🥺 Please help - Health Plan Coverage

[tambus10500]

TLWR: Can someone give me parental/big brother/sister opinions on if it is most smart to go with my current plan (MarketPlace - highest premium, lowest coverage, favorable mental benefits) instead of my employer plans (slightly lower but still high premiums, higher deductibles and unfavorable mental health benefits)? Very neurodivergent and no support system.

I'm currently on a marketplace plan since I lost my job in June. I really like the plan- it has a higher base premium (before my tax credit) but a lot of low or $0 copays and low deductible. My weekly mental health visits are $0 copay which is my favorite benefit because it's important to me to continue seeing my provider weekly.

I got a job but kept my market place insurance for the rest of the year. I make $49k a year and 8.39% of that would be about $342/month - anything more than that could be considered unaffordable (though my employer only has 12-15 employees so unsure if it adheres to the Monthly Minimum Standards that companies of 50+ employees adhere to). I am 100% responsible for the premium.

Could I still be eligible for a premium tax saving credit based on both of the employer plan monthly premiums being higher than $342/month? (Plan details below)

Plan 1) Premium: $349.07/month. Deductible: $3,000. Premium Annual: $4,188.84 (+$3,000 Deductible = $7,188)

Plan 2) Premium: $369.76/month. Deductible: $6,000. Premium Annual: $4437.12 (+$6,000 Deductible = $10,437.12)

Either way, I'm tempted to stay with my marketplace plan (whether I qualify for a tax credit or not) because the employer plans would have a $75/visit copay and I see my mental health provider once a week and this would make my visits unaffordable and needing to cut back a lot.

My thought is I'd rather pay a lot for my Healthcare .gov plan and get good benefits from my coverage instead of still paying a lot through my employer plans but with meh coverage and needing to pay $75/visit copay for mental health.

TLDR: Can someone give me parental/big brother/sister opinions of whether based on what I said I value most, if it is most smart to go with my current plan despite the highest premium?

Here are the plan summaries for more context. I calculate premium annual plus full deductible so get an ideal of the maximum coverage analysis. Besides the deductible and $20 premium difference, the coverage is the same ... very confused why the lower premium, lower deductible is cheaper...knowing our system ... I'm partially to believe there's some gotcha or some corporate greed trick I don't know about).

Company Plan Options:

Plan 1) Premium: $349.07/month. Deductible: $3,000. Premium Annual: $4,188.84 (+$3,000 Deductible = $7,188)

Plan 2) Premium: $369.76/month. Deductible: $6,000. Premium Annual: $4437.12 (+$6,000 Deductible = $10,437.12)

Both plans offer:

• $25 PCP Copay
• $75 Specialist Copay
• $50 Urgent Care (Deductible does not apply)
• 40% Coinsurance Emergency Room Care
• 40% Diagnostic/Imagery (X-ray, blood work, CT/PET Scan, MRI)
• $10 Medication Copay
• $75 Mental Health visit (Deductible does not apply)

Current Plan) Premium: $467.32/month. Deductible: $1,500. Premium Annual: $5,607.84 (+$1,500 Deductible = $7,107.84) (This is w/o my tax credit)

My Plan offers:

• $0 PCP Copay (Deductible does not apply)
  
• $75 Specialist Copay (Deductible does not apply)
  
• 30% Diagnostic/Imagery (X-ray, blood work, CT/PET Scan, MRI)
• 30% Coinsurance Emergency Room Care
• $0 Preferred Generic Medication
• $15 Generic Medication
• $0 Mental Health Visit (Deductible does not apply)
  

 

[tmarie]

@tambus10500 Your logic makes sense. You stated your priorities are your mental health visits so you want to choose a plan that is most favorable for this. At $75 a visit and one weekly visit your mental health visits will cost you an additional $3900 a year under the employer plan. So the premium on the employer plan being 4000+ and the additional 3900 for mental health visits puts you at nearly 8000 for the year in cost before any other type of care is needed. Staying with your current plan puts you at 5600 for the year, including the mental health visits but before any other type of care, and this is assuming there’s no subsidy, and you were paying the full price of the premium. Your gut feeling to stay on your current plan sounds like a smart plan.

 

[tambus10500]

@tmarie Thank you for the validation!

 

[tmarie]

@tambus10500 Absolutely! I know what it’s like to not have much good advice around you/ppl to check with. I help ppl compare coverage like this all day and I have a ton of clients priorizing plans with good mental health copays this year. Good luck! You can also get some local assistance from a licensed agent in your area by going to the help&assistance tab inside your marketplace account. Advice from an agent would be free to you also. And a good one should answer your questions all year.

 

[potterpoole]

@tambus10500 I work in customer service for insurance, but I don't sell it and don't pretend to be able to evaluate plans or make recommendations.

That said, I was curious if any of those have an option for HSA, FSA, or if your work makes HRA funds available. My work offers 2 versions of the insurance plan. The one I go with is the high-deductible. Even with $3k/yr going into my HSA, I spend way less, overall, on premiums, deductible, and various health care expenses. Not to mention, the HSA contribution is pre-tax.