I had another conversation today with a client about the cost of health insurance and how she feels that she cannot get her value out of the current plans available.
She does not qualify for a tax credit to offset the premium cost through an ObamaCare exchange.
In 2021, most Bronze plans are increasing the max out of pocket limits to $8,550, and the deductible is frequently more than $6,000.
It’s fantastic that we can have access to guaranteed issue plans through a health insurance exchange or marketplace for those of us who are self-employed or do not have access to a
company-based group plan. However, in most cases a healthy person will not meet a $6,000 deductible; so, for the expense, it hurts to only get the value of a free annual physical or mammography exam in a given calendar year.
And in the Denver, Colorado and Milwaukee/Madison, Wisconsin metro areas, a self-employed person usually cannot qualify for a tax credit due to the income threshold being so low and the cost of living being relatively high.
Furthermore, when a healthy person has a sizable claim, it is usually due to an injury accident (think skiing, mountain biking, falling off of a ladder or falling off of a horse, etc — ATVing!!).
- An ACL reconstruction might cost about $40,000 once you get the imaging done, then surgery and rehab.
- A meniscus scope would probably go $10,000. Two-day hospital stay with a head injury — $25,000 – $50,000 depending on whether or not there is an ICU stay.
The pain of these claims is somewhat blunted by the $8,550 maximum that you might be left with as your responsibility. Still, that’s a lot of cabbage…
For healthy people, about 85% of claims that I see are due to an injury accident.
What to do?
I’m a big fan of health insurance for healthy people… Yes, it exists in most states, certainly in Colorado and Wisconsin — off of the healthcare.gov and connectforhealthco.com exchanges.
I’ve been on a plan like this for more than eight years.
For those who can qualify, you will likely find that your monthly premium is reduced by 25 – 35%. Your max out of pocket can be as low as $500 — in the case of an injury accident (like above).
Even a greater value for families with kids involved in youth and school sports.
How is this possible? Built-in accident rider, or more specifically, accident supplement.
There is an off-exchange plan available which includes a built-in accident rider that pays your deductible in the case of an injury accident. The rider itself has a $500 deductible, so that’s how you end up with only a $500 out of pocket responsibility were you to need an ACL reconstruction due to a fall on the ski hill or an injury playing basketball or soccer.
Yes, you’re covered for heart attack, stroke, cancer or covid — things not injury accident related. In those cases the $5,000 deductible would apply.
What else is included before the deductible is met?
- Subsidized primary care office visits — five per year; subsidized urgent care access;
- Wellness/preventative inclusion; (5) chiropractic visits per year up to $100/each;
- Most generic meds under $10 — no cost; and most brand name meds under $50 — no cost.
- Over 90% of physicians/specialists/surgery centers and hospitals in the U.S. are IN Network.
In the past year, I’ve reconciled (2) $400,000 claims — one for a lacerated kidney on the ski hill and another for a teenager in a vehicle accident. Each left a $500 responsibility. Numerous other knee, ankle and wrist injuries. Broken clavicles happen a lot for mountain bikers. Always with a $500 responsibility.
Some cancer, too, unfortunately, as well as emergency appendectomies and sarcoidosis and COPD diagnoses — where the $5,000 deductible would apply.
Choose network access through Cigna PPO or UnitedHealth ChoicePlus PPO. This is an unlimited benefit plan, meaning that no matter how large your claim, the benefit will not run out.
Call me: 303.579.6397 (Boulder, CO) or 262.899.0052 (Waukesha, WI)