Chronic health conditions and ACA - how good/bad is coverage, really?

[Miss Piggy]

We are FI, could be RE, and our plan is to quit the rat race this summer. But to be perfectly honest, I'm scared as hell because of healthcare. Hubby has a serious chronic (and genetic) health condition, so health insurance is our absolute number one priority. This health condition is also our number one reason to retire early. We can COBRA for 18 months, but what about after that? We expect to pay $25,000/year for health insurance and care, but even with that, I need to know we'll be covered and protected.

Do any of you have firsthand experience dealing with a serious chronic health condition through ACA/marketplace insurance? Are my fears unfounded?  I mean, insurance is insurance, deductibles are deductibles, and an out of pocket max is an out of pocket max, right? But what about covered doctors, hospitals, etc.? Being able to stick with the health system we've been part of for 25 years is critically important. What questions should we be asking? What information should we be looking for?

Talk me off the ledge, my friends.

[Gin1984]

You need to look at your states market place.  I was on an ACA plan for little bit but it was part of a state that tried to make it work, I have friends here in Iowa where the ACA plans are awful.  That said, the protections of ACA or the longevity would be my concern as a person with a chronic condition.

[Abe]

I would recommend the following:

1. If there is a certain expensive medication(s) your husband needs, be 100% sure that they are covered by the company, and recheck annually. Have a list of them and just go down the list with the insurance company representative. Insurance companies are required to give this information if requested, and some will mail you a list of covered and uncovered medications for a given plan. If you want to PM me more details I can give you further advice on this. In my family's and patients' experience, even with "good" insurance, drug prices vary wildly from year to year as drug companies and insurance companies negotiate contracts.

2. Make sure that your physicians and hospitals are in-network. The insurance companies are required to provide a list if requested. Just like drug costs, this can also shift with short notice as insurance and medical groups negotiate contracts.

3. Ask your physicians what insurance companies they have had issues with. They may not have the above details, but can at least say "Company A gives us a hard time approving some drugs, while Company B doesn't argue about drugs but does argue about labs & tests".

4. Keep a detailed log of your health information, especially any medication changes or test results. It will make any arguments with insurance companies easier to handle since you won't have to go back and figure out details of care from months ago.




Those are the two main tools insurance companies have to control their costs, and they can be very vague in their marketing materials.

[Poeirenta]

Floating in the same boat over here. Every time we try to talk about what a FIREd life looks like, it derails into "what about health insurance?". PTF and hoping you get some detailed answers.

[Mr. Green]

Costs for any ACA health insurance plan will be tied to your income if it isn't more than 400% of the Federal Poverty Line (the subsidy cliff). I don't know what your anticipated income is in retirement but if health costs are a concern you might look into how you can best optimize you income to work with the subsidies to reduce costs. We used ACA insurance last year and for a 3 person household (my dad is a dependent) we could have an income of about $32,000 and the deductible for our insurance plan was $400 and the family max out of pocket was $1,600. This year we chose a plan that would allow us to have a higher income since we don't expect any big healthcare costs. The deductible and max OOP are a bit higher. Next year we may be having a child so we'll probably have a lower income again to take advantage of lower deductibles and max OOP amounts since a childbirth will max out whatever plan we pick.

Beyond the plan you pick, you'd just want to make to make sure the insurance network has all the doctors you need

[jim555]

If you have high out of pocket expenses nothing beats Medicaid with a $200 a year OOP Max.  Next would be a Silver plan with cost sharing reductions, these give lower OOP expenses for those in the under 250 FPL income ranges.  You could look at gold plans which might be not as bad price wise after subsidies.  If you need a specific drug make sure you research the formulary for plans in your area.

[skp]

FI also.  NOT RE because of health care costs.  I don't hate my job enough to be willing to pay over $1000 a month for health insurance.  So, I went part time instead.  Do you have that option?

[Miss Piggy]

Thank you for sharing your perspectives and advice on this. You've suggested at least a couple of things I hadn't thought of previously, including checking the formularies (I just learned that word a couple of weeks ago, as a matter of fact!) and asking the physicians which plans they have had good & bad experiences with.

Feels odd to say this on the MMM forum, but I'm far less concerned with costs than I am with coverage. We'll pay what we need to pay to get the doctors & drugs we need. It seems only right since we use more than our fair share of services and we're capable of paying for them.

[chasesfish]

I'm late to this thread but also in a similar delimma.

#2 on Abe's list is the biggest issue I've found.  The big 4 carriers tend to have the bigger networks, but you could still be restricted out with these "micro networks" depending on your state.

We recently changed the primary physician (neurologist) we use to manage my wife's condition.  This physician doesn't accept any insurance and operates a membership model practice.  The 14 minute managed care appointments weren't cutting it with the complexity of her case.  It doesn't change the need for having insurance for everything else, but removed much of the micro-network risk.

[FIFoFum]

The good news is that the point of the ACA is that they CAN'T charge you more for the coverage your husband needs. So your rates are entirely based on your zip code/geography, age, and income levels. If you are a heavy user, you still will be able to buy a plan with a deductible that limits your OOP costs (if you can stay in network).

The bad news is that there are no guarantees that your preferred providers will stay in ANY plan or that formularies, networks, and coverage won't change from year to year on the same plan - whether it is one offered by an employer, on the ACA marketplace, or through Medicaid expansion. Most people would presume more stability in the networks/coverage from the employer based health plan, and in many places, they would be correct. But at least once you're on the ACA marketplace, you can always switch plans each year during open enrollment if you find your provider coverage/network availability is shifting.

COBRA is crazy expensive compared to other options, so it pays to figure out what you're switching to and then make the switch. Also, you have specific windows in which you qualify to switch to an ACA plan due to job change. It doesn't include a buffer to use a random amount of COBRA, so pay attention to the timing as well. You don't want to use COBRA just long enough to then be stuck having to use it longer just to get to the next open enrollment window.

[jodelino]

When I retired in 2015 from a government job with GREAT group BCBS PPO health insurance, the COBRA premiums were actually less than ACA premiums (I don't qualify for a subsidy), and the COBRA coverage was the same great coverage I had in my job, so I kept that for the full 18 months allowed, and was very sorry to say goodbye to it.

I've been on an ACA BCBS HMO bronze plan (HSA eligible) for 2 years now, and currently pay $899/month.

I have several chronic conditions, and it was important to me to find a plan that covered one particular doctor. Easier said than done, because the BCBS online provider search function and BCBS customer service are very flawed. Both said that my doctor was NOT in network, but the insurance specialist in the doctor's office insisted to me that they took all BCBS plans--and she was right, my doc is, in fact, in network.

BUT--my plan does not cover any of the hospitals where this doctor performs surgery. How crazy is that? I hope not to need any more surgery from her, but if I did, as best I understand it, my choices would be: try to persuade BCBS to cover surgery in one of my doc's hospitals; negotiate for BCBS to pay what they would pay for an in-network hospital, and pay the balance myself; perhaps be faced with paying the entire hospital bill myself.

This is just an example of the challenges of leaving behind a great group plan. But I still don't regret doing it. I'm grateful that, thanks to the ACA I can buy insurance, and am not in the un-insurable category. I'm grateful that I can meet the high deductible, the high co-pays (just had an ER visit with a $1,000 co-pay), and the high out-of-pocket costs of my plan. I'm grateful that there is no lifetime maximum (not that I've come close to that). And I'm grateful that the ACA plans cover preventive tests with no deductible (just had a mammogram and a colonoscopy and didn't even have a co-pay on these--they were fully covered).

Good luck.

[mountain mustache]

I have several chronic conditions, and it was important to me to find a plan that covered one particular doctor. Easier said than done, because the BCBS online provider search function and BCBS customer service are very flawed. Both said that my doctor was NOT in network, but the insurance specialist in the doctor's office insisted to me that they took all BCBS plans--and she was right, my doc is, in fact, in network.

Good luck.

This right here is the biggest frustration with my ACA plan too (I also have BCBS). What I learned was that my health insurance is actually really good, but I have to do a lot of leg work to make sure every doctor I am seeing is covered. It has just become habit to call BCBS and the doctors office before making an appointment to 100% be sure that it is in network. Their online system is terrible, and not helpful at all. Last year I had some major health issues and two surgeries, and managing my insurance/claims, etc was like a 20 hour a week job. But, all of that aside, BCBS covered everything after my out of pocket max and didn't question any of my procedures, etc. I am super grateful for ACA, and the ability to have health care since my job does not offer it.

[chasesfish]

I'll second what @jodelino said about COBRA, don't just assume its crazy expensive and you're not going on it.  A large employer is going to have a healthier pool than the ACA's pool, which has some adverse nature to it since there's never been any real mandate forcing young/healthy people to buy insurance.

[hops]

For anyone with expensive meds who's eligible for copay assistance programs, the drug manufacturers often offer hotlines that can put you in touch with their insurance and pharmacy benefits coordinators. Obviously you can't take everything they say as the gospel and you still have to do your own homework, but AbbVie reps were able to tell us before my wife and I were even presented with our annual health insurance options about a couple of insurers that were poised to make unfavorable changes to coverage. They also offered to make sure I didn't run out of medication if there was a gap while we waited for a new insurer to approve coverage.