We were told that insurance premiums will be up 9% to 16% in the upcoming open enrollment and not to be surprised. Nothing an employer can do since this is an industry-wide increase. I am so exhausted tightening the belt year after year.

Hi all, this is my first experience with spousal surcharges and I'm wondering if what my employer charges is standard.

My insurance premium is $160/month for a high deductible plan. My workplace pays about $500/month on my behalf.

My spouse's job does not offer health insurance. If I added him to my plan, his premium would be $2170/month. That's just for him, not both of us.

It would make sense to me if I had to pay my spouse's premium ($160) plus my employer's part ($500) plus an additional surcharge. But to reach $2170, that surcharge would have to be $1510 per month. It seems like more of a penalty than a surcharge.

I understand that health insurance costs employers a lot, and when spouses are covered, that raises costs for my coworkers. I don't mind there being a spousal surcharge to keep those costs down. But I don't understand what the extra $1510 would be going towards. Is that an excessive surcharge, or am I just living in the much cheaper past?

I’m looking for some advice because our health insurance premiums are getting ridiculous, and I’m trying to figure out what other options we might have.
We’re a family of four in Texas, with our third child due in March 2027. I don’t receive health insurance through my employer, so we’ve been purchasing our own coverage through BCBS Texas.
Our premiums for 2027 are going to be approximately $1,800 per month ($21,600 annually), and that’s before deductibles, copays, or other out-of-pocket expenses.
The biggest complication is that one of our sons has severe Hemophilia A and requires ongoing treatment with Hemlibra. Because of this, having comprehensive insurance with reliable specialty medication coverage is absolutely essential. We can’t risk losing access to his treatment.
We have a decent household income, but we’re right around the income threshold for ACA Marketplace subsidies, depending on how our retirement and HSA contributions factor into the calculation. We may qualify for some assistance, but I’m not counting on it.
I’m just having a hard time accepting that we’re spending over $21,000 annually on premiums alone, especially with another baby on the way.
For those who have been in similar situations:
Have you found any alternatives to purchasing individual family coverage directly through an insurance company?
Are there any Texas-specific programs or options for families with children who have serious chronic medical conditions?
Has anyone successfully navigated Marketplace coverage with expensive specialty medications like Hemlibra?
Are there any legitimate ways to reduce premiums without sacrificing comprehensive coverage?
Is there anything I might be overlooking?
I’m not looking for short-term health plans, health-sharing ministries, or anything that could exclude preexisting conditions. We need legitimate, comprehensive health insurance.
I’d really appreciate any advice or experiences. Thanks!

I have a family member that has had ALTCS for two years, which is Arizonas long term care system that’s a part of AHCCCS Medicaid. She recently found 2,700 dollars in a bank account, which puts her over the limit of only having 2,000 in assets to qualify. She spent most of it and it’s below 2,000 now.

I’m very afraid that ALTCS will find out about it and cancel her insurance. She absolutely needs this insurance. She lives in a care home. She has a brain injury but can sometimes present normal, so I’m always worried they will find her ineligible if they reevaluate her. It’s super obvious she has one though if you spend time with her and have her do anything slightly complicated. I would never leave her alone at my place for fear she will hurt herself cooking or get lost trying to walk somewhere.

I’m her representative for all her affairs. I’m thinking it’s best to be honest and tell them about the bank account she found? They probably have electronic systems that find out if she is hiding assets like bank accounts, right? I don’t want to do anything that loses her benefits and causes her to be homeless. Any advice appreciated.

As the title says, my mom had an emergency stay in the hospital in Mexico while we (Americans) were there on vacation.

Hospital required direct payment, which I put on my credit cards. She reimbursed me from her savings as soon as we got home (about $35,000).

She has since passed away.

Is it possible that her insurance (Humana / Medicaid) will reimburse me for this cost, since it came out of her pocket (and my inheritance)?

What's the best way to persue it?

EDIT: She did not have travel insurance. I realize this would have been helpful.

The hospital did not accept any form of insurance anyway, only direct payment.

Yes, it was a life threatening emergency.

Currently I'm living in Florida. Next year I'll be living in VA for 4-6 months. After that, I'm not sure if I'll return to Florida or continue to travel. Is there a health insurance plan, or certain plan features/structure, that would be more useful for someone who travels around the Continental US?

Am I allowed to do state insurance for Florida and then a separate insurance plan for out of state? Or is that illegal/against some rule?

I know I'll have to find a new psych in VA for my ADHD meds. Other than that I don't have any serious health concerns.

I'll be meeting with an insurance broker sometime next month so I'm trying to prepare for that conversation as much as possible. I'd like to go into it with a rough idea of what I need. TIA!

Entered into a labor agreement with CJ that he would pay for labor if an equity agreement wasn't reached. Because he was always a scammer, he obviously didn't give any equity, and then paid $0 for the labor. Pure fraud and scam. Stolen wages. Theft of services. Swindler. Rocket health has a criminal in charge.

#fraud

#rockethealth

#austin

I’m looking at my open enrollment, using UHC surest choice +. Can anyone tell me the difference between a full benefit insurance rate schedule & a single benefit insurance rate schedule? I looked it up online & I don’t think that’s correct in this case. The rate for employee only is the same for both, but family is 2-4x as much on the single benefit

Sorry in advance for the long story…in summary: has anyone else been underpaid by imagine360 for a claim?? I would encourage anyone to double check their math on the “allowable claim limits”…

—-

I have Imagine 360 health insurance through my employer. I was having trouble finding a therapist who would directly take the insurance, so I went the route of paying out-of-pocket and submitting the claims for reimbursement (terrible choice, I know). Before starting with the therapist, I called Imagine360 and specifically asked questions about the claims submittal process, how much I could be reimbursed, etc. I remember specifically asking if there was a max amount a therapist could charge per session in order to be covered by the insurance (minus my co-pay). They told me no, that I would only be responsible for my co-pay (I was naive and believed them back then lol).

After going to a few sessions, I got the superbill from my provider and submitted my first claim. I didn’t hear anything for over a month, despite reaching out, and then finally heard back. Therapy was costing me $250 per session and they told me the allowable claim limit was $121.59 per visit. Minus $40 for my copay, that meant I would be reimbursed $81.59 per visit (meaning I was actually paying $168.41 per visit).

Obviously, I was extremely upset. I spoke with an Imagine360 representative and told them I was mislead to believe the insurance would cover the entire cost minus my copay. I asked them if they could provide me with the recording of the previous call where they told me it would be covered. They escalated my concern and put me in touch with higher up employee, let’s call her Sarah. Sarah was much more helpful and pulled the call record. She told me they couldn’t send me the audio, but they could send me a transcript of the call and she would request it.

In the meantime, she gave me further information about how the allowable claim limit is calculated. I did a bunch of research as well to figure out what it all means. My plan specifically states (and Sarah confirmed) that the allowable claim limit for specialist care claims is the “Medicare allowed amount in the geographic area plus an additional 55%.” Now that I had this to go off of, I found the physician fee schedule search engine on CMS.gov and searched for my CPT code, adjusted for specific MAC locality San Diego (where I live).

The search engine gave me a price of $121.59 (the EXACT same price they told me was my allowable claim limit, down to the cent). I thought wait… this is the Medicare allowed amount, mine is supposed to be that +55%… that’s a pretty significant jump. I called Sarah back and explained. She wasn’t able to provide any answers, but she looked up the numbers as I told her and seemed to agree with my assessment. The 55% was not added.

That conversation was last week and Sarah told me she would look into it and get back to me. Today I called her back because I still hadn’t heard from her. She told me that her supervisor told her the claim is correct and I’d have to submit an appeal if I still have an issue with it. She also told me that her supervisor instructed her NOT to share the call transcript with me and that those recordings are for internal education only… Sarah kept apologizing and saying she doesn’t really know how the claim team calculates the reimbursements. She agreed to escalate again and I’m supposed to get a call from her supervisor within the next 3 days…

Am I missing something?? Are the rates in the physician fee schedule search the wrong place to look? I figured I was in the right place if the dollar amount was the same down to the cent….
But still, they are trying to make me submit MORE paper work and wait who knows how long for the claim appeal process (which they could continue to deny and then what??). As far as the call transcript, it feels so fishy that I was told I could receive a transcript and then they took it back. Makes me assume that I was in fact given the wrong information on that call, but without the transcript it’s just my word against theirs.

If my claim didn’t add the 55%, I seriously doubt I’m the only one that’s happening to. If there’s an error in the system that calculates the allowable claim limit, then there are probably tons of people getting less money than they are owed (and they may not even know if they’re not double checking the math themselves).

Not to be dramatic, but would this be worth talking to a lawyer?? Has this happened to anyone else? What do you recommend saying when Sarah’s supervisor calls? What questions should I ask?

Thanks in advance for any advice/feedback!

UPDATE:
I determined, based on the search engine on CMS.gov, that if my provider changes the CPT code to 1 hour session instead of 45 minutes (which she is happy to do), the Medicare rate is $178.34. With the +55%, that’s an allowable claim limit of $276.42. Meaning it SHOULD cover the full $250.

Hi okay some background, and I apologize if this is all over the place I'm bad with explaining things, I will have a TLDR at the end. I'm 20 years old and my parents are both veterans, with my dad having retired from the navy and being the beneficiary (?) of our Tricare insurance. I've been on it my whole life and apparently once I turn 21 I get booted from the plan, as I'm not in college/university.

The thing is, I am very chronically ill and had to quit my job before the summer because my health/body simply couldn't keep up anymore and I was getting super burnt out. I see doctors (primary care, physical therapist, labs, cardiology, etc.) more than I see my own friends most the time, and work with a therapist and psychiatrist for my ADHD and treatment resistant depression - this is very necessary healthcare for me. I can barely afford all of that even with our very nice insurance, especially with being out of a job for the foreseeable future (I've been having a lot of issue with my doctors to figure out and treat a health issue that prevents me from standing/walking/any sort of physical labor).

The thing is, I know absolutely nothing about insurance or how it works. I am very stressed out about this situation because I turn 21 in January and seem no closer to figuring things out. My mom has never had to worry about how health insurance works because it's always been provided by her parents/jobs/my dad, so turning to her for advice hasn't been very useful. I'd like to ask my dad about it, especially considering the insurance is under his name, but in all honesty my dad is not the brightest person around and is entirely unhelpful and unreliable with... anything, really.

I live in WI but due to proximity and also my city not having pretty much anything available, 99% of my providers are in MN, and I was told before by someone that state insurance is shitty with what they'll cover and funding, and can be weird when it comes to out of state treatments/providers :/

I've heard about Tricare Young Adult which I believe I would qualify for after my birthday, but I don't really know what I am going to have to do to take care of these things. I think my family is on Tricare-Select just based off of the website's descriptions, but I can't wrap my head around how costs and all of that works or if TYA-Select will mean more expensive co-pay's or not. I know for certain I can't afford TYA-Prime's monthly payment, I am not even positive I'll be able to afford Select's but if that's my best option I'll try to scrape it together lol.

TLDR: I'm getting booted from my parent's Tricare after my upcoming birthday - but I'm chronically ill, require healthcare, and am not currently able to work. Plus I don't know how any of this stuff works.

Probably important info: I live in WI but majority of my healthcare is in MN due to proximity/what's available near me. I see a therapist, psychiatrist, my primary care, a physical therapist, and have my labs drawn - all regularly. Not including other bs healthcare I've been having to try and get.

What I'm wondering mainly:

• What is the process of switching/signing up for insurance like at all?
• Is Tricare Young Adult - Select a good plan/my best option?
  • Would it be similar or better/worse than Tricare-Select (which is I think my parent's plan)?
• I assume that Medicaid / State insurance is going to be a waste of time and energy, true or false?
• Is it possible to know how soon after my birthday/turning 21 I will have to deal with the insurance loss?
• I don't understand how the costs or rules for insurance work - help ?

My husband works for the State with a high tier insurance. Essentially copays on his insurance tier (like PPO) are so much lower than on my PPO from my employer.

My employer pays 80% of my PPO so the 20% are still on me and this is 3x as expensive as adding me as spouse to the insurance of my husband.

Are there any downsides?

Caresource JUST FOR ME dentist sought to have teeth extracted in the Cincinnati area. I used “find a doctor” and got nothing

So, in June of this year I had VSG, commonly known as the gastric sleeve. My surgeon got the prior authorization and it was approved by my insurance no issue. Surgeon is In Network, his office is In Network, the hospital I was at is In Network, and even my Anesthesiologist is In Network.

I was looking through my claims on the BCBSTX app, and it’s showing that many claims from his office are now denied when they were previously approved, and that my $61,000 surgery and one night stay is denied? Even though the prior authorization still says approved and all my EOB’s say I “may owe” $0.

I’m just worried my $61,000 surgery is somehow going to fall back on me even though it was completely approved during the prior authorization.

I don’t use healthcare too often, usually just for preventative screenings, to get my meds refilled, and a few visits for minor things. This year, I had switched down to a Bronze plan, and I’m noticing that I pay more for visits and services, plus I’ll never even get close to hitting my deductible.

Would I be better off just paying cash or going with a catastrophic plan? With my age and income, I’m looking at paying $700 or more in premium a month for just myself.

They are located in New Jersey. Age 79 and 76. Income for both is less than $40k a year. Currently they are paying about $470 a month for plan N for the two of them, but I see that I could get that down to as low as $286 a month for both. I understand that some plans offer additional perks, but their current plan is not one of them.

Right now the lowest cost option is provided by Medico Insurance Company. My understanding is that all plan N coverage is the same and that doctors and institutions who take medicare can't refuse Plan N no matter what company provides coverage.

So why is it that people who work at the front desk for various doctors institutions often first ask for the name of the Plan N insurance company and than when I say Horizon Blue Cross Blue Shield they are practically visibly happy. What would happen if I say Medico Insurance Company for example?

Are there some written or "unwritten" rules that are not obvious that would make it harder for them to get the care they need if they go with cheaper and lesser known insurance company that also offers Plan N. Are there any other pros and cons that average person can't see until something bites them in the ass.

I am a single 38 year old with no children or dependents. My employer offers health insurance and I have the option to choose pre tax or post tax. My benefit rep told me that I currently have post tax with my insurance for this year, and when I go to sign up for 2027, post tax is selected as the default option. My question is, which one would be the more logical one for me to choose? I dont want to owe any money at the end of the year, and the benefit rep also told me most people choose post tax...but upon researching it says pre tax is almost always better. It would be nice to see more money on my checks with pre, but what would that change for me? A smaller tax return? Owing money at the end of the year? I work 40 hours a week full time if this helps. Thank you guys in advance for reading this and to anyone who takes the time to help.

DC Health Link (Washington, DC ACA) says that the Affordable Coverage Exemption is available to anyone whose lowest cost ACA health insurance premiums exceed 8% of their estimated 2027 income.

I find that my cheapest Bronze plan (59 years old) costs about $13,789 per year.
8% of $127,000 is $13,789.

This tells me that even someone making $127,000 qualifies for an "Affordable Coverage Exemption".

Am I getting this right??

REF: https://www.dchealthlink.com/individual-responsibility-requirement#exemption

"Affordable Coverage Exemptions

Coverage is considered unaffordable if you would have to pay more than about 8 percent of income for the lowest cost plan available to you."

I (32F) have had a lot of dental work due to an accident.

#13-#15 have had root canal retreatment done this year, and my dentist said they are healing well. #13 and #14 have 5-year-old crowns. #15 has a brand-new crown, but this is the last attempt, so extraction will be the next step if anything happens.

#6-#10 got root canals 11 years ago, and crowns were placed immediately after. I still have the original crowns, and my dentist says they look fine.

There are some small fillings here and there on my upper teeth.

I feel like I will have a lot of procedures coming due to the age of my crowns, and eventually I will need an implant, either a full upper arch or individual ones. Also, I started doing cleanings every 4 months.

Right now I have dental insurance with Blue Cross Blue Shield (since 2023, so no waiting period). I already maxed out this year.

- $33/month

- $50 deductible and $1500 maximum coverage

- covers 80% basic services and 50% major services

I am looking to add Cigna 3000/100

- $29/month

- $100 deductible and $3000 maximum coverage

- covers 50% of basic and major services after the waiting period.

I am not sure if it makes sense to add a second insurance policy for future treatments. If so, which one should be primary insurance?

I went to the DHS office in Pa to apply for health insurance and SNAP (food stamps), but the caseworker I dealt with wasn’t the easiest to work with. I already struggle with pretty bad anxiety, and the whole process became overwhelming for me.
I had some additional paperwork to complete regarding my rent and who lives in my household. I wasn’t able to get everything submitted in time, and I eventually received what I believe was a fair hearing notice. Unfortunately, I got overwhelmed by that process, too, and never followed through with it.
Now, the original deadlines for both SNAP and health insurance have passed, as well as the extended deadlines.
My question is: Can I go back to the DHS office and start the application process over from scratch? Would I be able to fill out all the paperwork again and request a different caseworker?
I know I should have handled things sooner, but my anxiety really got the best of me, and now I’m trying to figure out what my options are.
Has anyone been in a similar situation or gone through this process? I’d really appreciate any advice or insight. Thank you!

i’m going to get health insurance though my employer but i’m so confused on copay, out of pocket max, and just health insurance in general. my whole life i’ve been on medical assistance cause my mom was on the poorer side or i wasn’t making a lot of money.

SO say my copay was $10, would i get a bill after that? for the rest of that cost?

im just so confused please help 🙃

I've just learned that I have an inguinal hernia that's going to need surgery, which averages about $12,000 in my area. This comes at the same time that I'm being presented with insurance for the first time in a long time (small business problems).

I haven't had to decipher anything like this in over a decade and just want to make sure I'm not screwing myself over before jumping on anything. Thank you for any advice in advance!

My plan is to spend the next year on the PPO to knock out my surgery and then speedrun everything else w/ the OOP and deductible having been met before the year is up. Once through the year, I'll end up on the HSA plan.

• PPO ($270/mo): $3,000 deductible and $6,000 individual out-of-pocket maximum. Most common in-network services have set copays before the deductible, such as $25 primary-care visits, $75 specialist visits, and $50 urgent care.
• HSA plan ($162/mo): $3,500 deductible and $6,450 individual out-of-pocket maximum. Most non-preventive care costs the plan’s negotiated rate until the deductible is met, then I pay 20%. No employer contribution.
• Both: In-network preventive care is covered at 100%. The HSA plan allows HSA contributions; prescription costs count toward its deductible, while they don’t count toward the PPO deductible.

There's also an $80/mo option for Select HSA 5500: $5,500 individual / $11,000 family deductible; $8,300 / $16,600 out-of-pocket maximum; 30% coinsurance after the deductible. There is a $1000 a year contribution to this one, but it just doesn't appear to be anywhere near an option for this year. Potentially next year, when surgery isn't in the plans.

How does this sound to those more experienced? My main concern and thought process isn't the yearly cost, but rather the upfront costs. I don't mind losing a few hundred in the year if I'm not having to worry about day to day costs potentially being heavy hitters. Going to see a specialist and get imaging on a plan that requires me to hit my deductible first sounds miserable.

Thanks again!