Early Retirement, ACA coverage in MO and EPO

[Floralscent]

We are early retirement mid to late 2025, relocating to MO and will be 1st time ACA applicants- receiving tax credit. It appears all ACA plans that I find in the state of MO are EPO. I am filtering by monthly premium and deductible maximums.

Coming from employer based health insurance, we don't have experience with EPO coverage and at this time, we don't even have a PCP in MO.
If I understand correctly, with an EPO you are covered in network by providers within the EPO and costs apply toward MOOP. However, any provider outside of the EPO (in MO or out of state) are out of network services and do not apply towards MOOP. I noticed there is a 50% co-insurance for not using EPO.

• 1. For those of you that have used EPO coverage, can you please share your thoughts on it? Any MO (Springfield area) specific comments would be great too!

We want to travel extensively in the US in retirement but having no MOOP for out of network is terrifying as you never know when you may need unexpected care.

• 2. For those that have EPO coverage, do you purchase travel insurance when traveling?

It is frustrating that health coverage costs are a large part of retirement. Having to think so in-depth about coverage/costs, while trying to make sure to avoid a gotch-ya...makes me want to toss hands in the air and just continue to work. So many people retire early that I am starting to think that either I am overthinking it or being ultra detailed to try to avoid surprises.

Thank you so much-

 

[PaunchyPirate]

To clarify, if you need emergency treatments out of your coverage area, I believe those will be covered at in-network rates. I’m not sure if it counts toward your MOOP. It is an ACA requirement that plans cover emergency care anywhere in the US.

The problem area is for the care you may need after the emergency situation is handled. It’s a very gray area that I’ve never seen written standards for.

So if you suffer a heat attack while climbing Pikes Peak, the initial ER room treatment should be covered. But when the doctors say you need a week of additional hospital stay before your release, it will be your own battle to get that part covered by your provider. They may or they may not.

Getting emergency care

Here are some steps you can take to improve your experience with your new health insurance coverage. In an emergency, you should get care from the closest hospital that can help you. That hospital will treat you regardless of whether you have insurance.

www.healthcare.gov

Emergency services - Glossary

Learn about emergency services by reviewing the definition in the HealthCare.gov Glossary.

www.healthcare.gov

 

[Koolau]

So if you suffer a heat attack while climbing Pikes Peak, the initial ER room treatment should be covered. But when the doctors say you need a week of additional hospital stay before your release, it will be your own battle to get that part covered by your provider. They may or they may not.

Man, that is messed up. What are you supposed to do? Drive home from Pikes Peak (hospital) and tell your PCP that you're supposed to be checked into a local hospital for a week?

Sounds like a recipe for disaster.

 

[surprising]

It is frustrating that health coverage costs are a large part of retirement. Having to think so in-depth about coverage/costs, while trying to make sure to avoid a gotch-ya...makes me want to toss hands in the air and just continue to work. So many people retire early that I am starting to think that either I am overthinking it or being ultra detailed to try to avoid surprises.

Thank you so much-

I have similar concerns about how to manage health care costs in early retirement. I want to take advantage of subsidies by keeping income down but then what happens if I have some huge unexpected expense that increases my ordinary income? What if I want to do some short term trading but all of those gains will be ordinary income? The temporary removal of the ACA cliff helps, but there's no guarantee that will exist past 2025.

 

[Koolau]

I have similar concerns about how to manage health care costs in early retirement. I want to take advantage of subsidies by keeping income down but then what happens if I have some huge unexpected expense that increases my ordinary income? What if I want to do some short term trading but all of those gains will be ordinary income? The temporary removal of the ACA cliff helps, but there's no guarantee that will exist past 2025.

I still give thanks that Megacorp provided subsidized health insurance to retirees. Without that, I'm not sure when I would have retired. It still wasn't cheap, but it made the costs knowable and limited. Virtually no "gothcas." Now that I'm on MC plus Megacorp helping with supplement, it's even cheaper at a time when I need it more.

Thank God for Megacorp's retirement plan.

 

[Aerides]

I'm not familiar with MO plans, so I'll speak from how it works with our FL BCBS plan. We have an in-network and out-of-network deductible (the latter being much bigger, ofc...)

If we need OON care, including while travelling in the US, we have coverage under the OON side. Not all providers have nationwide OON care, so look at the details offered.

what happens if I have some huge unexpected expense that increases my ordinary income? What if I want to do some short term trading but all of those gains will be ordinary income?

You plan and do the math when that happens. Perhaps sell only up to the subsidy caps, or stagger the sales at year end/start. We've seen folks here who had trading windfalls and then had to just pay back the subsidies at tax time. Not exactly a terrible problem to have. In general "huge unexpected" stuff is thankfully rather rare in our experience, after 8 years on the ACA.

 

[SecretlyFI]

Apparently this can vary alot by state. In NJ there are only EPO & HMO ACA plans (no PPO like megacorp had). In addition, none of the plans have ANY out of network coverage, except for emergency care. However, I did speak directly to BCBS and they explained how the "Pikes Peak" scenario works. The emergency care law requires that emergency care, including getting you to the point that you're stable and able to be discharged, be covered as if it were in-network, even if provided at a facility, and by providers, that are out of network. The emergency surgery or ER visit, followed by a hospital stay was exactly the example they gave me when I asked about OON coverage.

So, my plan is to have a robust annual travel insurance plan that has a fairly high out of state/out of country medical coverage limit, in addition to emergency evacuation.

 

[momoney]

1. For those of you that have used EPO coverage, can you please share your thoughts on it? Any MO (Springfield area) specific comments would be great too!

Cox is a local EPO in Springfield and I assume they have a smaller network than say Anthem? I wonder how this works in state? Would you even be covered outside of Springfield with Cox in other parts of the state?

 

[momoney]

Any MO (Springfield area)

If you don't mind, how did you decide on Springfield for early retirement?

 

[Floralscent]

If you don't mind, how did you decide on Springfield for early retirement?

Not sure where in the area yet but we really like what the area has to offer and healthcare seems to be good. But then there’s the EPO side of things.

Are you in that area or considering the move?

 

[Floralscent]

Cox is a local EPO in Springfield and I assume they have a smaller network than say Anthem? I wonder how this works in state? Would you even be covered outside of Springfield with Cox in other parts of the state?

I have the same questions and I feel like I’m missing something. How can EPO’s be beneficial to anyone that likes to travel outside their coverage area? Seems like a lot of risk on the consumer side since insurance companies likely do their best to find a way to not cover you.

May consider relocating to another state if I can’t get comfortable with an EPI in MO.

 

[PaunchyPirate]

I have the same questions and I feel like I’m missing something. How can EPO’s be beneficial to anyone that likes to travel outside their coverage area? Seems like a lot of risk on the consumer side since insurance companies likely do their best to find a way to not cover you.

May consider relocating to another state if I can’t get comfortable with an EPI in MO.

Unfortunately, since there is no national mandate/laws for full nationwide in-network coverage, insurance companies can come up with any network they want to cover. Their primary motivation is to make money. What they choose is likely driven mostly by what they HAVE to offer to be competitive in the given market.

The voting population of this country has made it clear they do not want complete universal care and would rather entrust our care to the free-market system. For better or worse. It is what it is.

 

[momoney]

I have the same questions and I feel like I’m missing something. How can EPO’s be beneficial to anyone that likes to travel outside their coverage area? Seems like a lot of risk on the consumer side since insurance companies likely do their best to find a way to not cover you.

May consider relocating to another state if I can’t get comfortable with an EPI in MO.

From Anthem EPO:
BlueCard: out of state protection
When you leave Missouri for work, school, or vacation, you shouldn’t have to worry about health surprises. That’s why most of our plans cover medically necessary emergency and urgent care in all 50 states and worldwide.

 

[PaunchyPirate]

From Anthem EPO:
BlueCard: out of state protection
When you leave Missouri for work, school, or vacation, you shouldn’t have to worry about health surprises. That’s why most of our plans cover medically necessary emergency and urgent care in all 50 states and worldwide.

This MAY help. But notice that this wording is still only saying emergency and urgent care. All ACA plans are supposed to provide the emergency part nationwide. I’m not sure about the urgent care part — are they going to cover you going to urgent care to get a Z-PAC, for example?

My BC/BS affiliate in Pennsylvania has 2 levels of Blue Card support. Lower end plans have the same wording as above —emergency coverage. Higher end plans extend the coverage to additionally include “routine care”, which makes it much more appealing and probably worth paying for if you want travel coverage.

I would examine the BC/BS plan details for such offers. Not all states have the enhanced option.

 

[Koolau]

Unfortunately, since there is no national mandate/laws for full nationwide in-network coverage, insurance companies can come up with any network they want to cover. Their primary motivation is to make money. What they choose is likely driven mostly by what they HAVE to offer to be competitive in the given market.

The voting population of this country has made it clear they do not want complete universal care and would rather entrust our care to the free-market system. For better or worse. It is what it is.

Like the old saying goes. Good, Fast, Cheap. Pick any two.

 

[engineernerd]

• 1. For those of you that have used EPO coverage, can you please share your thoughts on it? Any MO (Springfield area) specific comments would be great too!

• 2. For those that have EPO coverage, do you purchase travel insurance when traveling?

I have had individual high-deductible HSA-eligible coverage from an HMO for many years, and also for many years (though not AS many years) I have been snowbirding, which means spending several months each year outside my coverage area.

I am generally healthy, with minimal medical needs, and have never yet exceeded my deductible. So I don't worry about whether my routine care is "covered" or not. I visit doctors outside my HMO's network when they're more convenient, lower cost, or seem better for whatever reason. It's a calculated gamble. If something happens to cause me to exceed my deductible then I will have "wasted" my money on this out-of-network care. But it's really not that much money, so even if that does happen it won't bother me.

Luckily, all ACA plans have to cover emergency care nationwide. And since passage of the No Surprises Act, no hospital or other emergency-care provider can "balance bill" patients. Yes, follow-on care is a bit of a gray area, though the law has a "reasonableness" standard. It's nice if you have someone (spouse) who can advocate for you if/when you do end up getting an emergency appendectomy or something along those lines, to resist any efforts by the hospital to provide unnecessary care (ka-ching!) and also to notify your insurance.

I purchase travel insurance for international travel, except not for Canada since it's so close. The cost for evacuation/repatriation plus major medical insurance (for each trip) is quite reasonable in my experience. I shop on squaremouth for that.

 

[engineernerd]

When choosing an ACA health plan, I suggest paying great attention to two things.

(1) The out-of-pocket maximum:

The deductible has become almost meaningless compared to the out-of-pocket maximum for any year you need hospital care. It's typical for hospitals to charge $4,000 or $5,000 just for you to get checked in at their Emergency Rooms. And if you end up staying in a hospital room or using the operating room, there seems to be no ceiling to what they will attempt to charge. Think in six figures. It's that bad. Thank God for the No Surprises Act.

People who have significant assets in taxable accounts CANNOT afford to be uninsured or to seek non-covered hospital care - we could lose a painful chunk out of our nest eggs. We are unfortunately in a poor negotiating position compared to those with few assets. I think retirement accounts are not attachable but I'm not 100% sure that applies to all retirement accounts in all states.

(2) The insurer's reputation/customer reviews:

One way insurance companies defend themselves agains the greed of medical providers is by attempting to deny claims, mainly by abusing their pre-approval requirements. So search for online reviews by their customers. The insurer with the lowest premiums in my Exchange last year had simply AWFUL Google reviews. I did not choose them.

 

[momoney]

Can/do people ever buy supplements for these ACA plans? I'm guessing very few would because most can't afford insurance in the first place?

 

[PaunchyPirate]

Can/do people ever buy supplements for these ACA plans? I'm guessing very few would because most can't afford insurance in the first place?

There is no official "supplement" concept that applies to ACA plans as it does to using traditional Medicare with a supplement. I suppose you could purchase 2 plans of some sort, but then you'd have to figure out how to get the second one billed to cover what the first one doesn't.

 

[surprising]

People who have significant assets in taxable accounts CANNOT afford to be uninsured or to seek non-covered hospital care - we could lose a painful chunk out of our nest eggs. We are unfortunately in a poor negotiating position compared to those with few assets. I think retirement accounts are not attachable but I'm not 100% sure that applies to all retirement accounts in all states.

Are you saying that if I go the hospital and say I'm uninsured and want the cash price, they will ask for my taxable assets before deciding what they will charge me?

 

[momoney]

Are you saying that if I go the hospital and say I'm uninsured and want the cash price, they will ask for my taxable assets before deciding what they will charge me?

We used insurance when going out of state for surgery. But the surgeon did offer a cash price for the procedure. Guessing en EPO would not cover an ER visit as the result of a cash surgical procedure complication if the procedure could have been done in-network?

 

[engineernerd]

Are you saying that if I go the hospital and say I'm uninsured and want the cash price, they will ask for my taxable assets before deciding what they will charge me?

I have no idea what any particular hospital would do in that situation. These days, they probably don't even HAVE a "cash price." I strongly doubt a US hospital exists that will actually commit in advance to a firm price for anything. They'll always have weasel wording that lets them charge whatever they want in the end, for "reasons."

I've never heard of a hospital checking into anyone's assets ahead of time. I think their financial approach is to just throw stuff at the wall and see what sticks. And in some cases to surreptitiously whisk indigent patients away and dump them either at the local public hospital if there is one, or just out on the streets.

 

[engineernerd]

We used insurance when going out of state for surgery. But the surgeon did offer a cash price for the procedure. Guessing en EPO would not cover an ER visit as the result of a cash surgical procedure complication if the procedure could have been done in-network?

I think they have to cover a true emergency no matter the cause. And if you go to an in-network provider for treatment of your complication you should be covered same as for other medical issues. You give them the right, through the subrogation clause in your coverage agreement, to sue the surgeon if they believe the complication was the result of negligence.

I should clarify that I am not a lawyer, this is just what I think based on my reading of my coverage agreements over the years and what I've read about the ACA and No Surprises Act.

 

[Pluperfect]

How can EPO’s be beneficial to anyone that likes to travel outside their coverage area? Seems like a lot of risk on the consumer side since insurance companies likely do their best to find a way to not cover you.

As noted by others, emergency care is covered no matter where you are, so it's only routine care that has the network limitations and there aren't a whole lot of people who want to get doctor checkups while they're on vacation--they go to their usual doctors at home. So it's an issue for only a small number of people (like fulltime RV travelers who aren't old enough for Medicare), and therefore doesn't get addressed.

Of course there's the middle ground, where it's not a life-threatening emergency but still needs to be treated. So finding a policy that covers urgent care when outside your home area would probably give some peace of mind.

And the gray area of when an even is no longer considered an emergency. That's what always scared me when wondering about getting services only becuase they're an emergency and wouldn't otherwise be covered.

Someone upthread quoted some language about Anthem's Blue Card. The Blue Card is a way for Blue Cross people to have access to a nationwide network--that's what the Florida Blue plans that are popular with fulltime RV travelers have. But apparently not all Blue Card access is the same, since the language quoted above appears to limit it to emergency and urgent care, while the Florida plans don't impose a limitation like that (or didn't used to--I haven't checked in a couple of years).

I'd want to know how "urgent care" is defined--is it care that is delivered in a place that is identified in the plan documents/network as an "urgent care facility" or can it be delivered in a regular doctor's office as long as it's something that needs to be treated (as opposed to a routine physical?)?

 

[momoney]

So if you suffer a heat attack while climbing Pikes Peak, the initial ER room treatment should be covered. But when the doctors say you need a week of additional hospital stay before your release, it will be your own battle to get that part covered by your provider.

So don't delay your early retirement fretting over this edge case? Or find an UberAmbulance to get you in-network.