Healthcare doesn’t have to Break the Bank
Adulting 101: Cost Sharing vs. Insurance – Adulting Without Breaking the Bank
Hey friends! Finally old enough to enter the wonderful world of “adulting?” Congrats! But along with the freedom comes some not-so-fun responsibilities. Whether you’ve officially aged off of your parents plan or had a qualifying event take you off, if you’ve made it here it’s likely you’re now responsible for your own healthcare. Ugh – yes, I preemptively heard you all sigh. Here’s the thing: staying healthy shouldn’t drain your bank account. So, let’s break it down. There are two options: cost sharing and insurance, let’s see which one fits your #adultingbudget.
Cost Sharing: The Squad Approach (Think Splitting Netflix with Friends)
Ever watch those streaming service prices skyrocket? Yeah, not fun. That’s why you and your besties geniusly split the cost, right? Cost sharing for healthcare is kinda like that. A group of people with similar health needs pool their money together into a fund used to cover medical expenses. This can be a sweet deal for young and generally healthy peeps like you. Here’s why:
- Lower monthly payments: Think of it as subscription healthcare benefits, You can start or stop any time, You have monthly payments, and the flexibility to choose a plan that has only the benefits you need. Since everyone chips in a bit and is generally healthy – just like you, the overall cost is lower.
- Focus on health over budget: Many cost-sharing programs emphasize healthy habits to keep everyone’s costs down. Some, such as Redirect Health, even set up additional benefits such as a robust mental health benefit, access to naturopath visits and more.
- Out-of-pocket costs that won’t wreck your wallet: Every cost-sharing plan is different, but most have options with reasonable maximums for unexpected medical emergencies. (indipop can help you find plans with out-of-pocket maxes as low as $1,000, which is pretty darn good compared to some insurance deductibles.) This way, you know the max you’ll ever pay in a given year, even if you get hit by a medical curveball.
- Open Networks: See any doc you want, forget in-network, out-of-network drama. Cost sharing lets you pick whichever doctor your heart desires. This can be especially important if you have a specific specialist you trust or have a strong preference for continuity of care.
- Transparent pricing: No more surprise medical bills! You’ll know exactly what you owe upfront, before you receive any services. (Plus, some cost-sharing plans even have concierge care teams who negotiate bills for you. Score!) This can be a huge weight off your shoulders, especially when dealing with unexpected medical situations.
- Portability: Cost-sharing isn’t insurance, because of this they have the flexibility to work in all 50 states and sometimes even reimburse when on vacation outside of the country.
But There’s a Catch (That’s why this isn’t the unicorn health plan)
- Pre-existing conditions: Unfortunately cost-sharing isn’t right for everyone. Each plan has their own set of pre-membership condition limitations with their own look back periods. If you’ve been diagnosed with, treated, hospitalized for or had symptoms of a condition that could come back around, you could be independently responsible for that medical bill. There are conditions that are excluded, like Type I and II diabetes, high cholesterol and high blood pressure. We always recommend if you are not quite sure if you have a condition that may be considered pre-membership, ask the cost share or an expert in these subscription based plans like indipop.
Insurance: Why this may make sense for you.
We all know and well, maybe not love but tolerate our typical insurance routes. When it comes to benefits, we rely on our plans to get us through the toughest times in our life. Cost-sharing can be a great option to get us through our everyday and emergency care but there are some pieces of insurance that a lower rate cost sharing plan just can’t duplicate. Let’s take a look at why insurance may be a better fit for you.
- Chronic illness: If you’re chronically ill or have many undiagnosed symptoms, These things will be considered pre-existing in plans outside of open enrollment or when enrolling in a cost share. If it continues or worsen without benefits to cover the associated expenses it can be incredibly difficult on your wallet – even more so than your premium or deductible.
TIP: always check your plan that out of network providers there is a cap for out of pocket care. - The Mystery Box of Health: Got a lot of undiagnosed symptoms? (Adulting involves a lot of mystery boxes, doesn’t it?) You might not know exactly what ails you yet, but you still need access to healthcare. Insurance helps cover those unexpected medical expenses that can pop up during the diagnostic process. This can give you peace of mind knowing you won’t be financially crippled while figuring out your health.
- Playing by the Rules (Ugh, Taxes): Some states require you to have ACA-compliant insurance, which means it meets minimum essential coverage standards set by the Affordable Care Act in order for you to not be subject to a tax penalty. Not all cost shares and not all insurance are fully ACA compliant, double check.
The Downside of Insurance:
- Costly: Insurance plans can be expensive, with monthly premiums and deductibles that can strain your budget. (This is why shopping around and comparing plans is important!)
- Surprise Bills: Even with insurance, you might get unexpected medical bills. (It’s always best to check with your insurance provider before getting any services to avoid surprises.)
- Limited Doctor Choices: Some insurance plans restrict you to doctors within their network. (This can be a hassle, especially if you have a preferred doctor.)
- Enrollment Periods: You can only change or update your plan during specific times each year. (Missing open enrollment can mean sticking with your current plan for a full year.)
One more acronym to learn-DPC
A DPC or Direct Primary Care method is similar to the idea of seeing your neighborhood doctor. You pay a monthly membership fee and create an agreement with your DPC so that you can see them when you want to and each visit will either have a co-pay or receive a set amount of free appointments depending on how your DPC operates. A DPC will usually be in reference to a specific privately owned practice.
Some insurance companies may operate in a similar way to a DPC. Take Kaiser Permanente for example, to see a doctor with Kaiser you must have Kaiser insurance, if you have Kaiser insurance, you must see a Kaiser doctor. The main difference is;
- A DPC is not for high cost medical needs, like a broken limb or surgery.
- A DPC will often only be in one state or area depending on the size of the practice or company who owns the practice.
- A DPC is often used only for routine care but may include specialists as well. What it will likely not include is dental and vision benefits as well as coverage for medications.
Direct Primary Care is a fantastic option to complement your existing health insurance or cost-sharing plan. This provides an avenue for you to stay with your trusted doctor and having a plan in place for those high costs medical needs.
The Takeaway
So cost sharing or insurance? It depends on your situation. If you’re young and healthy, cost sharing might save you money and offer flexibility you just can’t get with insurance. But for those with chronic conditions or undiagnosed symptoms, insurance might be a better fit. Do your research, weigh the pros and cons, and choose what keeps you healthy and financially secure!
No matter which choice you make, having the benefits that are right for you is the difference between breaking a leg and thinking about your health or thinking about your bank account.
Remember: Being an adult is all about making informed choices. Embrace your new responsibility by researching these options for yourself. Stay healthy, you are the future!
Need more help deciding? indipop makes it simple with free consultation and comparison for each and every potential member.
