Self Employed Medical Insurance Cost

[MoustacheDArgent]

I'm looking at the new plans on Healthcare.gov and it's going to cost me about 9k to insure myself, and with the deductible, I'll have to spend a total of 17k before the insurance even kicks in.

None of my doctors take the marketplace insurance so I always have to pay cash for doctors visits, so really all it's good for is Emergency Room visits and hospital stays.

I don't qualify for any subsidies and I'm really starting to have a hard time justifying paying this much money.   Anyone else in the same boat?   I'm starting to consider just not having insurance.

[rantk81]

Just something to keep in mind...

I had surgery this year.  The "raw, un-adjusted" billed amount for everything was over a quarter million dollars, and counting.

After the "negotiated discounts" with all the providers, the reimbursement to all the providers (some from the insurance company, some from me), totaled only to about $30K.

If it weren't for the whole screwed up system where they bill you for the cost of a house, but will end up accepting the cost of a car for payment, but only if you have an insurance company "negotiate" on your behalf.... if it weren't for that screwed up system, I'd lean toward wanting to self-insure too.

Some places will lower the cost, if you are a cash payer... but you are at their mercy if they're willing to do that.  Especially if it is an 'after-the-fact' thing in an emergency.  And if they are particularly unscrupulous, and they find out you have FI-level assets, or own a business, they may be less willing to "negotiate".

In an emergency (or even, when it isn't an emergency, and they STILL can't tell you what something costs ahead of time), they can kind of, pull whatever number out of their ass they want, and bill you for it.  And if you are "out of network" or not using insurance, you don't really have a lot of protections or recourse.

[ejmyrow]

I don't know if this will help, but I wonder if you can get more minimalist insurance. For example, travelers often have insurance that just covers extreme emergencies (and of course you can have a high deductible).

[wenchsenior]

Just something to keep in mind...

I had surgery this year.  The "raw, un-adjusted" billed amount for everything was over a quarter million dollars, and counting.

After the "negotiated discounts" with all the providers, the reimbursement to all the providers (some from the insurance company, some from me), totaled only to about $30K.

If it weren't for the whole screwed up system where they bill you for the cost of a house, but will end up accepting the cost of a car for payment, but only if you have an insurance company "negotiate" on your behalf.... if it weren't for that screwed up system, I'd lean toward wanting to self-insure too.

Some places will lower the cost, if you are a cash payer... but you are at their mercy if they're willing to do that.  Especially if it is an 'after-the-fact' thing in an emergency.  And if they are particularly unscrupulous, and they find out you have FI-level assets, or own a business, they may be less willing to "negotiate".

In an emergency (or even, when it isn't an emergency, and they STILL can't tell you what something costs ahead of time), they can kind of, pull whatever number out of their ass they want, and bill you for it.  And if you are "out of network" or not using insurance, you don't really have a lot of protections or recourse.

Yup. INCREDIBLY risky to go without insurance. Even a very short hospital stay can run hundreds of thousands, let alone getting any sort of chronic conditions.

[Evgenia]

We had ACA plans (Blue Cross then Kaiser) for about 10 years, in California. You're self-employed, so your monthly premium is fully deductible on Schedule C (which you probably already know, but just in case). Are you *sure* you don't qualify for either a federal and/or state subsidy? We didn't think we did, either, and then I worked with a healthcare marketplace broker, who did a ton of work for us and found out we did, but also showed us how to ensure our tax accountant was calculating everything properly (he wasn't; we got a new tax accountant).

It does suck that a lot of doctors don't accept the plans. We ran into that (before we moved onto Kaiser, anyway, which isn't an option in all states alas) and would use HSA funds to pay it at least, which is why we chose an HSA plan.

Best of luck. It's so much harder than it needs to be.

[dandarc]

Where are you out of curiosity? Every place I've lived has had a blue cross option that most doctors in the area took. Was actually kind of awesome in our part of Florida when Florida Blue was the only exchange option - silver loading works exceptionally well when there's no competition.

[MoseyingAlong]

..... You're self-employed, so your monthly premium is fully deductible on Schedule C (which you probably already know, but just in case). .......

Just to correct this, the self employed health insurance deduction is taken on Schedule 1 Part II Adjustments to Income, not Schedule C.

[MoustacheDArgent]

ok so I combed through the plans and found one that cost $565 a month and has a $9200 deductible and pays nothing until the deductible has been spent and then pays emergency room/ hospital stays.   So many of these plans only provide co-insurance, meaning once the deductible is met then they will pay 50% of hospital costs.   These plans are terrible!

I'm in Texas and have a couple million in assets, so I suppose I need to get insurance so they can't come after me for a big hospital bill.   

[dandarc]

I mean, did you not realize the extent to which your employer was subsidizing health insurance if that's what's you've had before? A lot of the time, employer is covering a large portion of premium and also has their own deductible or co-insurance they pay on any claims from employees that you don't even see.

[sonofsven]

ok so I combed through the plans and found one that cost $565 a month and has a $9200 deductible and pays nothing until the deductible has been spent and then pays emergency room/ hospital stays.   So many of these plans only provide co-insurance, meaning once the deductible is met then they will pay 50% of hospital costs.   These plans are terrible!

I'm in Texas and have a couple million in assets, so I suppose I need to get insurance so they can't come after me for a big hospital bill.

After your deductible is met, you pay coinsurance until your max out of pocket is met, then everything is covered (as long as it is in network and prior approved).
If you are young-ish and in generally good health it makes sense to get an HSA bronze plan and max out your HSA yearly. I treat my HSA balance as an emergency fund in that it could cover my max out of pocket, if needed (In theory, at least. In reality, I paid my max oop in '24 and '25 and just cash flowed it, because I was loathe to remove funds from the HSA which is fully invested)

[rantk81]

For most, if not all, of the plans in my ACA market zip code, the out-of-pocket maximums are all really close to the maximum allowed amounts under law.  (Without adjusting for cost-sharing subsidies.)

If you are paying full price for these plans (without premium subsidies), I agree, they are generally really terrible plans, with high premiums, narrow networks, large deductibles, large out of pocket maximums.  But they can save you from having a catastrophic financial loss -- so long as you follow the rules with pre-approvals and staying in network.  And the thing they have going for them is, they are available and can't turn you away, no matter how expensive/sick you are :P

[RedmondStash]

I've generally found it worth it to have an ACA plan, because even when it doesn't pay for a doctor's visit, it does reduce the exorbitant cost of the visit down to the negotiated rate. Which is often half or less of the up-front stated cost.

I don't think I've ever actually paid my whole deductible; I pay for a lot out of pocket. But I'd be paying more if not for insurance negotiating rates. But the doctors near me generally do take ACA insurance.

[iris lily]

ok so I combed through the plans and found one that cost $565 a month and has a $9200 deductible and pays nothing until the deductible has been spent and then pays emergency room/ hospital stays.   So many of these plans only provide co-insurance, meaning once the deductible is met then they will pay 50% of hospital costs.   These plans are terrible!

I'm in Texas and have a couple million in assets, so I suppose I need to get insurance so they can't come after me for a big hospital bill.

We have insurance to protect our assets.

[iris lily]

I've generally found it worth it to have an ACA plan, because even when it doesn't pay for a doctor's visit, it does reduce the exorbitant cost of the visit down to the negotiated rate. Which is often half or less of the up-front stated cost.

I don't think I've ever actually paid my whole deductible; I pay for a lot out of pocket. But I'd be paying more if not for insurance negotiating rates. But the doctors near me generally do take ACA insurance.

how much is an “exorbitant” dr’s visit fee?

I have a direct care physician and pay around $1100 annually for unlimited visits. I do not get my “money’s worth” because I see the Dr about 1x annually, sometimes 2x, but I like the convenience and the assurance I can get into that practice within 1-3 days.

[RedmondStash]

I've generally found it worth it to have an ACA plan, because even when it doesn't pay for a doctor's visit, it does reduce the exorbitant cost of the visit down to the negotiated rate. Which is often half or less of the up-front stated cost.

I don't think I've ever actually paid my whole deductible; I pay for a lot out of pocket. But I'd be paying more if not for insurance negotiating rates. But the doctors near me generally do take ACA insurance.

how much is an “exorbitant” dr’s visit fee?

Often at least double the insurance-negotiated rate. At minimum, hundreds of dollars. For specialists and certain labs and tests, thousands.

[iris lily]

I've generally found it worth it to have an ACA plan, because even when it doesn't pay for a doctor's visit, it does reduce the exorbitant cost of the visit down to the negotiated rate. Which is often half or less of the up-front stated cost.

I don't think I've ever actually paid my whole deductible; I pay for a lot out of pocket. But I'd be paying more if not for insurance negotiating rates. But the doctors near me generally do take ACA insurance.

how much is an “exorbitant” dr’s visit fee?

Often at least double the insurance-negotiated rate. At minimum, hundreds of dollars. For specialists and certain labs and tests, thousands.

Well,sure, for specialists.

But how much is a doctor’s office visit foe a GP?

[dandarc]

I've generally found it worth it to have an ACA plan, because even when it doesn't pay for a doctor's visit, it does reduce the exorbitant cost of the visit down to the negotiated rate. Which is often half or less of the up-front stated cost.

I don't think I've ever actually paid my whole deductible; I pay for a lot out of pocket. But I'd be paying more if not for insurance negotiating rates. But the doctors near me generally do take ACA insurance.

how much is an “exorbitant” dr’s visit fee?

Often at least double the insurance-negotiated rate. At minimum, hundreds of dollars. For specialists and certain labs and tests, thousands.

Well,sure, for specialists.

But how much is a doctor’s office visit foe a GP?

"often at least double the insurance-negotiated rate. At minimum, hundreds of dollars."

[geekette]

But how much is a doctor’s office visit for a GP?

Logged in to look at some claims, some mine, some DH's.

physical, billed $333, allowed amount $224.85, paid $0 (preventative)
labs, billed $247.65, allowed amount $13.33
Cologuard, billed $681, allowed amount $524.14, paid $0 (preventative)
urgent care, billed $612, allowed amount $173.41
medical eye exam, billed $214, allowed amount $61
mammogram, billed $470, allowed amount $457.27, paid $0 (preventative)
problem visit, billed  $192, allowed amount $128.89
specialist, billed $258.20, allowed amount $149.57
labs, billed $491.85, allowed amount $119.82
MRI, billed $2079, allowed amount $1303.29
injection, billed $1244, allowed amount $499.71

[iris lily]

I've generally found it worth it to have an ACA plan, because even when it doesn't pay for a doctor's visit, it does reduce the exorbitant cost of the visit down to the negotiated rate. Which is often half or less of the up-front stated cost.

I don't think I've ever actually paid my whole deductible; I pay for a lot out of pocket. But I'd be paying more if not for insurance negotiating rates. But the doctors near me generally do take ACA insurance.

how much is an “exorbitant” dr’s visit fee?

Often at least double the insurance-negotiated rate. At minimum, hundreds of dollars. For specialists and certain labs and tests, thousands.

Well,sure, for specialists.

But how much is a doctor’s office visit foe a GP?

"often at least double the insurance-negotiated rate. At minimum, hundreds of dollars."

Ok,thanks.