Two boys wearing masks standing next to a bush.

We left our Group Health Plan for the ACA: Here is how it worked out

My husband and I are both partners in our firms, so neither of us have health care costs subsidized by employers. We have traditionally participated in his firm’s group plan, but rising costs over the past few years led me to look at other options. I started looking into the Affordable Care Act (ACA) plans available on the healthcare exchange in late 2018 when we were facing an 8% increase in our group health plan premiums going into 2019. At that time, the only plans available on the exchange in Georgia were offered by Ambetter and Kaiser, and neither of those carriers were accepted by our pediatricians. We stuck with the group plans for 2019. A year later, we were facing another 12% increase in our group premiums, and the deductible and maximum out-of-pocket costs were also increasing. These increases continued even though we always chose the same option- the High Deductible plan with HSA. You can read more here about why we max out our HSA contributions every year and never use the funds. I looked at the exchange again in late 2019 and was happy to see Anthem plans available in addition to the other two carriers. I checked and all our regular providers were in-network with Anthem, so I started considering the options in more detail. I should note, I also looked at some non-ACA compliant plans. There are a range of these available, and there are many options that are even less expensive than ACA plans. The reason I chose to limit my search to the ACA plans is that I could have confidence that these plans would cover preventive care, that pre-existing conditions would not be excluded, and I could trust that essential health benefits would be provided. The non-compliant plans may have missing benefits that I may not know to ask about in advance. The risk of having trouble getting coverage or reimbursement is higher with a plan that is not in compliance with the ACA. Using the healthcare exchange website, I selected an Anthem plan that is also HSA eligible, so as close as I could come to the coverage that we had under the group plan. While the deductible is much higher under this Anthem plan than with our previous group plan, the 44% savings in premiums more than makes up for it. Yep, we save about $950 per month on our health insurance premiums for our family of four by using an ACA plan instead of the group plan through my husband’s job. We don’t qualify for a subsidy – we pay the full price and we still save that much. We would have to spend over $11,000 in out-of-pocket health care costs before we even spent as much as we would have spent on premiums alone with the group plan. Even if we had a really bad health year, in which more than one member of our family required extensive out-of-pocket costs, we would be saving money with the Anthem plan from the healthcare exchange. So, we did it. Here is our experience: 1. Preventive care – covered at 100% just like in our group plan. We haven’t paid anything for well visits or immunizations or my mammogram. 2. Sick benefits – we have had to pay all the costs of other visits, minus the discount that we get from using an in-network provider. We have had many medical visits this year that were not preventive care. One of my kids broke his wrist this summer, requiring an urgent care visit and two visits with an orthopedic specialist. Two weeks after that cast was removed, the same child rolled his ankle and fractured two bones, resulting in two more visits with the orthopedic doctor and a boot for him to wear while it healed. Our other son also had a visit to the emergency room back in the spring. We paid in full for those visits since we have not met the deductible for the year. We have also paid out of pocket for lab work. Our total out-of-pocket this year has been about $6,000 (including pharmacy) in nine months. During that same period, we have saved more than $8,500 in monthly premiums. 3. Mental health benefits – we believe in the importance of caring for our mental health and talking to a therapist has benefited all of us from time to time. The only difference in coverage with our new plan is that our payments to an out-of-network provider do not count toward the deductible. It is more beneficial under the ACA plan to choose an in-network provider for mental health. 4. Pharmacy benefits – Anthem basically forced us to use the mail-in pharmacy for recurring prescriptions. For the most part, the cost has been pretty comparable to what we were paying before, and we actually appreciate the convenience of medicines just appearing in the mail every ninety days. There have been a couple of drugs, though, that for some reason cost more with Anthem’s pharmacy. For those we use a GoodRx coupon and fill it locally. It is really easy to do and we save a good bit of money that way. 5. Dental benefits – ACA plans are required to provide dental benefits for children, so we dropped our group coverage for them while keeping it for my husband and me. This is the one thing I will do differently next year. We had to change to a different pediatric dentist to stay in network, which was not pleasing to my children. In addition, the “coverage” just means that the amounts we pay for the visits and services are discounted and count toward our deductible, not that they are free of charge, the way regular cleanings and x-rays are with our group dental plan. We will add the kids back to our group dental plan next year. In conclusion, our experiment in leaving our group health plan for an Affordable Care Act plan on the healthcare exchange has been successful for us. I am planning to continue the same way next year unless something changes drastically with what is offered on the exchange or through our group. I encourage everyone to look at what is offered and compare it with the coverage you have now. If your employer is not paying the majority of your premiums for you, you may be able to save money through the exchange and have confidence that the plans comply with minimum requirements.

Material discussed is meant for informational purposes only, and it is not to be construed as investment, tax or legal advice. Please note that individual situations may vary. Therefore, this information should be relied upon when coordinated with individual professional advice.