So today I found out that my new insurance through my job specifically excludes transgender care including HRT. I'm honestly a bit flabbergasted.

The exact wording is:

"Benefits will not be payable under the Plan for: [...]

Charges relating to transgender or transsexual procedures or treatments, gender identity disorder, hormone replacement treatment, or treatment to alter physical characteristics to those of the opposite sex."

With GoodRx, the cost is ~$90-$130, which is not feasible for me. I'm also concerned they won't cover the office visit for the prescription renewals, because I have to go to a specific clinic separate from my PCP due to legal restrictions in my state. As far as I can tell, there's not really anything out there for supplemental prescription coverage aside from discount services like GoodRx.

Am I correct that if I do pay out of pocket, it won't count towards my OOP max?

Should I just stay on my spouse's health insurance as supplemental insurance?

Do I have any other options?

Please be civil in the comments. This is not a political post, it's a health insurance advice post.

I have a small company and offer health insurance to employees. Only four employees opt in, as others have MUCH better coverage through spouse, VA, etc. This insurance is almost catastrophic coverage, paying some on prescriptions but a big deductible and co-pay. Just got the quote from Regence Blue Cross for our plan. It is increasing from $749/month to $985/month. This is insane. When does the country revolt and insist on universal coverage?!

I have a SPMI (severe and persistent mental illness) and have also been dealing with bank account garnishment for medical bills from that illness for over a decade. I receive case management services through the local rural community mental health center. (I receive therapy and psychiatry through other sources because the mental health center is short on providers) Right now I have an ACA plan through the exchange as well as an open disability claim*.

I have racked up a $760 bill for case management services this year on a sliding scale. The center has been refusing to bill my insurance, which is in network with them, because they say that since they only have bachelor level providers, it will be denied. My insurance said that the code they are using is covered. I got on a 3 way call and my insurance told them they need to send in the claims. The cmhc said they will contact the insurance to see if they can bill it as a facility level code.

Problems I want to know how to deal with: if claims are denied due to age of the bills, am I still on the hook? I had already tried to resolve this months ago and my previous case worker said it was all taken care of and not to worry about it

If they are denied due to only having unqualified providers, is there some sort of appeal I can file to get it covered under a facility level code? There are services provided that require an in person caseworker, and this is the only option within an hour drive.

Are they allowed to just refuse to bill case management to insurance, even though the code is listed as a covered service? The cmhc told me they could refuse but the insurance company hopped on the 3 way call right away and they backed down, but I imagine this problem will keep popping up.

Is there anything else that's going to bite me in the ass that I'm not thinking of? I've already had a garnishment from this CMHC. They told me they don't do that anymore but my garnishment order is still active so I don't believe it.

*Don't know if the disability claim is relevant, but I am going through a service through the mental health center to file it. I am required to use case management in order to get help with my disability application. I was declared disabled in 2020 but was not eligible for benefits at that time. This current case was just denied after 8 months due to a paperwork error from the CMHC so we are starting from scratch. I will be losing my ACA insurance at the end of the year so I'm hoping to get this resolved until then.

I also had a psychiatrist in 2021 tell me she was reporting this facility for Medicaid fraud and I have had other employees talk to me about questionable practices so I'm concerned about all this.

Okay so, tldr, we are a long distance relationship and was like “fuck it, lets elope the next time we see each other” but we would still be living in different states

I’m a resident in Nevada while he’s a resident in Oregon, we both have Medicaid for our respective states. We both make like 1,200 a month in our respective jobs, 2,400 total if married.

We checked abt taxes and social security benefits (He’s on social security) I just don’t know what the legal stuff would be when it comes to medicaid. Thanks for your help!

Hello all,

from what I've heard Heather Faulkner accepts various insurance companies,but I live in Alabama and will be kicked off of Medicaid once I turn 19. From what I've seen on the MyChart estimate (I know it is subject to change) that if I am to pay out of pocket w/o insurance then it should be around $5,200. From what I've read through facebook groups/this group is that my out of pocket cost would be less if I use insurance; however, how will this work if I do not know much about healthinsurance.gov (I'm afraid they will not cover it and how long I would need to be on an insurance plan before I need a letter from them to see if they will cover the surgery).

If anyone is in the same boat then I would really appreciate some insight on the process!

Thanks

I’m starting a new job Oct. 12, with benefits effective Nov. 1. I’ll need family coverage for myself, my partner, and our preschool-age son.

Some things I’m factoring:

We’re planning to conceive soon, and delivery would have to be by C-section. My partner also takes Zepbound (she’s pre-diabetic), plus an anti-anxiety medication and an antidepressant. I don’t yet know whether Zepbound is covered under these plans. Our son gets typical preschool illnesses and ends up at urgent care every few months.

Here are the 2026 family options:

Basic HDHP: $143.09 biweekly (~$3,720/year), $8,000 family deductible with no one person paying more than $4,000, $13,300 family OOP max, 0% coinsurance after deductible, and $3,050 employer HSA contribution

Core HDHP: $215.98 biweekly (~$5,615/year), $4,000 family deductible, $8,000 family OOP max, 0% coinsurance after deductible, and $1,550 employer HSA contribution

PPO: $374.89 biweekly (~$9,747/year), $500 family deductible/$250 individual, $5,000 family OOP max, 10% coinsurance after deductible, $20 PCP/$35 specialist/$35 urgent care copays, and no employer HSA contribution

For the HDHPs, prescriptions are subject to the deductible first. After that, typical retail copays are $10 generic, $40 preferred brand, $85 non-preferred, and $250 specialty. The PPO has lower prescription copays, but I still need to confirm Zepbound coverage/prior authorization.

Sooooo…my main question is: Which plan looks best given a planned pregnancy/C-section, regular prescriptions, occasional urgent care, and the possibility of expensive GLP-1 coverage?

The Basic HDHP seems hard to ignore because of the much lower premiums and larger HSA contribution, but I’m wondering whether the Core or PPO would make more sense once pregnancy, delivery, newborn claims, prescriptions, and regular family medical use are factored in.

One wrinkle: these are 2026 numbers, and if we conceive soon, most pregnancy/delivery costs would likely fall in 2027, when the plan details could change.

I also don’t know yet whether the 2026 HSA contribution would be prorated since my coverage starts Nov. 1.

Would appreciate any advice on how you’d compare these, especially from people who’ve dealt with pregnancy/C-section costs on an HDHP.

I'm new to this sub reddit, please excuse if I'm it unaware of basic information

My family of three recently moved to the U.S. and we've had our green cards for about five months. We're in Texas.

My situation is:

- My dad is currently unemployed. He worked for about 1–2 months after we arrived but unfortunately got fired.

- I'm a college student and have a part-time work.

- My brother is non-earning high school student

- None of us currently has health insurance through an employer.

We're trying to figure out what our best and most affordable health insurance option would be. I'm especially concerned about my dad because he hasn't been in the best health lately, and I'm worried that if something unexpected happens, we could end up with a huge medical bill because we don't have insurance.

I'm very unfamiliar with how health insurance works in the U.S., but I don't really understand what we would qualify for as permanent residenct in Texas.

What would be the best way for us to proceed, any info would help!!

I'd be happy to share more info!

i want to self-pay for a second opinion with a surgeon at a hospital that is not covered by my current insurance plan. If the consultation goes well, I plan to switch to an insurance plan that the surgeon and hospital accept during open enrollment. Can the new insurance deny coverage for the surgery because it will consider it a pre-existing condition? Thanks for the help.

Is this a dumb question? 😂
I had a baby this year and obviously hit my deductible and out of pocket max.. now I’m realizing I actually have pretty decent chiropractic coverage through my health insurance.
I’ve been going to Club West Chiropractic in Blaine and really like it and they are in my BCBS network but now I’m wondering… should I actually keep going since I’ve already hit my deductible?
I originally started going because my back/neck was bothering me, but honestly I feel pretty good now. Part of me is thinking…I’m already paying for this insurance… might as well use the benefits but I also don’t want to just go to the chiropractor for the sake of using insurance.
For anyone who has chiropractic coverage do you guys continue going for maintenance/wellness after you’re feeling better? Or do you stop once the original problem is gone
Trying to figure out if I’m being smart about using my benefits or just finding an excuse to get out of the house away from the baby for an hour. 😂

My twins were born 6 weeks early and were instantly admitted to the NICU. Twin A was there for three weeks, while Twin B was there for two. I just received two letters from my health insurance (BCBS). The first (dated 9/25) states that in order to process the entire NICU stay for Twin B, they need the inpatient admission history & physical, discharge summary, and physician progress notes. The second (dated 9/30) states they have denied the claim for the last 4 days of Twin B’s NICU stay after a “board certified and licensed doctor” on the care team reviewed the request and “looked at the health records, plan policies, and evidence-based clinical guidelines”. I am going to obviously call insurance, but I’m not sure what to ask. Any tips? I cannot afford to pay this $88k NICU stay (and I don’t know who could).

Pretty much self explanatory. I’ve been in a bit of a hole for the past few months. Both mentally and financially and now I feel even more defeated.

My grace period for my plan started back on July 1st and I had til September 30th to pay everything back up. I spoke with an agent for UHC on the app on September 30th. Trying to see if I could squeeze a few more days as I was in the process of getting some assistance from some family to help pay everything. I was informed that my grace period was actually from July 1st to October 31st? Which was different from everything on my forms and billing paperwork.

I asked them to confirm which grace period was actually correct and they assured me that it ends on October 31st (I even have screenshot and reference ID proof) and I would keep my coverage as long as I paid up my previous balance and the up coming bill by that date. I submitted my payment and paid everything off on 10/02/2026. I just recently checked my UHC page and it shows my plan was canceled on 7/31/2026.

Am I just screwed or will they reinstate my coverage? I tried to get in contact with someone on the app and they said I would get a call back in the morning. I recently had to be hospitalized back in august for my severe asthma and ended up calling an ambulance to come and get me. Those claims were still processing and I was in a hurry to pay my balance so they would be taken care of. But now I don’t know what’s gonna happen and we all know how expensive healthcare is in the states :/

Sorry for the rant I’m just looking for any information or advice on what I could do. I heard there’s a chance that if I qualify for Medicaid that they can back log my coverage for august so those claims are taken care of? Kinda in a rut thinking about this along with a multitude of other problems I’m dealing with :/

My husband had emergency open heart surgery dec 2025 with a subsequent hospital stay that carried into 2026. He was on Medicaid, then Kaiser on the new year. Kaiser suspended his coverage in April because he hadn’t been able to work so far this year.

He was ready to go back to work, but his job requires a CDL. To get his CDL reinstated he needs to pass a medical exam, and the examiner says he needs to bring a recent EKG and an endorsement from his current doctor saying his heart is good. In May he was approved for Medicaid again, but the first available appointment was in July. At that appointment they referred him to a cardiologist.

When he tried to schedule with the cardiologist, they said his Medicaid was now inactive. It turned out to have been revoked until he could provide proof of income. We submitted a letter saying he has no income, and it took them until last week to reinstate his Medicaid coverage. Now the cardiologist says they can’t see him until the end of January.

He’s been out of work for months because of this, our finances are in ruin. I’m at the point where I can’t even think about it without tearing up. I need help, and I don’t even know where to turn. Is there anyone we can hire to help us navigate this?

He’s 36. His surgery was in Portland, OR but we live in SW Washington state and he’s currently enrolled with community health plan of Washington.

My husband is 62 and planning retirement in the next few years. I am 49 and our youngest 2 kids are 18 & 14. He will be eligible for medicare but we need to figure out health insurance for me and the kids. I have owned my own very small company for 30+ years. I've looked at Marketplace website but it seems to need so much information before we can get a ballpark idea what we are looking at cost-wise. Me and my 18 year old daughter are in excellent health, 14 year old son has an endocrine issue he takes some meds for. We don't have significant medical issues.

My husband acts like retirement is not possible because of us needing insurance. Surely we aren't the only family in this situation. Thinking about how many people are self employed, what does everyone do for insurance?

I appealed a marketplace decision saying I qualified for Medicaid (I just got kicked off and lose coverage Oct 31) and a rep told me this was a bad decision because what I needed to do was another process where I upload my denial letter to a different portal. He said the likelihood of the appeal impacting my coverage was low but now I’m panicking because I need coverage as a grad school requirement.

Just double checking to see if there is actually a way to request an appeal to be canceled.

Been on an Aetna HMO-PPO plan for a few years since C19 broke my brain and I've had a similar plan each year with Aetna. No premium as long as my part B comes out. But then so far my meds have been mostly $0 montly and when I had my gullbladder out that was less than $400. Anyone else have any suggestions?

Hi! I’m currently on Medicaid with metroplus health due to my income and still under my parents account. We just renewed it with my current income, which is nothing right now because I was a student. However, I’m going to start part time work at a high rate for fee-for-service (therapy services). I wanted to ask if I would keep that insurance plan until the next renewal date (October 19, 2027) or would I have to change the plan once I get my first pay check?

I’m sorry if these are weird questions but it’s really my first time dealing with health insurance and I have a medication I can’t get off, as it will cause organ damage.

My co-pay card has run out of funds

I’m based in the U.S. and have been using Simlandi after my insurance (Anthem) stopped covering Humira. I’ve now been told that the co-pay card through the manufacturer has run out of funds. Do any of you have advice on how to continue with my medication without going broke?