New to MarketPlace Ins- overwhlemed (medical, plan, hospital, doctor)

[Floralscent1]

Can anyone help clarify a few things about MarketPlace Ins? First a little background-


I am planning for early retirement and realize that health ins/medical bills will be the biggest expenses. When searching the marketplace for coverage, after entering age when I plan to retire and projected income, it appears that I will qualify for a monthly premium credit and cost sharing. When I look at the offered Silver Plans to try to choose the best one, I am overwhelmed by so many options and coverage differences once you start looking into plan specifics.


Currently I have employer sponsored health insurance and although I knew my coverage was great...I honestly had no idea how fantastic it really is. Over the last 5 years I have had medical bills for a two day hospital stay that included many, many tests/scans and an outpatient surgery that required a specialist. I take one Tier 1 and two Tier 3 prescriptions each day. I am oddly grateful for these medical experiences as it helps me estimate service costs and MarketPlace coverage when trying to select a plan.


1. Does anyone have advice on how to choose the best plan? It seems if you don’t take the time to really dig into plan details, and chart out real life situations, one could really get burned by needing a service that isn’t covered.


2. Is it difficult to find a good Dr. that accepts Silver Plans or Marketplace in general? I will be living in another state when retired and I have no idea who my Dr will be and that makes it sort of hard to plan ahead.


3. Currently, I don’t need a pre-auth for any service I need but it looks like most or all Silver Plans require pre-auth for most services to be covered, other than a simple office visit. What is the wait time for a typical pre-auth? Is it like pulling teeth to get a service covered?


4. Does anyone have an experience to share on a Tier 3 monthly drug that was expensive and the cost did not count toward the medical deductible? This seriously terrifies me.


5. I noticed there is no Out of Network coverage with any plans that I've seen. Traveling in the US was going to be a large part of my first few retirement years and I am wondering how others handle that risk. Do you purchase a travel insurance plan for your trip dates- even if for a month or two at a time?


If you made it this far, thank you for reading and for any help you can provide. Please share any resources you think might be helpful. I sincerely appreciate it!!!

[Rabrrita]

First, you can stay on your former employer's plan for up to 18 months after termination your employment relationship. You could be required to pay the full premium so be prepared for a shock when you see the actual cost of that plan. This will give you a year and a half to do your research.

Second, unless you want a subsidy, you are free to get a Self-Purchase Plan directly for the health insurance companies. Those plans, although not necessarily as cheap as you would pay with a marketplace plan using a subsidy, do offer more benefits similar to what you are use to with your employer sponsored plan.

lastly, travel insurance isn't what many think it is within the US so make 100% sure you fully understand exactly what you will get for what you pay.

[Variable]

To compare Marketplace plans, look at the Summary of Benefits document. It's the same format for all plans.
Here are things to compare

Deductible
Total Out of Pocket
What does the plan pay BEFORE deductible kicks in. Each plan can differ greatly in this area. Some plans pay things before deductible kicks in. They usually make you pay a set "co-pay" amount. For example, $100 co-pay for Urgent Care. This means you go to Urgent Care and max you pay is $100 in most cases. The Summary of Benefits, under the Urgent Care line, will specify whether you need to meet the deducible, then $100 co-pay or whether it's $100 co-pay (regardless if deductible is met).

Other items to compare: co-pay for ER and what is the co-pay amount, and whether you must meet deductible before co-pay comes into play or whether you can go to ER and pay the co-pay amount BEFORE deductible kicks in. Plans can vary greatly in this area and pay special attention to this.

Other comparisons between plans: co-pay for primary care and specialist. Co-pay for labs, x-rays, CAT-Scans, MRIs and whether you have to meet deductible 1st for each of these line items.

Whether the plan is an HMO, EPO, PPO or similar. Some HMOs allow you to visit some specialists without a referral. This is a nice feature.

Also, I usually review the list of in-network hospitals and providers in my area, for a specific plan, to see if it's a huge list or tiny list. If you plan to travel, are there providers in areas you plan to travel, if needed. A nationwide PPO is nice in these cases, for often these nationwide PPO plans are the higher cost plans.

A huge thing - research online ratings and reviews of the insurance company and plan you are considering. Some companies and plans have low volume of in-network providers and long waits to see the few doctors. Online reviews often flag these issues. Some plans are mostly Medicaid plans for poor people and hardly any doctors take these plans so there can be long waits to see a doctor.

If you take prescriptions, check ahead of your prescription is covered by the plan. They call this a formulary.