Anyone with employer insurance getting hit with a big OOP increase for 2014?

[cattlekid]

Howdy all!

I am still on my employer insurance as I gave Medicare the old heave-ho after my transplant bills all came in.  I was tired of paying the $300 per quarter for absolutely nothing because we had such a small OOP maximum for the year (I never made it to the point where Medicare would have been primary).

Well, that wasn't my brightest idea ever.  For 2014, our insurance premiums are going up approximately 30%.  That's a big increase but still VERY affordable in the grand scheme of things. 

What is going to absolutely be a killer is the new OOP maximum.  They have increased it from $2000 per covered person to $6250 per covered person.  From what I have read (and boy is it hard to find out this information), it is because the ACA is requiring a combined OOP maximum for health insurance, prescription coverage and mental health benefits.  Before, we had separate OOP maximums for each.  I always met the OOP for health insurance and I put that OOP in our Flexible Spending Account so I always knew I had it covered and even saved a bit by using pretax dollars for the FSA. 

Now, I'm on all generic anti-rejection drugs so my current drug regimen only costs $90 total per quarter. As far as I can see it, if we don't use any mental health benefits, we are looking at an almost tripling of our OOP maximum.  This is seriously chafing me. 

From what I have read online, it appears that my company has taken the liberty under the ACA of raising our OOP maximum to the extent allowable by current law.   I want to question them on why this decision was made, but I need some backup.  Is anyone out there who is currently on employer insurance facing the same change for 2014?  If so, has your employer provided any rationale for this change?  We self-insure, so I know they can design our health benefits in any way that meets the law.  Is the old existing OOP maximum no longer legal? 

Thanks in advance for any information anyone can provide!

[Deanne]

We self-employ, too and had increases, but nothing like what you're talking about. It used to be that our medical, dental, and vision were all covered under one benefit. Dental and vision didn't have extra premiums, but now they do. It isn't a large amount for single people, like me, but I think for married people with children, it ends up being fairly substantial. The out of pocket maximums only increased by a couple hundred a year, I think. I think it's something like $2700 for single people. The plans with FSA were discontinued. This is what I had. I'll need to switch to HSA instead. For me, I don't think it'll be a big deal, but time will tell. I just got Medicare and I read that I won't be allowed to fund the HSA because of it. I was hoping to use the HSA funds to pay the Medicare premiums. I need to ask about that part yet.

[cattlekid]

We aren't self-employed.  I work for a VERY HUGE multinational corporation and in the US, the corporation provides the funds along with our premiums and then they hire Blue Cross Blue Shield to administer the benefits.  So the corporation has leeway to design the insurance plans any way they want and we do have input on how they are designed.   But this OOP maximum business just seemed to get shoved in with such little fanfare that it looks like they are trying to pull a fast one, which isn't like them in the past.

We also lost our no-deductible plan for 2014.  We can either do the deductible plan with higher monthly premiums, or the HSA plan with lower premiums.  However, the HSA plan has such a high deductible after the HSA pays out that I am afraid of it.  We can combine our HSA with an FSA but that only goes so far because the FSA contribution is capped at $2500.

It looks like whatever way we turn, we are going to be forced to pay out substantially more for health care in 2014 than we have in the past.  I try to stay open minded about the ACA and not get into political discourse which is why I am trying to find out facts about why this change could have happened rather than just blaming the ACA outright.

As far as Medicare and an HSA, I believe you are correct that the two cannot be purchased together for a covered individual.

[MooseMom]

I can give some answers but only to the extent of my experience with my husband's employer's insurance.  He is an attorney for a large city outside of Chicago, and one of his duties is working with an insurance broker to get the best deal for the city's employees.  I've just spoken to him about this issue because now I'm curious.

Hubby and I are on BCBS HMO because since I had a pre-existing condition (my lovely fsgs) when we married, I was not eligible for the PPO.

According to him, our OOP maximum will remain unchanged.  The ACA will not affect anyone on the HMO.

The only employees who might be affected in any way by the ACA are those on the PPO family plan.  The "Cadillac plan" tax takes effect in 2018, and by that time, the PPO family plan may well bump up against the definition of "Cadillac plan".  Just this morning, hubby was in a meeting with insurance brokers to see if they could come up with some way to avoid this. 

Interestingly, hubby told me that the employees with the PPO pay 80% more in premiums solely for the privilege of not having to be referred to a specialist by a PCP.  Furthermore, the drug coverage is not as good as that offered by the HMO, particularly if you have a chronic condition that requires long term medications.

We have an FSA and yes, it was capped at $2500 by Congress last year, but that has nothing to do with the ACA.  It had been $2500 for several years, then was raised to $3000 for a couple of years and is now back down to $2500.

My husband's employer offers only BCBS PPO and HMO, so I have no experience with HSAs. 

So cattlekid, since you and I both have BCBS, are both in the same state yet are getting different information from our respective employers, I do wonder if your employer is indeed "trying to pull a fast one."  Bottom line is that my insurance will remain unchanged, so why won't yours?

EDITED TO ADD:  My comments refer ONLY to the coverage offered by my husband's employer and not to BCBS as a whole.  His employer does not self-insure, which makes me wonder if self-insurance is the culprit here.   

[Joe]

My employer uses BCBS PPO also, and we are not seeing that kind of an increase in our OOP maximums. Just a data point...

[obsidianom]

All I can say is that is why medicare is such a good deal in general. The deductable and costs to the beneficiary are all constant and cant be played with. Even with my wife working it is a better deal than aour regular group insurance for her and us. Mediacre is very cheap for what you get. I hope you can go back on it .

[MooseMom]

All I can say is that is why medicare is such a good deal in general. The deductable and costs to the beneficiary are all constant and cant be played with. Even with my wife working it is a better deal than aour regular group insurance for her and us. Mediacre is very cheap for what you get. I hope you can go back on it .

But for those of us under 65 who have had a transplant, it all gets a lot murkier.  We get booted off of Medicare after 36 months.

[cattlekid]

Yup.  And it gets even murkier for those of us under 65, who had a transplant prior to the end of the 36 month coordination period who never had Medicare become primary.

All I can say is that is why medicare is such a good deal in general. The deductable and costs to the beneficiary are all constant and cant be played with. Even with my wife working it is a better deal than aour regular group insurance for her and us. Mediacre is very cheap for what you get. I hope you can go back on it .

But for those of us under 65 who have had a transplant, it all gets a lot murkier.  We get booted off of Medicare after 36 months.

[MooseMom]

And murkier still for those who were fortunate enough never to have had to go on dialysis before getting a transplant.

Cattlekid, I hope you find some answers.  I'm really interested to hear what you find out.

[cattlekid]

MooseMom, from what I understand, you would have never qualified for Medicare to begin with. 

It is my understanding that Medicare starts either the first month you start dialysis, if you immediately start home training (PD or home hemo), or the fourth month you are on dialysis, if you start in center. 

If you have employer insurance, Medicare remains secondary payer for 30 months (not 36 as I misstated above) after which time it becomes primary payer. 

So in your situation, even though you have ESRD, you did not qualify for Medicare because you did not start dialysis. 

In my situation, I did not apply for Medicare when I started dialysis because my OOP maximum was so low that the yearly Medicare premium ate up any cost savings I would have incurred by letting Medicare pick up the 20% of my costs that my employer insurance did not pay.  I finally applied for Medicare about 15 months after I started dialysis because I was switching transplant centers and I was close to the new center's average time for transplant.  I ended up having to pay out a year's worth of Medicare premiums for very minimal benefits received.

And murkier still for those who were fortunate enough never to have had to go on dialysis before getting a transplant.

Cattlekid, I hope you find some answers.  I'm really interested to hear what you find out.

[MooseMom]

MooseMom, from what I understand, you would have never qualified for Medicare to begin with. 

So in your situation, even though you have ESRD, you did not qualify for Medicare because you did not start dialysis. 

Well, I thought the same thing, but it actually doesn't work that way.  It does not matter whether or not you've been on dialysis before tx.  I guess when you think about it, if you need a transplant, then you have ESRD, and if you have ESRD, you are eligible for Medicare no matter your age.  I became eligible for Medicare on the first day of the month I had a tx.  I am sure that no one would have even mentioned Medicare to me if I had not been eligible.  My entire tx team knew I had never been on dialysis, and Medicare knew I had never been on dialysis, but I'm still eligible for 36 months after tx.  I have my Medicare card right here.

[cattlekid]

Wow.  Didn't know that.  Thanks for clearing that up for me.   

MooseMom, from what I understand, you would have never qualified for Medicare to begin with. 

So in your situation, even though you have ESRD, you did not qualify for Medicare because you did not start dialysis. 

Well, I thought the same thing, but it actually doesn't work that way.  It does not matter whether or not you've been on dialysis before tx.  I guess when you think about it, if you need a transplant, then you have ESRD, and if you have ESRD, you are eligible for Medicare no matter your age.  I became eligible for Medicare on the first day of the month I had a tx.  I am sure that no one would have even mentioned Medicare to me if I had not been eligible.  My entire tx team knew I had never been on dialysis, and Medicare knew I had never been on dialysis, but I'm still eligible for 36 months after tx.  I have my Medicare card right here.

[jeannea]

It's confusing. I think that many employers are looking for a way to reduce their own costs. Even when a company is self-insured, when they contract with someone to coordinate the benefits, they still have to set up the premiums and coverage amounts and deductibles. My last company was self-insured and used Aetna for the last couple years I was there. It's very difficult. I was listening to NPR and while I forget the numbers the percentages that premiums have risen in the last 10 years is appalling. Way out of proportion with the rest of your life. High deductible plans have become quite popular over the last 5 years or so. My sister's plan is a $10000 family deductible. She knows that every year that is out of pocket. Usually though you have great coverage with those plans after you meet the deductible.

It's hard to say if your company is taking advantage or just trying to give you affordable health insurance. It could be either. All I know is there were bound to be changes with the ACA and there will be growing pains. We'll all just have to suffer through. I don't know what will happen with the politics but hopefully in the end people like us will be able to be covered somehow.

[cattlekid]

So I finally got the lowdown from my contact in Benefits.

We used to have three OOP maximums:  medical, regular pharmacy and specialty pharmacy. 

They are now combining all three together and (in her words) increasing them slightly so they don't have to increase our premiums more than they are already going up.

We are already getting hit with a 30% premium increase plus this increase in OOP maximums.  It is going to be a bonus for those who had bills on all three sides (medical, regular pharmacy and specialty pharmacy) but it's going to be a detriment to those of us who used to meet one of the OOP maximums but not necessarily the others.

I have already made strategic phone calls to my gastroenterologist to see if I can get my yearly colonoscopy outside of the hospital (I can) and to the transplant center to see if I can get my bi-yearly transplant labs done at my local lab instead of at the transplant center (I can do that also).

Basically, every time someone tells me that I HAVE to get something done going forward, I am going to question the heck out of them until I can get it down to the lowest possible cost option.  I guess that's what my employer wants us all to do anyhow - try to use health care as little as possible and for the lowest cost possible.

[MooseMom]

Cattlekid, can you tell if these changes are due to the ACA?

When you think about it, most of us don't really consider the costs of our healthcare because we're never told by our providers what anything costs, anyway.  We have no real incentive to shop around unless you are on an HMO which pretty much does that shopping for you.

If anyone can get it down to the lowest possible cost option, it's you!!  You are one of the most pro-active people around!

[cattlekid]

She did invoke the ACA in her email.  She basically said that the changes in the OOP maximums were to bring us into compliance with the ACA, both current and in the future (again, her words). 

I don't really buy it and I think it's just a way to cut costs.  From what I have read, the ACA requires one overall OOP maximum that includes medical, pharmacy and mental health benefits.  However, if my reading has been correct, for those plans (like ours) that used different managers for the medical and pharmacy, there is a one year delay in the requirement to make the changes, which of course, would just be kicking the can down the road.

As much good as I think the ACA might be doing for many people, I think it just kicked me in the shorts.  We already had no lifetime or yearly caps.  We had reasonable premiums, deductibles and OOP maximums and coverage for all of the "essential health benefits".  Some might have cost a couple of bucks instead of being "free"  but nothing overwhelming.  Of course, this also meant that from an employer perspective, I'm sure they were getting raked over the coals in the claims arena.  They are always barking about "expenses" all over the place so I guess this was inevitable. 

What it looks like to me though, is about a $5000 pay cut in the worst case scenario based on the increases in the premiums (inevitable) and the increase in the OOP maximum (hopefully, something I can mitigate).  Even though our company underpays IT folks, I've stayed for the last 14 years due to the benefits.  However, with the benefits starting to shrink, I might have to start testing the waters a bit.  I used to think that being loyal to one company got you somewhere, but now I realize that loyalty plus $2.00 might get you a cup of coffee.

Cattlekid, can you tell if these changes are due to the ACA?

When you think about it, most of us don't really consider the costs of our healthcare because we're never told by our providers what anything costs, anyway.  We have no real incentive to shop around unless you are on an HMO which pretty much does that shopping for you.

If anyone can get it down to the lowest possible cost option, it's you!!  You are one of the most pro-active people around!