I know this topic comes up from time to time so here's a real-world comparison for ya. Our employer-sponsored family health insurance runs out at the end of the month so DH and I looked at both ACA and a Health Share program. For a family of four, the premiums for the Bronze plan vs the comprehensive health share plan was $960 vs $800/mo. (This is for non-tobacco users and no preexisting conditions, and this is without dental coverage.) I think the health share is better on the numbers overall, as the deductible is 5k vs 17k and the copays very low--$35/$60. They do have a $99 application fee. There was an odd issue about a 60-day waiting period for seeing a doctor and/or specialist. The rep explained this was to dissuade people from hopping on their plan and then quitting right after they saw their specialist, or something like that.
So the health share is a significant although not huge savings over ACA. If it were all up to me I'd probably give the health share a try but we decided to go with ACA mostly because DH has philosophical issues with a plan that selects for the healthiest people (the rep herself mentioned this as their goal). The rep said the rates are determined by age (we are 40s). Another interesting thing to me was that the rep never brought up religion even though it features fairly prominently on their website. We are members of a church ourselves. I think I will ask my pastor who is also a friend if he is on a health share plan himself.
Health Share vs ACA
Re: Health Share vs ACA
It looks like the ACA subsidies will be increased for the next two years as part of Biden's plan.
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wheatstate
- Posts: 98
- Joined: Thu Aug 25, 2011 4:51 am
Re: Health Share vs ACA
This is a great topic and one important for the retirement community.
I don't have specific advice to your position, because I feel mine is different and I don't know if you are hitting your deductible/"health share"
When going into this some key decisions: single/family, subsidy/unsubsidized, hit deductible / don't, risk tolerance
Difference: you and your family vs me(single male)
Key Question as you talk to people in healthshare: How quickly is the health share paying medical bills?
In theory, I love a healthshare with less insurance regulation. In reality, I am nervous about their ability to pay my medical bills promptly.
For 4 years (2016-2019), I did Liberty Health Share. It started out at $200/month with $55 going to subsidize all my Direct Primary Care (DPC) / primary care physician membership. "Deductible"/co-share was around $1000. I never hit my deductible/co-share. I like a DPC for the small stuff on either insurance option. This shifted to $250/month with $40 reimbursement to DPC for the 2nd-4th years. In the 4th year, Liberty fell 10 months behind in reimbursement of DPC fees ($400 = $40x10 months). Their customer service was apparently overwhelmed and overloaded. They were a nightmare to get action and slow. I ended up getting the DPC fees back over the next 6 months, but I had lost confidence in Liberty's ability to pay for a serious $10k+ medical bill promptly. The reviews online were horrible for Liberty paying medical bills.
In that time, I decided to shift to a high-deductible, short-term traditional insurance. $10k deductible, doesn't meet ACA requirements, but no penalty, $90/month. Short-term, so they can drop you at the end of the year if you are racking u a bills. In this situation, you would sign up for ACA.
A bronze ACA plan is about $450/month unsubsidized in my state with a $6k deductible for one 40-something male. This seems like a lot being healthy, and unlikely to have a claim / hit deductible.
My summary would be:
If you are young and healthy, either is good. Recognize the additional risk that a health share can reject a claim.
If you have preexisting conditions and will hit deductible, ACA is probably better because a claim cannot be subjectively denied.
If you get a significant subsidy, a ACA plan is probably best.
It you don't get subsidy, have some risk tolerance and are healthy, a health share could be good option.
Thanks for bringing this up. I am curious what solution you find. I am also interested in other people's solutions. Has anyone had a health share and gotten significant bills paid?
I don't have specific advice to your position, because I feel mine is different and I don't know if you are hitting your deductible/"health share"
When going into this some key decisions: single/family, subsidy/unsubsidized, hit deductible / don't, risk tolerance
Difference: you and your family vs me(single male)
Key Question as you talk to people in healthshare: How quickly is the health share paying medical bills?
In theory, I love a healthshare with less insurance regulation. In reality, I am nervous about their ability to pay my medical bills promptly.
For 4 years (2016-2019), I did Liberty Health Share. It started out at $200/month with $55 going to subsidize all my Direct Primary Care (DPC) / primary care physician membership. "Deductible"/co-share was around $1000. I never hit my deductible/co-share. I like a DPC for the small stuff on either insurance option. This shifted to $250/month with $40 reimbursement to DPC for the 2nd-4th years. In the 4th year, Liberty fell 10 months behind in reimbursement of DPC fees ($400 = $40x10 months). Their customer service was apparently overwhelmed and overloaded. They were a nightmare to get action and slow. I ended up getting the DPC fees back over the next 6 months, but I had lost confidence in Liberty's ability to pay for a serious $10k+ medical bill promptly. The reviews online were horrible for Liberty paying medical bills.
In that time, I decided to shift to a high-deductible, short-term traditional insurance. $10k deductible, doesn't meet ACA requirements, but no penalty, $90/month. Short-term, so they can drop you at the end of the year if you are racking u a bills. In this situation, you would sign up for ACA.
A bronze ACA plan is about $450/month unsubsidized in my state with a $6k deductible for one 40-something male. This seems like a lot being healthy, and unlikely to have a claim / hit deductible.
My summary would be:
If you are young and healthy, either is good. Recognize the additional risk that a health share can reject a claim.
If you have preexisting conditions and will hit deductible, ACA is probably better because a claim cannot be subjectively denied.
If you get a significant subsidy, a ACA plan is probably best.
It you don't get subsidy, have some risk tolerance and are healthy, a health share could be good option.
Thanks for bringing this up. I am curious what solution you find. I am also interested in other people's solutions. Has anyone had a health share and gotten significant bills paid?
Re: Health Share vs ACA
I was just working on this problem myself:
viewtopic.php?p=237131#p237131
If you can get an ACA plan that provides HSA eligibility, the tax advantaged space makes the premium a little more affordable.
viewtopic.php?p=237131#p237131
If you can get an ACA plan that provides HSA eligibility, the tax advantaged space makes the premium a little more affordable.
Re: Health Share vs ACA
Thanks all for your interesting responses.
@cs: We did not consider subsidies. I'm not sure how it works if one is choosing not to work as DH currently is. I should investigate. @wheatstate: Your experience is a great case study. The rep did mention that they offered a catastrophic plan but advised against it because you have to negotiate with providers on your own behalf and pay upfront and get reimbursed later. That all sounds like an immense pain, although I suppose it also offers an opportunity to develop expertise in these areas. This option would likely also offer the cheapest premiums by a substantial amount.
Our hope is to continue to use very little healthcare. It's a complicated topic and I have no idea what the country needs. On the one hand, 1k/mo seems like a lot of money to me for a family who tries never to go to the doctor except for yearly pediatric check-ups. On the other hand, maybe we'd have to pay more than that in taxes for single payer if employed so I should grateful for the ACA option. I feel like the monthly premium on our employer insurance was $600-800 anyway, for a lot more coverage that we never used.
@Scott: Thanks for the reminder: we used to have an HSA and DH mentioned it when signing up, but so far I don't think it's part of our Bronze plan. We should probably take another look. Although my behavior with HSA money is weirdly careless. I see it as free money that might as well get spent, and start considering all kinds of unnecessary (to me) sort of alt-wellness treatments like chiro, sauna, etc. Somewhat similarly, I know someone who had an elective surgery (that didn't work) last year because they had unexpectedly maxed out their deductible on a necessary (unrelated) surgery. While maybe not textbook perverse incentives at work, I feel like it is worth stepping back to analyze structures that inform idiosyncratic, medical decision-making .
@cs: We did not consider subsidies. I'm not sure how it works if one is choosing not to work as DH currently is. I should investigate. @wheatstate: Your experience is a great case study. The rep did mention that they offered a catastrophic plan but advised against it because you have to negotiate with providers on your own behalf and pay upfront and get reimbursed later. That all sounds like an immense pain, although I suppose it also offers an opportunity to develop expertise in these areas. This option would likely also offer the cheapest premiums by a substantial amount.
Our hope is to continue to use very little healthcare. It's a complicated topic and I have no idea what the country needs. On the one hand, 1k/mo seems like a lot of money to me for a family who tries never to go to the doctor except for yearly pediatric check-ups. On the other hand, maybe we'd have to pay more than that in taxes for single payer if employed so I should grateful for the ACA option. I feel like the monthly premium on our employer insurance was $600-800 anyway, for a lot more coverage that we never used.
@Scott: Thanks for the reminder: we used to have an HSA and DH mentioned it when signing up, but so far I don't think it's part of our Bronze plan. We should probably take another look. Although my behavior with HSA money is weirdly careless. I see it as free money that might as well get spent, and start considering all kinds of unnecessary (to me) sort of alt-wellness treatments like chiro, sauna, etc. Somewhat similarly, I know someone who had an elective surgery (that didn't work) last year because they had unexpectedly maxed out their deductible on a necessary (unrelated) surgery. While maybe not textbook perverse incentives at work, I feel like it is worth stepping back to analyze structures that inform idiosyncratic, medical decision-making .
Re: Health Share vs ACA
@peanut - subsidies are based on MAGI - a very specific formula for calculating annual household income. Do you know what your annual income will be?
Apologies if you've already done this, but I'd strongly encourage looking into the subsidies and cost sharing.
Compare your MAGI to the poverty level for your family size. From memory:
1.If you are under 4x, you qualify for subsidies. These true up at tax time. The lower you get income, the higher they go, unless you get below 1.4x poverty in an expanded Medicaid state, or 1x in a non expanded state. If you prove income to the exchange, you can get the subsidies up front. If your income is low, you may be able to raise it, through roth conversions.
2. In the 1.4-2.5x poverty band, with a silver plan only, you also qualify for cost sharing. You can only get this up front. The benefit is really big, especially under 2x poverty limit. It's not free healthcare, but not too far off. Note that you cannot have cost sharing and contribute to an HSA.
3. If your income qualifies you for Medicaid, things can get pretty confusing. I personally am avoiding it. But, it can be very inexpensive healthcare. The rules are state specific and can vary for parents vs children.
4. Only very specific bronze plans are HSA eligible. The deductible cannot be too high.
5. If COBRA is available to you from your employer, you have 60 days from the end of the employer policy to accept it. This covers you retroactively, like your insurance never stopped. I am using it for two months with no insurance. Get really sick? I'll buy COBRA. Otherwise, I can use the money saved on premiums for my care.
6. Biden opened a special enrollment period on the exchange, from 2/15 to a few months later. This means if your planning was not optimal, it is very easy to change your mind right now.
Depending on your specific situation, optimizing here can be worth thousands.
Apologies if you've already done this, but I'd strongly encourage looking into the subsidies and cost sharing.
Compare your MAGI to the poverty level for your family size. From memory:
1.If you are under 4x, you qualify for subsidies. These true up at tax time. The lower you get income, the higher they go, unless you get below 1.4x poverty in an expanded Medicaid state, or 1x in a non expanded state. If you prove income to the exchange, you can get the subsidies up front. If your income is low, you may be able to raise it, through roth conversions.
2. In the 1.4-2.5x poverty band, with a silver plan only, you also qualify for cost sharing. You can only get this up front. The benefit is really big, especially under 2x poverty limit. It's not free healthcare, but not too far off. Note that you cannot have cost sharing and contribute to an HSA.
3. If your income qualifies you for Medicaid, things can get pretty confusing. I personally am avoiding it. But, it can be very inexpensive healthcare. The rules are state specific and can vary for parents vs children.
4. Only very specific bronze plans are HSA eligible. The deductible cannot be too high.
5. If COBRA is available to you from your employer, you have 60 days from the end of the employer policy to accept it. This covers you retroactively, like your insurance never stopped. I am using it for two months with no insurance. Get really sick? I'll buy COBRA. Otherwise, I can use the money saved on premiums for my care.
6. Biden opened a special enrollment period on the exchange, from 2/15 to a few months later. This means if your planning was not optimal, it is very easy to change your mind right now.
Depending on your specific situation, optimizing here can be worth thousands.
Re: Health Share vs ACA
@scott: Thanks for all that, very instructive indeed. Painfully so, as we appear to have made some mistakes! Specifically #5: did not know Cobra was retroactive. DH looked and saw that it was gonna be 2k/mo so we just dismissed it. We definitely should have opted for that for the 60 days. On #4, that explains a lot. Our Bronze plan deductible is 17k. I suppose an HSA makes most sense if one has a lot of pre-tax income tho. On #1-3, it is hard to say. DH is casually sending out applications when something interesting comes up, and we assume he'll find work in 4-6 months maybe? I suppose if unemployment lasts longer than that--becoming more of an involuntary situation--we could consider pursuing the subsidies. It doesn't seem quite right to try to get them now, I guess, just because they were not really intended for people in our situation.
Re: Health Share vs ACA
If his employment situation doesn't play out, you'll be able to get the subsidies at tax time anyways. The high end for a family of 4 is a MAGI around $104k. It is not asset tested, only income.
Cost sharing only matters if you'd use the insurance. It's the only benefit you lose by not electing up front. $17000 is a mind boggling deductible. Keeping MAGI under $52k lowers max out of pocket to $5700. I thought this was a good summary:
https://www.healthinsurance.org/obamaca ... subsidies/
IMO the ACA uses these benefits to approximate a progressive tax, funding more universal healthcare. This is part of why policy premiums are so high. Since I view it under that tax lense, I feel comfortable optimizing against it.
I can understand your perspective as well. It's a good argument in favor of the health shares.
Cost sharing only matters if you'd use the insurance. It's the only benefit you lose by not electing up front. $17000 is a mind boggling deductible. Keeping MAGI under $52k lowers max out of pocket to $5700. I thought this was a good summary:
https://www.healthinsurance.org/obamaca ... subsidies/
IMO the ACA uses these benefits to approximate a progressive tax, funding more universal healthcare. This is part of why policy premiums are so high. Since I view it under that tax lense, I feel comfortable optimizing against it.
I can understand your perspective as well. It's a good argument in favor of the health shares.
Re: Health Share vs ACA
I agree 17k is mind-boggling! And according to your linked explanation, it is apparently pretty much the max under ACA (17.1k). It feels like we are buying a catastrophic plan but paying comprehensive prices. Like DH said, we pay a lot* for the premiums, and then pay for healthcare anyway.
After looking more closely at the network today, DH found out our pediatrician's big clinic is not in it. (Upon calling, they did say we can continue to see their doctor and pay out of pocket, at 20-25% off--off what, I don't really know, presumably their mysterious chargemaster?!) Nor is my PCP, or any hospital we are familiar with. There is one that is close enough which seems good, however. Anyway, after some inconclusive discussion, we agreed I'd take over the project, so I will start over and follow the cobra trail first.
That's great to know about how the subsidies work. Funny thing, I googled why they aren't asset tested (bc I think that's a crazy loophole) and this article came up:
https://www.cnbc.com/2016/01/27/theyre- ... idies.html
No coincidence that the titular subjects are "all retirees who stopped working before they were 65 years old!"
*Perhaps this assumption is wrong, however. Are my policy premiums high? wheatstate was looking at $450/mo for one person. We are looking at $240/mo for each person in our family. Much more was paid together by DH's former employer and ourselves, granted for a much better plan. But the usage is the same.
After looking more closely at the network today, DH found out our pediatrician's big clinic is not in it. (Upon calling, they did say we can continue to see their doctor and pay out of pocket, at 20-25% off--off what, I don't really know, presumably their mysterious chargemaster?!) Nor is my PCP, or any hospital we are familiar with. There is one that is close enough which seems good, however. Anyway, after some inconclusive discussion, we agreed I'd take over the project, so I will start over and follow the cobra trail first.
That's great to know about how the subsidies work. Funny thing, I googled why they aren't asset tested (bc I think that's a crazy loophole) and this article came up:
https://www.cnbc.com/2016/01/27/theyre- ... idies.html
No coincidence that the titular subjects are "all retirees who stopped working before they were 65 years old!"
Btw I remember CL, late of the forum and who himself had a health share, saying that in his observation working in a hospital, big bills were always paid. IIRC it is not legally binding on them the same way it is for traditional insurance companies to pay them, however. The slight grey area here is a bit unsettling, and cancels out the 2k/yr savings over ACA for my risk appetite.wheatstate wrote: ↑Mon Feb 15, 2021 10:45 pm
Thanks for bringing this up. I am curious what solution you find. I am also interested in other people's solutions. Has anyone had a health share and gotten significant bills paid?
*Perhaps this assumption is wrong, however. Are my policy premiums high? wheatstate was looking at $450/mo for one person. We are looking at $240/mo for each person in our family. Much more was paid together by DH's former employer and ourselves, granted for a much better plan. But the usage is the same.
Re: Health Share vs ACA
I read the article. It is spot on. If I find myself with a significant medical need, I am going to defer to the new year and adjust income. I am purposefully doing my annual physical in the fall, just before open enrollment starts.
It also strikes home how quickly premiums have risen. For a 64 year old couple, in my state, 2021 premiums now start at $1600 per month. Coverage I'd actually want, is $2000 per month. When the system is that broken, I don't think there's any choice left but to work it. Everyone else is. An unfortunate outcome of the ongoing political battle over how insurance and healthcare will work.
My wife is an active healthcare consumer, due to chronic illness. Navigating the system has been instructive. I think your experience is a little atypical - you managed to identify the gap in coverage before it became a big problem.
I've learned to check each doctor is in network, each Rx is on the plan formulary and treatments meet any prior authorization rules. These are all available on the insurer's website. Confirming a certain doctor is in network can mean calls to both the insurer AND the health system. Sometimes the same doctor can work out of two systems, be in network from one, out of network for the other. Or - an office will be in network under the practice owner, but the professional you see won't show under the insurer's network search. They may or may not be in network.
A conversation with a friendly doctor can quickly make it clear which insurer to go with, in your state. We have multiple carriers on the exchange for our state, that you want nothing to do with. They offer the lowest premiums, of course.
I opted to pay the extra for a PPO over an HMO. I'm lucky to be in a state where PPO plans are still available. I'll always try to go in network, but I'm not chancing it. Solving the network problem, to me, is a very appealing aspect of the health shares. I have other issues with them, but I completely understand the choice.
Even with great employer insurance, we found ourselves needing to check GoodRx for drug coupons, sign up for drug company copay programs, etc. That only escalates on the exchange plans. I am now planning to consume all healthcare as though I do not have insurance, getting cash prices for everything. I learned the hard way - if you provide insurance but have not met your deductible, you can end up paying _more_ than the cash price.
Obviously it's a hot button for me
It also strikes home how quickly premiums have risen. For a 64 year old couple, in my state, 2021 premiums now start at $1600 per month. Coverage I'd actually want, is $2000 per month. When the system is that broken, I don't think there's any choice left but to work it. Everyone else is. An unfortunate outcome of the ongoing political battle over how insurance and healthcare will work.
My wife is an active healthcare consumer, due to chronic illness. Navigating the system has been instructive. I think your experience is a little atypical - you managed to identify the gap in coverage before it became a big problem.
I've learned to check each doctor is in network, each Rx is on the plan formulary and treatments meet any prior authorization rules. These are all available on the insurer's website. Confirming a certain doctor is in network can mean calls to both the insurer AND the health system. Sometimes the same doctor can work out of two systems, be in network from one, out of network for the other. Or - an office will be in network under the practice owner, but the professional you see won't show under the insurer's network search. They may or may not be in network.
A conversation with a friendly doctor can quickly make it clear which insurer to go with, in your state. We have multiple carriers on the exchange for our state, that you want nothing to do with. They offer the lowest premiums, of course.
I opted to pay the extra for a PPO over an HMO. I'm lucky to be in a state where PPO plans are still available. I'll always try to go in network, but I'm not chancing it. Solving the network problem, to me, is a very appealing aspect of the health shares. I have other issues with them, but I completely understand the choice.
Even with great employer insurance, we found ourselves needing to check GoodRx for drug coupons, sign up for drug company copay programs, etc. That only escalates on the exchange plans. I am now planning to consume all healthcare as though I do not have insurance, getting cash prices for everything. I learned the hard way - if you provide insurance but have not met your deductible, you can end up paying _more_ than the cash price.
Obviously it's a hot button for me
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wheatstate
- Posts: 98
- Joined: Thu Aug 25, 2011 4:51 am
Re: Health Share vs ACA
@Peanut and @Scott. Thanks for the discussion. I agree.
@Peanut, That is right that a Health Share is not insurance and isn't held to the same accountability. You get a card that looks like an insurance card has company info and policy number. The card also has a line that says, "This is not insurance." That always seemed like a liability as you went into the medical billing department. Potentially, a health share could deny a claim. I never accumulated enough medical bills to get past the "unshared" amount, so I didn't test/use the coverage. Unshared is similar to the deductible. I agree with your risk tolerance for family coverage.
That is comforting that CL stated that he saw health shares covering medical bills.
@Scott. You are right, the idea of a health share always being "in network" and all bills being "shared" after reaching the "unshared" level is very attractive. In theory, I love a healthshare and simplifying medical coverage. In reality, I am nervous about the medical coverage being there. Thanks for sharing your medical coverage expertise.
Here is the Better Business Bureau's file on Liberty Direct Health Share. Maybe it is better with a new CEO in Jan, 2020. Both Liberty and the BBB seem active on this link and more of the complaints are being resolved. At the same time, there 958 complaints in the past 3 years. I don't know how this ranks compared to other health shares or insurance companies as either number of complaints or unsatisfied percent of users.
https://www.bbb.org/us/oh/canton/profil ... complaints
@Peanut, That is right that a Health Share is not insurance and isn't held to the same accountability. You get a card that looks like an insurance card has company info and policy number. The card also has a line that says, "This is not insurance." That always seemed like a liability as you went into the medical billing department. Potentially, a health share could deny a claim. I never accumulated enough medical bills to get past the "unshared" amount, so I didn't test/use the coverage. Unshared is similar to the deductible. I agree with your risk tolerance for family coverage.
That is comforting that CL stated that he saw health shares covering medical bills.
@Scott. You are right, the idea of a health share always being "in network" and all bills being "shared" after reaching the "unshared" level is very attractive. In theory, I love a healthshare and simplifying medical coverage. In reality, I am nervous about the medical coverage being there. Thanks for sharing your medical coverage expertise.
Here is the Better Business Bureau's file on Liberty Direct Health Share. Maybe it is better with a new CEO in Jan, 2020. Both Liberty and the BBB seem active on this link and more of the complaints are being resolved. At the same time, there 958 complaints in the past 3 years. I don't know how this ranks compared to other health shares or insurance companies as either number of complaints or unsatisfied percent of users.
https://www.bbb.org/us/oh/canton/profil ... complaints