I've posted recently trying to understand Anthems payment of my husband's health insurance claims. Lots of tests, hospitalized in Aug 2024 for 4 days for a stroke , just underwent quadruple bypass. My questions are about OOP max. Why am I seeing 100 percent payment for a 10/25 claim submission but 20% coinsurance due on a 11/2/24 claim submission? If OOP max was met on 10/25 why are we getting charged a co-insurance payment on 11/2/24

Hey reddit, I moved to TX from PR. My insurance back in PR expired so I need to get one from the states. I'm old, almost 30 and I pretty much was never taught about how the Health Incudance markte place works or the providers when it comes to the terms.

Me being hispanic/latino I was recommended Ambetter by some family who are in the states as I'm still unemployed and have no source of income for myself. (Used to work in retail for 3 years, ended up with mental imbalance so i need meds to function.)

I was in a call with them to get stuff in their records and all that, and I was then asked to join a 3 way call with them and an Oscar representative to give them permission or something (it was in spanish, both the representative and my ambetter agent spoke in a different spanish dialect so i can't remember much.)

So, i pretty much am asking for a TLDR about Oscar and Ambetter, and to those who use Ambetter, I was told that I need to get a PCP that takes Ambetter, how do I do that exactly? Do I call the PCP office? Or do I let my Ambetter agent know which one I'm picking?

Will apreciate the help

The form was for verifying medical services for the insurance company. I live 10 minutes away from my folks but I don't actually live with them. I still clicked "yes" because I assumed they were asking about the person who the plan was under's address, not mine. Was that a correct assumption?

Looking for feedback on Blue Cross Blue Shield through The Healthy Insurance Dude. I have a choice of staying on Cobra or taking out a policy for my healthy family of 4 via #TheHealthyInsuranceDude. THID is $1200 less per month for a seemingly great nationwide PPO. Looking for feedback.

Hi all,

I am considering potentially shifting to an HSA plan this month for the first time, and I'm looking for advice.

I’m 33F, single no kids. No major illnesses or health scares to date. I’ve had a Kaiser HMO plan for the last two years, but only recently found out about HSAs. To me, a Kaiser HSA-eligible plan makes sense to me right now for the next few years hopefully, until I have more healthcare needs. I’ve read up on HSAs on this sub and elsewhere, but still feeling a bit lost and would appreciate any advice!

In the past two years, while on my HMO plan, my main healthcare needs have been: (1) for therapy weekly; (2) for Primary Care Provider visits not more than 5 times in total; (3) twice for routine bloodwork; and (4) once for an X-ray for a sprain. For my weekly therapist, I pay $250 directly to the (out-of-network) therapist, and then get reimbursed by Kaiser (my co-pay is $20/visit). At this point, I don’t anticipate any major changes in lifestyle and hopefully in my healthcare needs in the next 1-2 years. 

My employer will reimburse me $650 for my monthly premium, regardless of which plan I choose. They won't make any other contributions though.

Here is the comparison I’ve done:

Kaiser HMO plan (my current plan)

• Monthly Premium: $662
• Deductible: $0
• Co-pays: PCP as well as for therapist visits: $20/visit; Bloodwork: $20; X-ray: $40 Prescriptions (generic only): $5; ER: $150/visit; Urgent care: $40/visit
• Out-of-pocket maximum: $2,100

Kaiser HDHP/HSA eligible plan (this is the plan I'm considering switching to)

• Monthly Premium: $521
• Deductible: $1,700
• Co-pays: PCP as well as for therapist visits: $25/visit; Bloodwork: $30; X-ray: $65; Prescriptions (generic only): $15; ER: $500/visit; Urgent care: $50/visit
• Out-of-pocket maximum: $5,000

Based on this comparison and my background, does switching to an HSA-eligible plan still make sense? What other considerations should I be keeping in mind? I will be able to afford the $1,700 deductible (and should be able to max the 2025 HSA contribution of $4,300), but I still don’t quite understand whether it makes sense. I come from a different country, and I still can’t wrap my head around the American health insurance system. Any advice and tips would be very appreciated!

Through Kaiser. Is this only for pregnancy or can I use it for postpartum?

I'm a new green card holder. When I apply for Marketplace plans, I was forced to wait for Medicaid to contact me. I know I will not be eligible for Medicaid because I have to wait 5 year since getting the Green card for full benefit from Medicaid.

1. If I'm only qualified for Emergency Medicaid (due to the 5 year waiting period after receiving green card), am I eligible to reapply at Marketplace plans with Premium Tax credits?
2. Is there a way to just bypass the automatic transfer to Medicaid from Marketplace?

Hi everyone, I am 20 years old residing in California and I have been covered by medi-cal with Anthem Blue Cross all my life. I believe I am covered by the state as my mother is unemployed and does not have a plan provided by an employer.

I am soon planning to get my wisdom teeth removed but I am worried that I will get an appointment after I turn 21. I have read online that the age limit is 25 years old but that applies to parent’s insurances plan.

My question is: What age does my medi-cal expire? Is it 21 years old?

My husband and I are considering switching our insurance from Anthem Virginia (HMO plan) to Sentara. Our current Anthem plan does not seem to cover anything out of state that shows that the out of state providers are in network. Does anyone know if Sentara HMO covers providers out of state if the providers show in network?

I have a friend who may have had a minor stroke and this person probably needs to get vascular testing done among other things. He hasn't told anyone yet. It's been over 5 years since it happened but he is realizing he's had ongoing symptoms ever since and he thinks it's worth investigating.

Should this person, at this stage of wanting to investigate, choose the plan that has a $2500 in-network deductible where they would pay 100% of doctor and specialist visits with 90% coverage after deductible and 10k out of pocket max or should this person just go with the $5000 deductible plan where they will pay $35 for doctor visits, $55 for specialist visits until the testing is done?

What would conventional wisdom say to do? This person has no one to ask.

Hi! I am a 38F in Illinois, estimated gross income before taxes for my household is $230,000.

Background info: I have two insurance plans. My primary is an HMO (BCBS IL). My secondary, through my husband's employer, is a PPO (also BCBS IL).

I recently was seen at a reproductive immunologist. I knew going into this that they did not accept HMO plans of any kind, however they DO accept my PPO plan and are considered in-network with my PPO. Prior to my first appointment, I also took the extra step of calling BCBS PPO and gave them every single CPT code that this clinic gave me, to ensure that the services they provide are covered by the PPO plan (they are covered).
My understanding is that in this type of situation, in order to get the PPO to kick in and cover the claims, I first need to get my HMO to deny the claims (since they do not cover any of it, and they are my primary plan). The issue, though, is that the clinic claims they cannot (or will not) bill HMO under any circumstances, even in this case for what is essentially a formality. So when I went in, I just gave them my PPO plan info and didn't mention my HMO plan at all. Problem is, it was submitted to PPO and PPO paid the claims as though they were the primary plan, which they are not, so presumably they will now ask me to pay. But I should not have to pay, because I already hit my OOP max on my PPO plan and this visit should be covered now at 100%.

But since the clinic will not submit the claims to my HMO plan, I need to do it myself. This is my question: How do I submit the claims to my HMO so that I can get denied, and then move onto submitting to my PPO? Please note that I am *not* asking how to submit a claim so that I can be reimbursed; I am asking how to submit the claim for processing *directly* to BCBS IL HMO.

Thanks for any help you can provide!!!

I'm choosing a marketplace plan for me and my wife. (35yo austin-TX)

We don't have prescriptions and don't know any doctors in any field. So that would not matter to be HMO or PPO..

Since all the plans have a deductible of $16000+ we would have to pay for everything until $16000.
The only way I would pay that in a year would be if I have an accident. because I barely go to the doctor.

So, if I will have to pay until $16000 in a year for 50$ consultations if needed, would it be wise to choose the lowest premium?

all the options have a similar max-out-of-pocket of 18000

Hello,

I'm going in for a microdiscectomy due to a herniated L5S1 on Monday (12/2/2024). My doctor (and also the surgeon) did the per-authorization and all that to determine the cost of the surgery with my insurance. I've paid the facility bill for my expected costs. I just received a letter (Saturday before the surgery) that my Dr. is not covered in network since he is billing out of the surgery facility, and not his normal practice location that I've been seeing him for all the pre-surgery stuff.

Does this cover me under NSA since I didn't get this notice until 2 days before the surgery, I have no way in which to contact anyone due to the holiday, and no costs or anything else has been provided?

I'm freaking out about since my insurance is already a mess with how much this is costing me along with being unsure if I can even reschedule or cancel without losing the money (and since its near EoY if I can even reschedule with someone that is in network). Also, given that the letter I received was literally on a Saturday during a holiday week...its just a perfect storm of frustration.

I’ll be between jobs for 90 days, insurance kicks in day one of the new job. No expected need for medical care in that time. Can I elect COBRA on day 60 from end of benefits then use the 45 day grace payment period to bridge over to the new insurance plan but not actually pay for COBRA unless something comes up? Or am I committed to paying if I elect in?

I haven't been able to get a clear answer on this and have been looking around. I have been unemployed for all of 2024. I am living off of savings. Given it's a low income year, it's suggested to convert an old 401k to a Roth IRA and/or sell some long-term stocks. I do not know what the impact will be to Medi-cal if I do this.

This is what I understand:

• Converting an old 401k to a Roth IRA will be a taxable event and count as ordinary income but I will not receive any money as it goes from one retirement account to another.
• Selling off stocks will be a one-time/lump sum event but will be over $45,000 in one transaction. My understanding is that this will not be considered earned income.

Questions I have:

• If I do a 401k to Roth IRA conversion, when do I report this? what will be the impact?
• If I sell stocks, when do I report it? what will be the impact?

I spoke with someone at the agency and they said to report this when I renew in September. This doesn't seem correct. The supervisor also said I was supposed to have reported assets on my application except that's not even possible for 2024 as the state of California does not ask for asset information (https://www.dhcs.ca.gov/Get-Medi-Cal/Pages/asset-limits.aspx). I can't find any clear answers online and calling in has not been helpful.

I just found out I’m pregnant which is amazing because I didn’t think it was possible for me ! However I don’t have health insurance and my job doesn’t offer it being that I work in a restaurant. My fiancé is also in the service industry (baker) and doesn’t get health insurance either through work. I make too much a year to be on state unfortunately and don’t know what to do now. Living in Connecticut … any advice helps! Thank you

I’m looking to trying to find health, prescription, dental and vision coverage for myself and 3 children? I’m currently covered through my employer but I am leaning towards a career change to free up more time with my children. I am divorced and court ordered to maintain insurance coverage for the kids . Thank you for any advice.

Because the insurance guy has almost convinced me.

Hi,
For the first time every my company is offering a HDHP with HSA in addition to a traditional EPO plan like I've always had. Both plans have the same coverage with in network benefits only so I'm trying to get some assistance deciding from the financial side only.

HSA plan - employee contribution $334/month (family coverage)
Family deductible $10,000
Family Out of pocket max $16,600
routine preventative care 100% coverage
most other services are 20% after deductible

employees responsible for first $3,300 of deductible after which a Health Reimbursement Account (HRA) with cover remainder of the $10,000 deductible if make use of providers/services in one particular health system

EPO plan- employee contribution $608/month (family coverage)
Family deductible $10,000
Family Out of pocket max $14,300
office visit copay: PCP/specialist $50/75

employees responsible for first $2,000 of the deductible after which HRA will cover remainder of the $10,000 deductible if make use of providers/services in one particular health system

The EPO play with copays is just so familiar that I feel like using this one is easiest. Having to actually pay a couple hundred $ for every office visit would seem odd.

Appreciate the help.

I am asking advice about my health insurance plan options and opinions on which plans would be best for me based on my new needs. I am a 28 year old female, relatively healthy but with some recent medical changes. I was surprised in 2019 with a month long stay in the Neuro ICU for a couple tumors removed and a shunt implanted in the noggin to treat my hydrocephalus. So far I have only needed a yearly routine appointment that involves an MRI, shunt adjustment and consultation appointment for the scan. I meet with my primary doctor probably 2-3 times a year on average for mental health related concerns. Currently only taking 1 prescription and it’s a off-brand antidepressant. I had a seizure a couple years after my surgeries. I stopped taking my anti seizure medication about a year ago and haven’t had another seizure since. My VP shunt is eventually going to fail, and I understand surgeries will have to be taken place to correct this.

When my surgeries occurred I was fortunately a broke college student living off of state medical. I didn’t owe a fucking dime. I now have a big girl job with not the best health insurance plans, but nonetheless health insurance I need to purchase. Given my situation described above, what health insurance plan do you think is best for me? It’s only been five years since and I don’t know what is best is the best option for me given the unknown of my future medical needs. It’s either the following: My next scan could show growth, then boom I start radiation or need a surgery. My shunt could suddenly fail or become infected and replacement surgery required. Or my next scan could show absolutely no growth, my shunt keeps kicking ass and I live a relatively healthy life.

I attached a document showing my options.

Hello fam. So I just got a double jaw surgery 2 weeks ago because I needed it one cause of chewing problems and it was damaging my other teeth. Because of that I decided to look for a oral surgeon, the accept my insurance and I spoke with them to make sure my insurance could help me with it. They Check 4 times before my surgery and my insurance said they would help with 80% of the cost. Well I just got am email from my insurance, I went to my insurance and saw the claim, it says they it got denied but still it says I don't have to pay anything it just says $0 because of my discounts ( I don't really know what that means) also it still says that is in network. I have never really use insurance for something big like a surgery just for exams or small things. So I am really confused and scared, because I really can't afford to pay all that money. Also I have anthem healthkeepers.

Hi everyone,

I’m 24 Male from Georgia. Recently moved from London.

I’m in a really frustrating situation and need urgent advice regarding a doctor who overcharged me for services in October. According to my BCBS Georgia Explanation of Benefits (EOB), I was responsible for $145.45, but the doctor charged me $230—$84.55 more than the EOB amount.

Here’s what has happened so far: 1. Doctor’s Office: I’ve reached out to the doctor multiple times to resolve this directly. He has been rude and dismissive, refusing to refund the excess amount or even discuss it. At one point, he said, “This is America, and you need to get with it,” and claimed the session cost more than what the EOB stated. To make matters worse, he’s in-network with my insurance, so I don’t understand why this overcharge happened in the first place. Also, I realize now that when he asked for my credit card information virtually, he was extremely pushy, which should’ve been a red flag. I complied at the time, but I feel like I’ve been taken advantage of. 2. Insurance Company (BCBS Georgia): I contacted BCBS Georgia, but they said they can’t enforce the EOB amount. They tried reaching out to the doctor, but he didn’t respond to them either. They suggested I contact their fraud department, but I’m unsure if that will lead anywhere or what my next steps should be. 3. Bank (Capital One): I filed a dispute with Capital One, but they closed it, saying this is “what it is” and that I need to resolve the issue directly with the merchant.

I feel completely stuck. Both the doctor and the systems in place (insurance and bank) seem unwilling to help, and I don’t know what to do next.

Questions:

•	Has anyone dealt with a similar situation before? What did you do to resolve it?
•	Should I escalate this to the fraud department at my insurance company, or is there a better alternative?
•	Are there any consumer protection agencies or legal steps I can take to recover the overcharged amount?

This feels like an urgent matter, and I’d really appreciate any advice, resources, or guidance you can provide. Thank you so much in advance!

I’m a California resident but currently working abroad. My current employer does not cover any medical plans in CA so I will be uninsured when I'm here. If I’m pregnant and will come back around 28 weeks of my pregnancy, is there any insurance I can purchase to cover prenatal care and childbirth? I have checked and do not think I qualify for Medicaid or Medical, although this was also a bit confusing since I'm not making a salary here. Thank you for your advice.

I recently received a UC alumni Ameritas dental offer in the mail. The premium monthly cost would be the same as the delta dental. Curious to hear which would be best as they both seem to offer the same coverage for the same amount.

I have generally very good dental hygiene (brush 2x, floss 2x with water pick and floss, try to wear nightguard). I do have some fillings on my back molars and two caps on tooth 7 & 10 (the teeth beside my front two teeth). I would like to replace them soon as they’re yellowing and would like to whiten and replace the caps.

Any advice on choosing between the two insurances ? I’m familiar with delta dental but haven’t heard of Ameritas. TIA

Hello. Any suggestions for getting marketplace insurance with the broadest PPO network in the country for noon- emergency care. Willing to move to any state. Desperate

Longer story-I have long covid and am insanely worried as to how the upcoming BCBS PPO changes will affect me. Formerly an epidemiologist, I've now been staying all over the country trying to get good medical care for long covid (which is a myth, but I'm trying). Been able to at least try to do that with a greeaat BCBS PPO plan from the IL marketplace. With their upcoming changes, I'm concerned that they will make it hell to approve prior authorizations for seeing out of state providers. I travel all over the country trying to get care to get my life back, but since long covid is still a new disease, it's been horrible. Because of this amount of traveling, i can establish residency in any state at this point.

With that backdrop, what state marketplace individual PPO plan offers the maximum flexibility to see providers nationwide? Any input would be highly appreciated since I have to plan to move to that state before open enrollment's Dec 15th deadline. Thanks a ton for your input!

I recently had a QLE in the middle of the year and selected a HDHP for health insurance. I already had an FSA for this year that I have already used up all the funds. Now with this new plan, I can open an HSA instead, so I was not going to renew the FSA for next year, because I know I cannot have both per IRS rules. But the insurance brochure states I must open the HSA account within 90 days of my effective date to have this benefit. This will be before the new year when the FSA expires! I’m not sure what to do. Any insight? I can’t find any info online regarding details with middle of the year QLE insurance switches and resulting FSA/HSA overlap. Thanks so much

I turn 26 in May of 2025. Live in Michigan as well. I currently have healthcare through my parents. I go to a community college and work but on Healthcare.gov it automatically signed me up to possibly be approved for Medicaid. I guess I make such little amount. Should I send in the application now or wait until May? I doubt I will even be approved as I still live with my mom and she makes a good amount of money. From what I heard they look into her income even tho she doesn’t claim me a dependent. Also It won’t even let me look at other plans, I want to look at the cost of other healthcare plans because I do need dental and vision as well. Any help is appreciated. 🥰

https://imgur.com/a/IOQibwu

Which of these two health insurance plans should I choose? I am a healthy single male with no pre-existing health conditions and on my current insurance plan my deductible and out-of-packet max was $3500. I reached < $500 on each of them. I'm leaning toward the Low HSA plan since it'll only cost me a couple dollars extra for month and has a lower out-of-pocket max in case I have some super expensive operation.

I have maxed out out of pocket 1600 this year, then had a baby. My insurance deductible will increase from 1000 to 2000 after adding my baby. I was wondering if my cost already will be counted 1000 out of 2000, or will count all 1600 I spent (1600 out of 2000)? Thanks in advance for any advice!

I’m looking for coverage on the marketplace (I’m in South Carolina) and I keep running into Instil Health? I’ve never heard of it but apparently it’s for folks in South Carolina? It says it’s underwritten by BCBS. I looked at the listing of providers, and all I see is 3 doctors. That’s it. The same doctors every time. The price and coverage looks to be what I need, but not if nobody will accept it. Anybody know about this company? Thank you!