Personal Finance (Not Investing) • Retiring early: Health Insurance

... Blue Cross and affiliated companies usually also offered a more reasonably priced plan, but with much smaller networks and strict gatekeeping type restrictions on access...

Can you elaborate on the strict gatekeeping part? Was this for a PPO plan?

The Blue Cross plans I was referencing were HMO plans. So primary care physician referral is required to see a specialist. Platinum plan with $0 deductible and OOP Max of $2000 per person, for family coverage, runs $4200 per month, or $50,400 per year. Among the choices available, this is actually one of the more reasonable choices (vs. say $7000/month or $84k/year for a platinum UnitedHealth ACA plan that also requires approval for specialist care). And Blue Cross and United are the only major insurance companies offering ACA plans in my area. But it's just mind-boggling to think that I would need to budget for an additional $50k expense in order to retire early. And for those premiums, I would still have to deal with needing to see a primary physician for everything and possibly limited networks (I never got far enough along considering these plans to check the networks).

But even for PPO plans, the pre-authorization requirements are the most nebulous part of the process. There's no easy way for a consumer to check to see which tests and procedures would require preauthorization because it all depends on the particular circumstances (and is probably arbitrary to some extent depending on which reviewer gets your case). But physicians know which insurance companies are likely to approve or disapprove of certain procedures and tests because that's how they get paid. So they know if they order a certain test for a patient on a particular insurance plan, their office will have to spend a lot of time on hold trying to get pre-authorization and may never actually get it. In my case, when I had an ACA plan, I needed an MRI but was told by my physician that my insurance provider would never approve it. And then I couldn't see an orthopedic surgeon because the surgeon required an MRI prior to making an appointment. Basically, it was impossible to address the medical issue without switching insurance plans. I had the same issue several years ago with an employer-based plan and was able to get an MRI approved in 1 week and had surgery 2 weeks later.

Statistics: Posted by investorpeter — Fri Jan 26, 2024 9:25 am — Replies 56 — Views 3790

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