Health Insurance(in IL) options : what should I do?

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Hello,

So I'm not healthy but I don't have a specific diagnosis (neurological/neuro-muscular, ALS & MS had been ruled). As you can imagine, due to the expensive nature of CT/MRI/EEG/emergency room visits/etc, I decided to continue paying for insurance with a low deductible after I got laid off. I don't really go to the hospital and didn't until I got sick, I just stopped when most tests and certain diseases came back negative. I just monitor things myself but go in for routine tests/checks.

I also have some routine stuff (endoscopy & colonoscopy, mammogram etc) to do that I've put off in order to avoid paying the deductibles in 4 years I've been self-pay.....yes, a choice I regret now. My job doesn't provide insurance & I had to travel a lot for work this year which is why I didn't get some of these things done this year as planned.

I currently have a BCBS Gold Plan @ $375, $500 ded, 30% Copay, which is discontinued and these are my options for the 2017 on average

1) PPO Bronze: $380, $7000 ded, max $7100, 50% Copay
2) PPO Silver: $498 $3000 ded, max $7100, 30% Copay
3) PPO Gold: $592, $1750 ded, max $3100, 20% Copay
4) HMO Platinum, $588, $250 ded, max $3000, , 20% Copay

- I've always avoid HMO because most providers don't accept it & I need the flexibility given the nature of my problems to bypass my PCP and go see a specialist.
- I've always gone with a low deductible, so I'm used to the high premiums but the problem is now high premium, but deductibles & copay are astronomical.

Is it worth the extra $200/month to switch to HMO? How about $125 to downgrade to Silver? Or just downgrade to Bronze at cost?
 
I'm trying to run some hypothetical numbers to see if it worth it but its hard to estimate costs. Since its been 8 years, I was planning to get the endoscopy & colonoscopy done this year.

If I estimate a cost of $2K each
1) Bronze PPO : $0    * 12 new premium rates + 7000 ded = I pay $4000 OOO
2) Silver PPO   : $125 * 12 new premium rates + 3000 ded = I pay $4800, $4500 + $300 copay of $1000(4000-3000) balance
3) Gold PPO    : $212 * 12 new premium rates + 1750 ded = I pay $4844, $4294 + $450 copay of $2250(4000-1750) balance
4) HMO           : $200 * 12 new premium rates +   250 ded = I pay $3400, $2650 + $750 copay of $3750 (4000-250) balance

In this scenario, Silver & Gold is worthless cos I would actually pay more than $4K.

If I estimate a cost of $3K each
1) Bronze PPO : $0    * 12 new premium rates + 6500 ded = I pay $6000 OOO
2) Silver PPO   : $125 * 12 new premium rates + 3000 ded = I pay $5400, $4500 + $900 copay of $3000(6000-3000) balance 
3) Gold PPO    : $212 * 12 new premium rates + 1750 ded = I pay $5144, $4294 + $850 copay of $4250(6000-1750) balance
4) HMO           : $200 * 12 new premium rates +   250 ded = I pay $3800, $2650 + 1150 copay of $5750(6000-250) balance

Am I estimating this correctly? HMO would payoff if the costs of procedures are high.  Silver & Gold are so close that is seems like my choices are Bronze or HMO. I either get (1)  Bronze and don't do anything or get (4) HMO and make sure I do everything this year.  How does HMO work if I have travel (for work) to another state and get sick?

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If you are laid off with no income, why aren't you on medicaid?

atikovi said:   If you are laid off with no income, why aren't you on medicaid?
    I'm not laid off. I had insurance with my employer (got laid off 4 years ago) but now my new one doesn't provide health insurance hence self-pay.

As you are seeing, anything above Bronze is priced so that the higher premiums basically match the higher amount paid in coverage. The only reason I can see to go with anything higher is if you have a subsidy to reduce the premium.

Having no subsidy I have never chosen anything other than Bronze. Unfortunately, this year I was forced into an HMO (there are no PPO plans in this year's list here) so I have to deal with the gatekeeper garbage. I don't have much use for a PCP and will just have to waste time and money on such visits.

picghaw said:   my new one doesn't provide health insurance hence self-pay
 

  Ya left that out. No government subsidy you could qualify for?

atikovi said:   
picghaw said:   my new one doesn't provide health insurance hence self-pay
  Ya left that out. No government subsidy you could qualify for?


  I did mention it in the 2nd paragraph, but I know my OP is very long. I can't qualify for subsidy cos I make too much.

LorenPechtel said:   As you are seeing, anything above Bronze is priced so that the higher premiums basically match the higher amount paid in coverage. The only reason I can see to go with anything higher is if you have a subsidy to reduce the premium.

Having no subsidy I have never chosen anything other than Bronze. Unfortunately, this year I was forced into an HMO (there are no PPO plans in this year's list here) so I have to deal with the gatekeeper garbage. I don't have much use for a PCP and will just have to waste time and money on such visits.

 Yes, I am shocked since I've always gone for higher premiums in favor of low deductible just in case I had to run numerous tests. In one scenario above, getting a Silver plan was going to cost more money than Bronze.

Another sticking point is that I utilize a lot of natural remedies, organic eating, "being my own doctor" etc, so I really haven't used this expensive insurance that I've been paying for. I wanted to go ahead and do all routine checks that I've postponed but paying more than $400 feels like a waste at this point. I have to make the selection by 12/31 (special circumstance since current plan is discontinued) to start on 1/1/17 so I am leaning towards Bronze.

Could I change my mind and switch within the enrollment period or do I only get 1 chance to change? Thanks.

Another thing...so HMO doesn't cover "Out of Network" only emergency? What if you're out of state and get sick?

picghaw said:   Another thing...so HMO doesn't cover "Out of Network" only emergency? What if you're out of state and get sick?
  If it's bad enough you need medical attention that's what "emergency" is about.  Mine at least provides a nurse line that will give you directions as to what to do--and it's binding on them (if the nurse line tells me to go to the ER the ER is covered.)

How much do you actually consume in healthcare annually?

TravelerMSY said:   How much do you actually consume in healthcare annually?
  I don't consume much which is why I don't want to pay more than the $375 I already do . In the 4 years that I've been self-pay, I've only done a few routine checks recommended by the neurologist and I had some cardio tests(stress test, echo-cardiogram, heart monitor for 30 days) done last year. What seems to happen is when I do use it, its always for a lots of expensive tests.

Insurance is also for unexpected events. Get in a car wreck or have a cardiac event and you could face 5 or 6 figure hospital and doctor bills.

I'm leaning towards the Bronze PPO plan that is HSA eligible, I'm very nervous but the next logical choice is $588 for HMO. Since on average I don't use the insurance, I'll rather save the money and pay when I do use it. 

It looks like I can open my own HSA account, fund it and claim it as a deduction on my taxes? Does that sound right? I've spent days looking on this.

 

atikovi said:   Insurance is also for unexpected events. Get in a car wreck or have a cardiac event and you could face 5 or 6 figure hospital and doctor bills.
  I know. I'm going to get insurance, going without is not an option for me.

The quandary is what level since $400 gets me the minimum and I've always paid for Gold/Platinum..but also There's no Gold/Platinum PPO just HMO. Thanks.

The premium is 100% deductible if you're self employed. Might start a side business just for this perk. And personally, if I made so much that I didn't qualify for a subsidy, I'd just consider it another life expense.

atikovi said:    And personally, if I made so much that I didn't qualify for a subsidy, I'd just consider it another life expense.
  Not necessarily. For example a Single person making $40K doesn't qualify and so its not really a matter of making so much.

But the side business idea is something to think about.....



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