Selecting healthcare plan (ACA)- how to choose?

[Goddess]

Time to choose a healthcare plan through the Affordable Care Act ("Obamacare", to which I say, "thank God someone cares!"

Having lived overseas in countries with National Health, it's nothing scary and long overdue. The preventative care alone will keep many people out of the hospital.

Anyway, now I'm looking through the available healthcare plans on my state's website.

Forgive my ignorance: what's a copay? What's co-insurance? What's the difference?

Any hints on what type of plan to choose? I need regular check-ups and I have several prescriptions. In general, I don't get sick often, but, as most of us know, when I do get sick I get s-i-c-k, to the point where I may need hospitalization.

What should be my main considerations? Percentage covered? (All the PPOs look to be about 20%). Prescription coverage? (What are "non-preferred prescription drugs?"). Deductible? Maximum out-of-pocket? Fee for ER? (On some plans free, others $150 or $200).

What are the differences between gold/ silver/ bronze? I looked at a gold plan in detail, but actually the silver plans looked like a better deal (covered higher % of out-of-network consultations, etc.)

Any help that you can give me would be very...helpful.

 

[Clash]

A co-pay is an upfront fee you pay for a doctor appointment. I've had it range from 0-75 dollars depending on the policy, these were all either private or employer policies. The policy we have right no has now co-pay.

The co-insurance is what you pay beyond what insurance has paid. There is usually an out of pocket max you reach then insurance covers the bill 100%, excluding the co-pay.

With our policy now it is 80/20 % with no co-pay, once we reach out of pocket max; I think our max is 700.00 then insurance covers 100%

I have only glanced at info on the bronze, silver and gold but you want a plan with Tue least narrow network, make sure you find out if your Drs are covered under the policy as well as your choice of hospital before purchase.

Ours is an employer policy and it is PPO as well, so we can self refer to docs instead of having to get a referral from GP or ER.

I'm not sure about the ER fee our policy doesn't seem to have that.

 

[Goddess]

Sorry, follow-up questions,

The co-insurance is what you pay beyond what insurance has paid. There is usually an out of pocket max you reach then insurance covers the bill 100%, excluding the co-pay.

With our policy now it is 80/20 % with no co-pay, once we reach out of pocket max;

Sorry...how do you know what insurance pays? If it doesn't pay much, and you have to pay 20% of the remaining bill, that's scary!

In the second paragraph , what is the 80/20% for? Once you reach the out-of-pocket max (= then it kicks in), or until you reach it, then insurance covers 100%?

Thanks!

 

[Clash]

The policy is an 80%/20% plan meaning, if a bill was 1000.00 then the insurance would pay 80% of that 1000.00 dollars and you would pay the remaining 20%. Once you met your out of pocket max then insurance would cover bills 100%.

Of course there are some things that insurance doesn't cover at all, like some policies do not cover fecal calprotectin stool tests, others do.

 

[superzeeman]

I for one do not like the ACA as it caused my healthcare that I had to get cancelled and now my premiums are double what I was paying. How the heck is that affordable? I had excellent coverage with great prescription coverage and now I have horrible insurance.

 

[Goddess]

Clash- very clear, thanks.

Superzeeman, thanks, but that's off-topic.

Since you brought it up, maybe I can answer that a lot of people will be able to get health insurance for the first time ever. Maybe they won't have to wait until they're really sick to go to the ER.

If you have insurance, good for you. If you make enough that you don't need your premiums subsidized, congratulations.

It will change many people's lives for the better.

This topic here is how to choose a healthcare plan.
If you want to debate ACA further, start a thread about it.

 

[enumeras]

Goddess --

To find out how much everything will be ahead of time, you would have to contact your doctor to see what the codes will be or check a cpt manual. 99214 is typically the office visit from the doctor if you have a new problem. 46050 will be the procedure I'll be having done today.

The allowable is how much the insurance company is willing to cover for your procedure (not necessarily pay though, if you haven't met your deductible and co-ins).

If you have a ACA plan, you would want to look on your medicare site and search for the procedure you're having to see what the allowable is.

BTW, you don't have to wait till you're really sick. If you have bad coverage or no coverage the best thing to do is to go to an emergency clinic (if you have coverage w a high deductible, don't bother using it as the office will give you a self pay discount that will probably be less than the allowable from the ins company.)