My calculations are for the portion the employee pays directly, meaning the ~25% to ~30% the employer does not pay.
Since all employers of this caliber part the 75% portion as a benefit without option to receive it as cash compensation, it is not appropriate to consider the employer subsidized portion in the amount the employees pay.
> That's because if you get a bill for, say, $10K, the insurance company can decide they will only pay $8K so you're stuck with $2K. But not all of that $2K is counted against the out-of-pocket max. The insurance company will say only some smaller amount, say $500, will count as credit towards the out of pocket. So I get to write a check for $2K but in the eyes of the insurance company I've only paid $500 this year. Repeat a handful of times and I can easily go over the so-called max out of pocket in real money.
If you have an ACA compliant plan, which the platinum designation indicates it is, this should not be happening for in network services that have prior authorizations. Either the insurance company thinks you are being given superfluous treatment not supported by evidence, or the insurance company is ripping you off in which case you need to file an appeal.
https://www.healthcare.gov/marketplace-appeals/ways-to-appea...
I have had 2 childbirths since ACA was passed and both years we hit out of pocket maximum and did not have to pay a dime afterwards.
I'm talking about the employee-paid portion deducted from paychecks.
People who are surprised by this tend to be single. Most companies usually pay close to 100% of the employee premium. But they are far less generous on the family member premiums.
> this should not be happening for in network services that have prior authorizations
There's a lot of insurance company weasel wording in that phrase. Plenty has been written on how when you go to an in-network hospital, turns out that every doctor who shows up while you're unconscious (some of whom you'll never even knew saw you until the bills arrive a few months later) is actually an out-of-network contractor.
Lots of things shouldn't be happening, but happen every day in the US health care industry.
I can see this happening. However, in my ~3 different employer experiences, the employee and children are very well subsidized, and the spouse is the only one the employer usually does not cover to incentivize the spouse to use their own employer’s subsidies.
> There's a lot of insurance company weasel wording in that phrase. Plenty has been written on how when you go to an in-network hospital, turns out that every doctor who shows up while you're unconscious (some of whom you'll never even knew saw you until the bills arrive a few months later) is actually an out-of-network contractor.
This is true, and I had not experienced it. Good news is that is illegal now:
https://www.cms.gov/newsroom/fact-sheets/requirements-relate...
The last couple years have had quite a few good rules come into place, including another one that obligated your doctor/hospital to give you a good faith estimate for which you are only responsible for the estimate + $400.
It is still extremely risky and costly in the US, even if you have nice employer subsidies because the second you lose the ability to work, you are on the hook for many, many thousands of dollars of expenses at the same time you no longer have income. And then if you want government help before age 65, you basically have to liquidate all your assets and become poor forever. Dual income families are almost a requirement just for that reason.
Age 50 to 65 is extremely risky in the US. A few wrong steps and you are deciding between sacrificing your kids’ future to save yours.
You're wrong. I'm not speculating here, I'm talking about the real numbers.
My monthly premiums for a Platinum PPO plan through my employer (in Silicon Valley) is slightly over $2K/month (for a family of 3). Same plan at my previous employer, same price (a bit cheaper but that's because it goes up every year). This is also very similar to what an ACA plan would cost. Your guess of $500/mo is way off.
So out of pocket is ~$25K on premiums alone (pre-tax though).
> Why would it cost more than the “so called max out of pocket”?
You can easily go above what the insurance company calls "max out of pocket". Again, I'm not speculating here but telling real experiences.
That's because if you get a bill for, say, $10K, the insurance company can decide they will only pay $8K so you're stuck with $2K. But not all of that $2K is counted against the out-of-pocket max. The insurance company will say only some smaller amount, say $500, will count as credit towards the out of pocket. So I get to write a check for $2K but in the eyes of the insurance company I've only paid $500 this year. Repeat a handful of times and I can easily go over the so-called max out of pocket in real money.