Wednesday, March 19, 2014

An ACA (and Medicare) success story

I've been disabled for several years now - closing in on the 10 year mark, come to think of it. I've had Medicare for the duration and, for much of the time, have dual qualified for state Medicaid - the combination of the two making me eligible for Special Needs Plans with insurance companies. Basically, I could have kept the Medicare and Medicaid, and had to do a lot more oversight on the billing of my claims, and not had dental and vision, or I could choose to take an HMO plan with a private insurance company and let them handle most of the work + give me more benefits than the federal and state plans would on their own.

Seemed like a good option, so I've done that and it's worked out pretty well for me.

When I attempted to reenter the workforce a few years back, I lost that dual eligibility for awhile, and regained it when I was no longer working. At least, I regained it for a year. Going back to work made it so my Social Security payments increased ('cause I spent a year paying more into the system - that's how this stuff works, you get back money in relation to how much you've paid in over your lifetime working), and that increase took me just above the cut off line for dual eligibility.

Well, crap. Time to find new insurance, since I have a lot of medical expenses and basic Medicare a) doesn't cover medications unless you buy a part D plan and b) only covers 80% of costs, which will bankrupt me if I have to pay the 20% on things like, say, IVIG treatments ($40,000 each x 20% = $8,000 out of pocket for each treatment). But hey, my husband works and I could go on his insurance, right?

Theoretically, yes.

Except, this is his first week at a new job (close to home! better hours! full time status! yay good things!) and that meant his insurance had to change, too. No problem, we'll both use the insurance at the new place, it'll be fine.

Oh. The insurance at the new job is terrible. Crap again.

Okay, it's not objectively terrible, but it's terrible for us. It is probably a really good plan for people who are generally healthy and don't require a lot of specialist medical care. I have a ridiculous amount of doctor appointments on a routine basis, 10+ medications to fill a month, intermittent IV treatments that are very expensive, and monthly lab work to see if I need the treatment that month. My husband has a few medications he takes routinely and which require monitoring by a physician, and needs to see a specialist every now and then, himself.

If we took the insurance through his job, it would be $163/2 wk pay period, or $326/month, for coverage that largely wouldn't start covering anything until after the deductible was met, and even then might still be only 80-90% covered. On top of that, there are copays that don't even apply to the deductible. For a generally healthy person, this wouldn't be an objectively bad option -- indeed, it'd be better than most of the plans on the Insurance Exchange. But again, not good for us.

So I started researching. I figured that if I could find something better for even $100+ more a month, it'd be better than taking coverage that didn't fit our needs.

Turns out, people with chronic illnesses and disabilities are pretty much going to get screwed when it comes to finding insurance that covers all the things they need, as much as they need, and for the doctors they need. When I was looking for options for my needs, I wasn't finding much. But then I realized that I wasn't constrained to just the Insurance Exchange because of my eligibility for Medicare.

Ah! Medicare Advantage plans - perfect! There are ones that have a $0 premium, but don't include prescriptions, up to plans that have just about everything you could need for a substantially bigger monthly premium. I ended up finding one that is with my current insurance company, and covers basically all the same things just with the addition of some copays that my SNP insurance doesn't have, and won't require any change in my doctors. (I live in Pittsburgh, and Highmark and UPMC are still duking it out over which insurance will be accepted at which hospital system - I've got doctors at only 1 of the two, so I don't want to risk getting a plan with the other company and having it go badly for me.) My premium per month? A whopping $2.60, so $31.20 per year.

Excellent, that covers me, but what about my husband? He doesn't have the same needs I do, but he still needs a better insurance plan than his job is offering. Back to the Insurance Exchange I went.

With my needs taken care of, I realized that what I'd budgeted for insurance (that $326/month that his employer-offered plan would cost for both of us) now offered me a lot of leeway when it came to getting a plan for 1 adult. I dropped the bronze and silver plans off the results and kept the gold and platinum plans. Surprise surprise, I found a gold level plan that was far better for my husband's needs than the plan he would get through his employer, and that would still keep our costs down. The cost for just him through his employer would be $136/month, but for coverage that wouldn't fit what he needed. The plan I found on fits basically every need he has, keeps routine costs low with copays instead of coinsurance or 20%-after-deductible amounts, and covers all the doctors he sees or might need to see. It is in the other insurance/hospital system, but he doesn't have any doctors in the system that I do, so there's no reason that he has to stay there.

The cost per month for this awesome plan? $197/month, or $2,364 per year.

We'll get truly excellent dental and vision coverage through his employer (go figure), and our health insurances privately and separately through Medicare Advantage and the HIE, and our total cost per month will be $240.50, or $2,886 per year.

If we went with the employer plan, it would be $326/month, or $3,912 a year. This means we're saving an average of $85.50 a month or $1,026 a year in insurance costs. I was fully ready to pay more per month for better insurance, and instead we're saving money. That's a whole lot of win, in my book. I have better insurance and a better cost, on account of being legally declared disabled, but the HIE made it possible to find insurance for my husband that wouldn't have been available to him before the ACA took effect - and even if it was available, preexisting conditions would have barred him from it! Also, please note that all prices here reflect no tax credit - because my husband's job offers at least a bronze equivalent plan, we don't qualify for assistance.

If you don't have insurance, you've got about a week and a half to check out and see what you can get for yourself. Please, take a look and see if you can be as pleasantly surprised as I was.