October 17, 2023 • 45 mins
It’s one of the scariest times of the year. . . . it’s open enrollment time for health insurance. Every year, we’re all overwhelmed by the options and terminology of our policies, but this year Molly and Matt have full hearts and can’t lose. This year, they are determined to understand their coverage options and whether they should choose a high-deductible plan or one with a high premium. But first, they’re going to figure out what those terms mean in this episode. With the help of KFF Health News’ Julie Rovner, learn about the difference between an FSA and an HSA and what your plan is legally required to cover.
Sources Cited:
- Johns Hopkins Bloomberg School of Public Health - Primary Care Visits Available to Most Uninsured But at a High Price
- Forbes - How Much Does Health Insurance Cost In 2023?
- US Department of Healtth and Human Services - About the Affordable Care Act
See omnystudio.com/listener for privacy information.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
At some point in life. Everyone needs to see a doctor,
and arguably many of us should be going way more
frequently than we actually do. But seeing a doctor here
in the United States can sometimes result in an expensive bill,
especially if you're uninsured, and sometimes even if you are insured,
maybe your appointment, or your treatment or your provider wasn't
(00:22):
included as part of your medical coverage. According to research
led by the Johns Hopkins Bloomberg School of Public Health,
the average cost of an appointment with a primary care
doctor for an uninsured patient in twenty fifteen was one
hundred and sixty dollars, and from the same case study,
only seventy nine percent of the uninsured patients were even
offered an appointment. In May of twenty twenty three, Forbes
(00:44):
published in an article comparing the cost of health insurance
on the ACA marketplace. They found that the monthly cost
for an adult twenty one years of age ranged from
three hundred and thirty to four hundred and four dollars
depending on the plan, and for a twenty seven year
old adult that range increase, with the lowest plan costing
four hundred and five dollars to the highest level costing
about four hundred and twenty three a month, and these
(01:07):
rates are based on single adults without dependence. Now you
may be trying to do some math to sort out
if you can save some money by going without insurance.
I mean, how often do you see your primary care doctor?
After all? Aside from the fact that you should be
going to see your primary care doctor ideally every year
for a regular physical, there are other doctors you should
also be going to see regularly. I mean, there's your dermatologists.
(01:30):
You should be going every year for a skin check.
And if you're someone who visits the guynecologists, that's another
exam that should be done annually. And those types of
doctor's visits typically cost more than a primary care doctor.
Speaker 2 (01:42):
But perhaps the.
Speaker 1 (01:43):
Biggest reason why we need insurance is for those unexpected
health issues that can arise. What if you're in a
car accident or you find yourself really sick with a
more long term diagnosis. That's when medical costs can become
insurmountable and insurance can make a huge difference. The end
of October is typically the time of year when open
(02:04):
enrollment begins for a lot of health insurance plans. This
is the window of time when you can change or
enroll in a health insurance plan, and once that window closes,
you have to wait again to enroll or make any
changes until next year. But with so many options and
plans ranging significantly in cost, how do you know which
one is the best one for your needs and for
(02:25):
your budget? And what on earth is a ppo versus
an EPO? Start taking notes because this.
Speaker 3 (02:32):
Is grown up stuff.
Speaker 1 (02:37):
Hello, and welcome to another episode of grown Up Stuff
How to Adult, the podcast where we figure out things
like what's a premium and what's included in a deductible?
All in the name of adulthood. I'm Mollie and I'm
joined by my co host, Matt Stillo, and we hope
that you are healthy and well as you are listening
to this podcast because we're going to dig into health
(02:58):
insurance on this episode. What is it? Why do we
need it? Why does it seem to be written in
another language that relies so heavily on acronyms. But to
start us all off, Matt, what was your earliest experience
with health insurance and what has it been like in
your young life? Has it been good?
Speaker 3 (03:17):
Yeah, bad?
Speaker 2 (03:18):
Confusing?
Speaker 4 (03:20):
Well, thank you for calling me young on this podcast.
Because this year and I don't know how I feel
about very young, but.
Speaker 1 (03:27):
We all feel some sort of way about that age,
about all the ages. So you're doing great, Matt, You're
doing great.
Speaker 4 (03:32):
So for everyone out there who's like, you know, unemployed, underemployed,
you were in the right place because I was actually
on my parents' healthcare up until the last possible second.
I was like about to turn twenty seven, right before
like the enrollment period for the new year, and I
got this job, my first like full job with like
(03:54):
four oh one K and salary and healthcare, and I
was like I couldn't believe it. I like, I got
through that open enrollment and I was like, wow, under
the freaking wire because I was so worried about what's
gonna happen now, you know, that wave of relief quickly
subsided as I was reading through the healthcare plans because
what the hell? Yeah, all this lingo, like how is
(04:17):
a child right? Because twenty six is a child supposed
to figure that stuff out? Even my parents couldn't help
me because it's gotten so confusing in the last few years.
So after it was all said and done, I felt like,
did I make the right decision.
Speaker 3 (04:30):
I have no idea.
Speaker 4 (04:32):
Every subsequent year, I was trying to like do right,
Like I'm gonna get it this time. Yeah, I'm gonna
get it this time.
Speaker 1 (04:37):
Yeah.
Speaker 3 (04:38):
And I don't think even.
Speaker 4 (04:39):
To this day, I've ever really fully figured it out.
But I just want everyone to know out there that, like,
if you are confused by this, it is okay, We're
going to figure it all out together. But Molly, yeah,
I feel like you probably felt the exact same way.
Speaker 1 (04:52):
Oh. I mean, I'll hit submit and I'll go back
and review before the window of open enrollment closes, ultimately
decide I've made the right decision. But once that period ends,
I'm like, Nope, I've made the wrong decision. I know it.
I've made the wrong decision. But let's get to our
conversation with our guests, because I do think she's going
to be able to clarify a lot of this for us.
Speaker 4 (05:13):
Today we are joined by the one and only Julie Robner.
Julie is the Chief Washington correspondent and host of What
the Health, a weekly health policy news podcast from KFF
Health News.
Speaker 1 (05:25):
KFF Health News is a national newsroom that focuses on
health issues and was founded by the Kaiser Family Foundation,
which is now more commonly referred to as KFF. Julie
joined the KFF Health News team after sixteen years as
a health policy correspondent for NPR, where she helped lead
the network's coverage of the Affordable Care Act.
Speaker 4 (05:47):
Julie is also the author of the book Healthcare, Politics
and Policy, a Disease, and the recipient of the National
Press Foundation's Everett McKinley Dirkson Award for Distinguished Reporting of Congress. Well,
Julia Rovner, thank you so much for joining us on
this episode of grown Up Stuff?
Speaker 3 (06:05):
How do adult?
Speaker 4 (06:06):
And at this podcast, we'd like to really like ask
the most dumb question straight.
Speaker 1 (06:11):
Out of the gate, because you're kind of anything.
Speaker 4 (06:15):
Exactly, and that really dumb question is what exactly is
health insurance and why is it so important to have,
especially in the United States.
Speaker 2 (06:26):
Well, health insurance is supposed to prevent you from going
broke if something bad happens to you. A lot of
young people don't think they need health insurance because, after all,
they're less likely to get sick. But you know, even
a twenty five year old can get hit by a
bus or run into a tree. If you go skiing,
things can happen. Unfortunately, young people get very serious diseases.
(06:49):
And if you don't have health insurance, our healthcare system
is really, really expensive. You do not want to get
caught up in it if you don't have some kind
of insurance.
Speaker 1 (06:59):
You know, that's a really good point. Young people are
not exempt from getting cancer, unfortunately, and sadly, I've had
a handful of friends in their late twenties and early
thirties who have been diagnosed with cancer. And even things
like a broken bone can be really expensive without insurance.
But I myself have been in situations where I've either
been in between jobs or freelancing. So what are the
(07:20):
best options to get health insurance if we can't get
it through an employer.
Speaker 2 (07:25):
Well, congratulations, we now all have options which we didn't
when I was a young freelancer. That is exactly what
the Affordable Care Act was aimed at. It was aimed
at people that don't get their health insurance on the
job provided by an employer. So basically, if you're working
for yourself, you can buy insurance and it's pretty good
insurance on the healthcare exchange. And if you don't earn
(07:46):
a lot of money, you'll get a subsidy, in some
cases a really big subsidy, So not only will you
not have to pay very high premiums, and particularly if
you're younger, you might not even have to pay very
much if you have to go and get care. You
can get savings on your your co payments and deductible.
So there are a lot of ways that the Affordable
Care Act is aimed at getting people insured who were
(08:08):
not previously eligible, either for Medicare or Medicaid or an
employer to ensure them. So that's the good news. The
other way, of course, you can get insured or stay
insured if you've had a job in your between jobs
is there something called cobra which allows you to continue
your employer insurance until you get another job, or another
way to get insurance. But if you had insurance and
(08:30):
you lose it for pretty much any reason, you can
sign up under the Affordable Care Act at any time
of the year. You get your own personal open enrollment period.
Speaker 4 (08:40):
Just so that I'm clear on this, was there no
way to directly go to a health insurance company before
the ACA otherwise known as Obamacare, was enacted.
Speaker 2 (08:49):
There were lots of ways to go to a health
insurance company before the Affordable CARECT. The problem is they
might not have sold you insurance because they didn't always
have to. In states where they said you have to
take everybody even if they're sick, the insurance said, okay, bye,
we're just not going to sell in this state. So
there were a lot of people who wanted to get
insurance who couldn't. If you were really healthy, they were
(09:10):
likely to sell you. Insurance could have been, depending on
where you live, pretty cheap or pretty expensive. But sometimes
when it was really cheap, it didn't cover very much.
There were health insurance policies that would only cover up
to the first five hundred dollars worth of care that
barely gets you in the door at a hospital and
even a doctor's office in some case. So there was
(09:30):
a lot of bad health insurance and a lot of
health insurance it wasn't really insurance. And one of the
things that the Affordable Care Act did, and it was controversial,
was to say that these are going to be the
standard benefits that every accredited health insurance policy has to offered.
That of course made a lot of health insurance a
lot more expensive because hey, now it had cover actual stuff.
(09:54):
But I think a lot of people who didn't need
their health insurance very often didn't realize how little their
health insurance covered.
Speaker 4 (10:01):
Actually puts it in a great perspective, like you know
how historic the Affordable Care Act was. I was before
I had had my first job and have my first
health insurance plan, so I did not really realize how
big of a deal.
Speaker 3 (10:14):
That is.
Speaker 4 (10:15):
The one other thing that I wanted to ask you
about and maybe why it was included in the Affordable
Care Act, which is the dependents you know, children who
are on their parents' plan, they can stay on those
plans until you're twenty six.
Speaker 3 (10:27):
Why exactly was that included in the ACA?
Speaker 2 (10:30):
This was a huge, huge deal until then Moost kids
got kicked off their parents' plans when they turned eighteen.
If they went to college, they would buy student health plans.
Then they would graduate and they would have no insurance.
And it was a big problem and also was a
deterrent to do things like go join the Peace Corps,
you know, become a volunteer somewhere, take an internship, or
(10:51):
take any kind of job that didn't offer health insurance.
Because it's so dangerous to be uninsured. These days. So
basically what they said was, we're going to require employee
to allow kids to stay on their parents' plans until
they're twenty six. And the idea is that by the
time somebody is twenty six, they should be grown up
enough to find a way to have health insurance, either
be established as a freelancer or have a job that
(11:13):
provides insurance. But basically want to be able to get
kids through school and through higher learning and still keep
them insured. And also a lot of young people, as
I mentioned, at some point, don't think they need health
insurance and don't buy it, and this is just an
easier way for parents to make sure that their kids
are insured even as they are launching their own careers.
(11:33):
It was an extremely popular benefit. It was one of
the few benefits in the ACA that was completely bipartisanly popular.
Both sides wanted it, and it's obviously a fairly highly
used benefit.
Speaker 1 (11:51):
The Affordable Care Act or ACA or Obamacare is a
comprehensive healthcare reform law that was enacted in March twenty ten.
According to the US Department of Health and Human Services,
the law had three primary goals. One, make affordable health
insurance available to more people, to expand the Medicaid program
(12:12):
to cover all adults with income below one hundred and
thirty eight percent of the federal poverty level, and three
support innovative medical care delivery methods designed to lower costs
of healthcare generally. As Julie mentioned, one way they achieved
this was by increasing the age of health insurance dependence
to twenty six. Now, I personally didn't have the slightest
(12:35):
idea how to properly choose a health insurance plan when
I did turn twenty six, and I was often asking
coworkers what they chose for guidance. And that's because when
I was given these options, I felt like I needed
a translator for all of the different terms.
Speaker 4 (12:53):
Before we get into anything too specific, I think there's
a couple of terms that we should really like talk
about what they mean exactly. So first, would you mind
telling us what a premium is.
Speaker 2 (13:03):
A premium is the amount you pay basically to have insurance.
So it will usually be a monthly fee, and that's
what makes you a policy holder, is paying the premium.
Usually if it's employer provided insurance, the employer will pay
at least some, possibly most in a few cases. All
of the premium, but generally there is someone pays the
(13:24):
premium for you to have insurance.
Speaker 4 (13:26):
Awesome, Okay, I'm just going to rattle through the So
deductible what is a deductible.
Speaker 2 (13:31):
Deductible is how much you pay out of pocket before
your insurance starts paying Deductibles can most are in this
sort of couple of hundred to several hundred dollars range,
which in theory is what people can afford. It depends,
you know, if you have a family, sometimes it can
be you know, five hundred dollars for each member of
(13:51):
the family. That can turn into a lot of money
pretty quick. But the general rule of thumb is the
higher your premium, the lower you're deductible. So if you
don't think you're going to use a lot of health insurance,
you might want to get something with a lower premium
but a higher deductible, and vice versa. If you think
you will use insurance, you might want to get a
higher premium with a lower deductible so your insurance kicks
(14:12):
in faster.
Speaker 3 (14:13):
Awesome. And then what about like copay and co insurance.
Speaker 2 (14:18):
Yeah, those are two slightly different things. But the idea
is that once you reach the place where your insurance
starts paying for things. It's shared. Insurance rarely pays one
hundred percent of anything, So either they will charge you
a co pay. They will say, if you go to
the pharmacy and you get one of these, you know,
four hundred common drugs, you will have a copay of
(14:38):
ten dollars, and if you get a slightly more expended drug,
you'll have a copay of twenty dollars. Co insurance is
when they say, if you go to the doctor or
the hospital, we're going to pay eighty percent or ninety percent,
and you're going to pay the other ten percent. Co
insurance can turn into a lot of money these days
when health care is so expensive. You know, people think, oh,
(14:59):
it's I have a five percent co insurance if you
go to the hospital. Five percent can very quickly become
many thousands of dollars.
Speaker 4 (15:07):
Truly, it's insane. And so I have a deductible and
I hit that. But then why is there an out
of pocket maximum?
Speaker 5 (15:13):
Great question, That's a very good question, because, as I
just said, your co insurance can turn into a lot
of money very quickly, and that's why plans are required
to have an out of pocket maximum, so you don't
once you hit a certain number, usually in the near
ten thousand dollars range, you don't have to pay anything
more for the rest of the year.
Speaker 2 (15:34):
Then the calendar will reset and you'll have to start again.
But it's generally, yeah, even if you have health insurance,
you can end up on the hook for a lot
of money. That's why they have things like flexible spending
accounts and health savings accounts. Healthcare these days is really
expensive in the United States, even with insurance.
Speaker 1 (15:53):
Yeah, So to clarify just that, I understand this. So
your deductible, once you meet that, then they'll cover a
certain percentage of certain things right.
Speaker 2 (16:01):
Right up to your out of pocket maximum.
Speaker 1 (16:03):
It's like basically a video game. You're like, you get
to the first boss, and you get to the second boss,
and you get to the second bus. You win and
you get all these new things and you can do anything.
So after you hit that out of pocket though, then
they have to cover everything. Right, Is that correct?
Speaker 2 (16:15):
It's usually right? There are things then there we'll say, well,
you're not in networks, so we're not going to cover
all of it. There are exceptions to that. You know,
if it's not covered by the plan, then they can
make you pay it. CAFF Health News and NPR and
CBS have been doing something we call the Bill of
the Months for a couple of years now, where people
send us their medical bills that they just can't handle,
(16:36):
and we try to sort out what's going on. And
there are cases where people have been you know, they've
gone way over there out of pocket maximum, but they've
been billed anyway. Sometimes they're actually liable for those bills.
Sometimes they're not. Do you want the out of pocket
maximum for this year?
Speaker 1 (16:50):
Yes?
Speaker 2 (16:51):
Please? What is it for the twenty twenty four plan
your guests? The out of pocket maximum for a marketplace
plan can't be more than ninety four hundred and fifty
dollars for an ind of one, eighteen nine hundred dollars
for a family.
Speaker 1 (17:03):
It's a lot of money.
Speaker 2 (17:04):
That's not just a lot of money, And it says
the things that they don't cover. It doesn't you're out
of pocket. Doesn't cover premiums, it doesn't. It says it
doesn't cover anything you spend for services your plan doesn't cover,
doesn't cover out of network care and services, doesn't cover
costs above the allowed amount for a service a provider
may charge.
Speaker 1 (17:22):
So I was curious about what goes towards my deductible
because sometimes I think, I'm like, whoa, I've spent I
must have hit my deductible at this point, like I've
spent so much money. But you're telling me if I've
paid out of pocket for something my insurance doesn't cover
to begin with, then that doesn't count towards my deductible.
Speaker 2 (17:38):
No, And that's it's really important to know what does
and doesn't count towards your deductible. In some plans, out
of network care won't count towards your deductible, or you'll
have a separate out of network deductible and in network deductible.
Then usually that out of network deductible will be higher.
So it's not just anything you spend on medical care,
it's anything that you spend on medical care that would
(18:00):
be covered after you hit your deductible.
Speaker 1 (18:03):
Son of a bitch cheer leading. Oh and for one
more cherry. On top of this depressing deductible. Sunday, we
did some additional digging and discovered most plans do not
count your copays towards meeting your deductible.
Speaker 4 (18:24):
So what exactly is a healthcare network and like, why
are some doctors in it and then others not.
Speaker 2 (18:31):
Generally, a healthcare network is a group of providers, so doctors, labs, hospitals,
urgent care centers that have signed contracts with the insurer.
And generally the deal is the insurer says, we will
send you our patients, so you will get more patients,
and in exchange, you will give us a better price.
So those are that's how you stay in network. And
(18:52):
because the insurer knows what they're going to pay you,
the patient will only have to pay a limited amount.
Usually known it used to be sort of flat dollar
copayments ten or fifteen or twenty dollars. More commonly these
days it's co insurance, so you'd have to pay ten
percent or twenty percent, which can turn into a lot
of money. But generally, staying within your network of doctors, hospitals,
(19:17):
and other healthcare facilities is going to be a lot
cheaper than going outside the network, where the insurer doesn't
have a deal to get a better rate from the
provider and may have to pay more even if you're
gonna pay more too.
Speaker 1 (19:30):
And what's the best way for us to determine who's
included and who isn't.
Speaker 2 (19:35):
Oh, such a good question, that should be so easy.
There are provider directories where you can see who's in
the plan and who isn't, except it turns out the
provider directories are often wrong or incomplete. Unfortunately, this is
something that's been going on for decades, and now that
it's ever more important to know who's in your network
(19:56):
and who isn't, it's still really hard to find out,
so you have to call each provider until this year.
Last year there was also this problem about something called
surprise bills, where you go to an in network hospital.
You know what's in your network, but you get treated
by a doctor who's not in the network, and you
don't have a choice. It might be the pathologist or
(20:17):
the anesthesiologist. You know, you schedule surgery and you know
you're having surgery with this surgeon, and sometimes you'll call ahead,
is the anti caesiologist in my network? And it's like, well,
we don't really know who your anesthesiologist is going to
be that day, so you have no idea, and then
you would get these huge bills from emergency room doctors
or antithesiologist or doctors that you didn't choose. Congress finally
(20:38):
made that illegal, but only very recently.
Speaker 3 (20:41):
Oh my gosh.
Speaker 2 (20:42):
You know, the best way to find out if a
provider is a network is yes, I know, I know that.
You know, like people under forty eight talking to people
on the phone, but this is a case where you
might want to talk to people on the show. They
don't always know either, but it's worth asking. I mean,
I still go to providers that are you know, I'm
pretty sure a network, but you know, you keep asking,
are you really in my network? Am I really not
(21:04):
going to get a bill for a thousand dollars a year?
Speaker 1 (21:05):
Well?
Speaker 4 (21:05):
I glad that's not just me because I feel like
I have to do that every single time too, And
I'm like, is this really how it works? Like we
just have to do this all the time. Yeah, apparently
it is.
Speaker 2 (21:14):
Our health system is not the most efficient or user
friendly or inexpensive. It's it's a lot of things that
are not very good. I think there's a lot of
disagreement on how to fix the healthcare system, but there's
a whole lot of agreement that it is not working
well right now.
Speaker 1 (21:30):
It is complicated, But this is why these conversations are
so important so that we could be equipped with all
of the knowledge and the tools and the resources to
make the best decisions.
Speaker 2 (21:40):
This is a really important part of adulting. So I mean, yeah,
health insurance saving for retirement thinks that we're a lot
cheaper when I was a young adult, are a lot
more expensive now and you're a lot more on your own.
Speaker 1 (21:56):
We'll be right back with more grown up stuff how
to adult. After a quick break, and we're back with
more grown up stuff how to adults. Let's go into
you know, the major health insurance plan options. For those
(22:19):
of us who you know are employed, we know there's HMO,
p PO, E PO POS, hgh HP, which we're gonna
so yeah, so let's start with the top. HMO. What
does it stand for?
Speaker 2 (22:34):
So, an HMO stands for Health Maintenance Organization. It was
traditionally the most structured and limited way to get health insurance.
And basically what the HMO says is we're going to
get a certain amount of money a month for each
patient and work that's going to cover all their care.
So in theory, you should never get a bill or
rarely get a bill if you're in an HMO and
(22:55):
you basically have to go to all of their providers.
Traditional HMO like Kaiser per Empty, has their own hospitals
in many states, they don't in the eastern part of
the country where they offer insurance, so they will have
deals with other hospitals. But generally you have to stay
within the network, so it's the most restrictive. It's the
hardest to go out and see other specialists or go
(23:16):
other places. And generally it has had traditionally the lowest
premiums because it's the most restrictive. And then as you
go further out, every time it gets easier for you
to go outside of the network and get care from
other places, your premium goes up because it's likely that
the cost of the insurer is going to go up.
So you're generally trading off restrictions in providers versus amount
(23:41):
of premium.
Speaker 1 (23:42):
Interesting. So this then I feel like, and maybe I'm wrong,
but I feel like PPO and EPO kind of go
hand in hand, right.
Speaker 2 (23:50):
They do, And an EPO is sort of a cross
between a POPPO is a preferred provider organization. I'm in
a preferred provider organization where I don't have to go
to the preferred providers, but if I do, it's a
whole lot cheaper. So you're encouraged to stay in the
network as opposed to being required to stay in the
network EPO, which I think is exclusive provider organization. The
(24:13):
acronyms don't mean as much as they used to, which
is what gets a little bit frustrating to people. And
of course, the other thing that it's really important to
trade off, and I guess we'll get to this, is
it your premium, you're deductible are going to be directly linked.
And that's really true in the Affordable Care Act plant
it's like the lower your premium, the higher you're deductible,
the most you're going to have to pay out of
pocket before the insurance kicks in, you know. And if
(24:36):
you pay a higher premium, you'll have a lower deductible.
So unfortunately, there is sometimes arithmetic involved. It's not higher math.
Speaker 1 (24:43):
But it's math fair. As we always say, it never
hurts to do your homework or do the math for
that matter. Okay, now, pos I've seen this and it
does not mean piece of shit.
Speaker 2 (24:56):
It means a point of service, and that's basically the
PPO plan where you can go out of network and
they will pay a certain share. So typically, if you
stay in network, you'll only have to have a copey.
I think my cope is fifteen dollars, which is pretty
good for you know providers in network. It's really good. Yeah,
it's very good. If I go out of network after
(25:16):
I've hit my deductible, they'll pay seventy percent and I'll
pay the other thirty percent.
Speaker 1 (25:21):
Now, HDHP, I actually know at this dance or a
high deductible health plan right now, this is different.
Speaker 2 (25:28):
It is, and it's confusing because there are a lot
of sort of regular health plans, particularly the bronze plants
in the affordable character, that have high deductibles. That it
used to be when they started these the early two thousands,
people's deductibles tended to be in the you know, one hundred,
two hundred, three hundred dollars range, which I know sounds
(25:48):
like quaint today. Right the HDHP plans, the idea was
you would have a deductible of one thousand dollars or
fifteen hundred dollars, which is pretty standard right now. But
the catch you weren't going to have to necessarily pay
that whole deductible because you were also going to have
something called an HSA, a health savings account, and the
idea is that you and probably your employer would put
(26:11):
money away and save it and it would grow tax free,
and you could use that for medical expenses, either things
that weren't covered by your insurance or things that would
eventually be covered by your insurance once you hit your deductible.
It's a kind of catastrophic insurance. It says you're going
to pay this chunk up front, and if you really
need a lot of medical care, then your insurance will
(26:34):
kick in. The problem with this is that a lot
of people have HDHP plans and they don't have the
hsas that go with them, so they just have a
really high deductive health plan. That's an issue. The idea
is that they're supposed to be coupled with the health
savings accounts. Now. Health savings accounts were criticized a lot
when they were first started by people who were all for,
you know, universal coverage, but they said they mostly help
(26:56):
the rich. They help people who earn enough or to
take it saves money, yeah, to put money away that
they might need for health care. On the other hand,
if you're young, it's pretty good savings vehicle.
Speaker 4 (27:07):
So we talked about how like an HSA can come
with a high deductible health plan. But there's also this
account called the FSA. So where exactly does that come
into play, and what is the difference between these two accounts?
Speaker 3 (27:18):
Is one like better than another?
Speaker 2 (27:21):
There's a big difference. An FSA flexible spending account is
generally offered by an employer, and it says we will
take money out of your paycheck and we will put
it away and you can use it for medical expenses
tax free, which is very handy. So I would I
go to the doctor it costs three hundred dollars. I
haven't hit my deductible, so I now have three hundred
(27:42):
dollars bill that I've paid. I send it off and
it comes out of my get it back through my
flexible spending account, and I haven't paid taxes on the
income that's gone to finance that. There's some catches. If
you don't use up all the money within a certain time,
you can lose it. If you leave your within a
certain time, you can lose it. These rules have been
expanded a little bit, so it's a little bit more
(28:04):
flexible than it used to be. There's also some things
that you can spend it on and some things that
you can't. There's certain amounts of I believe you can
once again use it for over the counter products. You
could for a while and then you couldn't, and I
believe you now can again. So it's worth it to check.
But it's also a good way, you know, depending on
your tax bracket, it's a handy way to use tax
(28:27):
free money for medical expenses. Again, it's a way of
encouraging people to put money away to pay medical expenses
that insurance doesn't.
Speaker 1 (28:35):
But Julie FSA, though, does not increue interest the same
way an HSA does.
Speaker 2 (28:41):
No, that's correct. It just sits in an account and
there's an administrator and sometimes I mean, in my case,
you know my RFSA, I have a little credit card.
So when I go to the pharmacy and I need
to pay my thirty dollars, cope, I just hand them
the FSA credit card and then it goes through them.
But no, an HSA is an actual savings ACCOUNTESSA is
just sort of a place to kind of park money
(29:03):
for a year.
Speaker 1 (29:04):
What kind of yield interest yield are we talking here
with these hsas.
Speaker 4 (29:07):
Yeah, it's actually very similar to a retirement account where
you could invest in an innexx s and P five
hundred sort of a fund.
Speaker 2 (29:14):
Exactly is a retirement account for medical expenses.
Speaker 1 (29:22):
There are a number of different things you can pay
for using an HSA or an FSA, including menstrual care
products and sometimes even acupuncture. The biggest difference between the
two options. An HSA accrues interest and can be rolled
over from year to year, whereas an FSA you have
to use everything you have by the end of the
year or you lose it. However, your eligibility for an
(29:44):
HSA is dependent upon which health insurance plan you choose,
and often hsas are not offered when you have a
low deductible plan and you can no longer contribute to
an HSA. Once you enroll in Medicare, you can still
use what you have in an HSA, but you won't
be able to keep putting money into it, which leads
me to a very important point. And don't trudge me
(30:06):
for not knowing this, because I know I'm not the
only one. But what is medicare and what is the
difference between Medicare and Medicaid.
Speaker 2 (30:16):
Medicare is the federal health program for people who are elderly,
over sixty five and people with disabilities who qualify because
they have worked long enough to be eligible for Social
Security disability. So if you're over sixty five or you're
on Social Security disability, you are eligible for Medicare. Medicare
(30:36):
has a number of parts. The hospital part comes for free,
that's what you pay your payroll taxes. For the optional
part B you pay premiums for it. And now as
of two thousand and three, you can buy prescription drug
coverage because, believe it or not, until then, Medicare didn't
cover prescription drugs really, yeah, which was really bizarre.
Speaker 1 (30:57):
Yeah, especially since the older you get there or medications
I feel like you need.
Speaker 2 (31:02):
That's why they didn't cover it because it would have
been really expensive, so nobody had wanted to add it. Anyway.
That is Medicare, So that is all federal program. There's
obviously a lot of private insurance involved in it now
for people who are older and who are on Social
Security disability. Medicaid is for people with low incomes, and
(31:22):
it used to be you had to fit into a
category to get Medicaid. You had to be low income,
and a child low income, and a pregnant woman, low
income and elderly. There's many people who are on both
Medicare and Medicaid low income with a disability. As of
the Affordable Care Act, you no longer had to be
low income and something else. You only had to be
(31:42):
low income. This was a huge change because there were
a lot of adult and many young people who had
low incomes but were not a child or a pregnant
woman or somebody with a disability, so they were suddenly
eligible for Medicaid. The trick was that the federal government
made this an option for the states, so they didn't
have to do it under the Affordable Care It was
(32:04):
a very attractive option. The federal government paid one hundred
percent of the state share for the first three years
and still pays ninety percent. Now Medicaid is a joint
federal state program. Wealthier states have to pay half of
the Medicaid costs. So for the federal government to say
we're going to pay the whole thing for three years
and then we're going to pay ninety percent was a
(32:25):
gigantic incentive. Hospitals were dying to have states do this
because all of those people who didn't have any insurance
would show up at the hospital, a hospital would take
care of them, hospital would have nobody to bill. So
at this point most of the states have taken advantage
of it, but there are still I believe it's ten
hold out states that have not expanded Medicaid. And those
(32:49):
do include some really big states like Texas and Florida
and Georgia, and then other states in the South and
some of the Great Plain states. But the vast majority
of state now have expanded Medicaid. And so basically, if
you have a low enough income, you can get health
insurance through this joint federal state program.
Speaker 4 (33:09):
And so for the people who maybe listening that would
qualify as being low income, how might they go about
taking advantage of Medicaid.
Speaker 2 (33:16):
There should be a state Medicaid office. If you just
google your state's Medicaid program, it should come up. If
you go to the Affordable Care Act exchanges, the place
where you buy private insurance. There's supposed to be something
called the no Wrong Door policy where if you type
in all of your statistics and your income qualified, you
automatically get sent to Medicaid enrollment. Also, if you end
(33:39):
up in a hospital or a community health center. A
lot of places the providers themselves will help you enroll
in Medicaid because that's how they're going to get paid.
So there are a lot of people with incentives to
get you medicaid if you're in fact eligible for it.
Speaker 1 (33:54):
Julie, Matt and I have been going back and forth
on this because we've both chosen very different plans for
various reasons. But between an high deductible health plan with
a health savings account versus a PPO POS where you
have a broader network and a lower deductible, which one
do you think is a better plan to use? For
(34:17):
somebody like Matt and myself, I.
Speaker 2 (34:19):
Think it's an absolute personal choice. It has to do
with what level of risk, how much do you worry
about using healthcare or not using healthcare or saving for
the future. I mean it is they both have their places,
and it's the nice thing about having choices. It is
an individual decision. I could not recommend one over the other.
Speaker 1 (34:38):
That's right. You heard it here. My choice is right,
so's mass.
Speaker 2 (34:45):
So the question is, you know, it's a talk about
you know, taking your amount of risk. Do you think
you're not going to use any healthcare during the year,
then you might want to go with the lowest premium
plan you can find, and you might not have to
pay that deductible. If you don't use any care, you
don't have to pay a ductductible. So if you do
think you might be using medical care during the year,
and hint, hint, people should use at least some medical
(35:07):
care during the year. They're preventive stuff that you should have.
But if you think you can just you know, write
a check for that, pay it yourself, put it on
your credit card, whatever, then you might want to go
with some kind of a high deductible health plan. If
your employer offers to put money in an HSA, if
you take that high deductible health plan, all the better.
And if you can put a little bit of money
(35:27):
in that HSA, it shields it from taxes for you,
and it's hields it and the employer sometimes will put
in enough money to make up a good chunk of
your deductible, so that can be that can be a
good choice, particularly for younger workers who are less likely
to need medical care and more sensitive to the amount
of the premium. If you have doctor's health providers that
(35:48):
you are very attached to you should find a plan
that includes them. If you have certain prescription drugs that
you take, you should make sure that the plan includes them.
So there's homework to be done, but only it's how
much do you want to pay out of pocket? How
much do you think you might have to pay as
a deductible, and who and what is covered. Those are
(36:09):
the things you need to sort of go through, either
with an employer plan, and most employers offer you a
choice of at least a couple of plants, or with
an Affordable Care Act plan. No matter what I mean,
the good news is that you're going to have some choice.
The bad news is you're going to have to figure
out which choice is best.
Speaker 1 (36:25):
While some coverage differs from plant to plan, the Affordable
Care Act has required that certain things are covered by
any plan, like well woman visits, birth control prescriptions, certain
vaccines like the flu shot, preventive care like mammograms and kolonoscopies,
and dental envision coverage for children. However, if you are
an adult, dental envision are not a requirement of your
(36:48):
medical coverage.
Speaker 4 (36:51):
So we've got a medical plan, but then we find
out dental envision are not included.
Speaker 3 (36:56):
Why is that?
Speaker 2 (36:57):
Again, they're expensive, it's an add on. It's not something
that has traditionally been part of health insurance because.
Speaker 3 (37:05):
La la la.
Speaker 2 (37:06):
It didn't used to be that expensive. It wasn't an
insurable event. Now it's expensive. Low vision care still most
vision care is still not that expensive, but dental care
really is expensive. And again, like mental health care, we
didn't used to think that it was really important medically,
but it turns out oral health care is really important medically.
Uncared for teeth can cause heart disease, right in addition
(37:29):
to other things. I mean, it is really important. Medicare
still doesn't cover either dental care or eye care or
hearing aids. You can see it in There are some
private Medicare plans that do sort of as an enticement,
but standard Medicare does not. The health insurance business has
grown up slowly, shall we say, since the early nineteen hundreds.
(37:51):
At first it was just hospitals that you needed insurance for,
and then hospitals and doctors, and then hospitals and doctors
and prescription drugs, hospitals and doctors and prescription drugs, and
vision care and dental care and mental health care and
substance abuse care. There's a lot of things that make
it expensive, and insurance basically is trying to spread the
(38:12):
risk to the people who are healthy and who are sick.
And if it's too expensive for the people who are healthy,
they won't buy it, and if they don't buy it,
we get into that insurance death spiral. I'm also curious.
Speaker 1 (38:23):
You know, it's wonderful that well women's visits are included
in our standard care, but why isn't fertility included as
part of that kind of well women's coverage?
Speaker 2 (38:34):
Because it's expensive. Almost whenever you ask, there's only two
reasons why things aren't covered. They're not sort of accepted
as standard treatment. This is actually why obesity drugs aren't
covered for the most part, because until very recently, there
weren't any that worked. There just weren't any good obesity
to drugs. It was easy to say we're not going
to pay for them because there wasn't anything that we
(38:56):
knew scientifically worked that you could pay for. The other
thing is for things that were really expensive, and infertility
coverage is really expensive. And question is, you know, is
an inability to get pregnant? You know, a medical problem
and it varies, so I actually I'm read I now
found the statistics. So, as of September twenty twenty three,
twenty one states plus the District of Columbia have passed
(39:19):
fertility insurance coverage laws. Fifteen of those laws include IVF
coverage and seventeen cover fertility preservation. For instance, if you
are a young woman diagnosed with breast cancer, you can
have your eggs harvested so that you can get pregnant
after your treatment, if that's possible.
Speaker 4 (39:35):
Is there any sort of advice you can give someone
to going through this process for the first time? Is
there anything that we didn't cover? And then lastly, like,
do you have any like hope for the future that
this is going to get like less complex or easier
to navigate?
Speaker 3 (39:48):
Yeah?
Speaker 1 (39:49):
How do you see it changing and evolving too?
Speaker 2 (39:52):
Well? One thing I will say is that there are
lots of sources of help. There are navigators for the
Affordable Care Act. If you look at your state CELTHIC
ch Sure into Exchange, there are various counselors. You can
talk to an agent who can help you sort of
sort through this. You can talk to a trusted adult
who's been through this who can help you sort through it.
I mean, it's not easy, and you probably, certainly the
(40:14):
first or second or third time, should reach out and
get help. It's not intended to be easy. Am I optimistic?
You know? Twenty years ago I said things we're going
to have to really get bad before we really fix things.
And things are really bad, and we really you know,
we fix things a tiny, tiny piece at a time.
Do I think it's going to get fixed? Yeah? Do
(40:35):
I think it's going to get fixed anytime soon? Not
so much anymore.
Speaker 4 (40:39):
So the best thing you can do is really arm
yourself with information and figure out how it's going to
work best for you.
Speaker 1 (40:45):
Julie, where can we find you and find more great
advice about healthcare plans and insurance, et cetera. Where's the
best way to kind of continue to follow your work?
Speaker 2 (40:56):
I am at KFF healthnews dot org. We have us
separate page for our podcast. KFF Health News is what
the Health. We come out every week. We cover health
policy news and we have interviews with health policy newsmakers,
and we try to make it understandable for everybody. So
you can subscribe, as they say, wherever you get your podcasts.
Speaker 3 (41:16):
I will say.
Speaker 4 (41:17):
In doing a lot of the research for this episode,
I stumbled across a lot of KFF videos and before
I even really put two and two together, they were very,
very helpful.
Speaker 1 (41:24):
The work that you guys do is very, very cool, amazing.
I feel way more empowered with open enrollment coming up.
I seriously feel like I'm going to make some changes
to my to my what I normally choose after having
this conversation with you.
Speaker 4 (41:36):
Julie, thank you so much for sharing your time, your expertise,
everything we really appreciate.
Speaker 3 (41:41):
Thank you for being with us this afternoon.
Speaker 2 (41:43):
Oh sure this was fun. I mean, this is this
is what I do.
Speaker 1 (41:53):
Wowow wow wow wow. Healthcare in the United States is
complicated and there are a lot of different options and
exceptions to consider. Here's what I'm going to take with
me from our conversation with Julie. The Affordable Care Act
was monumental in the way it changed the requirements for
medical coverage and overall accessibility of health insurance and care.
(42:14):
There's no one, singular, superior health plan option that fits
for everyone. It all depends on what level of risk
you're comfortable with and how much you want to pay
for your regular monthly cost or premium. If you don't
think you're going to go to the doctor that much
in a single year, then go with a higher deductible
plan that allows you to pay a lower premium. If
(42:35):
you're more risk averse and want to make sure you're
not going to pay a ton if something bad happens
and you can manage a higher premium payment, then find
yourself a plan with a lower deductible. Once you reach
your deductible, your plan begins to increase its coverage, but
once you reach your out of pocket maximum, they should
be covering pretty much everything until the end of the year. Sadly,
(42:59):
there are a lot of things that are not included
in the balance towards your deductible or the out of
pocket max, including copays and other medical expenses that your
health plan doesn't cover. Hsas versus fssays HSA is a
crew interest, but are only available with certain health insurance
plans and your total balance and an HSA rolls over
(43:20):
year over year. An FSA or flexible savings account is
a place to park your money and it's a user
or lose it policy without any rolling balances at the
end of the year. However, Unlike an HSA, one hundred
percent of your elected amount is available on day one
with an FSA. Dental health is important. Don't forget to
(43:40):
floss well. Woman. Visits to your gynecologists are required by
a law to be covered in your health insurance plan.
Our current system is complex and figuring it out is
a lot to cover for just one episode, but there
are a lot of resources out there that can help
us better understand what our options are, and hopefully this
was a good starting point for you you. We may
(44:01):
revisit some of the more specifics around health insurance or
even just broader healthcare and upcoming episodes, but for now,
that's all for this episode. Matt, what is next on
this terrifying but rewarding road trip of grown up stuff?
Speaker 4 (44:15):
Speaking of terrifying, our next episode is dropping on Halloween, which,
if you were a child, might be a festive holiday
that involves dressing up in scary costumes, But if you're
an adult and you listen to this podcast, it is
throwing on whatever is in your closet with some sort
of animal ears and drinking alcohol.
Speaker 3 (44:32):
So we will be learning how to drink like adults.
Speaker 1 (44:34):
Oh thank god, because not only will it be Halloween.
But then right after that there's the holiday season, and
I have got a lot of friends givings and holiday
parties to attend, and I really want to be the
Nigdoni spagliato type of adult, But right now I am
still the can you make a Shirley temple with alcohol
in it? Type of adult?
Speaker 3 (44:51):
Do you actually order that?
Speaker 1 (44:53):
Yes, it's called a dirty Shirley and it's just a
Shirley temple with alcohol in it.
Speaker 4 (44:56):
Well, look, we all can't be Emma Darcy in order
a Nigroni spucky prosecco, but we can all learn how
to become refined and sophisticated beverage shrinkers in two weeks
on grown up stuff, how to adult, and.
Speaker 1 (45:07):
Remember you might not be graded in life, but it
never hurts to do.
Speaker 3 (45:11):
Your homework or floss your teeth.
Speaker 1 (45:13):
This is a production from Ruby Studios from iHeartMedia.
Speaker 3 (45:16):
Our executive producers are Malli Sosha.
Speaker 1 (45:18):
And Matt Stillo. This episode was engineered by Matt Stillo.
Speaker 3 (45:22):
And written by Molly Soosha.
Speaker 1 (45:25):
This episode was fact checked by Kasby Bias.
Speaker 3 (45:28):
With additional editing by Sierra Spreen.
Speaker 1 (45:30):
We want to thank our teammates at Ruby Studios, including
Ethan Fixel, Rachel Swan, Krasnoff, Amber Smith, Deborah Garrett, and
Andy Kelly.
At some point in life. Everyone needs to see a doctor,
and arguably many of us should be going way more
frequently than we actually do. But seeing a doctor here
in the United States can sometimes result in an expensive bill,
especially if you're uninsured, and sometimes even if you are insured,
maybe your appointment, or your treatment or your provider wasn't
(00:22):
included as part of your medical coverage. According to research
led by the Johns Hopkins Bloomberg School of Public Health,
the average cost of an appointment with a primary care
doctor for an uninsured patient in twenty fifteen was one
hundred and sixty dollars, and from the same case study,
only seventy nine percent of the uninsured patients were even
offered an appointment. In May of twenty twenty three, Forbes
(00:44):
published in an article comparing the cost of health insurance
on the ACA marketplace. They found that the monthly cost
for an adult twenty one years of age ranged from
three hundred and thirty to four hundred and four dollars
depending on the plan, and for a twenty seven year
old adult that range increase, with the lowest plan costing
four hundred and five dollars to the highest level costing
about four hundred and twenty three a month, and these
(01:07):
rates are based on single adults without dependence. Now you
may be trying to do some math to sort out
if you can save some money by going without insurance.
I mean, how often do you see your primary care doctor?
After all? Aside from the fact that you should be
going to see your primary care doctor ideally every year
for a regular physical, there are other doctors you should
also be going to see regularly. I mean, there's your dermatologists.
(01:30):
You should be going every year for a skin check.
And if you're someone who visits the guynecologists, that's another
exam that should be done annually. And those types of
doctor's visits typically cost more than a primary care doctor.
Speaker 2 (01:42):
But perhaps the.
Speaker 1 (01:43):
Biggest reason why we need insurance is for those unexpected
health issues that can arise. What if you're in a
car accident or you find yourself really sick with a
more long term diagnosis. That's when medical costs can become
insurmountable and insurance can make a huge difference. The end
of October is typically the time of year when open
(02:04):
enrollment begins for a lot of health insurance plans. This
is the window of time when you can change or
enroll in a health insurance plan, and once that window closes,
you have to wait again to enroll or make any
changes until next year. But with so many options and
plans ranging significantly in cost, how do you know which
one is the best one for your needs and for
(02:25):
your budget? And what on earth is a ppo versus
an EPO? Start taking notes because this.
Speaker 3 (02:32):
Is grown up stuff.
Speaker 1 (02:37):
Hello, and welcome to another episode of grown Up Stuff
How to Adult, the podcast where we figure out things
like what's a premium and what's included in a deductible?
All in the name of adulthood. I'm Mollie and I'm
joined by my co host, Matt Stillo, and we hope
that you are healthy and well as you are listening
to this podcast because we're going to dig into health
(02:58):
insurance on this episode. What is it? Why do we
need it? Why does it seem to be written in
another language that relies so heavily on acronyms. But to
start us all off, Matt, what was your earliest experience
with health insurance and what has it been like in
your young life? Has it been good?
Speaker 3 (03:17):
Yeah, bad?
Speaker 2 (03:18):
Confusing?
Speaker 4 (03:20):
Well, thank you for calling me young on this podcast.
Because this year and I don't know how I feel
about very young, but.
Speaker 1 (03:27):
We all feel some sort of way about that age,
about all the ages. So you're doing great, Matt, You're
doing great.
Speaker 4 (03:32):
So for everyone out there who's like, you know, unemployed, underemployed,
you were in the right place because I was actually
on my parents' healthcare up until the last possible second.
I was like about to turn twenty seven, right before
like the enrollment period for the new year, and I
got this job, my first like full job with like
(03:54):
four oh one K and salary and healthcare, and I
was like I couldn't believe it. I like, I got
through that open enrollment and I was like, wow, under
the freaking wire because I was so worried about what's
gonna happen now, you know, that wave of relief quickly
subsided as I was reading through the healthcare plans because
what the hell? Yeah, all this lingo, like how is
(04:17):
a child right? Because twenty six is a child supposed
to figure that stuff out? Even my parents couldn't help
me because it's gotten so confusing in the last few years.
So after it was all said and done, I felt like,
did I make the right decision.
Speaker 3 (04:30):
I have no idea.
Speaker 4 (04:32):
Every subsequent year, I was trying to like do right,
Like I'm gonna get it this time. Yeah, I'm gonna
get it this time.
Speaker 1 (04:37):
Yeah.
Speaker 3 (04:38):
And I don't think even.
Speaker 4 (04:39):
To this day, I've ever really fully figured it out.
But I just want everyone to know out there that, like,
if you are confused by this, it is okay, We're
going to figure it all out together. But Molly, yeah,
I feel like you probably felt the exact same way.
Speaker 1 (04:52):
Oh. I mean, I'll hit submit and I'll go back
and review before the window of open enrollment closes, ultimately
decide I've made the right decision. But once that period ends,
I'm like, Nope, I've made the wrong decision. I know it.
I've made the wrong decision. But let's get to our
conversation with our guests, because I do think she's going
to be able to clarify a lot of this for us.
Speaker 4 (05:13):
Today we are joined by the one and only Julie Robner.
Julie is the Chief Washington correspondent and host of What
the Health, a weekly health policy news podcast from KFF
Health News.
Speaker 1 (05:25):
KFF Health News is a national newsroom that focuses on
health issues and was founded by the Kaiser Family Foundation,
which is now more commonly referred to as KFF. Julie
joined the KFF Health News team after sixteen years as
a health policy correspondent for NPR, where she helped lead
the network's coverage of the Affordable Care Act.
Speaker 4 (05:47):
Julie is also the author of the book Healthcare, Politics
and Policy, a Disease, and the recipient of the National
Press Foundation's Everett McKinley Dirkson Award for Distinguished Reporting of Congress. Well,
Julia Rovner, thank you so much for joining us on
this episode of grown Up Stuff?
Speaker 3 (06:05):
How do adult?
Speaker 4 (06:06):
And at this podcast, we'd like to really like ask
the most dumb question straight.
Speaker 1 (06:11):
Out of the gate, because you're kind of anything.
Speaker 4 (06:15):
Exactly, and that really dumb question is what exactly is
health insurance and why is it so important to have,
especially in the United States.
Speaker 2 (06:26):
Well, health insurance is supposed to prevent you from going
broke if something bad happens to you. A lot of
young people don't think they need health insurance because, after all,
they're less likely to get sick. But you know, even
a twenty five year old can get hit by a
bus or run into a tree. If you go skiing,
things can happen. Unfortunately, young people get very serious diseases.
(06:49):
And if you don't have health insurance, our healthcare system
is really, really expensive. You do not want to get
caught up in it if you don't have some kind
of insurance.
Speaker 1 (06:59):
You know, that's a really good point. Young people are
not exempt from getting cancer, unfortunately, and sadly, I've had
a handful of friends in their late twenties and early
thirties who have been diagnosed with cancer. And even things
like a broken bone can be really expensive without insurance.
But I myself have been in situations where I've either
been in between jobs or freelancing. So what are the
(07:20):
best options to get health insurance if we can't get
it through an employer.
Speaker 2 (07:25):
Well, congratulations, we now all have options which we didn't
when I was a young freelancer. That is exactly what
the Affordable Care Act was aimed at. It was aimed
at people that don't get their health insurance on the
job provided by an employer. So basically, if you're working
for yourself, you can buy insurance and it's pretty good
insurance on the healthcare exchange. And if you don't earn
(07:46):
a lot of money, you'll get a subsidy, in some
cases a really big subsidy, So not only will you
not have to pay very high premiums, and particularly if
you're younger, you might not even have to pay very
much if you have to go and get care. You
can get savings on your your co payments and deductible.
So there are a lot of ways that the Affordable
Care Act is aimed at getting people insured who were
(08:08):
not previously eligible, either for Medicare or Medicaid or an
employer to ensure them. So that's the good news. The
other way, of course, you can get insured or stay
insured if you've had a job in your between jobs
is there something called cobra which allows you to continue
your employer insurance until you get another job, or another
way to get insurance. But if you had insurance and
(08:30):
you lose it for pretty much any reason, you can
sign up under the Affordable Care Act at any time
of the year. You get your own personal open enrollment period.
Speaker 4 (08:40):
Just so that I'm clear on this, was there no
way to directly go to a health insurance company before
the ACA otherwise known as Obamacare, was enacted.
Speaker 2 (08:49):
There were lots of ways to go to a health
insurance company before the Affordable CARECT. The problem is they
might not have sold you insurance because they didn't always
have to. In states where they said you have to
take everybody even if they're sick, the insurance said, okay, bye,
we're just not going to sell in this state. So
there were a lot of people who wanted to get
insurance who couldn't. If you were really healthy, they were
(09:10):
likely to sell you. Insurance could have been, depending on
where you live, pretty cheap or pretty expensive. But sometimes
when it was really cheap, it didn't cover very much.
There were health insurance policies that would only cover up
to the first five hundred dollars worth of care that
barely gets you in the door at a hospital and
even a doctor's office in some case. So there was
(09:30):
a lot of bad health insurance and a lot of
health insurance it wasn't really insurance. And one of the
things that the Affordable Care Act did, and it was controversial,
was to say that these are going to be the
standard benefits that every accredited health insurance policy has to offered.
That of course made a lot of health insurance a
lot more expensive because hey, now it had cover actual stuff.
(09:54):
But I think a lot of people who didn't need
their health insurance very often didn't realize how little their
health insurance covered.
Speaker 4 (10:01):
Actually puts it in a great perspective, like you know
how historic the Affordable Care Act was. I was before
I had had my first job and have my first
health insurance plan, so I did not really realize how
big of a deal.
Speaker 3 (10:14):
That is.
Speaker 4 (10:15):
The one other thing that I wanted to ask you
about and maybe why it was included in the Affordable
Care Act, which is the dependents you know, children who
are on their parents' plan, they can stay on those
plans until you're twenty six.
Speaker 3 (10:27):
Why exactly was that included in the ACA?
Speaker 2 (10:30):
This was a huge, huge deal until then Moost kids
got kicked off their parents' plans when they turned eighteen.
If they went to college, they would buy student health plans.
Then they would graduate and they would have no insurance.
And it was a big problem and also was a
deterrent to do things like go join the Peace Corps,
you know, become a volunteer somewhere, take an internship, or
(10:51):
take any kind of job that didn't offer health insurance.
Because it's so dangerous to be uninsured. These days. So
basically what they said was, we're going to require employee
to allow kids to stay on their parents' plans until
they're twenty six. And the idea is that by the
time somebody is twenty six, they should be grown up
enough to find a way to have health insurance, either
be established as a freelancer or have a job that
(11:13):
provides insurance. But basically want to be able to get
kids through school and through higher learning and still keep
them insured. And also a lot of young people, as
I mentioned, at some point, don't think they need health
insurance and don't buy it, and this is just an
easier way for parents to make sure that their kids
are insured even as they are launching their own careers.
(11:33):
It was an extremely popular benefit. It was one of
the few benefits in the ACA that was completely bipartisanly popular.
Both sides wanted it, and it's obviously a fairly highly
used benefit.
Speaker 1 (11:51):
The Affordable Care Act or ACA or Obamacare is a
comprehensive healthcare reform law that was enacted in March twenty ten.
According to the US Department of Health and Human Services,
the law had three primary goals. One, make affordable health
insurance available to more people, to expand the Medicaid program
(12:12):
to cover all adults with income below one hundred and
thirty eight percent of the federal poverty level, and three
support innovative medical care delivery methods designed to lower costs
of healthcare generally. As Julie mentioned, one way they achieved
this was by increasing the age of health insurance dependence
to twenty six. Now, I personally didn't have the slightest
(12:35):
idea how to properly choose a health insurance plan when
I did turn twenty six, and I was often asking
coworkers what they chose for guidance. And that's because when
I was given these options, I felt like I needed
a translator for all of the different terms.
Speaker 4 (12:53):
Before we get into anything too specific, I think there's
a couple of terms that we should really like talk
about what they mean exactly. So first, would you mind
telling us what a premium is.
Speaker 2 (13:03):
A premium is the amount you pay basically to have insurance.
So it will usually be a monthly fee, and that's
what makes you a policy holder, is paying the premium.
Usually if it's employer provided insurance, the employer will pay
at least some, possibly most in a few cases. All
of the premium, but generally there is someone pays the
(13:24):
premium for you to have insurance.
Speaker 4 (13:26):
Awesome, Okay, I'm just going to rattle through the So
deductible what is a deductible.
Speaker 2 (13:31):
Deductible is how much you pay out of pocket before
your insurance starts paying Deductibles can most are in this
sort of couple of hundred to several hundred dollars range,
which in theory is what people can afford. It depends,
you know, if you have a family, sometimes it can
be you know, five hundred dollars for each member of
(13:51):
the family. That can turn into a lot of money
pretty quick. But the general rule of thumb is the
higher your premium, the lower you're deductible. So if you
don't think you're going to use a lot of health insurance,
you might want to get something with a lower premium
but a higher deductible, and vice versa. If you think
you will use insurance, you might want to get a
higher premium with a lower deductible so your insurance kicks
(14:12):
in faster.
Speaker 3 (14:13):
Awesome. And then what about like copay and co insurance.
Speaker 2 (14:18):
Yeah, those are two slightly different things. But the idea
is that once you reach the place where your insurance
starts paying for things. It's shared. Insurance rarely pays one
hundred percent of anything, So either they will charge you
a co pay. They will say, if you go to
the pharmacy and you get one of these, you know,
four hundred common drugs, you will have a copay of
(14:38):
ten dollars, and if you get a slightly more expended drug,
you'll have a copay of twenty dollars. Co insurance is
when they say, if you go to the doctor or
the hospital, we're going to pay eighty percent or ninety percent,
and you're going to pay the other ten percent. Co
insurance can turn into a lot of money these days
when health care is so expensive. You know, people think, oh,
(14:59):
it's I have a five percent co insurance if you
go to the hospital. Five percent can very quickly become
many thousands of dollars.
Speaker 4 (15:07):
Truly, it's insane. And so I have a deductible and
I hit that. But then why is there an out
of pocket maximum?
Speaker 5 (15:13):
Great question, That's a very good question, because, as I
just said, your co insurance can turn into a lot
of money very quickly, and that's why plans are required
to have an out of pocket maximum, so you don't
once you hit a certain number, usually in the near
ten thousand dollars range, you don't have to pay anything
more for the rest of the year.
Speaker 2 (15:34):
Then the calendar will reset and you'll have to start again.
But it's generally, yeah, even if you have health insurance,
you can end up on the hook for a lot
of money. That's why they have things like flexible spending
accounts and health savings accounts. Healthcare these days is really
expensive in the United States, even with insurance.
Speaker 1 (15:53):
Yeah, So to clarify just that, I understand this. So
your deductible, once you meet that, then they'll cover a
certain percentage of certain things right.
Speaker 2 (16:01):
Right up to your out of pocket maximum.
Speaker 1 (16:03):
It's like basically a video game. You're like, you get
to the first boss, and you get to the second boss,
and you get to the second bus. You win and
you get all these new things and you can do anything.
So after you hit that out of pocket though, then
they have to cover everything. Right, Is that correct?
Speaker 2 (16:15):
It's usually right? There are things then there we'll say, well,
you're not in networks, so we're not going to cover
all of it. There are exceptions to that. You know,
if it's not covered by the plan, then they can
make you pay it. CAFF Health News and NPR and
CBS have been doing something we call the Bill of
the Months for a couple of years now, where people
send us their medical bills that they just can't handle,
(16:36):
and we try to sort out what's going on. And
there are cases where people have been you know, they've
gone way over there out of pocket maximum, but they've
been billed anyway. Sometimes they're actually liable for those bills.
Sometimes they're not. Do you want the out of pocket
maximum for this year?
Speaker 1 (16:50):
Yes?
Speaker 2 (16:51):
Please? What is it for the twenty twenty four plan
your guests? The out of pocket maximum for a marketplace
plan can't be more than ninety four hundred and fifty
dollars for an ind of one, eighteen nine hundred dollars
for a family.
Speaker 1 (17:03):
It's a lot of money.
Speaker 2 (17:04):
That's not just a lot of money, And it says
the things that they don't cover. It doesn't you're out
of pocket. Doesn't cover premiums, it doesn't. It says it
doesn't cover anything you spend for services your plan doesn't cover,
doesn't cover out of network care and services, doesn't cover
costs above the allowed amount for a service a provider
may charge.
Speaker 1 (17:22):
So I was curious about what goes towards my deductible
because sometimes I think, I'm like, whoa, I've spent I
must have hit my deductible at this point, like I've
spent so much money. But you're telling me if I've
paid out of pocket for something my insurance doesn't cover
to begin with, then that doesn't count towards my deductible.
Speaker 2 (17:38):
No, And that's it's really important to know what does
and doesn't count towards your deductible. In some plans, out
of network care won't count towards your deductible, or you'll
have a separate out of network deductible and in network deductible.
Then usually that out of network deductible will be higher.
So it's not just anything you spend on medical care,
it's anything that you spend on medical care that would
(18:00):
be covered after you hit your deductible.
Speaker 1 (18:03):
Son of a bitch cheer leading. Oh and for one
more cherry. On top of this depressing deductible. Sunday, we
did some additional digging and discovered most plans do not
count your copays towards meeting your deductible.
Speaker 4 (18:24):
So what exactly is a healthcare network and like, why
are some doctors in it and then others not.
Speaker 2 (18:31):
Generally, a healthcare network is a group of providers, so doctors, labs, hospitals,
urgent care centers that have signed contracts with the insurer.
And generally the deal is the insurer says, we will
send you our patients, so you will get more patients,
and in exchange, you will give us a better price.
So those are that's how you stay in network. And
(18:52):
because the insurer knows what they're going to pay you,
the patient will only have to pay a limited amount.
Usually known it used to be sort of flat dollar
copayments ten or fifteen or twenty dollars. More commonly these
days it's co insurance, so you'd have to pay ten
percent or twenty percent, which can turn into a lot
of money. But generally, staying within your network of doctors, hospitals,
(19:17):
and other healthcare facilities is going to be a lot
cheaper than going outside the network, where the insurer doesn't
have a deal to get a better rate from the
provider and may have to pay more even if you're
gonna pay more too.
Speaker 1 (19:30):
And what's the best way for us to determine who's
included and who isn't.
Speaker 2 (19:35):
Oh, such a good question, that should be so easy.
There are provider directories where you can see who's in
the plan and who isn't, except it turns out the
provider directories are often wrong or incomplete. Unfortunately, this is
something that's been going on for decades, and now that
it's ever more important to know who's in your network
(19:56):
and who isn't, it's still really hard to find out,
so you have to call each provider until this year.
Last year there was also this problem about something called
surprise bills, where you go to an in network hospital.
You know what's in your network, but you get treated
by a doctor who's not in the network, and you
don't have a choice. It might be the pathologist or
(20:17):
the anesthesiologist. You know, you schedule surgery and you know
you're having surgery with this surgeon, and sometimes you'll call ahead,
is the anti caesiologist in my network? And it's like, well,
we don't really know who your anesthesiologist is going to
be that day, so you have no idea, and then
you would get these huge bills from emergency room doctors
or antithesiologist or doctors that you didn't choose. Congress finally
(20:38):
made that illegal, but only very recently.
Speaker 3 (20:41):
Oh my gosh.
Speaker 2 (20:42):
You know, the best way to find out if a
provider is a network is yes, I know, I know that.
You know, like people under forty eight talking to people
on the phone, but this is a case where you
might want to talk to people on the show. They
don't always know either, but it's worth asking. I mean,
I still go to providers that are you know, I'm
pretty sure a network, but you know, you keep asking,
are you really in my network? Am I really not
(21:04):
going to get a bill for a thousand dollars a year?
Speaker 1 (21:05):
Well?
Speaker 4 (21:05):
I glad that's not just me because I feel like
I have to do that every single time too, And
I'm like, is this really how it works? Like we
just have to do this all the time. Yeah, apparently
it is.
Speaker 2 (21:14):
Our health system is not the most efficient or user
friendly or inexpensive. It's it's a lot of things that
are not very good. I think there's a lot of
disagreement on how to fix the healthcare system, but there's
a whole lot of agreement that it is not working
well right now.
Speaker 1 (21:30):
It is complicated, But this is why these conversations are
so important so that we could be equipped with all
of the knowledge and the tools and the resources to
make the best decisions.
Speaker 2 (21:40):
This is a really important part of adulting. So I mean, yeah,
health insurance saving for retirement thinks that we're a lot
cheaper when I was a young adult, are a lot
more expensive now and you're a lot more on your own.
Speaker 1 (21:56):
We'll be right back with more grown up stuff how
to adult. After a quick break, and we're back with
more grown up stuff how to adults. Let's go into
you know, the major health insurance plan options. For those
(22:19):
of us who you know are employed, we know there's HMO,
p PO, E PO POS, hgh HP, which we're gonna
so yeah, so let's start with the top. HMO. What
does it stand for?
Speaker 2 (22:34):
So, an HMO stands for Health Maintenance Organization. It was
traditionally the most structured and limited way to get health insurance.
And basically what the HMO says is we're going to
get a certain amount of money a month for each
patient and work that's going to cover all their care.
So in theory, you should never get a bill or
rarely get a bill if you're in an HMO and
(22:55):
you basically have to go to all of their providers.
Traditional HMO like Kaiser per Empty, has their own hospitals
in many states, they don't in the eastern part of
the country where they offer insurance, so they will have
deals with other hospitals. But generally you have to stay
within the network, so it's the most restrictive. It's the
hardest to go out and see other specialists or go
(23:16):
other places. And generally it has had traditionally the lowest
premiums because it's the most restrictive. And then as you
go further out, every time it gets easier for you
to go outside of the network and get care from
other places, your premium goes up because it's likely that
the cost of the insurer is going to go up.
So you're generally trading off restrictions in providers versus amount
(23:41):
of premium.
Speaker 1 (23:42):
Interesting. So this then I feel like, and maybe I'm wrong,
but I feel like PPO and EPO kind of go
hand in hand, right.
Speaker 2 (23:50):
They do, And an EPO is sort of a cross
between a POPPO is a preferred provider organization. I'm in
a preferred provider organization where I don't have to go
to the preferred providers, but if I do, it's a
whole lot cheaper. So you're encouraged to stay in the
network as opposed to being required to stay in the
network EPO, which I think is exclusive provider organization. The
(24:13):
acronyms don't mean as much as they used to, which
is what gets a little bit frustrating to people. And
of course, the other thing that it's really important to
trade off, and I guess we'll get to this, is
it your premium, you're deductible are going to be directly linked.
And that's really true in the Affordable Care Act plant
it's like the lower your premium, the higher you're deductible,
the most you're going to have to pay out of
pocket before the insurance kicks in, you know. And if
(24:36):
you pay a higher premium, you'll have a lower deductible.
So unfortunately, there is sometimes arithmetic involved. It's not higher math.
Speaker 1 (24:43):
But it's math fair. As we always say, it never
hurts to do your homework or do the math for
that matter. Okay, now, pos I've seen this and it
does not mean piece of shit.
Speaker 2 (24:56):
It means a point of service, and that's basically the
PPO plan where you can go out of network and
they will pay a certain share. So typically, if you
stay in network, you'll only have to have a copey.
I think my cope is fifteen dollars, which is pretty
good for you know providers in network. It's really good. Yeah,
it's very good. If I go out of network after
(25:16):
I've hit my deductible, they'll pay seventy percent and I'll
pay the other thirty percent.
Speaker 1 (25:21):
Now, HDHP, I actually know at this dance or a
high deductible health plan right now, this is different.
Speaker 2 (25:28):
It is, and it's confusing because there are a lot
of sort of regular health plans, particularly the bronze plants
in the affordable character, that have high deductibles. That it
used to be when they started these the early two thousands,
people's deductibles tended to be in the you know, one hundred,
two hundred, three hundred dollars range, which I know sounds
(25:48):
like quaint today. Right the HDHP plans, the idea was
you would have a deductible of one thousand dollars or
fifteen hundred dollars, which is pretty standard right now. But
the catch you weren't going to have to necessarily pay
that whole deductible because you were also going to have
something called an HSA, a health savings account, and the
idea is that you and probably your employer would put
(26:11):
money away and save it and it would grow tax free,
and you could use that for medical expenses, either things
that weren't covered by your insurance or things that would
eventually be covered by your insurance once you hit your deductible.
It's a kind of catastrophic insurance. It says you're going
to pay this chunk up front, and if you really
need a lot of medical care, then your insurance will
(26:34):
kick in. The problem with this is that a lot
of people have HDHP plans and they don't have the
hsas that go with them, so they just have a
really high deductive health plan. That's an issue. The idea
is that they're supposed to be coupled with the health
savings accounts. Now. Health savings accounts were criticized a lot
when they were first started by people who were all for,
you know, universal coverage, but they said they mostly help
(26:56):
the rich. They help people who earn enough or to
take it saves money, yeah, to put money away that
they might need for health care. On the other hand,
if you're young, it's pretty good savings vehicle.
Speaker 4 (27:07):
So we talked about how like an HSA can come
with a high deductible health plan. But there's also this
account called the FSA. So where exactly does that come
into play, and what is the difference between these two accounts?
Speaker 3 (27:18):
Is one like better than another?
Speaker 2 (27:21):
There's a big difference. An FSA flexible spending account is
generally offered by an employer, and it says we will
take money out of your paycheck and we will put
it away and you can use it for medical expenses
tax free, which is very handy. So I would I
go to the doctor it costs three hundred dollars. I
haven't hit my deductible, so I now have three hundred
(27:42):
dollars bill that I've paid. I send it off and
it comes out of my get it back through my
flexible spending account, and I haven't paid taxes on the
income that's gone to finance that. There's some catches. If
you don't use up all the money within a certain time,
you can lose it. If you leave your within a
certain time, you can lose it. These rules have been
expanded a little bit, so it's a little bit more
(28:04):
flexible than it used to be. There's also some things
that you can spend it on and some things that
you can't. There's certain amounts of I believe you can
once again use it for over the counter products. You
could for a while and then you couldn't, and I
believe you now can again. So it's worth it to check.
But it's also a good way, you know, depending on
your tax bracket, it's a handy way to use tax
(28:27):
free money for medical expenses. Again, it's a way of
encouraging people to put money away to pay medical expenses
that insurance doesn't.
Speaker 1 (28:35):
But Julie FSA, though, does not increue interest the same
way an HSA does.
Speaker 2 (28:41):
No, that's correct. It just sits in an account and
there's an administrator and sometimes I mean, in my case,
you know my RFSA, I have a little credit card.
So when I go to the pharmacy and I need
to pay my thirty dollars, cope, I just hand them
the FSA credit card and then it goes through them.
But no, an HSA is an actual savings ACCOUNTESSA is
just sort of a place to kind of park money
(29:03):
for a year.
Speaker 1 (29:04):
What kind of yield interest yield are we talking here
with these hsas.
Speaker 4 (29:07):
Yeah, it's actually very similar to a retirement account where
you could invest in an innexx s and P five
hundred sort of a fund.
Speaker 2 (29:14):
Exactly is a retirement account for medical expenses.
Speaker 1 (29:22):
There are a number of different things you can pay
for using an HSA or an FSA, including menstrual care
products and sometimes even acupuncture. The biggest difference between the
two options. An HSA accrues interest and can be rolled
over from year to year, whereas an FSA you have
to use everything you have by the end of the
year or you lose it. However, your eligibility for an
(29:44):
HSA is dependent upon which health insurance plan you choose,
and often hsas are not offered when you have a
low deductible plan and you can no longer contribute to
an HSA. Once you enroll in Medicare, you can still
use what you have in an HSA, but you won't
be able to keep putting money into it, which leads
me to a very important point. And don't trudge me
(30:06):
for not knowing this, because I know I'm not the
only one. But what is medicare and what is the
difference between Medicare and Medicaid.
Speaker 2 (30:16):
Medicare is the federal health program for people who are elderly,
over sixty five and people with disabilities who qualify because
they have worked long enough to be eligible for Social
Security disability. So if you're over sixty five or you're
on Social Security disability, you are eligible for Medicare. Medicare
(30:36):
has a number of parts. The hospital part comes for free,
that's what you pay your payroll taxes. For the optional
part B you pay premiums for it. And now as
of two thousand and three, you can buy prescription drug
coverage because, believe it or not, until then, Medicare didn't
cover prescription drugs really, yeah, which was really bizarre.
Speaker 1 (30:57):
Yeah, especially since the older you get there or medications
I feel like you need.
Speaker 2 (31:02):
That's why they didn't cover it because it would have
been really expensive, so nobody had wanted to add it. Anyway.
That is Medicare, So that is all federal program. There's
obviously a lot of private insurance involved in it now
for people who are older and who are on Social
Security disability. Medicaid is for people with low incomes, and
(31:22):
it used to be you had to fit into a
category to get Medicaid. You had to be low income,
and a child low income, and a pregnant woman, low
income and elderly. There's many people who are on both
Medicare and Medicaid low income with a disability. As of
the Affordable Care Act, you no longer had to be
low income and something else. You only had to be
(31:42):
low income. This was a huge change because there were
a lot of adult and many young people who had
low incomes but were not a child or a pregnant
woman or somebody with a disability, so they were suddenly
eligible for Medicaid. The trick was that the federal government
made this an option for the states, so they didn't
have to do it under the Affordable Care It was
(32:04):
a very attractive option. The federal government paid one hundred
percent of the state share for the first three years
and still pays ninety percent. Now Medicaid is a joint
federal state program. Wealthier states have to pay half of
the Medicaid costs. So for the federal government to say
we're going to pay the whole thing for three years
and then we're going to pay ninety percent was a
(32:25):
gigantic incentive. Hospitals were dying to have states do this
because all of those people who didn't have any insurance
would show up at the hospital, a hospital would take
care of them, hospital would have nobody to bill. So
at this point most of the states have taken advantage
of it, but there are still I believe it's ten
hold out states that have not expanded Medicaid. And those
(32:49):
do include some really big states like Texas and Florida
and Georgia, and then other states in the South and
some of the Great Plain states. But the vast majority
of state now have expanded Medicaid. And so basically, if
you have a low enough income, you can get health
insurance through this joint federal state program.
Speaker 4 (33:09):
And so for the people who maybe listening that would
qualify as being low income, how might they go about
taking advantage of Medicaid.
Speaker 2 (33:16):
There should be a state Medicaid office. If you just
google your state's Medicaid program, it should come up. If
you go to the Affordable Care Act exchanges, the place
where you buy private insurance. There's supposed to be something
called the no Wrong Door policy where if you type
in all of your statistics and your income qualified, you
automatically get sent to Medicaid enrollment. Also, if you end
(33:39):
up in a hospital or a community health center. A
lot of places the providers themselves will help you enroll
in Medicaid because that's how they're going to get paid.
So there are a lot of people with incentives to
get you medicaid if you're in fact eligible for it.
Speaker 1 (33:54):
Julie, Matt and I have been going back and forth
on this because we've both chosen very different plans for
various reasons. But between an high deductible health plan with
a health savings account versus a PPO POS where you
have a broader network and a lower deductible, which one
do you think is a better plan to use? For
(34:17):
somebody like Matt and myself, I.
Speaker 2 (34:19):
Think it's an absolute personal choice. It has to do
with what level of risk, how much do you worry
about using healthcare or not using healthcare or saving for
the future. I mean it is they both have their places,
and it's the nice thing about having choices. It is
an individual decision. I could not recommend one over the other.
Speaker 1 (34:38):
That's right. You heard it here. My choice is right,
so's mass.
Speaker 2 (34:45):
So the question is, you know, it's a talk about
you know, taking your amount of risk. Do you think
you're not going to use any healthcare during the year,
then you might want to go with the lowest premium
plan you can find, and you might not have to
pay that deductible. If you don't use any care, you
don't have to pay a ductductible. So if you do
think you might be using medical care during the year,
and hint, hint, people should use at least some medical
(35:07):
care during the year. They're preventive stuff that you should have.
But if you think you can just you know, write
a check for that, pay it yourself, put it on
your credit card, whatever, then you might want to go
with some kind of a high deductible health plan. If
your employer offers to put money in an HSA, if
you take that high deductible health plan, all the better.
And if you can put a little bit of money
(35:27):
in that HSA, it shields it from taxes for you,
and it's hields it and the employer sometimes will put
in enough money to make up a good chunk of
your deductible, so that can be that can be a
good choice, particularly for younger workers who are less likely
to need medical care and more sensitive to the amount
of the premium. If you have doctor's health providers that
(35:48):
you are very attached to you should find a plan
that includes them. If you have certain prescription drugs that
you take, you should make sure that the plan includes them.
So there's homework to be done, but only it's how
much do you want to pay out of pocket? How
much do you think you might have to pay as
a deductible, and who and what is covered. Those are
(36:09):
the things you need to sort of go through, either
with an employer plan, and most employers offer you a
choice of at least a couple of plants, or with
an Affordable Care Act plan. No matter what I mean,
the good news is that you're going to have some choice.
The bad news is you're going to have to figure
out which choice is best.
Speaker 1 (36:25):
While some coverage differs from plant to plan, the Affordable
Care Act has required that certain things are covered by
any plan, like well woman visits, birth control prescriptions, certain
vaccines like the flu shot, preventive care like mammograms and kolonoscopies,
and dental envision coverage for children. However, if you are
an adult, dental envision are not a requirement of your
(36:48):
medical coverage.
Speaker 4 (36:51):
So we've got a medical plan, but then we find
out dental envision are not included.
Speaker 3 (36:56):
Why is that?
Speaker 2 (36:57):
Again, they're expensive, it's an add on. It's not something
that has traditionally been part of health insurance because.
Speaker 3 (37:05):
La la la.
Speaker 2 (37:06):
It didn't used to be that expensive. It wasn't an
insurable event. Now it's expensive. Low vision care still most
vision care is still not that expensive, but dental care
really is expensive. And again, like mental health care, we
didn't used to think that it was really important medically,
but it turns out oral health care is really important medically.
Uncared for teeth can cause heart disease, right in addition
(37:29):
to other things. I mean, it is really important. Medicare
still doesn't cover either dental care or eye care or
hearing aids. You can see it in There are some
private Medicare plans that do sort of as an enticement,
but standard Medicare does not. The health insurance business has
grown up slowly, shall we say, since the early nineteen hundreds.
(37:51):
At first it was just hospitals that you needed insurance for,
and then hospitals and doctors, and then hospitals and doctors
and prescription drugs, hospitals and doctors and prescription drugs, and
vision care and dental care and mental health care and
substance abuse care. There's a lot of things that make
it expensive, and insurance basically is trying to spread the
(38:12):
risk to the people who are healthy and who are sick.
And if it's too expensive for the people who are healthy,
they won't buy it, and if they don't buy it,
we get into that insurance death spiral. I'm also curious.
Speaker 1 (38:23):
You know, it's wonderful that well women's visits are included
in our standard care, but why isn't fertility included as
part of that kind of well women's coverage?
Speaker 2 (38:34):
Because it's expensive. Almost whenever you ask, there's only two
reasons why things aren't covered. They're not sort of accepted
as standard treatment. This is actually why obesity drugs aren't
covered for the most part, because until very recently, there
weren't any that worked. There just weren't any good obesity
to drugs. It was easy to say we're not going
to pay for them because there wasn't anything that we
(38:56):
knew scientifically worked that you could pay for. The other
thing is for things that were really expensive, and infertility
coverage is really expensive. And question is, you know, is
an inability to get pregnant? You know, a medical problem
and it varies, so I actually I'm read I now
found the statistics. So, as of September twenty twenty three,
twenty one states plus the District of Columbia have passed
(39:19):
fertility insurance coverage laws. Fifteen of those laws include IVF
coverage and seventeen cover fertility preservation. For instance, if you
are a young woman diagnosed with breast cancer, you can
have your eggs harvested so that you can get pregnant
after your treatment, if that's possible.
Speaker 4 (39:35):
Is there any sort of advice you can give someone
to going through this process for the first time? Is
there anything that we didn't cover? And then lastly, like,
do you have any like hope for the future that
this is going to get like less complex or easier
to navigate?
Speaker 3 (39:48):
Yeah?
Speaker 1 (39:49):
How do you see it changing and evolving too?
Speaker 2 (39:52):
Well? One thing I will say is that there are
lots of sources of help. There are navigators for the
Affordable Care Act. If you look at your state CELTHIC
ch Sure into Exchange, there are various counselors. You can
talk to an agent who can help you sort of
sort through this. You can talk to a trusted adult
who's been through this who can help you sort through it.
I mean, it's not easy, and you probably, certainly the
(40:14):
first or second or third time, should reach out and
get help. It's not intended to be easy. Am I optimistic?
You know? Twenty years ago I said things we're going
to have to really get bad before we really fix things.
And things are really bad, and we really you know,
we fix things a tiny, tiny piece at a time.
Do I think it's going to get fixed? Yeah? Do
(40:35):
I think it's going to get fixed anytime soon? Not
so much anymore.
Speaker 4 (40:39):
So the best thing you can do is really arm
yourself with information and figure out how it's going to
work best for you.
Speaker 1 (40:45):
Julie, where can we find you and find more great
advice about healthcare plans and insurance, et cetera. Where's the
best way to kind of continue to follow your work?
Speaker 2 (40:56):
I am at KFF healthnews dot org. We have us
separate page for our podcast. KFF Health News is what
the Health. We come out every week. We cover health
policy news and we have interviews with health policy newsmakers,
and we try to make it understandable for everybody. So
you can subscribe, as they say, wherever you get your podcasts.
Speaker 3 (41:16):
I will say.
Speaker 4 (41:17):
In doing a lot of the research for this episode,
I stumbled across a lot of KFF videos and before
I even really put two and two together, they were very,
very helpful.
Speaker 1 (41:24):
The work that you guys do is very, very cool, amazing.
I feel way more empowered with open enrollment coming up.
I seriously feel like I'm going to make some changes
to my to my what I normally choose after having
this conversation with you.
Speaker 4 (41:36):
Julie, thank you so much for sharing your time, your expertise,
everything we really appreciate.
Speaker 3 (41:41):
Thank you for being with us this afternoon.
Speaker 2 (41:43):
Oh sure this was fun. I mean, this is this
is what I do.
Speaker 1 (41:53):
Wowow wow wow wow. Healthcare in the United States is
complicated and there are a lot of different options and
exceptions to consider. Here's what I'm going to take with
me from our conversation with Julie. The Affordable Care Act
was monumental in the way it changed the requirements for
medical coverage and overall accessibility of health insurance and care.
(42:14):
There's no one, singular, superior health plan option that fits
for everyone. It all depends on what level of risk
you're comfortable with and how much you want to pay
for your regular monthly cost or premium. If you don't
think you're going to go to the doctor that much
in a single year, then go with a higher deductible
plan that allows you to pay a lower premium. If
(42:35):
you're more risk averse and want to make sure you're
not going to pay a ton if something bad happens
and you can manage a higher premium payment, then find
yourself a plan with a lower deductible. Once you reach
your deductible, your plan begins to increase its coverage, but
once you reach your out of pocket maximum, they should
be covering pretty much everything until the end of the year. Sadly,
(42:59):
there are a lot of things that are not included
in the balance towards your deductible or the out of
pocket max, including copays and other medical expenses that your
health plan doesn't cover. Hsas versus fssays HSA is a
crew interest, but are only available with certain health insurance
plans and your total balance and an HSA rolls over
(43:20):
year over year. An FSA or flexible savings account is
a place to park your money and it's a user
or lose it policy without any rolling balances at the
end of the year. However, Unlike an HSA, one hundred
percent of your elected amount is available on day one
with an FSA. Dental health is important. Don't forget to
(43:40):
floss well. Woman. Visits to your gynecologists are required by
a law to be covered in your health insurance plan.
Our current system is complex and figuring it out is
a lot to cover for just one episode, but there
are a lot of resources out there that can help
us better understand what our options are, and hopefully this
was a good starting point for you you. We may
(44:01):
revisit some of the more specifics around health insurance or
even just broader healthcare and upcoming episodes, but for now,
that's all for this episode. Matt, what is next on
this terrifying but rewarding road trip of grown up stuff?
Speaker 4 (44:15):
Speaking of terrifying, our next episode is dropping on Halloween, which,
if you were a child, might be a festive holiday
that involves dressing up in scary costumes, But if you're
an adult and you listen to this podcast, it is
throwing on whatever is in your closet with some sort
of animal ears and drinking alcohol.
Speaker 3 (44:32):
So we will be learning how to drink like adults.
Speaker 1 (44:34):
Oh thank god, because not only will it be Halloween.
But then right after that there's the holiday season, and
I have got a lot of friends givings and holiday
parties to attend, and I really want to be the
Nigdoni spagliato type of adult, But right now I am
still the can you make a Shirley temple with alcohol
in it? Type of adult?
Speaker 3 (44:51):
Do you actually order that?
Speaker 1 (44:53):
Yes, it's called a dirty Shirley and it's just a
Shirley temple with alcohol in it.
Speaker 4 (44:56):
Well, look, we all can't be Emma Darcy in order
a Nigroni spucky prosecco, but we can all learn how
to become refined and sophisticated beverage shrinkers in two weeks
on grown up stuff, how to adult, and.
Speaker 1 (45:07):
Remember you might not be graded in life, but it
never hurts to do.
Speaker 3 (45:11):
Your homework or floss your teeth.
Speaker 1 (45:13):
This is a production from Ruby Studios from iHeartMedia.
Speaker 3 (45:16):
Our executive producers are Malli Sosha.
Speaker 1 (45:18):
And Matt Stillo. This episode was engineered by Matt Stillo.
Speaker 3 (45:22):
And written by Molly Soosha.
Speaker 1 (45:25):
This episode was fact checked by Kasby Bias.
Speaker 3 (45:28):
With additional editing by Sierra Spreen.
Speaker 1 (45:30):
We want to thank our teammates at Ruby Studios, including
Ethan Fixel, Rachel Swan, Krasnoff, Amber Smith, Deborah Garrett, and
Andy Kelly.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Super Bowl LIX Podcasts
Don't miss out on the NFL Podcast Network and iHeartPodcasts' exclusive week of episodes recorded in New Orleans!
24/7 News: The Latest
Today’s Latest News In 4 Minutes. Updated Hourly.