Need Advice Regarding Health Insurance, ObamaCare, Medicaid (Mark: dermatologist, condo)

[Chi_42]

Hello.

I live in Cook County, Illinois.

For many years, my health-insurance plan has been the Blue Value plan from Blue Cross Blue Shield of Illinois (BCBSIL). This plan is a PPO and is a non-ObamaCare plan. During the past year, my premium was $730 per month. In 2018, that premium will jump to $780 per month. So, I'm looking for a new insurance policy that is cheaper.

I have a primary doctor from NorthShore University HealthSystem. However, I do not see him very much. Most of my medical care comes from specialists. I have an endocrinologist from Northwestern Medical Group treating me for hypothyroidism. I have an independent allergist giving me regularly scheduled allergy injections for my allergies. And I have an independent dermatologist giving me acne medication and checking me for skin abnormalities. My current health-insurance plan covers all of these doctors.

I go to HealthCare.gov and see that there are 26 plans available to me. 5 of them are BCBSIL PPO plans. According to Healthcare.gov, the 5 BCBSIL PPO plans do NOT cover my primary doctor or my endocrinologist. But all 5 plans cover the allergist and the dermatologist.

Also, according to Healthcare.gov, the 5 BCBSIL PPO plans do NOT cover the acne medication given to me by the dermatologist.

I called BCBSIL and spoke to a customer-service representative. The representative told me that my endocrinologist and my primary doctor ARE covered by the 5 BSBCIL PPO plans. The representative told me that my acne medication, too, is covered by the 5 BCBSIL PPO plans.

And yet, I'm reading reports that BCBSIL PPO plans on the Marketplace (HealthCare.gov) are NOT covering Northwestern or NorthShore doctors.

So, are my primary doctor (from NorthShore) and my endocrinologist (from Northwestern) covered by the BCBSIL PPO plans or not? Is my acne medication covered by the BCBSIL PPO plans or not?



I have been told that I may be eligible for Illinois Medicaid. Specifically, I may be eligible for a program called ACA Adults. However, it is my understanding that Illinois Medicaid operates in an HMO-like manner. For every medical problem, I first have to see my primary doctor. I can see a specialist only if my primary doctor approves. Since most of my medical care comes from specialists (see above), an arrangement that gives the primary doctor control of my medical care can become a big problem and a big headache. So, is my understanding of Illinois Medicaid correct? Does Illinois Medicaid really require that the primary doctor be in charge of everything?



One option that I have is to have NO insurance at all. According to my calculations, the total amount of money that I will spend on health care (insurance premiums, out-of-pocket costs for doctor visits and prescriptions) in 2018 is as follows:

no insurance at all - $7100

the BCBSIL PPO plan on Healthcare.gov giving me the lowest total cost of health care - $9300

my current plan - $10500

Having no insurance at all would save me a lot of money.


Of course, these numbers assume that I will have the same medical conditions in 2018 that I had in 2017. Having no insurance would probably be disastrous if some new medical problem emerged, especially if that problem was catastrophic.

However, if I have no insurance and if some catastrophic problem emerges, then I can just apply for an ObamaCare Marketplace plan and have that plan cover my new illness. After all, ObamaCare Marketplace plans have to cover pre-existing conditions, right?

So, would having no insurance be a wise decision?



Any help would be greatly appreciated.

Thank you.

[Scottiegal]

That’s the problem with obama care...people are wise enough up to see it’s cheaper not to carry insurance and just pay the fee. The problem is the dems thought folks would just pay more because they should to cover the free insurance to those who can’t afford it. Again the middle class gets stuck with the bill. We just moved to a different state, while in illinois we paid 900.00 a month and a detuctible of 12 grand. Hardly a bargain infact robbery!

What you should do? Who can make heads or tails out of this mess? It would seem the best fisical decision for you would be to just buy the insurance when you need it.

[ToriaT]

Okay but you need to look at your assets. If you have a house, or condo you could be putting them at risk if you get sick. I would never go with no insurance. I would at least find an insurance plan that would cover catastrophic coverage.

[Chi_42]

Originally Posted by ToriaT

Okay but you need to look at your assets. If you have a house, or condo you could be putting them at risk if you get sick. I would never go with no insurance. I would at least find an insurance plan that would cover catastrophic coverage.

Does Illinois Medicaid (specifically, ACA Adults) cover catastrophic coverage?

[Missy2U]

Originally Posted by Chi_42

Does Illinois Medicaid (specifically, ACA Adults) cover catastrophic coverage?

I was on Medicaid for about a year - but I was unemployed. Even making $30K a year puts me over the limit for being eligible. Your best bet is to call them.

[Chi_42]

Well, I have some new information to add.

I mentioned in my first post that my allergist and my dermatologist are independent. Today, I found out that the allergist is affiliated with Advocate Health Care and that the dermatologist is affiliated with Presence Health.

I also found out that the only Marketplace plans from BCBSIL that my endocrinologist participates in, are the Blue Precision HMO plans. With an HMO, I would have to choose ONE hospital or medical group from which to get all of my medical services. Because I have four different doctors that are affiliated with four different medical groups, having an HMO could definitely be a problem.

Now we come to Medicaid. My dermatologist does not take Medicaid at all. The primary doctor and the allergist share one Medicaid plan, and the allergist and the endocrinologist share a different Medicaid plan. So, if I am in my primary doctor's Medicaid plan, the primary doctor can refer me to the allergist, but not to the endocrinologist.

Furthermore, the dermatologist and the endocrinologist prescribe for me brand-name medications that Medicaid does not seem to cover. I may be able to use the generic version of the dermatologist's medication, but I definitely can not use the generic version of the endocrinologist's medication.


As for cost of insurance, does Medicaid charge some kind of monthly premium? Or would I just pay some co-pay for every doctor's visit, blood test, or prescription (similar to a pay-as-you-go plan from a cell-phone provider)?

I mentioned in my first post that, in 2018, without any insurance at all, I would spend only $7100 for health care. That $7100 would consist of my out-of-pocket expenses for doctor visits, blood tests, and prescriptions. If I have Medicaid, then Medicaid can cover some of that $7100, and Medicaid can also function as a low-premium or pay-as-you-go catastrophic insurance. Is that a good idea?

[genesiss23]

Just remember Illinois Medicaid covers only 4 prescriptions a month. There are exceptions for anti-infectives, HIV, chemo and a few others. To get more than 4, you will have to get special approval. If you have Medicaid, your out of pocket expenses are very low.

You can only sign up for health insurance once a year.

[MassVt]

Originally Posted by Scottiegal

That’s the problem with obama care...people are wise enough up to see it’s cheaper not to carry insurance and just pay the fee. The problem is the dems thought folks would just pay more because they should to cover the free insurance to those who can’t afford it. Again the middle class gets stuck with the bill. We just moved to a different state, while in illinois we paid 900.00 a month and a detuctible of 12 grand. Hardly a bargain infact robbery!

What you should do? Who can make heads or tails out of this mess? It would seem the best fisical decision for you would be to just buy the insurance when you need it.

You can't buy insurance for those times you need it. It doesn't work that way...

Obamacare isn't free---it's partially subsidized. The policy holders pay some of the premiums themselves.

Obamacare is a whole lot better than the so-called "plans" the GOP tries to foist on us...