Health Insurance for Couple Early Retirement

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snugharbor
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Health Insurance for Couple Early Retirement

Post by snugharbor » Tue Jul 10, 2018 6:17 am

My brother lives in F airfield County, CT. For various reasons, he decided to retire a few years early. He and his wife have been on Cobra coverage from his former job and this coverage will run out soon. His income is more than the amount that would make them eligible for any subsidy under the ACA.
He has heart issues that are under control. He as never had a heart attack but did have arrhythmia issues a few years back. His wife is currently dealing with a relatively rare auto immune condition and also has spinal issues. They will be 62 and 61 in the fall so still a few years away from Medicare.
Her condition is one that may indicate an underlying cancer which has been ruled out for the time being or such a cancer could show at a future date or maybe never. She was working part time for their school system but had to leave her job due to the severity of her health issues. She was not eligible for health coverage at her job being part time.

He went online at the ACA site. It is important to them to have good coverage so he is in the process of signing up for the highest coverage he could find. It is an Anthem policy that will cost them $2,753 a month or about $33,000 a year. This policy also has a $10,000 yearly deductible.

I checked the list of medical conditions that would qualify his wife for quick social security disability. Her condition is not on the list.
When you go on disability it enables you to go on Medicare in two years from the date of being declared disabled. She could apply for disability through the regular channels.

My brother does some volunteer work for his city. I am wondering whether there is some way he could get into a group policy under the local government coverage paying the total amount for their coverage but maybe being able to have better or just as good coverage at less expense than what the ACA has offered them. Welcoming all suggestions from the members of this group as to whatever action that could take.

snugharbor
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Re: Health Insurance for Couple Early Retirement

Post by snugharbor » Tue Jul 10, 2018 8:19 am

I have been reading the "What I Spent in Six Months on Medicare thread" and it has really helped me to see what my brother is up against.

Still will welcome any advice you might have to offer him.

Rupert
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Re: Health Insurance for Couple Early Retirement

Post by Rupert » Tue Jul 10, 2018 8:31 am

I don't think buying into a group policy based on volunteer work is going to be an option, which leaves the ACA and alternatives to the ACA (which have been extensively discussed in other threads here -- search for "healthcare sharing ministry" or "short term health insurance"). Given their pre-existing conditions, I do not believe any of the ACA alternatives will be an option for them, as most (all?) of those alternatives exclude coverage for pre-existing conditions. So the ACA would appear to be their only option aside from one of them (the husband?) going back to work at a job with benefits. Is it possible that they might both qualify for SSD and, hence, early Medicare? I'd give it a shot. As you seem to know, however, it can take years to navigate the SSD process when your health condition is not on the quick list. Still worth it if means one or both them qualifies for Medicare even a little bit early.

Cpadave
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Re: Health Insurance for Couple Early Retirement

Post by Cpadave » Tue Jul 10, 2018 8:36 am

We are almost in same situation. We went with connticare HSA plan. This way we get at least some tax benefit. For next year I anticipate the premiums will be even higher. We have to look at all options at that time. So sad that there are not too many good options for those who want to retire a little early.

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Cyclesafe
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Re: Health Insurance for Couple Early Retirement

Post by Cyclesafe » Tue Jul 10, 2018 9:59 am

Relook at "highest coverage he could find". Often coverage is more expensive for reasons not related to quality of care. In Cali and similar ages, we pay $21k w/ $10k deductible with bronze HDHP PPO. We will be eligible for Medicare next year, thank goodness.

kd2008
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Re: Health Insurance for Couple Early Retirement

Post by kd2008 » Tue Jul 10, 2018 10:36 am

Consider the first year as a penalty year. So pay the highest premium needed but use that year to manage income for following years such that you can receive highest ACA subsidy.

In fact he should have used COBRA months to do it already. It will end up costing tens of thousands of dollars more than it should have.

Sunk costs are irrelevant. So ask him to focus on reducing future ACA premiums.

snugharbor
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Re: Health Insurance for Couple Early Retirement

Post by snugharbor » Tue Jul 10, 2018 11:11 am

I have been reading which income amounts go into the MAGI which determines your eligibility for a subsidy.
Since capital gains and such count toward it I was at a loss as to how he reduce his income to qualify. Both of us have inherited IRAs from our parents that require distributions. These distributions for me come up to about $9000.00 a year. Brother is younger. Then he has some capital gains from his after tax investments that he is using to pay the bills.

Would be very grateful to hear about income reducing strategies.

47Percent
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Re: Health Insurance for Couple Early Retirement

Post by 47Percent » Tue Jul 10, 2018 11:47 am

snugharbor wrote:
Tue Jul 10, 2018 6:17 am

He went online at the ACA site. It is important to them to have good coverage so he is in the process of signing up for the highest coverage he could find. It is an Anthem policy that will cost them $2,753 a month or about $33,000 a year. This policy also has a $10,000 yearly deductible.
You may want to check this (instinctive, I think) decision that just because they have known medical issues they have to have the highest coverage. In many cases (and I suspect in most cases), I think the HSA coverage will come out ahead.

Please do run the numbers and check out. You have to take the tax deductible HSA contribution, your premiums, and maximum out of pocket all in as one unit, and compare head to head against the full-up premium of your platinum coverage. Keep in mind, after your max out of pocket, everything is covered 100%. So you know your worst case hit up front. If you don't have any incidents, then you get to keep the money, and in addition HSA contribution may bring your MAGI down and help you squeak under the threshold to qualify for subsidy if you are near borderline.

The important thing is not to skimp on required medical care because of the HDHP high deductible --- but consider that as part of your budgeted expenses.

marcopolo
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Re: Health Insurance for Couple Early Retirement

Post by marcopolo » Tue Jul 10, 2018 11:59 am

snugharbor wrote:
Tue Jul 10, 2018 11:11 am
I have been reading which income amounts go into the MAGI which determines your eligibility for a subsidy.
Since capital gains and such count toward it I was at a loss as to how he reduce his income to qualify. Both of us have inherited IRAs from our parents that require distributions. These distributions for me come up to about $9000.00 a year. Brother is younger. Then he has some capital gains from his after tax investments that he is using to pay the bills.

Would be very grateful to hear about income reducing strategies.
First of all what was their plan when they decided to retire? They will run out of COBRA soon, they must have known that when they retired. The health insurance landscape, while being uncertain, did not actually change much in the last year or two.

The ACA insurance premiums have gone up quite a bit in the last couple of years (due to combination of rising health care costs and various policy decisions by the current administration), but only for the relatively small fraction of people that buy un-subsidized in the ACA marketplace. Around 85% of those purchasing on ACA marketplace receive subsidy. Due to the way many states have implemented the cost increases (google "silver switcheroo" if you want gory details), the premiums have actually come down for subsidized customers in many cases. Those in the unfortunate situation of having to purchase subsidized coverage are really taking the brunt of the cost increases.

Regarding ways to stay under income levels. The 2019 FPL is $16460 for a family of 2. So, you can get subsidies with a MAGI up to $65840.
So, lets assume his RMD in $8k, maybe another $20k in dividend/interest income (2% on a $1M in taxable accounts). That leaves $37840 in capital gains that can be used. Some of what he withdraws will be return of his capital. Let's assume he has 50% in unrealized gains. That means he can pull $75680 from his investments. So, a total of $103680 to live on and still get a healthy ACA subsidy. If his unrealized gains is a lower than 50% in some investments, then he can pull even more. Does he have Roth accounts? If so, he can pull additional money from there to live on without any impact to ACA credits. If he still needs more than that to live on, then I would think he should be able to afford full health insurance costs.
Once in a while you get shown the light, in the strangest of places if you look at it right.

HereToLearn
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Re: Health Insurance for Couple Early Retirement

Post by HereToLearn » Tue Jul 10, 2018 12:07 pm

You mentioned a $10,000 deductible, but I assume this is $5000/person because I could not find a plan with a $10K/person deductible via Access Health.

Has he looked at ConnectiCare to see if his and his wife's doctors participate? Anthem absolutely has the widest network, but I have been happy with ConnectiCare. Having said that, I do not have any chronic health conditions, but claim service & prescription service have been fine.

Also, advise him to allow two months to complete the enrollment process. He will need a letter from his employer confirming the end date of his COBRA that he can then upload to enrollment site. He will then need to re-enroll in November for January 1st, but the initial enrollment will be the more challenging one.

The premium subsidy falls off a cliff, so the advice offered about managing income level is very useful.

JoeRetire
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Re: Health Insurance for Couple Early Retirement

Post by JoeRetire » Tue Jul 10, 2018 12:13 pm

snugharbor wrote:
Tue Jul 10, 2018 6:17 am
For various reasons, he decided to retire a few years early. He and his wife have been on Cobra coverage from his former job and this coverage will run out soon.
Did he have a plan for keeping healthcare coverage before he decided to retire early?
He went online at the ACA site. It is important to them to have good coverage so he is in the process of signing up for the highest coverage he could find. It is an Anthem policy that will cost them $2,753 a month or about $33,000 a year. This policy also has a $10,000 yearly deductible.
Wow, that's expensive. Is he sure "highest coverage he could find" is the correct criteria?
Most locales offer the assistance of "helpers" in finding plans and choosing coverage. Perhaps he should get their help in this complicated process.
My brother does some volunteer work for his city. I am wondering whether there is some way he could get into a group policy under the local government coverage paying the total amount for their coverage but maybe being able to have better or just as good coverage at less expense than what the ACA has offered them.
Probably not. But it certainly won't hurt to ask.

Does he have the option to find employment with healthcare coverage for a few years?

Whatever he does, he should make sure to not let his coverage lapse. It might not be a problem with today's version of the ACA, but down the road all bets are off.

curmudgeon
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Re: Health Insurance for Couple Early Retirement

Post by curmudgeon » Tue Jul 10, 2018 12:40 pm

snugharbor wrote:
Tue Jul 10, 2018 11:11 am
I have been reading which income amounts go into the MAGI which determines your eligibility for a subsidy.
Since capital gains and such count toward it I was at a loss as to how he reduce his income to qualify. Both of us have inherited IRAs from our parents that require distributions. These distributions for me come up to about $9000.00 a year. Brother is younger. Then he has some capital gains from his after tax investments that he is using to pay the bills.

Would be very grateful to hear about income reducing strategies.
Fitting under the ACA subsidy limit (while having a more comfortable lifestyle) can require some planning and tweaking. In some cases (like having substantial pensions) it may not be practical, while in other cases it may not be worth the contortions involved. I would start by seeing how much subsidy he would get if he can keep MAGI below $65K. That would show the potential value of managing income down. While it is typically a substantial chunk of money for a couple in this age range, it will only be relevant for 3-4 years at max, and it may be too late to make changes needed.

One thing that really helps is keeping your cash flow needs down. If you are taking money out of IRAs (or cap gains) to pay a mortgage, from your financial perspective you are just moving money from one pocket to another, but you are creating AGI that will count against the subsidy limit. Having a paid-off house really helps managing the AGI. Some ways to manage housing cash flow if the house isn't paid off might be downsizing (with gains on the sale of a residence staying under the $500K exclusion) or getting a reverse mortgage, but those are pretty substantial steps which should be considered from a total retirement perspective.

Sometimes "less is more" with ACA plans. I have a bronze plan which is HSA eligible. It has a $6500 out-of-pocket max per person, and we pay most everything up till that point, but it gives us about $9K of HSA deduction space against our MAGI. If we have low medical expenses, it saves us a bunch, while if high medical expenses, the OOP max starts covering everything. If you want the broadest provider network, that type of plan may not be viable, though.

Managing the sources of your cash flow would come next. If everything needs to come from IRA/401K, then it will all end up in AGI. If you have taxable investments, then there are more options. You need to keep in mind both the income tax effects and the ACA MAGI effects. Muni bonds may avoid income tax, but the interest is counted for ACA. Similarly qualified dividends and LTCG may have minimal tax but also hit you in the subsidy. I tread dividends in my taxable as part of my cash flow (no reinvestment), and I am spending down fixed income from taxable which doesn't generate cap gains. If I wanted to maintain an overall specific AA, I would adjust that using IRA/401K and not sell equities with substantial gains in taxable. If I needed to sell equities in taxable, I would generally choose those with the least gains. It's also important to keep track of where you are on MAGI for the year, and possibly to maintain an emergency fund which would let you pay unexpected bills without having to generate taxable income that might take you over the ACA subsidy cliff.

It might be a little extreme, but you could consider a home equity line of credit (may not be easy to establish once retired, though) and draw against it for a few years to generate cash without AGI impact.

Watch out for state income tax refunds; they count against your AGI, while the current year state tax payments, even if deductible, don't help with the ACA limits.

--- edited to add

It can also be possible using capital gains/IRA withdrawals to alternate years with higher income (and no subsidy) one year with lower income and getting the subsidy the other year. The value of the subsidy is likely to be greater than the increased marginal rates. This assumes that the actual cash needs are still within striking distance of the MAGI limits.

snugharbor
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Re: Health Insurance for Couple Early Retirement

Post by snugharbor » Thu Jul 12, 2018 6:52 am

Thank you to all who responded. I have forwarded your responses to my brother and also suggested that he might want to oin and read here on Bogleheads. I have made a donation to the list and am grateful to have such a resource as this one available to me.

J295
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Re: Health Insurance for Couple Early Retirement

Post by J295 » Thu Jul 12, 2018 7:24 am

OP

From my perspective, it would be very helpful to have a summary of income sources/amounts so that we could confirm that in fact your brother SIL cannot keep modified adjusted gross income below the premium tax credit level. Perhaps we will be able to suggest modifications that may be helpful, such as an HSA which reduces modified adjusted gross income.

snugharbor
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Re: Health Insurance for Couple Early Retirement

Post by snugharbor » Thu Jul 12, 2018 9:14 am

Indeed such help would be invaluable but first my brother has to read here and participate. I have e mailed this thread to him and given him the Bogleheads site address.

I am the older sister who has already dealt with retiring a bit early at age 64 as did my husband who was almost 64 when he retired.
Husband is one year and nine months younger than me. I had the benefit of a departure package being offered to me by my employer.
I was under his coverage until Medicare age and he took Cobra from his job when he left which brought him up to Medicare age.
We studied information from many sources before making our decisions.

Thanks to all who have been so helpful.

snugharbor
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Re: Health Insurance for Couple Early Retirement

Post by snugharbor » Thu Jul 12, 2018 9:44 am

Also, my brother has the impression that if you qualify for a subsidy under the ACA that you are placed on some form of Medicaid.I do not think that is true. He wants to have very good coverage that will ensure that they can see the best doctors in the field should it become necessary.

I am getting off topic a bit here but our father had an intestinal bleeding issue maybe caused by a drug he was taking.
It was in a location that only a handful of doctors in the world would have been able to reach and cauterize. Dad was on Medicare with a good Medigap policy. His local GI doctor got him into see the one doctor in NY who could help him. She had worked with this specialist in the past so that was a help.

It is not always necessary to be very wealthy and have platinum insurance to be receive the best care. Dad passed about a year later of an unrelated issue at age 89.

So will try to get brother to read here and benefit from your help.

NotWhoYouThink
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Re: Health Insurance for Couple Early Retirement

Post by NotWhoYouThink » Thu Jul 12, 2018 10:05 am

I don't know about the ACA plans in CT, but in many states there aren't any plans that let you see all the best doctors in any field.

You aren't clear whether he is close to qualifying for a subsidy, or whether he's got a few million lying around he could spend if he needed to. Could be both. His best bet is probably to pick either
a) a plan that covers the doctors and hospitals most important to him, or
b) if a) is not possible, pick the cheapest plan.

If he has some available funds, and wants to keep seeing his current doctors, he could probably negotiate private payment for ongoing care. The insurance would actually then be used as insurance instead of pre-paid health care.

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Sandtrap
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Re: Health Insurance for Couple Early Retirement

Post by Sandtrap » Thu Jul 12, 2018 10:11 am

snugharbor wrote:
Tue Jul 10, 2018 8:19 am
I have been reading the "What I Spent in Six Months on Medicare thread" and it has really helped me to see what my brother is up against.

Still will welcome any advice you might have to offer him.
Beware the "ACA Subsidy Cliff" (search forum archives -- lots on this).
The financial penalty for going over it can be substantial.
Aloha
j :happy

Rupert
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Re: Health Insurance for Couple Early Retirement

Post by Rupert » Thu Jul 12, 2018 10:13 am

snugharbor wrote:
Thu Jul 12, 2018 9:44 am
Also, my brother has the impression that if you qualify for a subsidy under the ACA that you are placed on some form of Medicaid.I do not think that is true. He wants to have very good coverage that will ensure that they can see the best doctors in the field should it become necessary.
This is a common misconception about the ACA. Because it has been (intentionally) mischaracterized by its opponents, many people falsely believe it is some sort of government insurance or welfare. In reality, the ACA is just a statute that mandates the creation of marketplaces in each state for the sale of private insurance policies that provide a minimum level of health insurance coverage. Subsidies assist those below certain income threshholds in paying ACA premiums. Perversely, your brother is more likely to have access to "the best doctors in the field" in his state if his income is low enough to qualify for Medicaid. People on Medicaid are often limited to using doctors at state-run hospitals, which are often academic medical centers that attract "the best doctors."

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dm200
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Re: Health Insurance for Couple Early Retirement

Post by dm200 » Thu Jul 12, 2018 10:16 am

snugharbor wrote:
Thu Jul 12, 2018 9:44 am
Also, my brother has the impression that if you qualify for a subsidy under the ACA that you are placed on some form of Medicaid.I do not think that is true. He wants to have very good coverage that will ensure that they can see the best doctors in the field should it become necessary.
I am getting off topic a bit here but our father had an intestinal bleeding issue maybe caused by a drug he was taking.
It was in a location that only a handful of doctors in the world would have been able to reach and cauterize. Dad was on Medicare with a good Medigap policy. His local GI doctor got him into see the one doctor in NY who could help him. She had worked with this specialist in the past so that was a help.
It is not always necessary to be very wealthy and have platinum insurance to be receive the best care. Dad passed about a year later of an unrelated issue at age 89.
So will try to get brother to read here and benefit from your help.
No, ACA is not like Medicaid. My wife was on an individual plan before the ACA (very expensive) and then when the ACA came along, qualified for a subsidized plan - much lower costs to us.

pshonore
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Re: Health Insurance for Couple Early Retirement

Post by pshonore » Thu Jul 12, 2018 10:27 am

If enrolling in ACA be sure to check if your doctors (and hospitals) accept it. Depending on the state, not all do. If you don't mind switching, thats a moot point.

Dinosaur Dad
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Re: Health Insurance for Couple Early Retirement

Post by Dinosaur Dad » Thu Jul 12, 2018 10:52 am

I also live in Fairfield County. I did find one option that involved essentially buying into an existing Union-based plan, but it has preexisting conditions limitations. Your brother should ask about that...maybe via an insurance broker...it's called
IBOTU Local 713 Welfare Fund. I show an "information" number of (516) 741-5564.

Otherwise it's basically just the exchanges, which as you note are really expensive out here if your income's over the limits. What a mess for those in this position.
"Take calculated risks - that is quite different from being rash." | General George S. Patton

mrgeeze
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Re: Health Insurance for Couple Early Retirement

Post by mrgeeze » Thu Jul 12, 2018 11:08 am

kd2008 wrote:
Tue Jul 10, 2018 10:36 am
Consider the first year as a penalty year. So pay the highest premium needed but use that year to manage income for following years such that you can receive highest ACA subsidy.

In fact he should have used COBRA months to do it already. It will end up costing tens of thousands of dollars more than it should have.

Sunk costs are irrelevant. So ask him to focus on reducing future ACA premiums.

+1 !!!

Thing to do is get MAGI income below the ACA max which for a couple is about 64k.
From there you qualify for 100% subsidy on a catastrophic plan.

There are a lot of ways to do this (even borrowing might make sense).
Investment tax harvesting works wonders also.


You may spend a few $$$ on healthcare during the year but you know you'll be covered if/when somebody gets real sick.
Our plan has out of pocket max around $7500 per person,then we are fully covered.
Last year we spent about $2k between us, mostly prescriptions for my wife.
We paid zero in premiums.

We plan to continue this way (we are both 60 this year) till "repeal and replace" fixes everything. :wink:

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dm200
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Re: Health Insurance for Couple Early Retirement

Post by dm200 » Thu Jul 12, 2018 11:09 am

pshonore wrote:
Thu Jul 12, 2018 10:27 am
If enrolling in ACA be sure to check if your doctors (and hospitals) accept it. Depending on the state, not all do. If you don't mind switching, thats a moot point.
My belief and experience is that keeping "favorite" doctors is overrated. In several cases, in fact, with 20/20 hindsight, the new ones are much better than the old "favorits".

J295
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Re: Health Insurance for Couple Early Retirement

Post by J295 » Thu Jul 12, 2018 12:41 pm

Our ACA network coverage is excellent.

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bottlecap
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Re: Health Insurance for Couple Early Retirement

Post by bottlecap » Thu Jul 12, 2018 2:30 pm

Have your brother contact a health insurance broker. Over the last few years health care insurance has become wildly expensive despite inflated deductibles and it has become impossibly complex. That’s why I would go to a broker in his situation.

The bottom line is too retire early - before something forces you out of the work force - you’ve got to be able to pay for your expenses. If he can, great. If not, it’s back to the grindstone....

I do think a broker can help see if there is an option for him.

Good luck,

JT

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dm200
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Re: Health Insurance for Couple Early Retirement

Post by dm200 » Thu Jul 12, 2018 3:00 pm

J295 wrote:
Thu Jul 12, 2018 12:41 pm
Our ACA network coverage is excellent.
That experience is very common, from things I hear and read.

randomguy
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Re: Health Insurance for Couple Early Retirement

Post by randomguy » Thu Jul 12, 2018 3:29 pm

NotWhoYouThink wrote:
Thu Jul 12, 2018 10:05 am
I don't know about the ACA plans in CT, but in many states there aren't any plans that let you see all the best doctors in any field.
I doubt there are very many medical plans anywhere that yet you see the "best" doctors in any field. Seriously is there any plan that has Mayo, Cleveland, John Hopkins and University of Texas MD Anderson (depending on if you have cancer, diabetes, neurological, heart and who knows what else you might prefer one to the other) all in network? And that assumes that the best cancer treatment for your specific cancer is at the top hospital and not some say the 20th rated one who just happens to employ the best guy in the field. If you want the best, you are going out of network and paying a crap load of money. If you are willing to settle for say top 50, your chances of picking an in network place goes up but again a lot depends where you live.

You can't say anything in general about ACA networks any more than you can say things in general about employer or private networks. My ACA is a standard bluecross one like the couple million private insurance employees get. I could also get a Kaiser plan that is just like them. There are also some narrow network plans from the insurance companies I have never heard of:). You would have to do research on the plans you have available.

As far as keeping your doctor. A decade ago, I changed insurance companies through work 4 years in a row (combo of company looking for cheaper plan, company being bought out, new company looking for cheaper plan:) ). Half the time I kept my doctor. The other half I had to switch. And then the year after we kept the same insurance but the doctor left the network. You deal with it.

NotWhoYouThink
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Re: Health Insurance for Couple Early Retirement

Post by NotWhoYouThink » Thu Jul 12, 2018 3:41 pm

randomguy, in case your quote was directed at me, my wording was in response to OP's preference stated here, and just was a caution that what the brother wants may not be available in his state's plans. But I don't know, because I've only ever looked at my state's plans for this year only, and the available plans are quite narrow.
snugharbor wrote:
Thu Jul 12, 2018 9:44 am
Also, my brother has the impression that if you qualify for a subsidy under the ACA that you are placed on some form of Medicaid.I do not think that is true. He wants to have very good coverage that will ensure that they can see the best doctors in the field should it become necessary.

I am getting off topic a bit here but our father had an intestinal bleeding issue maybe caused by a drug he was taking.
It was in a location that only a handful of doctors in the world would have been able to reach and cauterize. Dad was on Medicare with a good Medigap policy. His local GI doctor got him into see the one doctor in NY who could help him. She had worked with this specialist in the past so that was a help.

It is not always necessary to be very wealthy and have platinum insurance to be receive the best care. Dad passed about a year later of an unrelated issue at age 89.

So will try to get brother to read here and benefit from your help.

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dm200
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Re: Health Insurance for Couple Early Retirement

Post by dm200 » Thu Jul 12, 2018 3:42 pm

randomguy wrote:
Thu Jul 12, 2018 3:29 pm
NotWhoYouThink wrote:
Thu Jul 12, 2018 10:05 am
I don't know about the ACA plans in CT, but in many states there aren't any plans that let you see all the best doctors in any field.
I doubt there are very many medical plans anywhere that yet you see the "best" doctors in any field. Seriously is there any plan that has Mayo, Cleveland, John Hopkins and University of Texas MD Anderson (depending on if you have cancer, diabetes, neurological, heart and who knows what else you might prefer one to the other) all in network? And that assumes that the best cancer treatment for your specific cancer is at the top hospital and not some say the 20th rated one who just happens to employ the best guy in the field. If you want the best, you are going out of network and paying a crap load of money. If you are willing to settle for say top 50, your chances of picking an in network place goes up but again a lot depends where you live.
You can't say anything in general about ACA networks any more than you can say things in general about employer or private networks. My ACA is a standard bluecross one like the couple million private insurance employees get. I could also get a Kaiser plan that is just like them. There are also some narrow network plans from the insurance companies I have never heard of:). You would have to do research on the plans you have available.
As far as keeping your doctor. A decade ago, I changed insurance companies through work 4 years in a row (combo of company looking for cheaper plan, company being bought out, new company looking for cheaper plan:) ). Half the time I kept my doctor. The other half I had to switch. And then the year after we kept the same insurance but the doctor left the network. You deal with it.
Yes - very good points.

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