OH ANOTHER. What insurance DOES cover. Lookin at you fertility. Esp when it’s secondary to health issues like cancer, or you’re a same sex couple or single parent by choice. Soooo hard to get answers.
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I think it would be worthwhile to tell people what HIPPA is, and why it’s important.
Alternate path, just advise people to join the military, or the foreign service. Great benefits, lots of travel, some sand.
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So I’ve been reading this, but I don’t even really know where to start.
Difference between a high deductible plan, and an HMO, maybe?
Discussion of Medicaid expansion and lack there of? This may be a bit of a problem with the long lead up time to publication, because I expect a list of states that have not expanded will change.
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I think this is actually three questions… What is a premium, deductible, coinsurance, copay, HSA, FSA, and out of pocket max? How to find out which are applicable to my plan? (all this describes the payment structure of the plan)
And what is a PPO, HMO, and EPO? (these designate what doctor you go can see)
In theory, at least, there is no reason you can’t have a high deductible HMO.
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In theory, you’re right(I think). Not sure a copay model would be legal in a HDHP; I guess if it didn’t kick in until after the deductible is met.
If this were fiction, no one would find such a stupidly complicated system believable. And that’s even before you get into how broken it is.
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Yea, most HDHPs have a copay after deductible is met, and they’re allowed to have co-pays prior to deductible if it’s for preventive Essential Health Benefits under the ACA. Additionally, 64% of employees in the US are actually under federal self-insured employer plans which are not bound by the ACA in the same way.
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Ha! Not the best option, because if you’re disabled or chronically ill, the military or foreign service won’t take you anyway 
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Seriously, this is gonna be DARK book thus far.
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I found this part of it incredibly confusing when I tried to apply for an ACA plan back in 2020 after finishing grad school and found the application really hard to navigate for anyone without just like, one single stable source of annual income. Tried to apply by guessing what my annual income would end up being based on a job I knew I would be starting but hadn’t started yet, then after talking to a navigator realized that’s not how you’re supposed to do it and that because I technically had 0 income only for the specific month in which I happened to be applying, I qualified for Medicaid (and thus wasn’t able to apply for ACA plans). The whole thing was a pain and took two months to sort out and get approved, by which time I had income again and technically no longer qualified.
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This is how I got on Medicaid! My postdoc ended and I was trying to get an ACA exchange plan and it was like “you’re not eligible” and I freaked out until they were like “nah you’re not allowed to pay money for your insurance”
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Huh. I’ve always had a percentage of cost covered after deductible, not a co-pay. Didn’t know some had co-pays.
Self insured plan here, and state, so I guess it might well be exempt from some of the requirements of the ACA, but I’ve not found the exceptions yet. I’m sure I hope I never do.
My HDHP has some co-insurance and some co-pays just to keep it spicy.
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This is bad spicy. BAD SPICE.
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Nerdy deets ahead that probably won’t make it into the book.
Self-funded non-federal governmental plans are super interesting because they’re actually regulated entirely differently than commercial private plans. Only a small part of the ACA actually applies - technically the ACA modifies Part A of title XXVII of the PHS Act, which is the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Non-Federal governmental plans may still opt-out of certain provisions of the PHS Act including the some portions of the ACA. But they are not allowed to be exempt from most of the things we associate with the ACA: restrictions on annual limits, pre-existing conditions, and other provisions of the Patient’s Bill of Rights.
The things that non-federal self-funded plans can opt-out of:
- Standards relating to benefits for newborns and parents (Newborns and Mothers Health Protection Act of 1996);
- Parity in the application of certain limits to mental health and substance use
disorder benefits (Mental Health Parity and Addiction Equity Act of 2008); - Required coverage for reconstructive surgery following mastectomies
(Women’s Health and Cancer Rights Act of 1998); - Coverage of dependent students on a medically necessary leave of absence Michelle’s Law, 2008.
Essentially, all self-funded plans are not required to provide into the “essential health benefits” (fun fact, it was their lobbying that allowed them to remove drugs that treat autoimmune disorders from the cost-sharing limitations for preventative drugs). Many self-funded plans modify or opt-in “ESB Benchmark plans”.
However, if they do provide such benefits, they are prohibited from placing lifetime dollar limits on them. Specific covered services that are not EHBs are not subject to the prohibition on lifetime limits for a self-funded plan.
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I have a question I’m hoping someone can chime in on sooner rather than later, as it may impact decisions I need to make in the next little while. I was just reading something that suggests that ACA plans in states which have not expanded Medicaid are of poorer quality than plans in states with Medicaid expansion. Is this true?
I haven’t seen any studies that show that, I think it depends on what you define as poor quality - all ACA plans will be compliant with the ACA.
Many of the states without medicaid expansion have health care access issues that extend beyond insurance plans, due to concentrations of wealth in cities, and high poverty rates in rural areas. Residential segregation is more common in many of the southern non-expansion states due to the history of Jim Crow laws, which impacts access to hospitals and providers. This can make plans worse because there’s fewer in-network providers. Without medicaid expansion, in high poverty counties (which are mostly rural in the US), there’s little incentive for providers to move to those counties.
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Yep.
Yep.
Yep.
Yep.
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(Please ignore code issues above. Internet is more complicated, too and right now I’m depending on a low-quality Wi-Fi hotspot from the public library because storms took out our home Internet last night.)
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I’ll fix that for you 
Hope your internet issues get fixed!
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Thanks! That should basically be one yep per sentence you wrote…
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