Very general health-care question: am I missing something?

[pdean]

Hi all,
I'm 55 and about to choose healthcare for the first time as a self-employed person. (I worked for an independent school until 2012 and was able to continue the school's policy for three years.)

My wife has her own policy through work, and we have no kids.

At present, I have to have PET scans twice a year (in remission from lymphoma), so my costs can be assumed to hit my out-of-pocket maximum.

That said, it seems to be that in terms of cost comparison, all I really need to do is calculate monthly premiums + OOP max to get the total yearly cost of a plan. But I'm afraid that that's too simplistic, and that I'm missing something.

Thoughts? Thanks so much!
Patrick

[BCBiker]

You would probably want to go for a lower deductible policy (gold) given the guaranteed expense of the PET scans plus associated oncology visits. Those costs could easily get to the level of what you would have to pay in deductible.  It may be possible that the cost could be lower for deductible + (monthly premium for bronze*12) than (monthly premium for gold*12).  If so then you could go for the bronze... Your total cost from you cancer surveillance could end up lower than the bronze deductible and you would be even further ahead.

For those that read this and think that Obamacare is a certain sign of the coming apocalypse, Patrick would have been considered guaranteed uninsurable prior to Obamacare because of his preexisting condition. Or if there was an insurance company willing to write a policy the cost would have been likely 10's of thousands of dollars per year.  This pre-existing condition would force him to work until Medicare kicks in purely to keep on a group health plan. There are a lot of limitations of Obamacare but this is a clear win for Patrick.

Patrick, could you let me know if any of the things I said above are inaccurate or untrue. Good luck on your transition to a new policy!

[likeavision]

That said, it seems to be that in terms of cost comparison, all I really need to do is calculate monthly premiums + OOP max to get the total yearly cost of a plan. But I'm afraid that that's too simplistic, and that I'm missing something.

Congrats on being in remission.

As for the costs, the above is more of a worst case scenario.  You should also look at your deductible and your coinsurance rates.  For example, let's say the cost of a PET scan is billed at $1,000 by your provider.  Your insurance company will have some predetermined amount they are willing to pay for a PET scan (say $250).  That's how much they will allow for this test.  It's possible, but unlikely, that your provider will require you to pay some or all of the difference between what they billed and the insurance company allowed (known as balance billing).  If your coinsurance rate for this covered service is 10% and your deductible is $100, then you would pay $100 (the deductible) plus $25 (your 10% coinsurance on the $250 allowed amount for the service) for a total of $125 and the insurance company would pay the remaining balance of $125.   The next time you have a PET scan done during the same plan year, the insurance company would pay $225 and you would pay $25.

Of course, I have no idea how much PET scans actually cost but you should have an idea from past medical bills and can probably use the coverage amounts by your previous health insurance company to gauge how much of those charges will be allowed.  With that information in hand, you can better assess what your projected costs are going to be.  A smaller deductible and a lower coinsurance rate (e.g., 10% versus 20%) may result in more savings and keep you from hitting your OOP max.

[Bob W]

You need to shop PET scan costs.    You will see 1000 percent difference.  You can also negotiate the price.    If you like to travel you could find them for probably 25% abroad and the trip would be deductible.     http://www.medicaltourismco.com/computed-tomography-ct-scan-abroad/

[MnemonicMonkey]

First, can you get on your wife's plan? You're typically insurable on a spouse's employer plan if self employed or you work for a small (exempt) business. This would probably be your easiest/cheapest route. Probably too late for open enrollment though.

If your assumption that you'd hit OOP max is true, then yes, cost is premium + max OOP. However, blue book on a PET scan is ~1500ea, so even at a 50% copay, you might not hit your max OOP. ($1000 deductible + $1000 copay on remainder is only $2000.)

Also consider is what the coverage is if something turns up positive (heaven forbid). It's all about how much risk you can afford to assume.

https://healthcarebluebook.com/page_ProcedureDetails.aspx?id=490&dataset=MD&g=PET+Scan+Image+%28with+CT+of+whole+body%29

[pdean]

Thanks to all for these responses. I'm going to go back and price out previous scans (I've been doing it for 5 years now) and run the coinsurance numbers.
Thanks again!