Newbie Here Regarding the ACA

[johkar]

Hello - a little background first. My husband and I retired in 2018; he was 58, I was 57. We were able to get health insurance from my employer, with them subsidizing the premiums by 40%. Other than that though, we paid the premiums ourselves, it has never been paid by my former employer. We liked the coverage; it was United Health Care, and even though it was pricey, it was good coverage.

Then for 2023, former employer changed the provider to a branch of UHC called Surest. It's been mostly nightmarish. Same cost, different claim payment structure, terrible service.

So we are looking at ACA plans for our state (Iowa), which we never have before. Our income will allow us to get a decent amount of subsidy, so the prices and benefits seem pretty good from what we've looked at so far.

So now questions: Are there things we need to think about regarding this step? Once I drop my retiree health insurance, we cannot go back. Any issues with moving from a benefit like this to an ACA plan? Husband will need coverage for 1 more year; I will need it for 2.5 years, until we become Medicare eligible. I would appreciate any insight you all can offer.

 

[Aerides]

It's really the same as any plan change. Besides the financials (premiums, deductibles, copays) you want to look at coverage. Are the docs you like in the plans you are looking at? Every state and sometimes county has different plans and providers so it really depends where you are and what is available to you.

 

[MichaelB]

Typically if you’ve met your deductible for the year you would want to get as much done as possible before year end.

You also want to look for coverage you might have from your employer policy you won’t get with an ACA policy, such as dental care.

Have you looked at specific ACA policies to make sure their provider networks suit your needs? Some members complain of poor options for their marketplace plans.

 

[badatmath]

Can you still get subsidies if you turn down the retiree insurance? Here is a link that explains how it works if you turn down employer insurance. IDK any details on it beyond this.
https://blog.healthsherpa.com/can-i-enroll-in-obamacare-if-my-employer-offers-insurance/

 

[MichaelB]

Can you still get subsidies if you turn down the retiree insurance? Here is a link that explains how it works if you turn down employer insurance. IDK any details on it beyond this.
https://blog.healthsherpa.com/can-i-enroll-in-obamacare-if-my-employer-offers-insurance/

If you drop retiree health care coverage and enroll in a marketplace plan during open enrollment you are eligible for premium assistance (subsidy)

From KFF https://www.kff.org/faqs/faqs-healt...er-coverage-and-subsidies-in-the-marketplace/

I’m 63 and enrolled in a retiree health plan from my former employer. Can I look for better coverage and subsidies in the Marketplace?

Yes, as long as you do so during the Open Enrollment period.

If you are enrolled in employer-provided retiree health coverage, and if your income is at least 100% of the Federal Poverty Level, you may also qualify for premium tax credits. However, there’s one exception. Some employers may provide retired employees with access to an account, called a health reimbursement arrangement (or HRA) that the retiree may use to reimburse medical expenses, including an individual policy through a Marketplace or in the non-group market. A retiree that signs up for an HRA offered by a former employer is considered to have minimum essential coverage from an employer and would therefore would not be eligible to claim a premium tax credit if he or she enrolled in a Marketplace plan.

From Healthcare.gov https://www.healthcare.gov/retirees/

If you have retiree health benefits

If you have retiree coverage and want to buy a Marketplace plan instead, you can. But:
You can’t get premium tax credits and other savings based on your income. This is true only if you’re actually enrolled in retiree coverage. If you’re eligible for but not enrolled in retiree coverage, you may qualify for premium tax credits and lower out-of-pocket costs based on your household size and income.
If you voluntarily drop your retiree coverage, you won’t qualify for a Special Enrollment Period to enroll in a new Marketplace plan. You won’t be able to enroll in health coverage through the Marketplace until the next Open Enrollment period.

 

[cathy63]

... So now questions: Are there things we need to think about regarding this step? Once I drop my retiree health insurance, we cannot go back. Any issues with moving from a benefit like this to an ACA plan? Husband will need coverage for 1 more year; I will need it for 2.5 years, until we become Medicare eligible. I would appreciate any insight you all can offer.

Does your retiree plan provide coverage when you travel out of your state or out of your plan's service area? Most ACA plans only cover emergencies if you're traveling and their definition of emergency might not match yours.

 

[badatmath]

If you drop retiree health care coverage and enroll in a marketplace plan during open enrollment you are eligible for premium assistance (subsidy)

From KFF https://www.kff.org/faqs/faqs-healt...er-coverage-and-subsidies-in-the-marketplace/



From Healthcare.gov https://www.healthcare.gov/retirees/

Much better explanation than I found. I had vague memories of someone at w*rk discussing this but they wanted to split the coverage - former employee on retiree and spouse on ACA. I don't recall exactly what they found out only that they didn't seem to like it. . .

OP, just to confirm your employer coverage is dead gone at 65? Mine changes to a small HRA that I would be reluctant to lose voluntarily.

 

[johkar]

Typically if you’ve met your deductible for the year you would want to get as much done as possible before year end.

You also want to look for coverage you might have from your employer policy you won’t get with an ACA policy, such as dental care.

Have you looked at specific ACA policies to make sure their provider networks suit your needs? Some members complain of poor options for their marketplace plans.

My retirement insurance coverage has a separate dental policy that we plan to keep. That is allowed even when you are 65 and go on Medicare.

We are in the process now of looking at the networks, with the hospitals/doctors/urgent care clinics/drugs that are included.

 

[MichaelB]

We are in the process now of looking at the networks, with the hospitals/doctors/urgent care clinics/drugs that are included.

This is worth spending time on. From what I’ve read here on ER Forum discussions about ACA policies over the past decade, the top complaints are the large deductibles, the lack of policy options, and small / limited / inadequate provider networks.

 

[johkar]

Much better explanation than I found. I had vague memories of someone at w*rk discussing this but they wanted to split the coverage - former employee on retiree and spouse on ACA. I don't recall exactly what they found out only that they didn't seem to like it. . .

OP, just to confirm your employer coverage is dead gone at 65? Mine changes to a small HRA that I would be reluctant to lose voluntarily.

Yes, retiree coverage ends at age 65 when we become Medicare eligible.

 

[Jimmie]

Make sure your estimated modified adjusted gross income for when you are receiving ACA subsidies for your monthly premium reflects reality. If you earn more than your MAGI, the excess ACA subsidy benefit $s will have to be paid back in your tax bill for that year.

 

[ratface]

I have had a crappy HMO Bronze plan with a third rate Insurance Company for the past five years, I gambled on not getting seriously sick but in retrospect I don't think that is a good idea. I ran into difficulty finding a good urologist in Network but did find a good podiatrist. That said the waiting times for both specialist was several months. On the positive side the crappy insurer paid for everything required by the ACA including routine care and lab work. I would not hesitate using the ACA, you can buy any level of insurance you need. It's easy to use from year to year and fits the void. Based on years of use I would only Buy a PPO plan at the highest level I could afford or at least a silver plan. Yes the deductibles are high but you can lower those by moving up the rung on coverage. If an option I would avoid any plan tied to just one network. If you are qualifying for subsidy it's a no brainer and nothing to be skeptical of, go for it and use it to bridge into Medicare.

 

[johkar]

If you drop retiree health care coverage and enroll in a marketplace plan during open enrollment you are eligible for premium assistance (subsidy)

From KFF https://www.kff.org/faqs/faqs-healt...er-coverage-and-subsidies-in-the-marketplace/



From Healthcare.gov https://www.healthcare.gov/retirees/

Thank you, this is very helpful.

 

[johkar]

I have had a crappy HMO Bronze plan with a third rate Insurance Company for the past five years, I gambled on not getting seriously sick but in retrospect I don't think that is a good idea. I ran into difficulty finding a good urologist in Network but did find a good podiatrist. That said the waiting times for both specialist was several months. On the positive side the crappy insurer paid for everything required by the ACA including routine care and lab work. I would not hesitate using the ACA, you can buy any level of insurance you need. It's easy to use from year to year and fits the void. Based on years of use I would only Buy a PPO plan at the highest level I could afford or at least a silver plan. Yes the deductibles are high but you can lower those by moving up the rung on coverage. If an option I would avoid any plan tied to just one network. If you are qualifying for subsidy it's a no brainer and nothing to be skeptical of, go for it and use it to bridge into Medicare.

Thanks, this is definitely stuff we will think about. Not sure if we have any PPOs available for our area, but will look into it. So far, we've been looking at a Gold plan HMO. But like you said, no one plans to get seriously ill. Will look had at the in network providers.

 

[johkar]

Make sure your estimated modified adjusted gross income for when you are receiving ACA subsidies for your monthly premium reflects reality. If you earn more than your MAGI, the excess ACA subsidy benefit $s will have to be paid back in your tax bill for that year.

Yes, understood. Since retirement, we've been pretty good at estimating out our income sources at the beginning of each year, based on our estimated spending needs. So think we are pretty confident we can stay in the right MAGI neighborhood.

 

[orchid55]

If all that you have are HMOs you might want to look very carefully at the network provided. In my state we only have narrow network HMOs. Our coverage area for our last plan was our county and one other county. The rest of the USA was out of network with emergency room coverage only. If you were admitted to an out of network hospital it was never covered.

If you plan to travel outside of your network area at all, you might want to stick with the annoying retiree plan.

 

[Rianne]

We have been on the ACA since 2014, then in 2022 moved to Medicare. Our best option in IL was a high-deductible HSA-approved PPO plan. Our monthly premiums were ~ $8/month for both of us. The deductible was high, $12K but we were lucky, relatively healthy, and only had DR appointments and some blood work. Our healthcare system gave good discounts with the insurance so it wasn't worth getting co-pay covered plans. The ACA saved a lot of $$. We were able to reduce our income with the HSA contributions and contributed to the tIRA, which also reduced income.

You have to really investigate what Iowa offers. Every state and zip code has different requirements. Our bottom line, once the $12K deductible is met, the plan pays 100%. And we never came close. Today, employees can pay that much for premiums and out-of-pocket costs, easily for employer-sponsored plans.

 

[Irishgirlyc58]

This is worth spending time on. From what I’ve read here on ER Forum discussions about ACA policies over the past decade, the top complaints are the large deductibles, the lack of policy options, and small / limited / inadequate provider networks.

Boy howdy. I'm researching ACA plans for my son. He does my tech support and I do his insurance.
This year there are only two provider options and one is an "EPO". However, the local hospital in not in the EPO. So he would have to go about 40 miles south.
He can't get Kaiser which would be better coverage and $150/month less in premiums but we don't live in the Kaiser covered area because-their facilities are about 35 miles south of us.
How does that make any sense!

It drives me nuts.

 

[nvestysly]

johkar,

My corporate medical plan for retirees was/is very expensive. Consequently, DW and I chose not to enroll in medical for retirees. However, if retirees choose a dental or vision plan you remain in the retiree category and can elect medical insurance at any point in the future. You may want to verify if this option is available to you.

DW and I are getting closer and closer to Medicare age so it's less and less likely that we'll need to re-enroll in the corporate medical insurance but it's comforting to know we can enroll if needed.

Regarding ACA... be sure to sign-up with the youngest person as the primary insured. This doesn't change the premiums or subsidy but it provides for an easier transition when the older person enrolls in Medicare. The younger person remains the primary insured and the older person simply drops off. Otherwise, it can be a hassle (not always) to remove the older person (if primary) and allow the younger person to continue the ACA coverage.

 

[RunningBum]

Make sure you look at actual premiums, deductibles, Max out of pocket costs, and co-insurance. Don't just assume bronze is only good if you don't have to use it much, and silver or gold will be less risky for having high costs. It doesn't always work out that way. I have a gold available to me that's best only from about $8K-$20K of claims. But it has a high max OOP, so a Bronze HSA eligible plan is better for larger claims than that. A different bronze plan is best below $8K. That's as best I can tell, because the co-pays depend on what kind of expense I'm incurring. You definitely want to look beyond the primary care co-pay, because if you have major expenses you are probably looking at specialists, operations, drugs, and hospital stays.

Along with the calcs for which plans are best at various claim levels, I'm also looking for which plans are never too much worse than the best, at any reasonable claim level. The one I'm likely to go with is never more than $1000 expensive at any reasonable level, while the cheapest one is $4000 more as claims rise, and the best gold is $2000 more at very low claims. Every year is different. Unless I find an error in my calcs this will be the first year I don't use an HSA eligible plan.

Of course having your preferred doctors in the plan is a key, but all of mine are in all available plans this year, so that's easy.

 

[johkar]

johkar,

My corporate medical plan for retirees was/is very expensive. Consequently, DW and I chose not to enroll in medical for retirees. However, if retirees choose a dental or vision plan you remain in the retiree category and can elect medical insurance at any point in the future. You may want to verify if this option is available to you.

DW and I are getting closer and closer to Medicare age so it's less and less likely that we'll need to re-enroll in the corporate medical insurance but it's comforting to know we can enroll if needed.

Regarding ACA... be sure to sign-up with the youngest person as the primary insured. This doesn't change the premiums or subsidy but it provides for an easier transition when the older person enrolls in Medicare. The younger person remains the primary insured and the older person simply drops off. Otherwise, it can be a hassle (not always) to remove the older person (if primary) and allow the younger person to continue the ACA coverage.

We are planning to keep the retiree dental insurance, so I will have to ask about eligibility to opt back in. Had never even thought of that! Yes, the retiree benefits are pricey, over $13k annually for the both of us, for the medical portion. Thanks for the tip on using the younger person as the primary insured.