[OrangeBlossomBaby]

Originally Posted by Plinker

How about zero deductible, zero or very minimal monthly payments and a $5400 out of pocket maximum for pre-Medicare retirees with multi-million dollar net worths.
Easily accomplished:

Access Denied

Of course, because the multi-million-dollar income earners need to welch off the system, costing the middle-class more since they /can't/ change their income, since they're still working and rely on that paycheck for living.

Excellent example of why the insurance companies are valuing their plans at $2000/month or more.

[tophcfa]

Originally Posted by OrangeBlossomBaby

The tiers have changed a LOT since the ACA was first passed. Also medical needs of subscribers change from one year to the next, especially as we get older. As of January 1, my new plan will be BlueSelect Bronze 2139.

I'm expecting to need hip replacement surgery next year. The customary cost, for operation, facility fee, doctors and anasthetics, pain meds, follow up visits, scans and xrays and whatever the heck else they do, will be somewhere around $25,000.

Under my CURRENT plan - BlueSelect Silver 1443A, I pay $436/month just to be on the plan. It has a 7000 per person deductible and a 8500 per person out of pocket expense. Having the procedure at the hospital instead of a surgical center is only covered to something like 40%, leaving me with having to pay 60% of the balance. Certain other parts of the surgery aren't covered at all, though I'll get some kind of schedule of fees discount. It's pretty complex, lots of things that are and aren't covered, covered only partly, with a bunch of exclusions.

The tl;dr is I'll likely be on the hook for around $15,000 total for the surgery, assuming I have no other medical issues all year, and including my premium.

For the NEW plan, it's a $9100 out of pocket max, 0 deductible. That basically means I pay for all my expenses as I go, and once it hits $9100 total payout, everything else is covered at 100 or with a reasonable additional copay (like $50 for a doctor's visit for a sprained ankle or whatever else).

This new plan will cost me $146/month, for myself and beloved spouse.

The tl;dr of the new plan is I'll be on the hook for around $10,000 total for the surgery, assuming I have no other medical issues all year, and including my premium.

I hear ya, I have essentially the same insurance except I pay a crap load more in monthly premiums without the tax credit subsidies. I got really sick in 2021 from an infectious disease from a tick bite and had to spend 8 days in critical care in a Gainesville Hospital before they finally figured out was was wrong with me and how to treat it (basically the same treatment used for Malaria). They ran just about every imaginable test on me trying to diagnose what was making me so sick. The billable expenses from that episode ran close to a quarter million dollars, but I only had to pay the max out of pocket, which was close to 10 grand. Now I need a second knee replacement (too many years of pounding ice moguls in Vermont), but I’m going to suck it up a little longer until I turn 65 because it will be way cheaper once I am on Medicare.

Best of luck with the hip.

[OrangeBlossomBaby]

Originally Posted by tophcfa

I hear ya, I have essentially the same insurance except I pay a crap load more in monthly premiums without the tax credit subsidies. I got really sick in 2021 from an infectious disease from a tick bite and had to spend 8 days in critical care in a Gainesville Hospital before they finally figured out was was wrong with me and how to treat it (basically the same treatment used for Malaria). They ran just about every imaginable test on me trying to diagnose what was making me so sick. The billable expenses from that episode ran close to a quarter million dollars, but I only had to pay the max out of pocket, which was close to 10 grand. Now I need a second knee replacement, but I’m going to suck it up a little longer until I turn 65 because it will be way cheaper once I am on Medicare.

Best of luck with the hip.

Thanks! Same to you with the knee. I almost got the hip done this year, but it turned out the excruciating pain I experienced was probably just a mild bone infection caused by the cortisone shot they gave me to relieve the hip pain (go figure). THAT pain resolved itself, the cortisone shot worked perfectly otherwise. And now, it's just starting to wear off.

It's my third and final cortisone shot, I'm not allowed to get more than 3 lifetime. Once the pain progresses back to where it was before I got the last shot, it's time to replace the thing.
So - probably next year. If not, then I will have saved a fortune in premiums without needing expensive care, so it'll be a win-win.

[La lamy]

Originally Posted by golfing eagles

Hard to say. If you go to the Florida Blue website, you can get a pretty accurate estimate. Personally, I retired at 56, I'm now 63, and my 2023 premium will be $17,600 for the year with a $7,000 deductible and no pre-existing conditions. (Bronze plan). I was self-employed, so no employer benefits, don't qualify for "Obamacare", and even if I did, I wouldn't accept it.

Wow, as a Canadian those insurance costs are astronomical!!

[kkingston57]

Originally Posted by Michael 61

Moving in a few weeks to my new home in TV from another state. I am under 65, so too young to qualify for Medicare. My earnings last year exceeded the cap for Obamacare. I will need to get insurance through the Florida exchange. Is this something I should try to navigate on my own through Florida’s healthcare website, or are their brokers I could go to help me choose a plan. I don’t even have a doctor yet in Florida, and need to make sure that the eventual plan I get will be honored by my primary care provider as well as a few specialists (dermatologist and cardiologist) I will see a few times a year.

I had same issue in 2021. ONLY carrier in Sumter County was Florida Blue and was able to get a PPO plan. Happy with the plan and cost around 10k.

[kkingston57]

Originally Posted by Rainger99

Should getting healthcare be this complicated?? Whether it is pre-Medicare or Medicare??

Not a problem for me, but I had only one choice last year in Sumter County. No insuance company wants to insure 64 year olds.

[kkingston57]

Originally Posted by PoolBrews

It's not a penalty, you just have to return the difference. i.e. if you claim a certain income and it says you get $1,700/month in credits, and then at the end of the year your income was higher so the credit should have been $1,600/month, you have to pay the $1,200 ($100 x 12) back when filling out taxes.

Agree 100%. Last year I had capital gains which pushed my premum up $800 a month since I did not anticipate high capital gains in 2021 and instead of getting an IRS check, I sent them a check.

[tuccillo]

There is a difference between income and net worth. "multi-million-dollar income earners" aren't "welching" off the system but they are paying a crap-load of taxes. Retired and under 65 with high net worth and low reported income can get a subside. Complain to the people who wrote the obamacare law such that the means testing is on reported income and not net worth. Just like with every other aspect of the tax law, people will adopt tax reduction strategies.

Originally Posted by OrangeBlossomBaby

Of course, because the multi-million-dollar income earners need to welch off the system, costing the middle-class more since they /can't/ change their income, since they're still working and rely on that paycheck for living.

Excellent example of why the insurance companies are valuing their plans at $2000/month or more.

[golfing eagles]

Originally Posted by tuccillo

There is a difference between income and net worth. "multi-million-dollar income earners" aren't "welching" off the system but they are paying a crap-load of taxes. Retired and under 65 with high net worth and low reported income can get a subside. Complain to the people who wrote the obamacare law such that the means testing is on reported income and not net worth. Just like with every other aspect of the tax law, people will adopt tax reduction strategies.

Exactly. Which is why I refused to get a subsidy even though I have essentially zero income. While the law has a few good points, it is also deeply flawed and was more political than medical in nature. Back in 2009 I was on one of the committees that was developing part of "Obamacare". I quickly resigned when I found out there were 70 people on this committee and only 2 physicians, most were politicians and bureaucrats, and it was obvious the outcome was already pre-determined.

[tophcfa]

Originally Posted by tuccillo

Retired and under 65 with high net worth and low reported income can get a subside. Complain to the people who wrote the obamacare law such that the means testing is on reported income and not net worth. Just like with every other aspect of the tax law, people will adopt tax reduction strategies.

The scenario outlined above is highly unlikely. If one is truly a high net worth individual than the income on their investments will almost certainly put them well above the income cap to receive Obamacare income tax credit subsidies. For a high net worth individual to keep their income low enough to qualify for subsidies, they would basically have to stuff their savings under a mattress. Who in their right mind would forego many thousands of dollars of investment income to save a few thousand dollars in health care premiums? I suppose there are some examples of idiots that stashed their savings in crypto to avoid reporting income, but how did that work out for them?

[tuccillo]

I agree that the number of people who can do this is limited. If most of your money is in IRAs then it is entirely possible you can do this. You could be living off of non-qualified money that doesn't generate a tax event or much of a tax event. Did you read the link posted previously? It was about financial advisors and clients who are doing this. I know savvy people who have done this.

Originally Posted by tophcfa

The scenario outlined above is highly unlikely. If one is truly a high net worth individual than the income on their investments will almost certainly put them well above the income cap to receive Obamacare income tax credit subsidies. For a high net worth individual to keep their income low enough to qualify for subsidies, they would basically have to stuff their savings under a mattress. Who in their right mind would forego many thousands of dollars of investment income to save a few thousand dollars in health care premiums? I suppose there are some examples of idiots that stashed their savings in crypto to avoid reporting income, but how did that work out for them?

[mtdjed]

Originally Posted by tophcfa

Absolutely not, but you know what happens when the Government gets involved with anything.

Or doesn't get involved. I used one of our urgent care facilities on a Sunday recently for sudden dizzyness and balance problems. I walked in waited 15 minutes and was taken into a room and was asked by the nurse what my problem was. Took my pulse and BP, checked my response to several simple head and eye movements. Nurse went and discussed with doctor and returned with script for Meclizine (which you can buy off the shelf). Total time less than 1/2 hour, never saw doctor. Advice was vertigo and go to see my doctor if it did not get better in a day or so.

Urgent care bill to Medicare was $2800, and Dr was $1300, Total was $4100+. Medicare authorized a total of $300 (Less than 8% of charge).

What happens to a person with no insurance? How is this type of billing tolerated? I know Medicare has payment codes for provider services, but such a difference leads to total mistrust of all involved.

Perhaps someone on this forum can help explain.

[OrangeBlossomBaby]

Originally Posted by mtdjed

Or doesn't get involved. I used one of our urgent care facilities on a Sunday recently for sudden dizzyness and balance problems. I walked in waited 15 minutes and was taken into a room and was asked by the nurse what my problem was. Took my pulse and BP, checked my response to several simple head and eye movements. Nurse went and discussed with doctor and returned with script for Meclizine (which you can buy off the shelf). Total time less than 1/2 hour, never saw doctor. Advice was vertigo and go to see my doctor if it did not get better in a day or so.

Urgent care bill to Medicare was $2800, and Dr was $1300, Total was $4100+. Medicare authorized a total of $300 (Less than 8% of charge).

What happens to a person with no insurance? How is this type of billing tolerated? I know Medicare has payment codes for provider services, but such a difference leads to total mistrust of all involved.

Perhaps someone on this forum can help explain.

Yup.

Dehydration caused fainting in the town square. Needed IV fluids, nothing else. Mandatory ambulance ride: $670. Two sets of chest x-rays because patient was stressed out (I mean who would NOT be stressed out after being transported to the ER?), 1.5 hours laying on a gurney watching TV with no visitors allowed, full CBCs, to get 2 bags of fluids that only took 1/2 hour to administer. Patient didn't know they could just refuse more service and walk out, the spouse was not permitted in to explain that to him.

Finally after 1.5 hours the spouse was able to flag down a medical employee to explain the situation, and was allowed in. Patient was angry, had wanted to go home an hour before, didn't want ANY of the tests he was told he HAD to take...

Nurse made nasty comments...

and the bill for THAT lovely service was $2000.

Oh that $600+ ambulance ride was one BLOCK away from the ER.

Insurance covered only part of the cost because UFHealth's free-standing emergency center was considered "out of network" and therefore not covered, so the payment to ambulance and UFHealth ended up being around $1800 total.

[melpetezrinski]

Originally Posted by PoolBrews

It's not a penalty, you just have to return the difference. i.e. if you claim a certain income and it says you get $1,700/month in credits, and then at the end of the year your income was higher so the credit should have been $1,600/month, you have to pay the $1,200 ($100 x 12) back when filling out taxes.

If you fall within the income limits, you not only qualify for a subsidy amount that will lower your monthly premium but you also get lower copays and a lower out of pocket max. Now, if you significantly underestimate your income (maybe you sold stock or a rental property for a $50k capital gain), you will have to pay part of the subsidy back that reduced your premium. This is a fairly straightforward process. However, what about the copays? Maybe you initially had zero copays with the estimated low income and now with the actual higher income, you should have been paying $20 copays all year. These would have been paid directly to the doctors' office or hospital, etc. How are these recaptured or clawed back?

[steve3860]

Originally Posted by Michael 61

Moving in a few weeks to my new home in TV from another state. I am under 65, so too young to qualify for Medicare. My earnings last year exceeded the cap for Obamacare. I will need to get insurance through the Florida exchange. Is this something I should try to navigate on my own through Florida’s healthcare website, or are their brokers I could go to help me choose a plan. I don’t even have a doctor yet in Florida, and need to make sure that the eventual plan I get will be honored by my primary care provider as well as a few specialists (dermatologist and cardiologist) I will see a few times a year.

It should be based on what you will make this year. Last year after having covid I was unable to work. After losing my job I signed up for Obama Insurance. I estimated my income for this year at $18k. I ended up making $20k no problem. The year before I made $120k for the year.