HC Marketplace NON-MEDICARE advice needed

[OrangeBlossomBaby]

I'm sure if you have medicare or Medicare Advantage you're doing a fine job, your advice is awesome, and everyone appreciates it. My question isn't for you.

For those of us who are not old enough yet for Medicare but poor enough to qualify for subsidies, we have the Marketplace.

I can stick with my FloridaBlue bronze plan at $164. It's a PPO, I can use the Villages Health for everything, and Dr. Williams the ortho surgeon is in network if I manage to actually need the hip replacement I've been assuming I'd need for the past three years (but I'm still walking so - don't need it yet).

At the worst, I'd be out $9200 (the out of pocket max) for a hip replacement plus $164/month for the premiums. At best, I'd be out around $600 for the year, PLUS $164/month, for lab work, meds, etc. The expected expenses, since I'm a "high risk" for skin cancer, is around $4000 a year out of pocket for skin cancer surgeries, tests, radiation therapies, plus monthly premiums.

An option would be to switch to Ambetter Gold, which is an HMO. It's $204/month, but the deductible is only $750 and the out of pocket is only $7000 instead of the $9200 for Florida Blue. The local HMO group for them is Premier, which happens to be in the same parking lot as Villages Health. I'd have to change dermatologists, to the Care dermatology center in Sumter square. I currently use Dr. Gurgen's office and while they're nice folks, they're also surgery-happy. They even want to excise a "mild" displasia (atypical mole) and I have to sign a refusal waiver just because I told them I'd rather wait til it's "severe" before I deal with yet another surgery this year. It might be 4 more years before it becomes "severe." Or it might be next Tuesday. Either way I'm gonna wait and watch. It's the one thing I'm "conservative" about for crying out loud.

So - does anyone here have experience with the Ambetter HMOs in The Villages? Any thoughts about the Care dermatology group? And the Orthopedic Institute, just past Stonegate on 441?

[Pugchief]

I'm not a fan of HMOs. They are cost saving, right up until you need something they don't offer or a Dr that is out of network.

If you know that you will need a hip replacement, it would probably be worthwhile to switch to a gold plan for one year, and then go back to bronze next year. You'll have to run the numbers, but it's generally better to pay the higher premium if you know you will have major surgery.

[villagetinker]

Make sure you check out the primary care facility, and their reviews.

[OrangeBlossomBaby]

Make sure you check out the primary care facility, and their reviews.

Premier is the group. I just checked Yelp, it's mostly 1 stars. The 5 star reviews read as though they were all written by the same person.

I was hopeful. I guess I'll be sticking with my crappy bronze Florida Blue for another year, and hope I don't have another 5 skin cancers that need surgery, OR that I finally end up getting the hip replacement. Hip replacement surgery is around $25,000 if you pay cash, no insurance. So the out of pocket of "only" $9200 would be a big deal. That's why I keep hoping I need it :)

[rustyp]

I'm sure if you have medicare or Medicare Advantage you're doing a fine job, your advice is awesome, and everyone appreciates it. My question isn't for you.

For those of us who are not old enough yet for Medicare but poor enough to qualify for subsidies, we have the Marketplace.

I can stick with my FloridaBlue bronze plan at $164. It's a PPO, I can use the Villages Health for everything, and Dr. Williams the ortho surgeon is in network if I manage to actually need the hip replacement I've been assuming I'd need for the past three years (but I'm still walking so - don't need it yet).

At the worst, I'd be out $9200 (the out of pocket max) for a hip replacement plus $164/month for the premiums. At best, I'd be out around $600 for the year, PLUS $164/month, for lab work, meds, etc. The expected expenses, since I'm a "high risk" for skin cancer, is around $4000 a year out of pocket for skin cancer surgeries, tests, radiation therapies, plus monthly premiums.

An option would be to switch to Ambetter Gold, which is an HMO. It's $204/month, but the deductible is only $750 and the out of pocket is only $7000 instead of the $9200 for Florida Blue. The local HMO group for them is Premier, which happens to be in the same parking lot as Villages Health. I'd have to change dermatologists, to the Care dermatology center in Sumter square. I currently use Dr. Gurgen's office and while they're nice folks, they're also surgery-happy. They even want to excise a "mild" displasia (atypical mole) and I have to sign a refusal waiver just because I told them I'd rather wait til it's "severe" before I deal with yet another surgery this year. It might be 4 more years before it becomes "severe." Or it might be next Tuesday. Either way I'm gonna wait and watch. It's the one thing I'm "conservative" about for crying out loud.

So - does anyone here have experience with the Ambetter HMOs in The Villages? Any thoughts about the Care dermatology group? And the Orthopedic Institute, just past Stonegate on 441?

Check the network coverage of each plan.

HMO - limited network designed around a local area.
PPO - large nationwide network. Works well for snowbirds.

[cjky2k]

Premier is the group. I just checked Yelp, it's mostly 1 stars. The 5 star reviews read as though they were all written by the same person.

I was hopeful. I guess I'll be sticking with my crappy bronze Florida Blue for another year, and hope I don't have another 5 skin cancers that need surgery, OR that I finally end up getting the hip replacement. Hip replacement surgery is around $25,000 if you pay cash, no insurance. So the out of pocket of "only" $9200 would be a big deal. That's why I keep hoping I need it :)

1. My son has Ambetter in Michigan and is happy with cost and coverage, but can’t speak to it florida.

2. My husband and I use Premier for our primary care. He still has a few years to go before Medicare and not a lot of practices take those not on Medicare. We see no reason to look elsewhere. Issues addressed promptly. No problem getting seen quickly when needed. Husband has PPO and I have Medicare and Medigap so cannot say if their handling of HMO patients would be different.

3. Use Care dermatology and have been very pleased. They are aggressive about freezing off “suspicious” things which I like. But neither of us are considered high risk” for skin cancer

Hope this helps.