Early Retirement, ACA coverage in MO and EPO

[Pluperfect]

Can/do people ever buy supplements for these ACA plans?

Maybe a fixed indemnity plan? It provides cash payments to you for specified medical events (e.g. a hospital stay, a doctor visit).

They were originally intended as income replacement if someone is unable to work due to a medical event, but now can serve to defray out-of-pocket expenses (deductible, copays, coinsurance).

They're kind of dangerous because they're often marketed in a way that makes people think they're getting major medical insurance. This is from an article about trying to regulate fixed indemnity plans:

This rule change was proposed to prevent fixed indemnity plans from being designed with fee schedules that resemble major medical coverage at first glance, in an effort to minimize consumer confusion. Ultimately, that rule was not finalized, but HHS noted in 2024 that they may revisit this issue in future rulemaking.

healthinsurance.org/glossary/fixed-indemnity-health-insurance/

But if someone understands what it is they're getting when they buy a fixed indemnity plan, they have their place. I think it's like a person with a Medicare Advantage plan buying a cancer policy; the cancer policy pays cash benefits directly to him, and he can use those payments toward paying his Advantage plan's maximum out-of-pocket, which he'll probably hit if he's getting cancer treatment.

Of course whether it's a financially sound decision to buy one is an entirely different matter.

 

[cmc333]

I live in Missouri and had ACA for 2 years before Medicare last year. ACA is MO is very dependent on which county you live in. I live an hour outside Greene County (Springfield) but close enough I go to Springfield for the doctors. Yes, you are covered at any of the Cox hospitals in the littler towns around, but seriously Springfield has the best doctors. 2 years ago when I had ACA, I had a plan that included Cox because we had been patients at Cox for 18 years prior. My cost as a 63 yo female was a little over $400 a month, with a $7500 deductible and $9k MOOP. I didn't use the Rx portion because it was cheaper to buy my relatively cheap drugs from Amazon. I'm pretty sure Springfield prices are less than where we are, or were at least less 2 years ago.

Yes, I always bought travel insurance when we traveled. Yes, emergency and Urgent care is covered anywhere in the US, but it might be a fight if you need to stay in the hospital and your insurance company says it wasn't necessary. Where we live BCBS wasn't even an option so went with the cheapest plan that included Cox doctors and hospitals.

Now thankfully we are both on Medicare and Medigap so don't have to worry about the costs so much. I will say that we both have been very happy with Springfield Cox doctors and hospital; not so much at the littler satellite places in the counties surrounding Springfield.

There is also Mercy hospital in Springfield that I know nothing about. I'm not sure how many specialists they have. Cox is the bigger by far and has a lot of specialists. Not sure if I can answer any other questions for you or not.

 

[ncbill]

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.

IIRC, my Nationwide annual travel insurance covers hospital to hospital transfers.

So from a local hospital near Pikes Peak to my local in-network hospital.

 

[momoney]

IIRC, my Nationwide annual travel insurance covers hospital to hospital transfers.

So from a local hospital near Pikes Peak to my local in-network hospital.

How much does a plan like this cost or where can I get a quote?

 

[engineernerd]

IIRC, my Nationwide annual travel insurance covers hospital to hospital transfers.

So from a local hospital near Pikes Peak to my local in-network hospital.

My HMO requires me to call their hotline within 24 hours or as soon as I can, if I am transported to an out-of network hospital because of an emergency. They reserve the right to transfer me - at their expense - to an in-network hospital when I am stable enough.

So to the OP my advice is to obtain and read a copy of the coverage document before you commit to a plan and before you decide about travel insurance.

Out-of-network emergency care does count towards the MOOP. Everything that is covered counts.

 

[Floralscent]

I live in Missouri and had ACA for 2 years before Medicare last year. ACA is MO is very dependent on which county you live in. I live an hour outside Greene County (Springfield) but close enough I go to Springfield for the doctors. Yes, you are covered at any of the Cox hospitals in the littler towns around, but seriously Springfield has the best doctors. 2 years ago when I had ACA, I had a plan that included Cox because we had been patients at Cox for 18 years prior. My cost as a 63 yo female was a little over $400 a month, with a $7500 deductible and $9k MOOP. I didn't use the Rx portion because it was cheaper to buy my relatively cheap drugs from Amazon. I'm pretty sure Springfield prices are less than where we are, or were at least less 2 years ago.

Yes, I always bought travel insurance when we traveled. Yes, emergency and Urgent care is covered anywhere in the US, but it might be a fight if you need to stay in the hospital and your insurance company says it wasn't necessary. Where we live BCBS wasn't even an option so went with the cheapest plan that included Cox doctors and hospitals.

Now thankfully we are both on Medicare and Medigap so don't have to worry about the costs so much. I will say that we both have been very happy with Springfield Cox doctors and hospital; not so much at the littler satellite places in the counties surrounding Springfield.

There is also Mercy hospital in Springfield that I know nothing about. I'm not sure how many specialists they have. Cox is the bigger by far and has a lot of specialists. Not sure if I can answer any other questions for you or not.

cmc333- thank you for the MO specific info! We will likely end up in Greene County and good to know about Cox Health vs Mercy.

Medica seems to have most affordable ACA plans but online reviews are terrible. My guess though are those with great insurance experiences don’t take the time to write a review. Do you have knowledge of consumer happiness with Medica from people you know in MO? Just wondering. Travel insurance seems reasonably priced for medical only when needed.

Thanks to all for having this great convo!

 

[PaunchyPirate]

Just be certain the travel insurance you purchase actually covers domestic travel. A lot of them are for international travel only.

 

[SecretlyFI]

How much does a plan like this cost or where can I get a quote?

I haven't completed my research, but I started with this article:

https://www.usnews.com/insurance/travel/annual-travel-insurance#:~:text=Get%20annual%20coverage%20for%20medical%20expenses%20and,for%20medical%20expenses%20and%20emergency%20medical%20evacuation.

It compares & contrasts a number of different annual travel insurance policies. It's about a year old and maybe there's a newer article available, but it's a place to start.

Just be certain the travel insurance you purchase actually covers domestic travel. A lot of the are for international travel only.

+1. Some of the key points I started to notice, that are worth comparing are:
Is the policy just domestic or just international or both.
Amount of medical expense covered per person and is the limit per trip or annual.
Any emergency dental coverage also?
Does the medical coverage limit change (decrease) when you reach a certain age?
Are pre-existing conditions covered immediately, or a certain amount of time after enrolling, or not at all.
Amount of emergency medical evacuation coverage and any relevant terms & conditions on that (to nearest hospital, or hospital of my choice, etc.)
Does the policy also cover trip cancellation, and is it cancel for any reason, or just for any "covered" reason - which is typically illness or other named issue.
What about other typical trip insurance aspects: trip cancellation, baggage delay, rental car coverage, etc.
Then, of course, premium amount.

 

[engineernerd]

Does the policy also cover trip cancellation, and is it cancel for any reason, or just for any "covered" reason - which is typically illness or other named issue.
What about other typical trip insurance aspects: trip cancellation, baggage delay, rental car coverage, etc.
Then, of course, premium amount.

For international trips at least, these kinds of coverages don't seem like a good bargain. Much higher premiums.

 

[SecretlyFI]

For international trips at least, these kinds of coverages don't seem like a good bargain. Much higher premiums.

Maybe. Like I said, I haven’t done a full deep dive on it yet. But I did a preliminary quote with Seven Corners, sine they had the highest rating for medical and nice high medical expense amounts. For 2 of us, the annual premium was $1100. That was for $250k of medical coverage, $500k evacuation, pre-existing condition coverage and a bunch of other trip insurance provisions (cancellation, delay, etc.). There was no limit on the number of trips in a year and each trip could be 40 days or less.

This seemed like a good deal to me, since we’ve paid $500+ for coverage just for a single trip in the past. I’ve found the individual trip policies can get really expensive because they are based on the cost of your trip and the age of the travelers.

 

[cmc333]

cmc333- thank you for the MO specific info! We will likely end up in Greene County and good to know about Cox Health vs Mercy.

Medica seems to have most affordable ACA plans but online reviews are terrible. My guess though are those with great insurance experiences don’t take the time to write a review. Do you have knowledge of consumer happiness with Medica from people you know in MO? Just wondering. Travel insurance seems reasonably priced for medical only when needed.

Thanks to all for having this great convo!

Truthfully, I never heard of Medica. It might only be available in the larger population areas and Springfield is the 3rd largest city in MO. I can't say Mercy isn't good; I just know that Cox is non-profit and they spend a lot of money on getting new buildings, new machines, new personnel. Mercy is growing too, but much more slowly. Most people in Springfield area are very friendly and there's always a lot of events going on. Personally, I haven't really found any good restaurants - this area of MO is very southern food oriented and I'm more Yankee/California food oriented.

 

[momoney]

This is from a Cox EPO plan. If you are critically ill, you have probably already met your deductible. So do I understand this correctly? After the deductible is met you could see any out of network doctor and it would be covered?

 

[PaunchyPirate]

This is from a Cox EPO plan. If you are critically ill, you have probably already met your deductible. So do I understand this correctly? After the deductible is met you could see any out of network doctor and it would be covered?

View attachment 54194

I don't know what source provided the information in the screen shot. But at first glance, I think this display is saying what YOU would have to pay. Not what the plan covers. Surely before deductible is met, you are paying 100% of the visits. So I would think that same logic applies in the above display to the after deductible too.

I've attached a screen shot from the document that I find most helpful in the high-level summary of the plans. This document is standard across all the insurers. The contents in it differ, but the structure is virtually identical across the board which makes it easier to make comparisons.

I just randomly picked a Cox plan in a Springfield zip code. It clearly says out-of-network is not covered at all.

You have to be careful. Some data presented to you will display what the insurance company will pay and other times it is what YOU will have to pay.

 

[momoney]

I don't know what source provided the information in the screen shot. But at first glance, I think this display is saying what YOU would have to pay. Not what the plan covers. Surely before deductible is met, you are paying 100% of the visits. So I would think that same logic applies in the above display to the after deductible too.

I've attached a screen shot from the document that I find most helpful in the high-level summary of the plans. This document is standard across all the insurers. The contents in it differ, but the structure is virtually identical across the board which makes it easier to make comparisons.

I just randomly picked a Cox plan in a Springfield zip code. It clearly says out-of-network is not covered at all.

You have to be careful. Some data presented to you will display what the insurance company will pay and other times it is what YOU will have to pay.

Ok that makes more sense, "Full Price" makes it confusing.

 

[momoney]

cmc333- thank you for the MO specific info! We will likely end up in Greene County and good to know about Cox Health vs Mercy.

Medica seems to have most affordable ACA plans but online reviews are terrible. My guess though are those with great insurance experiences don’t take the time to write a review. Do you have knowledge of consumer happiness with Medica from people you know in MO? Just wondering. Travel insurance seems reasonably priced for medical only when needed.

Thanks to all for having this great convo!

One interesting thing to look for. If I put in a zip code for Springfield health plans the provider directories don't list any healthcare in St. Louis as in network (probably because it limits to 100 mile radius). If you add a St. Louis provider when shopping for a plan some of the national plans like Aetna actually lists them as "Takes this plan".

Just something to keep in mind if you wanted access to more specialties.

 

[PaunchyPirate]

Ok that makes more sense, "Full Price" makes it confusing.

I do agree that "Full Price" is odd in that screen. I could be wrong with my previous comments. But I think I'm correct. Perhaps for specialists, they don't even give you a rate they have negotiated with the in-network doctors. If that's the case, then the plan is even worse.

 

[cmc333]

One thing to think about is the long wait to get in to see a new general practitioner. Some wait times are as long as 6 months. Too many people/not enough doctors.

 

[momoney]

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.

If you don't mind me asking, how much do you estimate it will cost you to live in the Springfield area of Missouri in early retirement?

 

[engineernerd]

Maybe. Like I said, I haven’t done a full deep dive on it yet. But I did a preliminary quote with Seven Corners, sine they had the highest rating for medical and nice high medical expense amounts. For 2 of us, the annual premium was $1100. That was for $250k of medical coverage, $500k evacuation, pre-existing condition coverage and a bunch of other trip insurance provisions (cancellation, delay, etc.). There was no limit on the number of trips in a year and each trip could be 40 days or less.

This seemed like a good deal to me, since we’ve paid $500+ for coverage just for a single trip in the past. I’ve found the individual trip policies can get really expensive because they are based on the cost of your trip and the age of the travelers.

We just bought $1,000,000 evacuation/repatriation coverage plus $100,000 emergency medical coverage for a 31-day trip to Antarctica (flying to Argentina then boarding a boat) for $44/person. Other trips (Svalbard cruise, African safari trips) had similar low trip insurance cost for exclusively evac and medical.

Medical costs are a lot lower in other countries, so that might be a factor in the low premiums.

 

[SecretlyFI]

We just bought $1,000,000 evacuation/repatriation coverage plus $100,000 emergency medical coverage for a 31-day trip to Antarctica (flying to Argentina then boarding a boat) for $44/person. Other trips (Svalbard cruise, African safari trips) had similar low trip insurance cost for exclusively evac and medical.

Medical costs are a lot lower in other countries, so that might be a factor in the low premiums.

So when shopping for exclusively evac and medical coverage for a trip, do you just enter zero or a very small amount for “trip cost”?

Assuming that works in getting quotes, from places like insuremytrip and squaremouth, I guess it’s effectively self insuring the trip cost in case of cancellation, but securing insurance in case medical or evac is needed. That sounds like a good alternate approach at a reasonable cost.

 

[Surewhitey]

I didn't see anyone mention the max OOP before the tax deduction... Maybe a consideration for worst case.

When you can deduct medical expenses​

Many medical expenses are deductible, however, to be eligible to claim the deduction, you’ll need to both itemize your taxes and spend a significant portion of your income on health care costs. In addition, you’ll need to have paid these medical expenses out of pocket (after-tax), not through an HSA (pre-tax).

To qualify for the medical deduction, your unreimbursed medical and/or dental expenses need to exceed 7.5% of your adjusted gross income (AGI) for the year — and you can only deduct those expenses that exceed the 7.5%.

Generally, most Americans don’t regularly meet this 7.5% threshold. However, if you’ve had a significant health event, a chronic health condition or a year with unusually high medical needs, it’s worth exploring whether you qualify for this deduction.

 

[Surewhitey]

We have a friend couple who always purchases a travel insurance policy as they're from Canada... Peace of mind for them as they are entering their 70's.

 

[Cujet]

I purchased as inexpensive a plan as I could, one that offered features that made sense for my situation. Maybe if I don't get sick, I'll save some money.

My conclusion was that the end of year costs would be the same, no matter what. Pay $10K less in premiums and get $10K deductible and $10K moop numbers. Coverage for the ER is roughly similar between those two plans above.

If out of network coverage is needed, it's another $10K to $15K on top of the more expensive plan above.

Really good coverage is available, but my cost hovers in the $30K per year range per individual.


It is also worth noting that relatively minor procedures can be paid for with cash, often for a discount. This takes some negotiation.