ON CONSUMERISM
By Arthur Vidro
Until Dec. 15, more than 50 million Americans can sign up for 2025 health insurance. Some are folks enrolling for a year of coverage through the HealthCare.Gov marketplace; most are folks altering their Medicare coverage.
Phone calls arrive daily from strangers claiming they can find us wonderful Medicare plans that somehow also save us money on groceries, which makes no sense, but that’s what they claim. They refuse to give me their phone number. Which means they’re scam artists.
Anyway, we get our health insurance through the HealthCare.Gov website, created as part of the Affordable Care Act.
Before choosing a plan on that site, you input personal information. Name, address, date of birth, citizenship status, Social Security number, the usual stuff. Questions are asked about your dependents, or your dependency on others. They ask about other possible sources of health insurance. You are asked to give an estimated income for 2025. If you don’t give your income, then you won’t qualify for needs-based governmental assistance for your premiums.
No questions are asked about medical history.
The site directs you to a list of available plans in your state. In New Hampshire, there are 38 plans to choose from.
Each state’s plans fall into four categories: Platinum, Gold, Silver, Bronze. Platinum plans provide the fullest coverage, Bronze plans the skimpiest.
In the Granite State, the three insurance companies offering plans are Ambetter, Anthem, and Harvard Pilgrim, and there are no Platinum plans.
The Gold plans have the most expensive monthly premiums; the Bronze plans the least expensive. Silver falls in between.
Some plans duplicate other plans, but with dental and vision insurance tacked on (albeit for a higher premium).
Basically, the lower the monthly premium, the higher the deductible and out-of-pocket maximum. It’s a bit like gambling. You can opt for the cheapest premium, but if medical problems strike, you’ll be on the hook for humongous bills.
Thanks to Uncle Sam’s financial assistance, we qualified for some Bronze plans that would give us a monthly premium of $0.
But the per-visit costs, the pharmaceutical costs, the share of emergency room bills or surgeries that the patient has to foot, all these and other factors, deserve consideration.
To illustrate, for 2024 I chose a Silver plan with a modest monthly premium. This has been an expensive year for me; emergency room and hospitalization in late March, and ongoing breathing tests at the hospital since. Plus, some expensive medications and nearly monthly visits to the pulmonologist.
By June I had blown past my in-network deductible of $4,150. That deductible is for me alone, not for the household. When autumn arrived, I blew past my in-network out-of-pocket maximum of $7,250 (again, that’s for me alone).
So what 2025 plan to choose? I’ve heard good things about Harvard Pilgrim, and once had a plan of theirs, and they did fine by me. But their premiums seem to be higher than the two other insurers.
The company I usually sign up with does its darndest to coerce customers into using pharmacies of its own choosing — they even threaten to drop your drug coverage. They also resisted my pulmonologist’s attempts to treat me, denying his first choice of inhaler, then repeatedly denying his choice of injectable treatment. Eventually I donated blood for about a dozen lab tests, just to prove that the injectable treatment was likely to help. Only then did the insurer sanction it. (Not that they agreed to pay for it, but that’s another story.)
There is one good thing about my usual insurer. See, there’s a little-known section of the Affordable Care Act that requires an insurer to spend at least 80% of the collected premiums on health care services, such as doctor and hospital bills. No more than 20% of premiums may be spent on administrative costs, such as salaries and advertising.
Just about every year, my usual insurer, because it excels at not paying for treatments, fails to reach the 80% threshold. When that happens, the customer eventually receives a rebate check reflecting the insurer’s excessive profits.
That annual rebate check has come in handy.
But now I’m switching to a different insurer, one I hope will pay more for medical treatments and maybe even exceed the 80% minimum.
Plus, I’m opting for a Gold plan, primarily to minimize deductible and out-of-pocket limits.
Both the HealthCare.Gov and the Medicare websites allow you to identify your medications and doctors, to help you verify they are part of a plan’s network.
If your medicines or doctors are not included, then seek a different plan.
