Out of pocket only refers to covered billing codes (originally said expenses). And that varies state to state by insurer. But in the case of blue cross blue shield Texas the SPEC test was "covered" but the injectible radioisotope was not. Nor was the injection itself. Or the IV catheter insertions. Or the related ECG. Etc etc.

Out of pocket only applies to covered benefits. Which in many cases are selectively chosen by the insurers.

Also understand the tax and benefits implications of various corporate structures. Being a C-corp vs S-corp in the US can have major tax implications in the event of a major healthcare expense or even routine premium payments. Talk to an accountant and attorney for advice relevant to your situation/jurisdiction.

That would certainly explain it. I've been lucky enough to not need much medical care, so I'm not familiar with the ins-and-outs of actually using my insurance.

Thank you for sharing your experience!

Is it really such a safe assumption that a group insurance plan would provide better coverage than an ACA marketplace plan?

Because that is what you are implying, that group plans are all better than the individual plans people are talking about.

Group plans are subsidized by your employer, which makes it cheaper than the ACA plans at certain incomes. Also the group plan I have has lower deductibles than the ACA does.

The ACA did do a great thing in controlling what insurers have to cover, which prevents insurers from being super selective on coverage.

The claim I question is the claim that group plans actually cover a great deal more than marketplace plans (to the tune of being worth $75,000 a year...).

I'm quite sure that the various mandates in the ACA impacted many group plans, not just individual insurance. Maybe places with strong unions had plans that already exceeded the ACA mandates.

Honestly that number was mentally calculated late at night based on my personal experience and actual costs including taxes.

Most group plans at decent employers have many, many fewer billing code exclusions. They also tend to offer better choice of providers than most individual plans (many individual plans use a limited selection of doctors who have agreed to lower rates, etc for the insurer). This can also mean less wait time for specialist visits and therefore less time with lost income.

Additionally being employed with group coverage you generally as a salaried employee will not be fired for being sick. So your income does not dip due to you being unavailable for work as you can continue to draw salary.

As a hypothetical example: let's say you are in an accident and can only manage to work 20 hours a week for six months after (not unrealistic). If you are the primary or only source of sales/billable hours/invoicing for your firm you have to plan for a loss of income during the recovery time. What taxation considerations are there if you have to draw funds out of the company for medical bills? If you're structured certain common ways they get taxed at your full income rate in addition to the corporate tax rate (if the funds have been retained in the corporation as profits).

When calculating all those externalities $75k was the off the cuff number I came up with. I don't vouch for its total accuracy.

But some of those things are just benefits of having an employer. They tend to come with group insurance, but it isn't the group insurance that decides to keep you on during the illness or recovery.

That's fair. The point I was hoping to make though is that being self employed or even running your own startup has significant non-obvious financial risks/externalities when it comes to emergencies and healthcare in the US. Those risks have to be offset with cash beyond what many people assume is sufficient due to non obvious factors. Planning and good advisors are key.