fabrisse | Reading

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This is part of Understanding Health Insurance

Introduction
A Health Plan is a Contract
The Three-Stage Model ⇐ You are here

The Three-Stage Model

When you have health insurance, you have a contract (health plan) with the insurance company that says that for the duration (the plan year) of the contract, you will pay them the agreed upon monthly fee every month (the premium), in exchange for them paying for your health care... some.

How much is "some"? Well, that depends.

To understand what it depends on, you have to understand the three-stage model that health plans are organized around.

This three-stage model is never described as such. It is implicit in the standard terms (jargon) of the health insurance industry, and it is never made explicit. There is no industry term (jargon) for the model itself. There are no terms (jargon) for the three stages. But health insurance becomes vastly easier to understand if you think about it in terms of the three-stage model that is hiding in just about every health plan's terms (agreements).

( Read more: 12,170 (sic!) riveting words about health insurance in the US] )

This post brought to you by the 221 readers who funded my writing it – thank you all so much! You can see who they are at my Patreon page. If you're not one of them, and would be willing to chip in so I can write more things like this, please do so there.

Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!

neotoma

Thick-slice bacon, a dozen eggs, bacon-gruyere wheel, spinach pastry, lemon tart, rosemary pull-apart rolls, gingerdoodle cookies, a quart of chicken & dumpling soup, a quart of pickled red onions, cranberry chevre, farmhouse goat cheese, apple cider, apples (Nittany, Braeburn, Stayman), shallots, red onions, garlic heads, white turnips, grilled spiced olives, Greek country mixed olives, and a pound of black beans.

I talked briefly with an elderly woman who had just moved into the area and was attending the market for the first time -- she was trying to find organic apples. I don't think you can really grow apples here as a market farm organically. There are just too many critters that love to chomp on apples here, but I hope she finds something she is willing to buy.

I plan to make another apple-shallot pie tomorrow; I'll be working extra to get ready for the quarterly report at work, but I am also likely to be snowed in, since the forecast is snow, 1 to 5 inches.

My fridge failed Monday and it took the housing office until Wednesday (2 maintenance requests, 2 follow up phone calls, and 1 email to the property mananger cc'd to the county councilor's aide for housing issues) to get it replace. I had to throw out everything but hard cheese and vinegar-based condiments, so I shopped a little more aggressively than usual this week.

Current Mood: cold

siderea

So, I, uh, got my RSI/ergonomics debugged!* I then promptly lost two days to bad sleep due to another new mechanical failure of the balky meat mecha and also a medical appointment in re two previous malfunctions. But I seem back in business now. The new keyboard is great.

Patrons, I've got three Siderea Posts out so far this month and it's only the 12th. I have two more Posts I am hoping to get out in the next three days. Also about health insurance. We'll see if it actually happens, but it's not impossible. I have written a lot of words. (I really like my new keyboard.)

Anyways, if you weren't planning on sponsoring five posts (or – who knows? – even more) this month, adjust your pledge limits accordingly.

* It was my bra strap. It was doing something funky to how my shoulder blade moved or something. It is both surprising to me that so little pressure made so much ergonomic difference, and not surprising because previously an even lighter pressure on my kneecap from wearing long underwear made my knee malfunction spectacularly. Apparently this is how my body mechanics just are.

siderea

Canonical link: https://siderea.dreamwidth.org/1890494.html

0.

Hey Americans (and other people stuck in the American healthcare system)! Shopping for a health plan on your state marketplace? Boy, do I have some information for you that you should have and probably don't. There's been an important legal change affecting your choices that has gotten almost no press.

Effective with plan year 2026 all bronze level and catastrophic plans are statutorily now HDHPs and thus HSA compatible. You may get and self-fund an HSA if you have any bronze or catastrophic plan, as well as any plan of any level designated a HDHP.

2025 Dec 9: IRS.gov: "Treasury, IRS provide guidance on new tax benefits for health savings account participants under the One, Big, Beautiful Bill"

Bronze and Catastrophic Plans Treated as HDHPs: As of Jan. 1, 2026, bronze and catastrophic plans available through an Exchange are considered HSA-compatible, regardless of whether the plans satisfy the general definition of an HDHP. This expands the ability of people enrolled in these plans to contribute to HSAs, which they generally have not been able to do in the past. Notice 2026-05 clarifies that bronze and catastrophic plans do not have to be purchased through an Exchange to qualify for the new relief.

If you are shopping plans right now (or thought you were done), you should probably be aware of this. Especially if you are planning on getting a bronze plan, a catastrophic plan, or any plan with the acronym "HSA" in the name or otherwise designated "HSA compatible".

The Trump administration doing this is tacit admission that all bronze plans have become such bad deals that they're the economic equivalent of what used to be considered a HDHP back when that concept was invented, and so should come with legal permission to protect yourself from them with an HSA.

Effective immediately, you should consider a bronze plan half an insurance plan.

( Read more [3,340 words] )

This post brought to you by the 221 readers who funded my writing it – thank you all so much! You can see who they are at my Patreon page. If you're not one of them, and would be willing to chip in so I can write more things like this, please do so there.

Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!

duskpeterson

The Emorian borderland, like the remainder of the borderland, is famed for the friendliness of its villagers. Despite that, do not be surprised if you are asked to pay for your room and board. Past foreign visitors have often taken advantage of the villagers in order to escape the high price of inns elsewhere in Southern Emor.

In the westernmost villages, you will find a blend of Emorian and Daxion life; though no bards live here, villagers can often be heard singing. As you travel further east, the singing will slowly cease, replaced by talk of blood-lineages and the seven gods and goddesses. You are now in the portion of the Emorian borderland that lies north of Koretia.

The borderland is the only part of Emor where vineyards can be found. Despite the relative coolness of the Emorian borderland, Emor's wines are among the best in the Three Lands. Especially popular is sweetened wild-berry wine (don't try the unsweetened variety unless you enjoy bitter drinks, which you probably do if you're Koretian) and wall-vine wine, made of a mild-tasting grape that grows only in the Emorian borderland.

Farming is also common here. Eastern mainlanders who farm will find much to interest them in these lands that have been plowed since ancient times.

Travelling east, you will eventually reach a crossroads. To travel on to Emor's capital, turn left.

[Translator's note: Hidden Blade shows life in an Emorian borderland village.]

siderea

Canonical link: https://siderea.dreamwidth.org/1890011.html

This is part of Understanding Health Insurance

Introduction
A Health Plan is a Contract ⇐ You are here
The Three-Stage Model

Health Insurance is a Contract

What we call health insurance is a contract. When you get health insurance, you (or somebody on your behalf) are agreeing to a contract with a health insurance company – a contract where they agree to do certain things for you in exchange for money. So a health insurance plan is a contract between the insurance company and the customer (you).

For simplicity, I will use the term health plan to mean the actual contract – the specific health insurance product – you get from a health insurance company. (It sounds less weird than saying "an insurance" and is shorter to type than "a health insurance plan".)

One of the things this clarifies is that one health insurance company can have a bunch of different contracts (health plans) to sell. This is the same as how you may have more than one internet company that could sell you an internet connection to your home, and each of those internet companies might have several different package deals they offer with different prices and terms. In exactly that way, there are multiple different health insurance companies, and they each can sell multiple different health plans with different prices and terms.

( Read more... [7,130 words] )

This post brought to you by the 220 readers who funded my writing it – thank you all so much! You can see who they are at my Patreon page. If you're not one of them, and would be willing to chip in so I can write more things like this, please do so there.

Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!

siderea

Canonical link: https://siderea.dreamwidth.org/1889543.html

Preface: I had hoped to get this out in a more timely manner, but was hindered by technical difficulties with my arms, which have now been resolved. This is a serial about health insurance in the US from the consumer's point of view, of potential use for people still dealing with open enrollment, which we are coming up on the end of imminently. For everyone else dealing with the US health insurance system, such as it is, perhaps it will be useful to you in the future.

Understanding Health Insurance:
Introduction

Health insurance in the US is hard to understand. It just is. If you find it confusing and bewildering, as well as infuriating, it's not just you.

I think that one of the reasons it's hard to understand has to do with how definitions work.

Part of the reason why health insurance is so confusing is all the insurance industry jargon that is used. Unfortunately, there's no way around that jargon. We all are stuck having to learn what all these strange terms mean. So helpful people try to explain that jargon. They try to help by giving definitions.

But definitions are like leaves: you need a trunk and some branches to hang them on, or they just swirl around in bewildering clouds and eventually settle in indecipherable piles.

There are several big ideas that provide the trunk and branches of understanding health insurance. If you have those ideas, the jargon becomes a lot easier to understand, and then insurance itself becomes a lot easier to understand.

So in this series, I am going to explain some of those big ideas, and then use them to explain how health insurance is organized.

This unorthodox introduction to health insurance is for beginners to health insurance in the US, and anyone who still feels like a beginner after bouncing off the bureaucratic nightmare that is our so-called health care system in the US. It's for anyone who is new to being an health insurance shopper in the US, or feels their understanding is uncertain. Maybe you just got your first job and are being asked to pick a health plan from several offered. Maybe you have always had insurance from an employer and are shopping on your state marketplace for the first time. Maybe you have always gotten insurance through your parents and spouse, and had no say in it, but do now. This introduction assumes you are coming in cold, a complete beginner knowing nothing about health insurance or what any of the health insurance industry jargon even is.

Please note! This series is mostly about commercial insurance products: the kinds that you buy with money. Included in that are the kind of health insurance people buy for themselves on the state ACA marketplaces and also the kind of health insurance people get from their employers as a "bene". It may (I am honestly not sure) also include Medicare Advantage plans.

The things this series explains do not necessarily also describe Medicaid or bare Medicare, or Tricare or any other government run insurance program, though if you are on such an insurance plan this may still be helpful to you. Typically government-run plans have fewer moving parts with fewer choices, so fewer jargon terms even matter to them. Similarly, this may be less useful for subsidized plans on the state ACA marketplaces. It depends on the state. Some states do things differently for differently subsidized plans.

But all these different kinds of government-provided health insurance still use some insurance industry jargon for commercial insurance, if only to tell you what they don't have or do. So this post may be useful to you because understanding how insurance typically works may still prove helpful in understanding what the government is up to. Understanding what the assumptions are of regular commercial insurance will hopefully clarify the terms even government plans use to describe themselves. Just realize that if you have a plan the government in some sense is running, things may be different – including maybe very different – for you.

On to the first important idea: Health Insurance is a Contract.

Understanding Health Insurance

mecurtin

Whoozat? Purrcy and I were resting together, until all of a sudden he wondered what the human was doing in his bed. Besides being warm, of course.

Purrcy the tuxedo tabby stares over his shoulder at the camera, one ear flicked off to the side, as if slightly affronted. He's lying on the bed, partly visible over the mound of someone's legs covered by a red blanket.

Purrcy the tuxedo tabby stares over his shoulder at the camera, one ear flicked off to the side, as if slightly affronted. He's lying on the bed, partly visible over the mound of someone's legs covered by a red blanket.

The Nameless Land by Kate Elliott is the second part of a duology with The Witch Roads, about Elen, a Deputy Courier in the Imperial-China-esque Tranquil Empire who gets caught up in the machinations of princes and demons, when all she wants to do is keep her head down, walk her circuit carrying mail, talking to people, keeping an eye out for deadly Spore infestations and stopping them before they spread, and seeing her beloved nephew Kem on his way in life.

Sidebar: Elen is 34, and we had a to-me hilarious convo on Bluesky when Elliott (who is 2 years younger than I am) said she was taken aback by how many readers describe Elen as "middle-aged", because *she* doesn't think of 34 as middle-aged, "middle-aged" is just a euphemism for "old"!

I think this is hilarious because from my youth I figured 0-29 was young, 30-59=middle-aged, 60+=old, that's just MATH, people, stop kidding yourselves! But then we talked about it at dinner and it turns out Beth & Dirk have very vibes-based definitions of "middle-aged" as well. Frankly I'm disappointed.

Poll #33917 Our Middle Ages

Open to: Registered Users, detailed results viewable to: Access List, participants: 52

How do YOU define "middle-aged"?

30-60
11 (21.2%)

35-65
13 (25.0%)

40-70
18 (34.6%)

other set of numbers
7 (13.5%)

vibes: raising a child and/or secure place to live (home ownership, v stable rental), or could/should be
1 (1.9%)

other vibes
1 (1.9%)

other other
1 (1.9%)

Back to the duology! One reason I love Elliott is that she often writes from the POV of non-elites who don't think elites (princes, emperors, billionaires, etc.) are that great, and she maintains it, she doesn't fall into the "except for this one" trap. This is *so* rare, even writers who are making a determined, conscious effort to avoid what Pratchett described as our "major design flaw, [the] tendency to bend at the knees" will still fall into it -- e.g. by having crucial non-elite characters we've identified with turn out to be close family members of the leading elite (royalty, rich people, etc.). Which the writers do to add family drama to the mix, but which also falls back into the old, OLD trap of "only the families of the elites count as Real People".

Because Elliott really cares about the little people, even when they're spending time with the high & mighty, her plots have less narrativium than usual & more "buffeted by the winds of fate" or "let's roll the dice, WHOOPS lost that saving throw" quality. The Witch Roads story isn't "how Elen saves the world/changes her society", it's "how Elen protects her child, comes to understand herself better, and gets to a [a better place in life, spoilers]."

But that also means that on some level it's disappointing, because I've been so conditioned to expect SFF to be about how someone at least *helps* to change the world. But in Elliott's little-people fantasy, the protags don't really do that, because they're in such hierarchical societies that a change at the top really boils down to "meet the new boss, same as the old boss".

The only thing that really bugs me is a me-thing. As in Antonia Hodgson's The Raven Scholar, we have a fantasy society where people have some ability to choose their occupations--which completely overlooks the fact that in a premodern society almost everybody has to be a peasant farmer. (I'm now going down a research spiral; stay tuned.)

duskpeterson

North of Border Port lies a beach. Its serene beauty belies its bloody history.

It is here that, on half a dozen occasions, the Daxions beat back the Emorian armies that were intent on conquering Daxis. Finally frustrated by all these attacks over the border, the Daxions undertook an amazing task of landscaping, bringing the Western Ocean several miles inland from where it had lain before. Once the Daxions were finished, their border with Emor had narrowed to a brief passageway between a mountain and the deep Ocean.

Guarding the border has been exceedingly simple since then. Indeed, on the one occasion on which Daxions permitted Emorian soldiers to cross the border – in 976, when Daxis agreed to allow the Emorians to travel south in order to attack the Koretian capital from its naked back – it took so long for Emor's vanguard to pass over the border, one horse at a time, that a concerned Koretian borderlander was able to alert Koretia's council in the south to the coming attack. Alas, his message was not heeded, and Koretia fell to the Emorians.

The Daxions, on the other hand, have not been attacked from the north since they persuaded the Ocean to guard them. Their true vulnerability lies now to the east, which is why Daxis attempts to maintain good relations with Koretia these days.

Because the border is so narrow, you will likely have to wait several hours to cross the border into Emor, during the busy season. You may wish to spend your time exploring the caves nearby.

[Translator's note: That narrow little border causes some trouble for travellers in Breached Boundaries.]

mecurtin

Purrcy is not supposed to be on the mantlepiece, which is quite high (5ft I guess), but very occasionally he's spotted mice up there so we're not really stringent at keeping him off, even if we could.

Purrcy the tuxedo tabby crouches on a fieldstone mantlepiece, gazing at the camera. He's in front of a copper relief of a pegasus (Fletch) I made in 10th grade Art class, a jute rope dragon from Thailand, and next to a wooden box.

Purrcy the tuxedo tabby crouches on a fieldstone mantlepiece, gazing at the camera. He's in front of a copper relief of a pegasus (Fletch) I made in 10th grade Art class, a jute rope dragon from Thailand, and next to a wooden box.

Every afternoon Purrcy jumps onto his little platform next to my study chair and demands Pets! Attention! & of course I obey. There are SO many purrs.

Purrcy the tuxedo tabby has twisted his head around, the better to receive neck and ear scritches. His eyes are intent, his whiskers vibrating.

Purrcy the tuxedo tabby has twisted his head around, the better to receive neck and ear scritches. His eyes are intent, his whiskers vibrating.

So early in November I stalled out on reading a bunch of new SFF because they're all books about social change through war, and I can't think that way right now.

And then it was Nov.11th, so I thought about WWI. I read:

Five Children on the Western Front, by Kate Saunders. Saunders noticed that the boys from Five Children and It & the other Psammead books were headed for the Great War, and wrote about it. To keep this being a story for children, she added a younger sibling, Edie (Edith), who's really the focus of the narrative along with the Lamb (Hilary). He's 11 in Oct. 1914, as the story begins when the Psammead re-appears in the gravel-pit the same day Lieutenant Cyril is heading off for the Front.

In the Five Children and It the children make wishes, most of them with hilarious unintended consequences. This book is more like The Story of the Amulet,[1] with the children helping the Psammead, who has lost almost all his magic. It turns out that he used to be a god in the ancient Near East, and he needs to repent of many of his careless, destructive, godly deeds lest he be stuck in a magicless world forever.

The book is structured around the Lamb and Edie learning a story from the Psammead's history that he *should* feel ashamed about, and then being granted a wish that lets them see a scene from the present day that's a parallel to that story.

Saunders uses this structure because writing about *children's* silly wishes in the context of WWI would be obscene. She's showing the Great War as the massive, unintended consequence of (thoughtless) wishes by the great & powerful, men who have godlike power over the lives of people like Cyril, Robert, the rest of the young men of Europe, and all the people who care for them.

I think you really have to have read the Nesbit books to get the full experience of reading this one. It's definitely not "more of the same", any more than WWI is "more of the same" of the Edwardian period. OTOH, the characterizations of teen/young adult Cyril, Anthea, Robert & Jane don't IMHO follow from their characterizations in the books. Saunders has made all four of them less conventional, especially Anthea (going to art school) and Jane (prepared to fight both society and Mother to become a doctor).

I think this would be a very good book for a child who's loved E. Nesbit but has gotten a bit older & more thoughtful, started to wonder about things like the passage of time and how things change. It's a good introduction to the way WWI ushered in the massive changes of the 20th century. But warning: it WILL make you cry.

[1] It turns out I never read The Story of the Amulet as a child, only Five Children and It and The Phoenix and the Carpet. So I just started reading it now, and yikes on bikes! that's a LOT of racism & antisemitism, wow. I don't know if I can finish it TBH, though it does make The Magician's Nephew a LOT clearer. Lewis was writing a homage to Nesbit, but I have to give him credit, a little: his treatment of Calormen, especially in The Horse and His Boy and The Last Battle, is *worlds* less racist than anything Nesbit wrote. And note that Nesbit was a founder of the socialist Fabian Society, while Lewis, though apolitical, was *definitely not* socialist. Nesbit, at least in what I read of Amulet, is *more* imperialist than Lewis, though that may partly be due to the passage of time.

duskpeterson

ONLINE E-BOOK (html, epub, mobi, pdf, and xhtml)

Free at my website.

The Motley Crew (The Thousand Nations). When a young man named Dolan flees from the north, he faces danger on all sides. The Northern Army wants him back. The Empire of Emor wants him dead. His native homeland of Koretia may not want him at all. And his only protection is a man with motives that are mysterious and possibly deadly.

New installment:

2 | Flight Through the Forest. When you're fleeing from high danger, you have little choice in your companions.

EARLY ACCESS

My readers at Patreon and Ream get the first look at Twisted (The Thousand Nations: The Motley Crew side story). That short story will go into general release next month.

BLOG FICTION

Tempestuous Tours (Crossing Worlds: A Visitor's Guide to the Three Lands #2). A whirlwind tour of the sites in the Three Lands that are most steeped in history, culture, and the occasional pickpocket.

New installments:

Royal chapel.

Ambassador's Balcony.

Introduction to the borderland.

Border Port.

NEWS & UPCOMING FICTION

As some of you already know, I posted last month's update two days after I tripped on an uneven sidewalk, banged my head three times against a metal fence, and acquired a concussion, not to mention a broken leg. (I consider that update to be one of the greatest accomplishments of my life.)

Unfortunately, the concussion delayed my completion of "Heir" and its accompanying Blood Vow omnibus, since putting together an omnibus requires a concentrated mind I just don't have at the moment. I've moved those two projects to next year's schedule. In their place, I've juggled my release schedule in order to offer my Ream and Patreon readers a side story this month from The Motley Crew.

The timing of my next e-book installment release is a little uncertain at the moment, since my recovering head is still at the stage where, every time I edit a story, I introduce more errors than I correct. However, I hold out hope that I'll be able to get a new e-book installment out in January. In the meantime, as you can see, I'm continuing to bring out blog fiction.

Fortunately, the concussion hasn't stopping me from writing stories. Among other things, I've finished composing Motley Mayhem, the third novel in the Thousand Nations series.

( Ways to offer me a tip, financial or nonfinancial )

siderea

Canonical link: https://siderea.dreamwidth.org/1888828.html

Hey, Americans and people living in the US going through open enrollment on the state ACA marketplaces who haven't yet enrolled in a plan for 2026!

Just about every state in the union and DC (but not Idaho) proudly touts an end date to open enrollment sometime in January. This year for most states it ends January 15th, but in CA, NJ, NY, RI, and DC, it's January 31st, and here in Massachusetts, it's January 23rd. (Idaho's is December 15th.) [Source]

That sure sounds like the deadline is sometime in January.

No, it kinda isn't.

( tl;dr: Just assume if you want insurance to start Jan 1, the deadlines are to enroll by Dec 8 and to pay for the first month by Dec 15. Important deets within. [950 words] )

This post brought to you by the 220 readers who funded my writing it – thank you all so much! You can see who they are at my Patreon page. If you're not one of them, and would be willing to chip in so I can write more things like this, please do so there.

Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!

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fabrisse

December 2025

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Page Summary

siderea - Understanding Health Insurance: The Three-Stage Model [healthcare, US, Patreon]
neotoma - Farmer's Market -- 13 December 2025 (Reed Plant Day, 23rd of Frost, Year 234)
siderea - Update [me, health, Patreon]
siderea - Choosing Health Insurance: HSAs: FYI re bronze, catastrophic plans [healthcare, US, Patreon]
duskpeterson - FIC: Emorian borderland (Tempestuous Tours)
siderea - Understanding Health Insurance: A Health Plan is a Contract [US, healthcare, Patreon]
siderea - Understanding Health Insurance: Introduction [healthcare, US, Patreon]
mecurtin - Purrcy; The Witch Roads
duskpeterson - FIC: From Daxis to Emor (Tempestuous Tours)
mecurtin - Two Purrcies; Five Children on the Western Front
duskpeterson - UPDATE: Flight Through the Forest (The Motley Crew #2) + Thousand Nations early access fiction
siderea - Choosing Health Insurance: Two Unobvious Marketplace Deadlines [US, healthcare, Patreon]

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The Three-Stage Model

Health Insurance is a Contract

Understanding Health Insurance: Introduction

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EARLY ACCESS

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NEWS & UPCOMING FICTION

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Understanding Health Insurance:
Introduction