[spazzyfry123]

Reminder to all that tomorrow, 12/15, is the deadline for 2026 elections.

Curious what those that may not have an employer-sponsored health insurance plan are doing for 2026. While I am not self-employed, my employer had made changes to their health insurance provider mid-2025 that made our enrollment effectively impossible as we really only have one option for a hospital network in our area - one that has been in litigation with the new health insurance provider and, as a result, non-insurable. This means that for anything from a routine doctor's visit to hospitalization and anything in between will require nearly two hours one-way to have insurance coverage. We elected to forego and enter the private market.

We just had our third child (finally, a boy for some estrogen offset!) a few days ago. I've been holding on 2026 elections so as to have everything needed to include the newest addition and not have to go through the paperwork once more soon thereafter knowing that the newest addition would be here right before the cut off. So here I sit going through it. What was previously presented to me with monthly premiums being a projection as official election season hadn't opened showed to be a 25% (!) increase in premium YoY. Really had to pick my jaw off the floor for that one. Now that I'm going through it officially right now, I am now presented with an actual YoY monthly premium increase of 49% to retain our existing health insurance plan. No, the new addition has nothing to do with the hike. As I've negotiated with my employer to subsidize my health insurance costs, that remains in place, but at a fixed rate. With the increases, this 49% premium increase nets in a 110% increase in my personal out of pocket monthly premium.

What. The. $%*@.

To get in the neighborhood of what we have been spending on monthly premiums in 2025: I need to change from a PPO to an HMO; office visits go from $0 to 50% out of pocket; generic drugs go from $0 to $30; our deductible increases by 750%; our max out of pocket increases by 700%; because of the plan type change, none of our existing providers are considered in network so we will need to change absolutely everything.

...or to keep our existing network: Plan to either accept the 110% monthly premium hike or keep effectively all the increases above but ALSO increase our monthly premium by 24% (54% out of pocket increase). So in effect, absolutely all of the benefits will cost us significantly more out of pocket for day-to-day use in comparison to our existing plan and need to pay 54% more month-to-month for the pleasure of doing so.

Suddenly the phone call I got a couple weeks ago from my previous employer wanting me back isn't looking so bad. My monthly health insurance bill will be reduced by a mortgage payment by making that change alone by having an employer-sponsored healthcare plan.

Happy hunting out there, folks...

[RickFLM4]

I am self employed but fortunately my wife went back to work and we have insurance through her employer. Premiums are pretty reasonable for us (because employer pays a huge chunk) but I hate to think what the cost would be as we close in on 60 y/o if we were still buying individual insurance.

What I have noticed is that the insurance company (BCBS of SC) has really tightened up on what is allowable and sticks us with the bill for anything they don’t like. As an example, doctor orders blood test. Quest charges $85. BCBS says their agreement with Quest means the allowed charge is $7 - $6 paid by BCBS and $1 by me. Six months later the same test is ordered by the doctor and BCBS disallows it (frequency) so now Quest looks for the full $85 from me. Multiply that by 1/2 dozen tests for both the wife and me and we’re out of pocket about $1,000 for routine bloods test over the past year (started in 4Q 2024). I don’t even know what tests the doctor orders - I just show up and have blood drawn. Now I guess we need to ask exactly what tests are being ordered and research coverage for each one on the BCBS website, challenges our doctors, shop around, etc. so much for “managed care” by insurers.

Anyway, all that is to say if they don’t get you with premiums, they get you with inflated costs - or both. We will soon be seeing bankruptcies of people with insurance who can’t pay the bill they got stuck with, much like we see bankruptcies of uninsured patients. The whole thing is an absolute mess and I have been saying for 20 years, the solution needs to start with the inflated prices charged by providers and the relationship between those prices and what insurers pay vs. what uninsured people (and now what insured people with rejected claims) pay.

[spazzyfry123]

Originally Posted by RickFLM4

I am self employed but fortunately my wife went back to work and we have insurance through her employer. Premiums are pretty reasonable for us (because employer pays a huge chunk) but I hate to think what the cost would be as we close in on 60 y/o if we were still buying individual insurance.

What I have noticed is that the insurance company (BCBS of SC) has really tightened up on what is allowable and sticks us with the bill for anything they don’t like. As an example, doctor orders blood test. Quest charges $85. BCBS says their agreement with Quest means the allowed charge is $7 - $6 paid by BCBS and $1 by me. Six months later the same test is ordered by the doctor and BCBS disallows it (frequency) so now Quest looks for the full $85 from me. Multiply that by 1/2 dozen tests for both the wife and me and we’re out of pocket about $1,000 for routine bloods test over the past year (started in 4Q 2024). I don’t even know what tests the doctor orders - I just show up and have blood drawn. Now I guess we need to ask exactly what tests are being ordered and research coverage for each one on the BCBS website, challenges our doctors, shop around, etc. so much for “managed care” by insurers.

Anyway, all that is to say if they don’t get you with premiums, they get you with inflated costs - or both. We will soon be seeing bankruptcies of people with insurance who can’t pay the bill they got stuck with, much like we see bankruptcies of uninsured patients. The whole thing is an absolute mess and I have been saying for 20 years, the solution needs to start with the inflated prices charged by providers and the relationship between those prices and what insurers pay vs. what uninsured people (and now what insured people with rejected claims) pay.

Fair example here in recent months staying in the same bloodwork vein (ba dum tss). For our current 2025 plan, we pay out of pocket for a pretty high tier family plan to cover myself, my two healthy toddlers, and, at the time, my pregnant wife to introduce spazzyfry 3.0. As a part of that latter bit, routine bloodwork was needed for both myself and my wife for a baby health check. Something we went through with the last two kiddos, no big deal. The provider sent our bloodwork to the incorrect third-party testing facility that, as far as we can tell through our digging, is not covered by any insurance plan on this side of the red white and blue - despite their frequent use of the alternate that anyone would use. We have no say in who they choose, but they absolutely know who is covered by our (and, well everyone's) insurance. Give-a-damn-o-meter was pegging red that day. We're out of pocket to the tune of $2,400 for that blood test. *insert Billy Mayes "but wait there's more!"* There's two of us, so two tests. Make that $4,800! No level of dispute, arguing, anything has amounted to anything. It's left with, "well, man, that's like your opinion" as the work was done and "there's nothing we can do." Blatant F-up at the hand of someone else and we're smoked. Had they checked the box directly beneath the one they did, it would have been sent to the other third party to receive identical quality and would have been covered by my insurance 100% - no co-pay, no impact to deductible, nada.

[Henn28]

It’s going to get worse, before it gets better unfortunately.

[kscarrol]

We've been with Blue Cross Blue Shield for three years now. Can't really complain given they have approved everyone of my wife's cancer treatments, surgeries etc. We have a max out of pocket of $5,600 per person per year and that will be paid January after her first chemo treatment in 2026. After that zero out of pocket for the rest of the year. I don't want to know what they've paid since this journey began in late 2024. 2026 premium went to about $3,700 from $3,500 but we had our oldest graduate from college and get a job with insurance so he is off our plan. Of course if he were on our plan the increase would have been more, likely around $4,200 or a 20% increase.

For anyone considering retiring before 65 (Medicare eligible), be prepared to pay. I'm glad we went with their top tier plan as our youngest is a type 1 diabetic so it was worth paying for the better coverage. Of course that has paid off with my wife's cancer.

[RickFLM4]

Originally Posted by spazzyfry123

Fair example here in recent months staying in the same bloodwork vein (ba dum tss). For our current 2025 plan, we pay out of pocket for a pretty high tier family plan to cover myself, my two healthy toddlers, and, at the time, my pregnant wife to introduce spazzyfry 3.0. As a part of that latter bit, routine bloodwork was needed for both myself and my wife for a baby health check. Something we went through with the last two kiddos, no big deal. The provider sent our bloodwork to the incorrect third-party testing facility that, as far as we can tell through our digging, is not covered by any insurance plan on this side of the red white and blue - despite their frequent use of the alternate that anyone would use. We have no say in who they choose, but they absolutely know who is covered by our (and, well everyone's) insurance. Give-a-damn-o-meter was pegging red that day. We're out of pocket to the tune of $2,400 for that blood test. *insert Billy Mayes "but wait there's more!"* There's two of us, so two tests. Make that $4,800! No level of dispute, arguing, anything has amounted to anything. It's left with, "well, man, that's like your opinion" as the work was done and "there's nothing we can do." Blatant F-up at the hand of someone else and we're smoked. Had they checked the box directly beneath the one they did, it would have been sent to the other third party to receive identical quality and would have been covered by my insurance 100% - no co-pay, no impact to deductible, nada.

One thing my wife employed has as a benefit is something called Health Advocate. They have helped us submit appeals and if the appeals are denied they will try to negotiate with the provider to lower the bill. Can’t say how successful they will be yet but at a minimum they saved me some time and aggravation because talking to either BCBS or providers is very aggravating. I get very aggravated thinking I am paying for BCBS, which has negotiated rates with Quest, but they don’t apply if the claim is rejected. If Quest charged us the BCBS negotiated price and we just had to pay our $1 + BCBS’s $7, ok fine.

[RickFLM4]

Originally Posted by kscarrol

We've been with Blue Cross Blue Shield for three years now. Can't really complain given they have approved everyone of my wife's cancer treatments, surgeries etc. We have a max out of pocket of $5,600 per person per year and that will be paid January after her first chemo treatment in 2026. After that zero out of pocket for the rest of the year. I don't want to know what they've paid since this journey began in late 2024. 2026 premium went to about $3,700 from $3,500 but we had our oldest graduate from college and get a job with insurance so he is off our plan. Of course if he were on our plan the increase would have been more, likely around $4,200 or a 20% increase.

For anyone considering retiring before 65 (Medicare eligible), be prepared to pay. I'm glad we went with their top tier plan as our youngest is a type 1 diabetic so it was worth paying for the better coverage. Of course that has paid off with my wife's cancer.

They also paid for my wife’s knee replacement without an issue and covered the PT to my expectations. BCBS seems good about the “big stuff” which is obviously the most important. But they have become very petty about what would be “little stuff” to them that ends up as a bill to us 10x what BCBS would have to pay.

100% on health care if retiring before 65. My BIL retired without a good plan and is now complaining about how much health insurance costs. Since rates are somewhat tied to age, it has to be super expensive from age 50 or so through Medicare age, and that is not an age bracket to start skimping on coverage.

(I hope your wife is continuing to do well!)

[Esteban]

^ Ditto for kscarrol’s wife.

[kscarrol]

Originally Posted by RickFLM4

(I hope your wife is continuing to do well!)

Thank you but unfortunately that is not the case. Readers Digest version, no sign of the original colon cancer but she now has ovarian cancer.

[RickFLM4]

Originally Posted by kscarrol

Thank you but unfortunately that is not the case. Readers Digest version, no sign of the original colon cancer but she now has ovarian cancer.

Dammit. Really sorry to hear that. She (and you) has been through a lot. Best wishes for her treatments.

[spazzyfry123]

Originally Posted by kscarrol

We've been with Blue Cross Blue Shield for three years now. Can't really complain given they have approved everyone of my wife's cancer treatments, surgeries etc. We have a max out of pocket of $5,600 per person per year and that will be paid January after her first chemo treatment in 2026. After that zero out of pocket for the rest of the year. I don't want to know what they've paid since this journey began in late 2024. 2026 premium went to about $3,700 from $3,500 but we had our oldest graduate from college and get a job with insurance so he is off our plan. Of course if he were on our plan the increase would have been more, likely around $4,200 or a 20% increase.

For anyone considering retiring before 65 (Medicare eligible), be prepared to pay. I'm glad we went with their top tier plan as our youngest is a type 1 diabetic so it was worth paying for the better coverage. Of course that has paid off with my wife's cancer.

As we knew we were going to have a baby, we elected for a top-tier plan with low deductible/OOP ($2000/$3000 for the full family). Higher monthly premium would pay for itself in no time compared to other plans knowing that we would hit deductible. It made sense for 2025 and we planned to scale it back without introducing too much risk for 2026. Now we are looking at increasing our costs to have considerably less coverage.

Originally Posted by kscarrol

Thank you but unfortunately that is not the case. Readers Digest version, no sign of the original colon cancer but she now has ovarian cancer.

So sorry bud. She'll kick cancer's tail!!

[spazzyfry123]

Originally Posted by RickFLM4

One thing my wife employed has as a benefit is something called Health Advocate. They have helped us submit appeals and if the appeals are denied they will try to negotiate with the provider to lower the bill. Can’t say how successful they will be yet but at a minimum they saved me some time and aggravation because talking to either BCBS or providers is very aggravating. I get very aggravated thinking I am paying for BCBS, which has negotiated rates with Quest, but they don’t apply if the claim is rejected. If Quest charged us the BCBS negotiated price and we just had to pay our $1 + BCBS’s $7, ok fine.

Before my employer swapped over to the current health insurance company, I had used Health Advocate as well (also BCBS then, now employer uses United). It was a bit hit or miss for us as we had a nightmare of a time at the tail end of 2024 as I transitioned to my current employer juggling Cobra, BCBS, and providers incorrectly telling us in-network vs out-network while my wife was going through some unfortunate health issues. In concept it seemed great, but I feel we had to get through two or three tiers of pay grade before we got to something of substance to support. I don't even want to know how many hours my wife and I spent bouncing through that mess. It definitely wasn't the difference of $1 and $7 with the hospital stays

[Watching The World Burn]

So I naturally pay nothing for healthcare, but the offset is that I will wait much longer to receive it that you Americans will. Still, I won't go bankrupt which is a plus...assuming I don't die while waiting. That said, once you are in the system, it moves pretty quickly and well from what I understand...its getting the initial visit that can be time consuming.

Is there any good solution here though? On one hand, free healthcare, but you have to wait to receive it. On the other, insurance companies will dictate the care you receive, charge significant premiums, and you can have screw ups that can cause you to go bankrupt, but you will receive timely health care and hopefully live.

I have honestly wondered (though I haven't looked into it) what the insurance premiums are for Americans - anyone want to share what the monthly costs are and the portion if any funded by your employer so I know the actual cost assuming no payment by anyone other than me? The notion in my head is as I age, what if the premiums were reasonable and I took out insurance in America so that if the wait was too long in Canada, I just go to America and make use of the insurance. Not even certain I could do that if I'm not resident there - maybe I'm not insurable. But the idea is there.

[spazzyfry123]

Originally Posted by Watching The World Burn

So I naturally pay nothing for healthcare, but the offset is that I will wait much longer to receive it that you Americans will. Still, I won't go bankrupt which is a plus...assuming I don't die while waiting. That said, once you are in the system, it moves pretty quickly and well from what I understand...its getting the initial visit that can be time consuming.

Is there any good solution here though? On one hand, free healthcare, but you have to wait to receive it. On the other, insurance companies will dictate the care you receive, charge significant premiums, and you can have screw ups that can cause you to go bankrupt, but you will receive timely health care and hopefully live.

I have honestly wondered (though I haven't looked into it) what the insurance premiums are for Americans - anyone want to share what the monthly costs are and the portion if any funded by your employer so I know the actual cost assuming no payment by anyone other than me? The notion in my head is as I age, what if the premiums were reasonable and I took out insurance in America so that if the wait was too long in Canada, I just go to America and make use of the insurance. Not even certain I could do that if I'm not resident there - maybe I'm not insurable. But the idea is there.

Them taxes though...

That's an awfully big can of worms. There are a zillion options to choose from with a variety of risk tolerance to navigate. Assuming no government subsidies which are, generally speaking, income driven, you could be ranging anywhere from $1600 to $3000+ a month on premiums alone if looking at a family to insure. As the premium increases, the deductible/max out of pocket tend to decrease.

So you could drop $1800/mo to get an insurance card with your name on it, but you may have to spend $15,000 (random number - again a zillion options to choose from) before you meet the deductible before insurance benefits even kick in. Which with a "lower" premium, generally means only a percentage of what is billed will be covered once you meet your deductible. So in that case, you'd need to spend your $1800/mo, but then still have to pay 100% of whatever the bills amount to until you've spent $15,000 out of pocket. At that point, the coverage may deem that insurance will then start paying 40% of whatever the bills are. Insurance will pay that until you have met your personal out-of-pocket maximum - in this example is $25,800. Only once you have paid $25,800 out of pocket in addition to the $1800/mo you are spending, then insurance will cover 100% of the bill thereon. The $1800/mo could be $3000/mo. In which the $15,000 deductible/$25,800 max OOP could turn into $2500 deductible/$5000 max OOP.

Then there's the myriad of terms depending on what it is you are doing. An urgent care visit could have a $100 fixed copay plus whatever out of pocket you need to meet to get you in the door. But a general doctors visit for routine stuff could be 50% of the cost...or a flat $40 copay...or $0.

Or you may need to look into having a coinsurance in addition to your primary insurance.

As you shop for these plans, there are comparison tools and cost estimators to help you support. It will give a generalized cost estimate of what to expect to spend after you answer some questions of your expected use (high use like cancer, or low use for a young, healthy family). My situation lands in the latter thankfully, but it still tells me to expect to spend $40k+ a year for health related costs. And we're talking about just to have insurance so that my family can go to routine check ups with maybe the one off of taking a kid to the urgent care because they need stitches because they fell out of the tree they were climbing.



Regardless, I don't know if that would even be an option given that you aren't a US citizen. I honestly have no idea, but given that part of the application process asks questions surrounding citizenship, social security details, etc...

[Watching The World Burn]

Originally Posted by spazzyfry123

Them taxes though...

That's an awfully big can of worms. There are a zillion options to choose from with a variety of risk tolerance to navigate. Assuming no government subsidies which are, generally speaking, income driven, you could be ranging anywhere from $1600 to $3000+ a month on premiums alone if looking at a family to insure. As the premium increases, the deductible/max out of pocket tend to decrease.

So you could drop $1800/mo to get an insurance card with your name on it, but you may have to spend $15,000 (random number - again a zillion options to choose from) before you meet the deductible before insurance benefits even kick in. Which with a "lower" premium, generally means only a percentage of what is billed will be covered once you meet your deductible. So in that case, you'd need to spend your $1800/mo, but then still have to pay 100% of whatever the bills amount to until you've spent $15,000 out of pocket. At that point, the coverage may deem that insurance will then start paying 40% of whatever the bills are. Insurance will pay that until you have met your personal out-of-pocket maximum - in this example is $25,800. Only once you have paid $25,800 out of pocket in addition to the $1800/mo you are spending, then insurance will cover 100% of the bill thereon. The $1800/mo could be $3000/mo. In which the $15,000 deductible/$25,800 max OOP could turn into $2500 deductible/$5000 max OOP.

Then there's the myriad of terms depending on what it is you are doing. An urgent care visit could have a $100 fixed copay plus whatever out of pocket you need to meet to get you in the door. But a general doctors visit for routine stuff could be 50% of the cost...or a flat $40 copay...or $0.

Or you may need to look into having a coinsurance in addition to your primary insurance.

As you shop for these plans, there are comparison tools and cost estimators to help you support. It will give a generalized cost estimate of what to expect to spend after you answer some questions of your expected use (high use like cancer, or low use for a young, healthy family). My situation lands in the latter thankfully, but it still tells me to expect to spend $40k+ a year for health related costs. And we're talking about just to have insurance so that my family can go to routine check ups with maybe the one off of taking a kid to the urgent care because they need stitches because they fell out of the tree they were climbing.



Regardless, I don't know if that would even be an option given that you aren't a US citizen. I honestly have no idea, but given that part of the application process asks questions surrounding citizenship, social security details, etc...

Wow. Thanks for taking the time to respond, but I'm still a little shocked at the premium. I mean I knew it would likely be significant, but if say we went with the top end of your range, that's $36K / year just for insurance, never mind the copays, deductible, etc that you would also need to account for on an annual basis.

I would say Canada is relatively decent for cancer treatment, there are mandated times in which you have to be seen (but again, first has to be proven to be cancer and that's where you can get lost). But I'd now have to consider what the actual cost might be out of pocket for the procedure vs insurance - basically consider the self funding model.

Not a model I'd recommend for Americans, its only that I have the luxury of a backup being the health care system in Canada. Though I will be the first to admit that the system here is essentially broken or nearing that...the very reason it hasn't quite yet is the heroic efforts of doctors to try to hold it together and make calls to each other to go through back channels to get people treated and advocate for them. But eventually they will burn out, they can't continue like this. I don't know what happens then to be honest, but I expect it to happen in my lifetime.

It's a crazy thing, but I don't think the Americans or us have it figured out - neither strikes me as an ideal system. At the same time, not certain you could even strike a balance between the two systems either and call it better...they are pretty much opposites of each other in most regards.

[spazzyfry123]

Originally Posted by Watching The World Burn

Wow. Thanks for taking the time to respond, but I'm still a little shocked at the premium. I mean I knew it would likely be significant, but if say we went with the top end of your range, that's $36K / year just for insurance, never mind the copays, deductible, etc that you would also need to account for on an annual basis.

I would say Canada is relatively decent for cancer treatment, there are mandated times in which you have to be seen (but again, first has to be proven to be cancer and that's where you can get lost). But I'd now have to consider what the actual cost might be out of pocket for the procedure vs insurance - basically consider the self funding model.

Not a model I'd recommend for Americans, its only that I have the luxury of a backup being the health care system in Canada. Though I will be the first to admit that the system here is essentially broken or nearing that...the very reason it hasn't quite yet is the heroic efforts of doctors to try to hold it together and make calls to each other to go through back channels to get people treated and advocate for them. But eventually they will burn out, they can't continue like this. I don't know what happens then to be honest, but I expect it to happen in my lifetime.

It's a crazy thing, but I don't think the Americans or us have it figured out - neither strikes me as an ideal system. At the same time, not certain you could even strike a balance between the two systems either and call it better...they are pretty much opposites of each other in most regards.

Here's an exact offering that's on my screen right now as reference. Insuring myself, wife, and three kids.

$2,936.19/mo premium
$2,000 deductible ($40,000 if we go out of network of what the insurance covers)
$3,000 max out of pocket (there is no maximum spend if out of network)
$0 copay for typical visits
20% covered for specialty visits, imaging, lab work, ER, etc. after you meet your deductible (until you meet the max out of pocket

So in this example, we should expect to pay a hair over $38k in the year at most, but a hair over $35k at a minimum.

Or if we go in the opposite direction and focus on a smaller monthly premium at the expense of a higher risk should something go sideways and we need serious healthcare (car accident, surgery, etc.)

$1,602.37/mo premium
$19,000 deductible (100% cash with no insurance support if we go out of network)
$20,300 max out of pocket (100% cash if out of network)
50% of whatever the bill is regardless of what the visit is for, but only once I meet my deductible - 100% of the cost lands with me until we meet the $19,000 deductible

So in this example, we will be a hair over $19k for the year at a minimum assuming we do absolutely zero related to actual healthcare visits. That's just to get the card with our name on it. But we will need to then spend another $19k to even begin to see any type of support from insurance as 100% of all bills have to be paid by us until we meet that deductible. This is with the expectation that we would spend a maximum of a bit over $39k in the year. Could be a "good" option for a healthy family that doesn't use healthcare to "only" spend $19k a year. But for what? Just to have the safety net is really all it is knowing that if something catastrophic happened you'll max out at $39k. Which I suppose is the nature of any type of insurance, but Christ...

[Watching The World Burn]

Originally Posted by spazzyfry123

Here's an exact offering that's on my screen right now as reference. Insuring myself, wife, and three kids.

$2,936.19/mo premium
$2,000 deductible ($40,000 if we go out of network of what the insurance covers)
$3,000 max out of pocket (there is no maximum spend if out of network)
$0 copay for typical visits
20% covered for specialty visits, imaging, lab work, ER, etc. after you meet your deductible (until you meet the max out of pocket

So in this example, we should expect to pay a hair over $38k in the year at most, but a hair over $35k at a minimum.

Or if we go in the opposite direction and focus on a smaller monthly premium at the expense of a higher risk should something go sideways and we need serious healthcare (car accident, surgery, etc.)

$1,602.37/mo premium
$19,000 deductible (100% cash with no insurance support if we go out of network)
$20,300 max out of pocket (100% cash if out of network)
50% of whatever the bill is regardless of what the visit is for, but only once I meet my deductible - 100% of the cost lands with me until we meet the $19,000 deductible

So in this example, we will be a hair over $19k for the year at a minimum assuming we do absolutely zero related to actual healthcare visits. That's just to get the card with our name on it. But we will need to then spend another $19k to even begin to see any type of support from insurance as 100% of all bills have to be paid by us until we meet that deductible. This is with the expectation that we would spend a maximum of a bit over $39k in the year. Could be a "good" option for a healthy family that doesn't use healthcare to "only" spend $19k a year. But for what? Just to have the safety net is really all it is knowing that if something catastrophic happened you'll max out at $39k. Which I suppose is the nature of any type of insurance, but Christ...

So I guess with option 1 you will at least spend $35K each year regardless of whether you need it or not, and you *could* spend another $3K that year if something bad were to happen.

With Option 2, you will spend at least $19K each year regardless of whether you need it with the possible exposure of needing $20K saved up in the event that something bad were to happen.

The savings on an annual basis for option 2 is $16K without considering deductible.

However, with option 2, essentially all costs fall on you up and until you spend $20K, assuming you stay in your network. On the flip side, option 1 does require you to spend between $2-3K before it kicks in...so perhaps you look at your exposure being $17K instead of the $20K above - you'd be spending the first $3K either way in each plan if something bad happens.

Seems to me if you are young and expect to be healthy, you should plan financially for option 1, but choose option 2 and put the difference of $16K on the base plan into investments. And then continue to put the difference between the two plans each continuing year and earn investment income on it.

That assumes though that said issue is dealt with within one year and not spanning multiple years, although realistically, you would hopefully have enough saved by then to cover multiple years.

Interesting conundrum though. Leaves me wondering how much lower taxes really are and if they can really cover the difference. Maybe.

[RickFLM4]

Originally Posted by Watching The World Burn

So I naturally pay nothing for healthcare, but the offset is that I will wait much longer to receive it that you Americans will. Still, I won't go bankrupt which is a plus...assuming I don't die while waiting. That said, once you are in the system, it moves pretty quickly and well from what I understand...its getting the initial visit that can be time consuming.

Is there any good solution here though? On one hand, free healthcare, but you have to wait to receive it. On the other, insurance companies will dictate the care you receive, charge significant premiums, and you can have screw ups that can cause you to go bankrupt, but you will receive timely health care and hopefully live.

I have honestly wondered (though I haven't looked into it) what the insurance premiums are for Americans - anyone want to share what the monthly costs are and the portion if any funded by your employer so I know the actual cost assuming no payment by anyone other than me? The notion in my head is as I age, what if the premiums were reasonable and I took out insurance in America so that if the wait was too long in Canada, I just go to America and make use of the insurance. Not even certain I could do that if I'm not resident there - maybe I'm not insurable. But the idea is there.

Our health insurance costs about $20K/year for my wife and me (no dependents). We pay about 40% and employer pays about 60% of that premium. $1,000 deductible (each) and $8K combined max out of pocket. Standard 20% copay unless/until max OOP is reached. Rx depends on “tier” but in general $10/mo. unless you use mail order (which we don’t due to hot weather in summers). Certain screening tests are covered 100% by law (e.g., colonoscopies, mammograms, etc.). All amounts noted are for in network providers. We would not entertain going out of network because costs are much higher. Separate policies for dental and vision.

Per my earlier post, if a claim is denied by insurer, we are responsible for “full” (inflated) cost of provider and it will not count towards deductible or max OOP.

Our premiums are not impacted by age because it is through her employer. Premiums for individual insurance would be impacted by our age (late 50s) and would almost certainly be much higher.

[RickFLM4]

Originally Posted by Watching The World Burn

So I guess with option 1 you will at least spend $35K each year regardless of whether you need it or not, and you *could* spend another $3K that year if something bad were to happen.

With Option 2, you will spend at least $19K each year regardless of whether you need it with the possible exposure of needing $20K saved up in the event that something bad were to happen.

The savings on an annual basis for option 2 is $16K without considering deductible.

However, with option 2, essentially all costs fall on you up and until you spend $20K, assuming you stay in your network. On the flip side, option 1 does require you to spend between $2-3K before it kicks in...so perhaps you look at your exposure being $17K instead of the $20K above - you'd be spending the first $3K either way in each plan if something bad happens.

Seems to me if you are young and expect to be healthy, you should plan financially for option 1, but choose option 2 and put the difference of $16K on the base plan into investments. And then continue to put the difference between the two plans each continuing year and earn investment income on it.

That assumes though that said issue is dealt with within one year and not spanning multiple years, although realistically, you would hopefully have enough saved by then to cover multiple years.

Interesting conundrum though. Leaves me wondering how much lower taxes really are and if they can really cover the difference. Maybe.

Yes, generally those younger and healthier choose high deductible, which also lets you fund a tax-advantaged account to pay OOP costs. As you age or have health issues (or children) it often makes sense to opt for the certainty of the lower deductible / lower max OOP.

There are also different types of plans (PPO vs. HMO, among others) that affect the network you can access and how you can access care. With a PPO you generally can just see any provider in the network without a provider referral. In some cases, procedures need to be pre-approved to ensure coverage (e.g., my wife’s knee replacement). Access is generally good to great in cities and suburban locations.

[Watching The World Burn]

Originally Posted by RickFLM4

Our health insurance costs about $20K/year for my wife and me (no dependents). We pay about 40% and employer pays about 60% of that premium. $1,000 deductible (each) and $8K combined max out of pocket. Standard 20% copay unless/until max OOP is reached. Rx depends on “tier” but in general $10/mo. unless you use mail order (which we don’t due to hot weather in summers). Certain screening tests are covered 100% by law (e.g., colonoscopies, mammograms, etc.). All amounts noted are for in network providers. We would not entertain going out of network because costs are much higher. Separate policies for dental and vision.

Per my earlier post, if a claim is denied by insurer, we are responsible for “full” (inflated) cost of provider and it will not count towards deductible or max OOP.

Our premiums are not impacted by age because it is through her employer. Premiums for individual insurance would be impacted by our age (late 50s) and would almost certainly be much higher.

Presumably there is a way to determine whether the claim will be denied by the insurer though before doing that procedure? I assume so at least - otherwise you are stuck playing a medical /financial version of russian roulette.

[RickFLM4]

Originally Posted by Watching The World Burn

Presumably there is a way to determine whether the claim will be denied by the insurer though before doing that procedure? I assume so at least - otherwise you are stuck playing a medical /financial version of russian roulette.

Sometimes…

In some cases, it is obvious a charge will not be covered and the provider tells you (e.g., anything deemed “cosmetic”).

In others, you could technically find out by having the provider explain what will be charged and how it will be presented to the insurer and then either go through a long list of insurance company detailed rules to make your own determination/guess or call the insurer to find out in advance. Doing so sounds much easier said than done, so there is opportunity for surprises per my earlier (simple) example about lab work.

Generally for anything very significant, such as non- emergency surgery, the provider will obtain pre approval.

[dreamingat30fps]

It's getting ridiculous. I'm self employed so I have to buy my own insurance. I have BCBS and my plan is going from like $560/mo to like $780. They already did this a couple of years ago which is why I downgraded to the $560 plan back then and now they are doing it again. Plus this plan has a fairly high deductible and max out of pocket.

My main issue is I take one very expensive medication and I live in FL and NC so I need a plan that will cover me in both places. A lot of the cheaper plans will only cover FL doctors. I'm really over this crap every year.