COBRA to ACA with Pending Procedure

[snappytom]

I have been on COBRA since retiring which expires at the end of July. Plan has always been to get ACA coverage for 18 months until Medicare kicks in. The COBRA coverage is a decent PPO with a $1500 deductible. Typical ACA plans in my area are more expensive (not eligible for subsidies) and have deductibles up to $7500 with less comprehensive coverage overall. Off-Exchange coverage may also be an option.

All of this is not a surprise, I retired early knowing there would be this period of expense prior to Medicare.

I generally am a very light user of medical services with annual physicals and blood tests, and routine screenings like colonoscopies. Not currently being treated for anything.
It now appears I may need a Hernia surgery, will know the details in a couple weeks. The hope is to get it done under the current policy with the lower deductible before getting ACA coverage.

This plan appears reasonable providing I can get the surgery scheduled but I wanted to ask this group to check my thinking.
Do I have any potential downside here other than paying more out of pocket after July ?

May seem like a silly question but I value E-R.org input.

 

[Aerides]

I would look for an aca plan for the rest of the year which includes that doctor, and perhaps that hospital, in case of delays or follow ups. It might mean you pay more for a plan for 5 months to ensure continuity of care, but you can always change to something else at year end.

 

[disneysteve]

I would just make sure the surgeon and facility accept the ACA plan you get. If you have the surgery in June there will be some follow up visits likely going out at least 6 weeks post-op. You want to make sure you can still follow up with the surgeon under the new plan if the change happens during that time, and later in case you experience any issues.

We switched from COBRA to ACA on January 1, 2024. I made sure all of our doctors and facilities accepted the ACA plan so it was a seamless transition. Plus ACA is $1,000/mo cheaper than COBRA but the OOP costs are higher thanks to the deductible and larger copays.

 

[EastWest Gal]

Check with the physician's office and facility where it is scheduled to be done to get an estimate of cost up front. They should be able to give you at least some information, and also how much your insurance will pay.

Sometimes, with surgery and fractures, there is a global fee that is charged that includes follow-up visits. Check with the surgeon's office to see if that is the case. With a typical hernia repair, follow-up should be relatively straight forward, and there may not be a global fee covering all follow-up visits. If not, a follow-up visit should be relatively straight forward, and will likely be coded 99212 unless there is a complication. You can ask the office how they typically code a hernia repair and follow-up visits. (They should be able to give you the CPT codes-a five digit number for each procedure and visit).

The facility should have a publicly available charge sheet. Most health systems now have them, as a pdf on their websites. This is the charge submitted to the insurance, not your out of pocket expense.

I would probably not let the tail of follow-up visit cost wag the dog of your insurance premium.

Note that in 2024, your premium cannot be more than 8.5% of your income based on an average Silver plan. The income level at which subsidies completely disappear is about $200,000/year for one person in our area. Are you sure you don't qualify for subsidies? The cliff was eliminated in 2021, but will come back in 2026.

 

[snappytom]

All good info, much appreciated.

Realized that I am hoping to coordinate the timing of events I largely have no control over. Making sure my current GP and the Surgeon are in network for the future coverage is key along with getting all costs up front.

I have an application in progress with healthcare.gov but need to wait until I am within the 60 day window of COBRA termination before completing it.
Also like the comment about getting the best ACA plan for 2024 continuity of care and then re-evaluating coverage for next year.

Unfortunately it's not my first Hernia Rodeo. Going back to the same surgeon who patched me up over 25 years ago.