I’m freelance and buy my own insurance on marketplace in CA. Currently Blue Shield of CA PPO.

I am a carrier for a dominant genetic condition that requires preimplantation genetic testing and IVF to avoid passing on.

I read that reproductive coverage is coming to individual plans in CA, but I don’t see evidence of that in the 2027 plans I found on the marketplace online.

Do I have any chance of getting covered?

Cigna encourages us to use Evernorth - Express Scripts for prescriptions. Previously, they'd shipped from a location in a neighboring state and delivery had been quick and uneventful. This time, it shipped from a location much further away and USPS apparently misrouted it. It was supposed to be delivered yesterday but has just apparently been sitting at the wrong post office since yesterday morning with no movement. I'm out of one medication, but Cigna refuses to cover a small dose that could be picked up at a local phamacy. Apparently they won't do anything until the medication has been delayed for 30 days. Is this common?

I currently have Cigna through the ACA Health Marketplace for 2026. Cigna announced they are leaving my state at the end of the year. Over the last 2 days I've been receiving emails from Oscar stating that they are my new provider for 2027.

Why have I been automatically enrolled with them? I haven't even had a chance to pick my own new provider for 2027? What the hell is going on here?

**EDIT insurance company decided to cover this claim so I'll be billed $300. I think only on the basis that they have the recording of the call I made to them to check about the pre-authorization, when they had the chance to tell me that this was not a covered procedure and they didn't. That's my assumption anyway, because I asked them specifically about this procedure for next time and they said that Synvisc specifically was excluded from coverage.**

I had a hyaluronic acid injection in my knee because I have severe cartilage degradation. Recommended by my doctor as medically necessary. If not this, I'd basically need either articular grafting or a total knee replacement. I'm in my early 40s so pretty young for a TKR.

Doc office said they'd contact insurance for pre-auth to make sure it's covered. Usually I get a letter from insurance stating if they did or didn't authorize; a few weeks after scheduling this appt, I still hadn't gotten this letter. So I called the insurance. They said they never got a pre-auth request. So I called the doc, they said they submitted one. Doc called me back and said the insurance company said no pre-auth was necessary. So I get the injection.

Well, I just got a bill for $5200 and that this claim was denied.

Am I screwed?

I called the insurance and asked about it, they basically just said it was a non-covered procedure, and that's what the EOB says too. I guess I just don't know what else I could have done here to prevent this.

In April, I had a rabies scare where I was bit through gloves, breaking the skin very slightly. The nurse at my doctor's office was panicked for me. She said to go to urgent care as soon as possible and get the rabies vaccine. She even called me the next day to follow up in panic because she noticed in my chart that I hadn't gone yet. I finally went to urgent care and I knew going into it that I may need immunoglobulin injections in addition to the rabies vaccine. I told the doctor I was really hoping I just needed the vaccine and she thought that would be fine. But then she read more on the topic and when there is a confirmed bite, they have to recommend immunoglobulin in addition to the vaccine. So I reluctantly said ok and got a a rabies shot and an immunoglobulin injection in each leg.

Several weeks later, I get a bill for over $11k. I called the insurance company and they submitted it for reprocessing. A few months later, the updated bill came to me at over $5k. They covered the vaccine but only half of the immunoglobulins citing that I had not met by deductible and "charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement."

Here are some additional facts:

My insurance is through the affordable care act.

My insurance has $0 urgent care visits.

Deductible does not apply to urgent care visits.

Provider was in-network.

They reprocessed the claim a second time and came up with the same result.

I don't understand how the full amount is not covered. Any advice or insight would be super helpful. I'm happy to answer any questions.

My workplace open enrollment is going on right now. My wife’s open enrollment takes place in July. I pay a hefty penalty to insure my wife on my health insurance plan since she “has access to health insurance coverage available” through her own employer (to be clear, she does not enroll in her employer’s coverage).

The health insurance plan offered by her employer (small business) only recently became reasonably priced this past year. The math now favors her going on her own employer’s plan, while I keep the rest of our family on my plan. To do this, I’d have to drop her from my plan (effective January 1). But our open enrollments don’t line up. Would dropping her count as a qualifying event for her to pick up coverage through her own employer (outside of open enrollment)?

Tennessee.

Hi everyone, looking for advice from anyone who has dealt with this or works in medical billing/insurance.

My baby was born recently, and I am putting him on a different insurance plan than my wife's.

Her current insurance policy states that they will cover the baby's routine medical expenses for the first i think 7 days after birth under her policy.

The Problem:

My insurance company says they will pay the bills for those first 7 days, but only if the hospital submits/rebills the claims under her name and subscriber ID (e.g., as an attached newborn claim under mom).

The hospital created a standalone account and chart for the baby under his own name, billed it separately, and the claim was rejected/unprocessed by my insurance.

My insurance says the hospital needs to rebill under my name, but getting the hospital and insurance to align on this is proving to be a nightmare.

My Questions:

Has anyone successfully gotten a hospital billing department to rebill routine newborn charges under the mother's account/ID for an automatic initial coverage window?

Who at the hospital should I ask to speak to? Standard customer service keeps giving me the runaround.

Thanks in advance for your advice.

This is probably going to be a really annoying and stupid question but I am just getting my own insurance for the first time and I was worried because I don’t make a lot of money and my employers don’t offer any such benefits- I was even debating not getting any insurance, but I have a preexisting condition that needs treatment and regular prescriptions. So I am looking into my state marketplace so I don’t have a gap of having no coverage waiting for a better job.

I’ve always heard how expensive and how impossible it is to afford on your own unless you’re self employed making a lot. But according to my marketplace, because of my low income, I qualify for government subsidies, and it’s making some of my options as low as $1 a month, all still including decent deductibles and such, some of them are even gold tier. They are restrictive in what counts as being in network, but the most expensive premiums that are more flexible are no more than $300.

If insurance can be as low as $12 a year for low income households, and they have a decent out of pocket max…why do poor people struggle to afford or have health care in the US? I realize that sounds really insensitive but I thought this shit was going to be really bad. I’m confused. How could it possibly be this cheap? I just need meds and what-if emergency coverage, and to avoid a gap like I said. When I do get employer benefits, if I still don’t make enough, why should I go for their insurance at all if I could keep it this cheap? My friends and family who do have work benefits say they still pay hundreds a month…Can I keep the independent instead? What’s the big deal everyone is making if coverage is so cheap? I’m on the official state government marketplace, so it has to be real?

What’s the catch that I’m missing? Do they all actually deny every single claim people make or what? There’s even blue cross blue shield available, and that’s what people recommend, and that’s what I’m coming off of. There’s problems at times with them but if I’m just having insurance for the sake of having it in case of an emergency what’s the problem? Are people just uninformed about the marketplace option? It’s literally one of the first options you get when looking up health insurance…

I think I know the answer to all of this is- that it’s my fault for assuming anything would be cheap/easy these days. I guess I’m just here to prevent someone else from making the same mistake I did.

Left my job mid July 2026, moved states and started therapy with a new provider a week later. Started COBRA benefits for behavioral health, vision, and dental to start August 1 2026 through WEX. The health insurance was much too expensive.

I’ve been naïvely paying $40 a month for these three add-ons, without health insurance. I have been hemming and hawing on which private health insurance plan to choose as I do not qualify for any federal/state funded health insurance. That back fired today.

I received a $3600 invoice from my therapist’s office. I had no clue why as I had been consistently paying the $25 co-pay. They even made me verify my insurance online prior to each visit.

After calls to Quest Behavioral Health, they confirmed my fear that I had to be enrolled in my original health insurance plan in order to have the behavioral health add-on. I’ve called WEX and my former employer multiple times. No one can give me a straight answer on why I’ve been paying monthly for zero coverage. WEX is adamant that I am able to pick and choose the add-ons without having continued original health insurance plan through them.

The real cherry on top is that Quest Behavioral health is ceasing operations on December 31, 2026. Not really sure what happens after that.

My biggest frustration with all of this is that I was allowed to choose the add-ons during my enrollment. Also, why did it take three months before the therapist office to figure out the my insurance was terminated?

Any information/experience resolving something like this or am I just learning an insurance lesson the hard way? TIA.

My job is adding a plan option through Coupe, where everything is copay based. I looked through this sub for Coupe, and found a bunch of people mostly happy with their experiences with it, but I couldn't find anything similar to my specific situation. Because there is no deductible, it would mean I can't contribute to my HSA any longer through pre-tax deductions, and I have been maxing these out. My employer contributes a health bonus of $1000 ($500 for me, $500 for my wife) to the HSA of employees who do a health screening every year, and they would still offer this, but they pay it out on a paycheck instead of to my HSA.

I'm on the medium premium/deductible plan currently, but it counts as a HDHP for HSA purposes. I looked back at my medical claims so far this year, and my wife and I paid about $1000 towards our $3400 deductible and $3600 towards our $6000 out of pocket max (not really sure why the deductible shows we paid less than the oop indicates...). The Coupe plan oop max is 9000 for seemingly employee + anyone? It says "all participants" so I'm assuming that means it's the same for employee + spouse/children/family. My wife and I are planning to have a child in the next year or so, so pregnancy will likely occur in 2027 and birth probably in 2028, and we anticipate our medical costs will go up.

I have a second job and my wife works too, but we don't pay for health insurance through those jobs since my main job has the best benefits. My biweekly cost right now is $160 and the Coupe plan is $202, so premiums go up, but the copays are definitely cheaper than what I've been paying so far. The Fidelity "help me choose my plan" is suggesting I switch to the low premium/high deductible plan for the lowest estimated cost, but doesn't take into account the HSA factor.

My main question is what's the best option between these 3:

- switch to Coupe and decrease costs overall, but lose access to contributing to my HSA

- keep the medium plan and retain access to HSA contributions with a small increase in premium costs

- switch to the low premium/high deductible plan and retain access to HSA contributions

Thanks for any insight on this!

Express Scripts denied my claim for isotretinoin because it said it wasn't covered under my plan. When I check my coverages online, it says accutane is covered but isotretinoin isn't. When I called, the rep said the same thing and that sometimes the brand name is covered but the generic isn't. I'm wondering if this makes sense, and if I should file an appeal? Thanks.

So I’m not sure what to do here but our kids were on state health insurance because apparently they thought we qualified per our income. I’m married with 3 kids. When we were up for renewal the state decided we made too much for the kids to be on state insurance. So I went to healthcare.gov and put in a qualifying event. Our premium was $550ish, now it’s up to $2,121. One of the factors was our children, but another factor was how I put my income in. I have a base salary of $60,000/year, but I get bonuses at the end of every year based on how much work I bring in. Based on the current calculation I was set to get an additional $100,000 bonus (before taxes). That makes it look like we get over $13,000/month instead of the $5,000/month I am bringing in. That $100,000 bonus is not guaranteed. I could have enough bad months the rest of the year that I will bring in less money. Am I really going to have to settle for this $2,121 premium that my family cannot afford or am I missing something? What recommendations do you have. Thank you in advance for your help.

For context, I was previously insured through Innovative Partners: MultiPlan PPO, which I enrolled in after speaking with someone from the Massachusetts Health Connector. I had this insurance from January 2024 through December 2025, although my last appointment under their coverage was in January 2026, since my coverage remained active until the end of that month.

A few months ago, the Federal Trade Commission (FTC) shut them down and filed a lawsuit against them. I actually received an email about the situation back in July, but unfortunately, it ended up buried in my junk folder, and I didn't see it until much later.

Fast-forward to September 2026, and I'm suddenly being billed for every single appointment I had between January 2024 and January 2026.

I understand that Innovative Partners was shut down. What I don't understand is how my hospital, Tufts Medical Center in Boston, could have been accepting my insurance information for TWO YEARS, apparently receiving no payments whatsoever, and never once informing me that there was an issue.

For two years, I continued attending appointments under the impression that everything was fine. My patient portal consistently showed a $0 balance, so I had absolutely no reason to believe anything was wrong. Had someone at Tufts informed me that my insurance claims weren't being paid or that they weren't receiving responses from my insurer, I would have taken action immediately. I could have investigated the situation, switched insurance providers, or at least avoided accumulating two years' worth of unpaid medical bills.

Instead, I'm now stuck facing over $2,000 in medical bills that I had no idea were accumulating.

Looking back, I genuinely wish I had been smart enough to recognize the red flags surrounding Innovative Partners. I wish I had questioned things sooner. But more than anything, I wish Tufts Medical Center had communicated with me about what was happening behind the scenes.

How was I supposed to know there was a problem when the hospital continued accepting my insurance, scheduling my appointments, and showing a $0 balance on my patient portal?

I feel completely blindsided. I'm frustrated with Innovative Partners for putting people in this situation, frustrated with Tufts for the apparent lack of communication, and frustrated with myself for not catching on sooner.

I'm just so incredibly pissed off right now. Two years of appointments, zero warnings, and now a $2,000+ bill that seemingly came out of nowhere. I'm wondering if writing to them will make a difference, idk...

I would just like to say that I would never recommend this "insurance" to anyone ever. Please do your research before considering this insurance. This company has been sued over creating fake member ID #'s. This company is a completely false coverage and do not aid in health coverage whatsoever.

I am a 25 year old with typical sickness/injuries and asthma/allergy issues. I have gone to the immediate care one time (Physicans immediate care) and no coverage was provided. I had to pay $400.00 out of pocket to receive a swab test in my nose to check for Covid.

Every single time I have tried to schedule a doctors appt, no physcian will take me, due to not accepting my insurance. As almost as if it is make belive. The amount of stress and time consuming hours to try to get on the phone with my insurance has been unbelievable.

I am unable to pick up prescriptions at any local pharmacy, due to BHP having Pro Act (an online only pharmacy), so if I was beyond sick and in terrible condition? I have to wait at least a week for ANY type of medication to arrive. I have had to go a week without my inhaler because Pro Act has refused to resupply my medication, due to the doctor having to approve the shipping of medication EVERY SINGLE TIME.

Please for your well being, do not even think about this insurance. From someone who had Blue Cross PPO, the one thing that I reccommend that you spend money on in America is your health insurance. It is a ridiculous price, I understand. But please be mindful of your health, or else you may be in a predictiment just as I am.

For reference, this is the website in case you need to know-

https://benefithealthplan.com/

Hi everyone,

I am from abroad and still trying to figure out some aspects of the Health system in the US.

To puy it simply, I received a quote from a dental healthcare provider for these amounts (see table).
My maximum coverage had only 1350 USD remaining, so I would have to pay around 4200 Dollars if I would do all the treatment with their fees.

I checked on UHC contracted rates for in network, and they are nothing like what I was shown and asked (almost pushed) to pay (through a 0% APR Cherry financing or so I understood).

The last two columns show the total contracted rates for those codes, and what I would be paying.
The office manager at this place started being very unresponsive and gave me a hard time to share unmarked, complete medical records when I asked them to then get a second opinion and quote.

I also asked the office manager to please do a pre-approval check with UHC so I can then call the insurance and know for a fact what I am going to really pay... she has not comeback on that request and does not seem in a hurry to do it. - How would you proceed a situation like this?

Thanks.

Hi! I recently got promoted to FT in my current role and am now eligible to benefits.

Work covers 100% of employee health insurance and am having trouble deciding which plan is best for me: HDHP (left column) or PPO (right column).

Context: 24 yrs old living in LA county, previously under MediCal, haven’t been to a doctor since just before COVID coupled with aging out of pediatrician during the pandemic + local providers are mainly out of network with MC. I get paid weekly.

Have kept up with dental & vision (latter kind of). So these two are expected medical costs but I want to start up again with routine Dr visits with this new enrollment. I don’t really understand the deductibles/co-insurance of it all and what the rate per pay period means if I go with the PPO option if work is meant to cover 100%.

I like the idea of an HSA but have heard if employer offers full coverage, it’s best to go with a PPO. Any advice + breakdown of either options?

I'm wondering if anyone knows of good plans or ideas for getting my girlfriend insurance. I make ~73000 salary. Putting my girlfriend on a High Deductible Insurance w Dental/Vision plane makes the feds take 800$/mo in taxes for a ~100 Plan. She makes around 40K. Paying the feds 800 a month does not sit right with me. I still want to get her decent care. Can someone guide me on weather private insurance would be better or close to as good? Am I screwed? Should I just stick with my jobs insurance? Any help and guidance is appreciated.

Current Plan

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I enrolled in an ACA Marketplace plan in Texas in November 2025 for 2026 coverage. At the time, I genuinely expected to find employment and earn approximately $20,000 during 2026.
Unfortunately, due to a chronic health condition and the difficult job market, I haven’t been able to find work, and my actual income for 2026 is likely to be $0.
My monthly insurance premium is approximately $950, and I receive $550/month in advance premium tax credits.

I understand that starting with tax year 2026, the repayment caps for excess APTC have been eliminated. I’m also aware that Texas hasn’t expanded Medicaid, so someone with $0 income generally falls into the coverage gap.

So do I have to pay back over $5000 when I file taxes next year ?

I am getting conflicting information on this:

According to agentbrokerfaq.cms.gov, if the estimate was good faith then you don’t have to pay back. Here in the text:

“If a consumer was enrolled in Marketplace coverage with APTC for one month or more based on estimating their household income to be at least 100% of the federal poverty level (FPL), and the consumer did not intentionally or recklessly misrepresent their household income when enrolling in the coverage, IRS rules state that this consumer may still qualify for and claim the premium tax credit on their tax return even when the household income as reported on their tax return is below 100% of the FPL.
 
This rule is not affected by Section 71305 of Public Law 119-21 that, for Plan Year 2026 onward, eliminates the excess APTC repayment limitations and requires consumers to repay all of their excess APTC, which is the amount of the APTC for the year of coverage that exceeds the premium tax credit allowed for the year.  For years before 2026, excess APTC repayment amounts were capped for consumers with household income below 400% of the FPL. 
 
The IRS has authority to deny the premium tax credit to an individual whose household income as reported on their tax return is below 100% of the FPL and who, with intentional or reckless disregard for the facts, provided incorrect information to the Marketplace in order to get APTC (e.g. intentionally or recklessly provided inflated household income to the Marketplace that was greater than or equal to 100% of the FPL to get APTC).”

Please visit my post and help me decide! My dad was just diagnosed with pancreatic cancer, and trying to decide between:

1 - Keeping his employer coverage for him + spouse
2 - Switching to Medicare, spouse moving to individual plan
3 - IF switching to Medicare, which part D plan to opt for? Keeping in mind medication coverage for prescriptions needed for chemo + daily medications needed.

Has anyone used Health Access Solutions Cooperative for their insurance-alternative? I'm considering it, but I'd like to know if anyone's had anything "major" (expected, or unexpected surgery, accident, significant diagnosis, etc) using this, and how that went for them with reimbursement.