zero deductible (the amount you owe for health-care services before your health insurance begins to pay). This plan has a $2,500-per-person limit on out-of-pocket expenses ($5,000 per family). I don't need a referral to see a specialist. My co-pay for visiting a primary doctor for injury or illness is $10, and there's a $30 co-pay on preferred brand drugs. My cost for a hospital stay is $300 per day for a maximum of five days. (I pay nothing after that.)
I've already checked to see if my wife's Ob/Gyn accepts the insurance. I still need to do likewise for our primary-care doctors and hospitals that are closest to our home. This is important. As Kaiser Health's Jay Hancock has reported, in a process some describe as the "narrowing of networks," some insurers are dropping practitioners they deem too expensive or inefficient. (Those doctors beg to differ.)
Where childbirth is anticipated to cost $7,540 in total, under this plan the patient portion is $580. Where managing type 2 diabetes is estimated to cost $5,400 a year, under this plan the patient pays $1,430.
My least expensive choice: IBX Bronze (PPO) costs $1,150.71 monthly with a $6,000 deductible per person/$12,000 per family. (That is the limit on my out-of-pocket expenses.) I don't need a referral to see a specialist. Under the ACA, preventative care, screening, and immunization are covered without a co-pay or deductible. To treat injury or illness, there is no charge for a primary-care visit once I have paid the deductible. (Same for an X-ray, or blood work or a CT/PET scan or an MRI). Brand-name drugs? No charge, but again, only after I have paid the full deductible. And the same applies for a hospital stay.
Where childbirth is expected to cost $7,540, the patient pays $6,150. And if managing type 2 diabetes costs $5,400 per year, the patient would pay $3,760.
My current plan, provided via my affiliation with the Kline & Specter law firm, is an IBX Personal Choice that costs $2,246.90 with zero deductible and no out-of-pocket maximum so long as we stay within the network. (That plan includes our daughter.)
There's a lot to think about, including do I want to pay more up front and get co-pays, or opt for a lower monthly payment with a high deductible?
Here is one certainty: Evaluation of these plans and consideration of these issues has ended the days where all I cared about was whether I was covered and not the cost.