Health Insurance Time -> Less PPO’s, Harder Choices for Pre-Medicare Fulltime RVers
Big breath, big breath. It’s that time of year again and it’s not my favorite time either. For those of us out there who are pre-Medicare fulltime RVers we need to think about health insurance. For 2016 the choices have changed, yet again, and the “new” choices are making our filltime nomadic life more difficult. Plus we don’t have a lot of time to dilly dally. The ACA exchange opened up a few days ago and we only have until Dec 15th to make our choices for plans starting Jan 1st, 2016, so it’s time to get cracking!
First things first, for those of you who want to understand more about ACA (aka Obamacare) insurance I suggest you get yourselves over to Kyle’s website at RverInsurance.com. Not only is he a licensed agent and a fulltime RVer himself, but he just wrote an excellent RVer 2016 Guide to Open Enrollment (FREE) which I suggest everyone reads before going further. It’s going to answer most of your questions.
Secondly, I’m not a health insurance agent and none of the advice on this page should be considered qualified insurance advice. These are simply my personal notes and layman opinions, so please direct all final questions to a qualified agent. Yet again I’m going to suggest Kyle’s website because he’s an expert (I’m not), plus I like to support good fulltime RVer businesses (and in case you want to know, I’m not affiliated in any way).
Thirdly, as with my other health care posts I’m going to request that we do not bring politics into this discussion. I’m open to discussing options and how to best navigate the system, but I will not discuss the politics that led us here, no matter which side you’re on. I will delete any comment that has politics in it. Be forewarned 🙂
Phew! With all those disclaimers done, it’s finally time to get onto what I’m going to post about today. I’ve already covered all the details of ACA in previous posts so I won’t go over them again. Also I’m not going to discuss Medicare or Medicaid. What I DO want to talk about is how the landscape has changed in 2016 for pre-Medicare (younger-aged) fulltime RVers and what options we’re looking at today. Here it goes.
A Reminder -> On Versus Off-Exchange Plans
I’m only going to do one reminder and that’s about the difference between on and off-exchange health care plans. There are two main ways you can buy individual “Obamacare” health care plans, either through the official ACA Exchange** or off-exchange**, and there is really only one reason to buy on-exchange -> if you qualify for subsidies (= cost reductions) based on your projected income.
In 2016 the MAGI income limits for subsidies are $11,770-$47,080 as as single, $15,930-$63,720 as a couple (see full table HERE). If your projected 2016 income is within these limits you qualify for a subsidy, and you MUST buy your plan through the ACA exchange in order to get those cost reductions. If your income is more than this you don’t qualify for a subsidy so you DON’T have to buy your plan on the exchange.
The advantage of subsidies is that they significantly lower your health-care costs. As an example if we make more than $63,720 next year the very cheapest plan for Paul and I in SD (Avera HMO) is $573/month. If our MAGI Income is $50,000 next year that cost lowers to $241/month. At $40,000 income level the plan costs are $115/month. It’s huge! You can figure out your own subsidy details using the online calculator provided HERE. The disadvantage of subsidies is that you have far fewer health plan options. There are waaaay more plan options off-exchange. I’ll talk about both types of plans in this post.
** Kyle offers both methods through his website
There Are Less PPO Plans On Exchange in 2016 (And It’s A Trend)
Last year one of the biggest issues we had in South Dakota (where we are currently domiciled) was lack of access to any reasonable nationwide health care plans.
There were zero nationwide plans on the SD ACA exchange which basically meant that if we bought one of those plans we would have ZERO network outside of SD for healthcare. We’d be covered for emergency care out-of-state, but nothing else. There were several nationwide off-exchange options, but they were prohibitively expensive. So what we opted to do instead was take out a Short Term Insurance (STM) plan for the year which covered us out-of-state, but also exposed us to the ACA tax penalty (STM plans are not considered ACA-compliant and thus incur the tax penalty). So, all of this year we’ve paid $265 per month plus the tax penalty.
Going into 2016 our plan was to switch our domicile to TX which (in 2015) offered a one of the very best nationwide health care plans, Blue Choice PPO. Then came the bomb no-one saw coming, least of all me. A few months ago BCBS suddenly announced it was pulling ALL of its PPO plans from the ACA exchange in Texas for 2016. Boom! Now, all of a sudden there are no nationwide plans on the exchange in Texas for 2016, and all the RVers who switched their domicile to TX for health care reasons last year (and there were many who did) are now faced with going to an HMO-style plan (= no out-of-state network) or buying an off-exchange plan (= very expensive).
In my opinion this is the sign of a general trend in the industry.
I’ve head from folks in several other states who’ve seen PPO plans cancelled or pulled from the individual marketplace for 2016. Insurances are going more “local”, basically because it’s cheaper and my “hunch” is that this trend will continue. So, even if you manage to switch domicile to a state that has great nationwide health insurance this year, there are no guarantees that state will offer that same plan next year. In fact given what we’ve been seeing so far, odds are they won’t. Switching domicile takes time & $$ (sometimes quite a lot of $$) so is it worth it to go through the process just for the chance of a year of decent health insurance?
Last year I really thought it was. This year I don’t think so anymore.
But Florida Still Has Options
Out of the 3 big “fulltime RV” states (FL, TX, SD), Florida is now the only one that is still offering a decent nationwide network on the ACA exchange for 2016.
Assurant pulled out of Florida for 2016, but Florida Blue is still there. Their EPO plans (Blue Select and Blue Options, specifically) although not “technically” PPO actually allow you to use the extended nationwide BCBS network (= Blue Card) outside of Florida, which essentially makes them nationwide. It’s pretty darn close to perfect and if you’re in FL it’s a great plan to get.
Should you switch your domicile to FL to get access to these health care plans?
It depends. If you’re planning to fulltime soon and haven’t yet chosen your domicile, then I think Florida is worth a look. If you’re currently fulltiming with domicile in either SD or TX then you need to look hard at the $$ and details to decide if it’s worth the switch. Remember that domicile choice is not ONLY about health care. There’s car/RV insurance costs, registration costs, business laws (if you have a business), banking, voting, estate laws etc. ALL of these should be considered when you chose your domicile. Add-in the fact that you need to physically go to FL to get your drivers license, and lastly keep in mind that these same health plans may or may not be available in 2017.
Only you can decide if it’s worth it for you. For us it is not.
So, If You’re Domiciled in TX or SD What Are The Options???
There are basically only a select few options left for us Texan & South Dakotan fulltimers:
1/ Buy An HMO-Type Bronze Plan On Exchange
As a fulltime Rver you can still buy health plans on the exchange in both TX and SD, just not nationwide ones. In TX you can get a BCBS HMO. In SD there’s Avera. You’ll need to select a primary care physician and what you’ll get is a plan that’s pretty much local-only and only covers emergency care out-of-state.
Is this good enough?
Well I guess it “could” be. You’re covered for emergency situations out of state, but for post-emergency care, regular doc visits or anything else you have to either pay yourself (out of pocket) or get your butt back to your domicile state for covered medical care. I don’t particularly like it for the same reasons I identified in my post last year, but for some folks it may be within their acceptable risk limits. Only you can decide if it’ll work for you.
2/ Buy An HMO-Type Silver Plan On Exchange
What? Why would you buy a Silver HMO Plan if you won’t buy the cheaper Bronze?? Well, it’s hidden in the plan details:
- In SD, one of the options on the exchange is the Avera Silver PPO Plan (MyPlan 3500). Although it’s still essentially HMO (there are zero in-network docs outside of SD) it actually offers a co-pay-insurance for out-of-network care. There’s a 40% co-insurance, which means you’ll get 60% of your costs covered (after your deductible is met) if you need non-emergency care out-of-state.
- In TX, the Blue Advantage PLUS Silver HMO 102 plan has a similar set-up with 50% co-insurance for out-of-network care. The cheaper BCBS Bronze Plan does not offer anything like this.
Neither of these plans is ideal, but they give you SOME help with coverage out-of-state which is waaay better than nothing at all IMHO. In addition, if you qualify for cost-sharing the Silver Plans offer even more advantages with lower deductibles and lower out-of-pocket costs. For anyone buying on-exchange I think they are worth a hard look.
3/ Buy A PPO Plan OFF Exchange
There are still very good nationwide network plans available OFF exchange in both TX & SD, but they are not cheap. (remember that there are NO subsidies off-exchange). If you make enough money that you don’t qualify for subsidies, buying off-exchange will offer you many more options with better networks than what you can get on exchange. Amongst other options in SD there is Wellmark, in TX there is Humana One and United Healthcare. Check out further details through Kyle’s website.
4/ Buy A Short-Term Insurance Plan
Short-Term Plans are really targeted at folks who only need a few months of coverage (say, between jobs or before going on Medicare), but they can be bought by us regular folks for up to a full year. Last year we chose this route and it turns out this is still a possibility for this year. If you had a STM plan last year you may be able to renew again this year (check with your plan provider). If you’ve never had one, but just want a solid nationwide plan this is a real, viable option.
The big gotchas? These plans are not considered “ACA compliant” so if you have them for more than 3 months you have to pay the tax penalty (= in 2016 this is $695/person or 2.5% of income, whichever is higher). Plus they will NOT cover pre-existing conditions and there are NO subsidies either. So, if you are already ill or can’t afford the 2016 tax penalty these are not good options for you. However if you’re young and healthy and/or you don’t qualify for subsidies, they could make sense for you.
The short-term plans are typically much cheaper than off-exchange plans and many offer solid nationwide coverage (if you apply thro’ Kyle’s site make sure you chose the STM plans, not the “lite”). Should you decide to go this route price it out and ADD the tax penalty ontop to get your total costs.
5/ Go With A Ministry HealthShare Plan
Let me say up-front this is not for everyone, but it’s an option some of you may want to look at especially if you don’t qualify for subsidies, you don’t want to participate in the ACA and/or you are looking for something more affordable.
The Ministry Healthshare plans are faith-based health-sharing plans. It’s important to understand that these are not regulated insurance plans and provide no guarantee of payment. What they offer is a “sharing” of costs after certain requirements (specific to each ministry) are met.
Many exclude pre-existing conditions and/or have eligibility requirements that not everyone might be comfortable with (e.g. need to limit alcohol, or not have sex outside a Christian marriage or be a practicing Christian -> each provider is different, so read plans in details before you decide). However they are typically exempt from the tax penalty and what they offer is a very inexpensive way to get help with health care costs outside of the ACA system.
The top providers are Medi-Share, Christian Healthcare Ministries, Samaritan Ministries and Liberty Healthshare. Of these four, Liberty has the loosest eligibility requirements. You can see a comparison chart for the first three HERE (pdf download). If you’re interested in this avenue look through the details & requirements in the links.
What Are Wheelingit Going To Do?
I’m not 100% sure yet, but I think we’re leaning towards either option #2 (most likely) or renewing #4. We really liked the STM plan we had this year, but the penalty costs are going to start to get painful in 2016. The Silver Avera plan is not ideal since it doesn’t give us a real network outside of SD, but it does cover emergency care out-of-state and if we end up needing non-emergency care it does cover some of those costs too (after deductible). I think it’s a compromise we can live with. We are also considering signing up to Telemedicine which will give us the ability to consult a physician remotely without going into an office. It could cover a bit more of the gap between our insurance and need to access to doctors on the road. We’ll make our final decision soon.
That’s it folks. Feel free to post questions and comments below. Remember no politics please.
Related Posts & Links:
- Health Insurance & SD Domicile -> Are There Any Options Left For Younger Fulltime RVers?? -> My post from last year around this same time. Click HERE
- The ACA And It’s Impact On Fulltime RV Health Insurance -> My original ACA post. Click HERE.
- Self-Medical Care -> My 3-part series on self-care. Click for Part I, Part II and Part III.
Nina, thanks for the write up. We plan to keep our TX domicile for 2016, but since we will be in San Diego doing some house sitting, we may just sign up for Kaiser and use our house sitting address for healthcare. I think we will be Ok, as we can’t go thru the exchange, as we will make too much $$ for 2016. The TX United Healthcare Bronze plan, which would give us coverage is about $200 more a month than Kaiser in San Diego. Your thoughts?
So my understanding is that this (legally) constitutes address fraud and you could get yourself in a quite a pickle if they find out. You’re supposed to use your legal domicile address for health insurance whether you’re applying on or off exchange. If you’re planning to switch domicile to CA that’s another matter, but I’d talk to an agent before you consider using a friends address. Personally I’d recommend looking at one of the other options, such as short-term insurance. It’ll get you nationwide coverage at (very likely) lower costs without any potential legal “gotcha’s”.
Nina
Thanks Nina, will look into it. We won’t switch to CA as we are only there temporarily. I would think it is not an issue as we would only get our healthcare in the area that we contract for, which would be San Diego.
The state may decide that you are a Ca resident based on the address of your health insurance. They will then tax your income as a resident and require you to register your vehicles in the state and obtain Ca drivers license.
Good point Ron. I forgot to mention CA residency laws. I can’t remember the exact number of months, but once you spend a certain amount of time in CA they consider you a resident and will require you to register and pay taxes. CA is pretty aggressive at pursuing taxes, so this is not something to be done lightly.
Nina
Great post. This health care thing is really generating a lot of aggravation.
I read the post that Kyle did this week. The temporary insurance seemed like an interesting idea, and I really like the telemedicine idea too.
The temp solution worked very well for us this past year. We have several friends who signed up (and used it for claims) in 2015 and they all reported positive experiences. We’re still calculating on the whole “STM + penalty” versus “ACA exchange plan” and may still end up renewing the STM. Not sure yet. I do think it’s a good, viable nationwide option for younger, healthy folks.
Nina
Stumbled upon your website and blog as we face 2016. We live half year in Florida (domiciled) and half year in Utah. My wife, in good health, had high deductible HSA (no preconditions allowed, no maternity, no drug rehab, etc.) and like you as well, the plan folded up when ACA came about. We went with Coventry HSA, her doctors participate, but is an HMO – so absolutely no coverage out of network and nothing paid goes to deductible. Our plan has always been to return to Florida in the event of a major misfortune. Will review your short term+penalty plan for 2016. Might work, but as the penalty keeps rising, suppose a short term fix even if. Also looking hard at adding “accident insurance” or “emergency indemnity” coverages. These are cheap and could go a long way toward taking care of an incident while in Utah. Seeing rates of $15 a month for standard plans and $30 for Cadillacs. Example: $7,000 paid for a hospital admission and $1500 a day for a month. Thanks for all the research. You’ve given me no hope for a way out, but certainly some ideas to help contain costs and maintain coverage for several more years before Medicare time.
The Medicaid Gap continues to rear its ugly head—no way I can afford any insurance without subsidies. South Dakota still has not expanded Medicaid, plus vehicle registration costs there rose significantly this year. So am seriously exploring changing domicile to Arizona—but Arizona is one of those states that demand a physical address from full-time RVers. Arghhh.
Indeed, the Medicaid Gap is something I didn’t address (at all) in this post and it is a serious issue for anyone earning below the subsidy limits. I wish I had some snazzy advice for you, but the Gap is a major flaw in the whole ACA law. You may want to look at short-term insurance or one of the healthshare plans to see if they are within your budget or means. Since you are in the Medicaid gap you should qualify for an exemption from the tax penalty, so you won’t have to pay that even if you go w/ a short-term plan. I really hope you manage to find a usable solution.
Nina
Wow, after reading this I am doubly glad I put in 22 years in the Army and only have to navigate through TRICARE. Great explanations. Thanks, Nina.
Lisa,
I would be interested in knowing how you navigated TRICARE. I am retired E-8, and seriously considering fulltime RVing for a couple of years. I am currently using TRICARE Prime and my wife has free medical coverage as part of her civilian job retirement. I am planning on using my son’s TX address as my home address.
Here’s the question I’ve been trying to have answered lately: Do I really need a national plan to have “in network” doctors for routine health care? Considering that I’m paying for almost all of my routine care out of pocket anyway because of the high deductible all of these plans carry. So in theory, I could get the cheapest HMO available in my domicile market and have that act like a catastrophic insurance policy. I’d have to return to my domicile for any big medical procedures but everything else I’d just pay out of pocket.
The problem I foresee in relying on “out of network” doctors for routine care is that I may get charged the far higher uninsured price by providers not in my network. Even though we currently pay for most of our medical care (because it comes nowhere near our deductible) we get huge discounts that my insurance company has negotiated off of the provider’s sticker price. Our experience this year is that our insured price has averaged just 1/8th the amount originally charged. I’m not sure we’d still get those “negotiated” prices if we used an out of network doctor. Worse, I’m not sure there’s anyway to know in advance.
If I could get a clear answer to that question, I might not sweat having a national insurance program.
It’s a good question and I’ll try to answer it as best I can based on my own understanding.
We’re actually huge supporters of cash-pay (see the 3-part series I linked to at the bottom of the post) and we pay most of our routine care out of our own pockets without involving our insurance. We’ve been doing this for years and we’ve been very happy with it. So, theoretically we don’t need any kind of “network” at all. We just chose whatever docs we want & negotiate a cash pay rate.
Where the issues crop up is for emergency & un-planned major medical items. In other words, stuff you don’t plan for that can potentially be big, big $$. Now, Emergency care is covered per ACA law for any plan you choose, even HMO plans, so in theory you *should* be fully covered if you have an emergency out-of-state. In practice, however there is a catch and that catch is called is balance billing. This is where having a network (or some kind of out-of-network coverage) is important. If you end up in a non-network hospital for your emergency care, and that hospital decides your insurance hasn’t paid enough they can “balance bill” you whatever extra amount they decide they need directly. There are NO caps on this and only a select few states that prohibit it. It’s one of the biggest “gotchas” of emergency (and non-network) care, it’s not regulated at all under ACA law and it can mean thousands of additional $$. I wrote a bit more about this in my original ACA post HERE.
Secondly, if you don’t have any kind of network outside your state the care you get MUST be recorded as an “emergency” for it to be covered under ACA law. What if it’s not submitted as an “emergency”? What if you get transferred from the emergency room to the recovery room and that’s not recorded as “emergency” care? Suddenly you’re liable for the whole bill and if you have a long recovery and cannot get back to your domicile state it can be a very, very big bill.
So, in my mind the biggest risk you face is that you need some kind of major medical care (emergency or otherwise) outside of state and you don’t have the time (or ability) to negotiate a cash rate. If you’re out of network it could end up being a very costly mistake, even if it’s billed as “emergency care” (because of balance billing). If you have an insurance that has a strong network or (at a minimum) covers *some* of your out-of-network costs, then at least you’ll be somewhat covered in this situation.
You have to decide if the risk of not having a network and/or not having any out-of-network coverage is acceptable to you. Make sense?
Nina
Thanks for the detailed response. I think trying to negotiate a “cash pay” rate with providers might be the way to go. I’ll look at those other articles.
Cheers
Brian
One thing to be aware of is that cash pay rates, even if negotiated, are usually substantially higher than rates paid through an insurance company or by Medicare/Medicaid. Example: Cost of mammogram if not insured — and that’s designated by a number of different names: uninsured, private pay, self-insured, self-pay, cash pay — $1800. “Negotiated’ discount — 10%. Cost to me: $1620. Cost through insurance or Medicare/Medicaid: $300 total, so on an 60/40 plan, I would pay $180. Same exact procedure. Same exact cost to the imaging center. Yet the price differential is extreme. Uninsured folks pay an extreme premium, even though they are generating only a tiny fraction of the total revenues of most health care providers. The imaging center I am using as an example obtained only 2-5% of it’s total annual revenues from self-pay individuals. The other 95-98% of their revenues were generated from Medicare, Medicaid and insurance companies. Those companies all paid $300 for the exact same mammogram for which the imaging center charged me $1620 (after discount). And, btw, that same imaging center was posting a 28-39% profit margin. Every. Single. Year. So it’s not like they were losing money offering $300 mammograms to insurance companies….
I find it depends a lot on the doctor/facility, whether you’re in or out-of-network and the procedure. I’ve seen both sides in my 8 years of mostly cash-pay. I’ve been to dermatology appointments that only cost me $200 (including mole removal and biopsy) whereas it would have cost me substantially more going through insurance (where I typically have a $5-$10K deductible). Same for a small surgery I had done some years ago. It cost me $2000 total whereas it would have been charged substantially higher through the insurance. It aaaall depends on whether your insurance has negotiated rates (at the facility you’re using) and what the finance policy is of the doctor/hospital. Places that cater primarily to cash pay patients will be inexpensive for cash pay. Those that do not can (at times) be substantially more expensive for cash pay.
NOTE/ Medicare/Medicaid are a separate deal as they have standard rates negotiated with the government. Since I am pre-Medicare and do not qualify for Medicaid I can never take advantage of these rates. I have to depend on my insurance carrier and whether I’m in-network/out-of-network (currently everything is out of network for me outside of SD) and whether they happen to have any negotiated rates with the facility I’m visiting.
Nina
As a pre-Medicare full timer domiciled in Texas on the ACA BCBS PPO, this is the post I have been both looking forward to, as well as dreading. I knew the bad news was coming, just waiting for Nina to pull my ostrich head out of the sand. 😉 You continue to provide such valuable information for which I am so appreciative!
I am SO SORRY you’re losing that great medical coverage. BCBS PPO was such a great insurance. It’s a hard year for Texan Fulltime RVers.
Nina
What a wonderfully thorough post. But no surprises there!
It looks like states that have the Blue Card program may have the best networks when you travel a lot.
I am looking to change my domicile to North Dakota where Blue Cross has the Blue Card program still. I explained my travel to Blue Cross and also that I am still a resident of WI but intend to move my domicile. He said no problem with travel and their network, no plans to change that he is aware of and all I need is a North Dakota address (sister and farm land rental so covered with mail address). Most of my income is via computer from WI so will have to continue to pay taxes in both states.
WI HMO said when I worked in Yellowstone 2 months that had to drop their coverage because I was out of their service area, eventhough my agent in WI said I should have emergency coverage with this type of travel. WY (Blue Card program) had no problem signing me up with a local WY address and WI domicile but the agent did say she was expecting changes to the extensive Blue network in WY in the future I know what Kyle is saying about domicile and do plan to change mine in the future. I only do a mammogram and general checkup every 2 years but don’t want to be caught without catastrophic coverage.
I worry about the STM due to the preexisting conditions. It is getting so that they can find some reason not to pay. I see this from a healthcare provider standpoint as well. Our healthcare agency is having a heck of a time getting insurance companies to pay the bill.
I think you’ve found a great solution for your situation. As you said the Blue Cross Blue Card program essentially gives you a nationwide network, even if your base plan is not PPO. Not many states offering it anymore, but in the ones that are (like Florida) it’s a great solution. It’s perfect that you own land in ND since that’s one of the hard things about fulltiming. Many states require you to have a physical address (either rental, land, etc.) in order to establish domicile, get insurance etc.
We’ve not been able to find another state (outside the “big 3” TX, FL, SD) where we can easily establish domicile as fulltimers. Looked at both OR and WA this past year, but it wasn’t possible (both require a physical address which meant either renting or buying land). SO we’re stuck with what we’ve got.
Nina
Only problem with my land is that I cannot get a physical address without putting in a landline (no house, just crops). I went to the sheriff and EMS and they said they use coordinates in rural areas that don’t have mail delivery. So good thing my sister is available.
Is that something just in that area? When we had the tree farm in Virginia, we went to the post office/post master to request an address. They gave us one, no problem.
I live in ND. I would think you could get a physical address. All section lines have street address, you just need the PO to give you a number for it.
The Blue Plan is good, but, ND does NOT have a single temporary insurance plan available.
Hi Nina – Thanks for the easy to read summary of where things are, and yes to Kyle’s great information, and if shopping – also encourage going with a fellow Full Time RV’er. Kyle has helped many people, just by his many posts.
We too are Pre 65, with the one with the beard a bit closer then he can believe!! We too choose SD as our Domicile, for many reasons, of which one was reasonable PPO plans available to us, when we were doing our ‘Can we retire?’ analysis. This was prior to anyone knowing the full impact to Pre 65 gang post ACA. We do not qualify for any exchange subsidies.
Ok, one question, and one comment I’m factoring into the the Pre-65 health care decision.
Question:
In SD, the ‘in state for over 6 months’ to sign up for a PPO, is how things were described to me. Even off exchange, do you not need to have some form of ‘in state’ for over 6 months foothold? (We’ve considered buying a spot at Hart Ranch as such a foothold. Or, renting a small studio in Sioux Falls or Rapid City for 6 months, again, for foothold purposes.)
Comment:
We are FMCA members, and have their FMCA Assist. This provides Emergency Related medical transportation, as well as assistance on coach shuffling if needed, back to the state of primary care. IF, the Emergency Attending Doctor and the Administrator overseeing FMCA Assist – feel it is in your best interest for recovery. (I had an interesting conversation, on what constitutes ‘best interest’, like being with your Primary Care Doc as well as in your ‘home turf’ for emotional support by friends and family. Yes, these were all certainly a factor to be considered with the ER Attending Doc. But, would it be enough to have the Administrator of the plan concur? No straight forward answer on that, and no one I could find to ask that specific question to.
Long winded way to say, that in addition to HMO, obtaining Emergency Travel Related Insurance supplemental coverage, is also worth investigation by those in our shoes.
We’re waiting to see what my companies Group Retirement Health Care plan options will be for 2016, find out on 11/15. It’s BCBS North Carolina, which requested for a 30+something increase in rates for 2016 – but that may not hold true for Group Plans, we’ll see. Even so, at a $17.5K insurance cost for 2015, and $6K each deductible, we’ll be between $25-27K for our health care only related costs for 2105. I was looking for other options to avoid this heavy budget busting costs in 2016. No way will costs go down, and they may not offer the PPO option anymore. And another bonus, was for 2015 this remained HSA too, which was a plus.
OK – One last question:
Did I not read that many people are electing to not sign up for ACA compliant Health Care, paying the penalty (Which for us would still be close to $11K). Then if something did happen, like an accident, they then went ahead and applied for a Health Care plan? No restrictions for pre existing, and though expensive, especially the penalty, would they not at least still be able to sign up for a plan to help them thru the rest of the recovery phase of the post accident?
Thanks again for the info, and the links. And great caution about not jumping to Florida as the last PPO Pre 65 state available on exchange… Could be gone in 2017. And not the only factor for sure.
Best,
Smitty
I’ll try to answer your questions as best I can:
1/ The 6-month SD rule -> Last year many insurances in SD (I specifically remember Sanford and BCBS, but there might be more) were requiring 6-month in-state proof. In fact we got rejected several years ago for BCBS for this very reason (they wouldn’t accept our mail forwarding address). Last year Assurant (off exchange) were NOT requiring the 6-month proof, so I know they were a viable (albeit very expensive) option for fulltime RVers, but I am not sure of the current situation for off-exchange plans in SD. There might still be some requiring 6-month proof, there might be some who don’t. I recommend asking Kyle for the latest info. If you find out more, let us know…
2/ Emergency Transport to Home State -> Yup, it’s a great, extra insurance to have. I mentioned it in my post last year, but forgot to mention it this year. MedJetAssist is another company that provides a similar service.
3/ Signing Up For Insurance “On the Fly” -> You can’t sign-up for health insurance outside of the official open enrollment period unless you have a “life changing event” (i.e. moving states, getting married, having a baby etc.). So, in theory you could decide to go without insurance and then switch domicile if you needed to sign-up half way thro’ the year. That would qualify you for special enrollment. It’s not really ideal since you’d need to go thro’ the whole domicile switch in order to get insurance and that (in itself) could take a month or so to complete. If you’re in the middle of an accident or major illness you’d be without insurance until that was completed.
Nina
Thanks Nina – And the “life changing event” was my thoughts as far as signing up on the fly. We both have durable power of attorney for each other. And though a real PITA, if something major were to happen that would require major 6 figure + expenses, we could alter our domicile to a state where we elected to do the full recovery. For sure not ideal, but legal as I understand things.
I have no idea what the Group Retirement Health Care plan will cost for 2016 yet, but for sure it will not go down below the $17.5K we’re paying in 2015.
So, paying the penalty, having emergency medical and transport coverage available, and basically continuing our own out of pocket pay for normal maintenance type care – could pencil out for us in 2016. Having the fallback to life changing event domicile change, and signing up for coverage, as a fallback.
I’m not saying we’ll do this, and would double check the specifics with Kyle before doing so, especially on the viability of say being in a long term recovery mode and then signing up for a healthcare plan in the new domicile state – when would the coverage kick in? I would assume, upon the effective date of signing up with the carrier. And, more important, am I correct that they could not reject us due to a current condition such as long term recovery.
Will be getting with Kyle on quotes for both off exchange in SD, as well as STM options too. Then as we did last year, we’ll compare the options with whatever the Group Retirement Health Care will be for 2016. Kyle was pretty straight forward about his last year, that if we wanted to retain PPO – staying with the Group Retirement Heath Care was the way for us to go in 2015. While we would prefer PPO’s, with good multi state in network options – the reality of post ACA world may mean we need to consider different options.
We’ll see. And thanks again for the post, and also to others that share their thoughts and opinions in their responses to you – it’s how we all help each other wade thru this Pre 65 pile of, well to be polite, confusion:)!
Best to you and all,
Smitty
Thank you for this fantastic post! What you’ve put together is a great resource, not only for RVers, but also for folks like us who live on a sailboat and travel around on water. Not sure what we’re going to do in 2016, but you’ve given me great food for thought. Cheers – Ellen
Great job on insurance evaluation..
Whole thing makes me –well…sick
I worked in Doctors office for 20 years in insurance department. This new health care law is to advantage only the insurance companies…Not the patient.
In Arizona BCBS is offering on-exchange “HMO” bronze plans with a nationwide network. I put the “HMO” in quotes because there is no requirement to get a referral to see a specialist, so I am not sure why they call it an “HMO.” My best guess for why they call it an HMO is because the plan only covers care from providers in the BCBS network. In any event, the “HMO” label apparently doesn’t necessarily mean referrals are required, or that the network is limited to one state. On a related note, another Arizona insurance company is offering a “PPO” plan that does require a referral from your primary care physician to see a specialist!
I wonder if the AZ BCBS plan is allowing use of the Blue Card (similar to Florida Blue?) and that’s why you’re getting a nationwide network. In TX, they’re not allowing this so the HMO is really just an HMO.
Nina
Is there some website that will show you what states have the Blue Card is available? I have looked at Blue Cross website and they list all the states in separate links but it is not always easy to figure out.
Not that I know of, unfortunately. I WISH they made it easy to figure out.
The only thing I can find is this:
http://www.bcbs.com/shop-for-health-insurance/coverage-home-and-away.html
But it’s just a general link & you have to contact an agent or go to your “local” BCBS website to get details about any particular state.
Nina
Montana BCBS is still offering a PPO “travel” plan through the Marketplace. I am assuming it is not easy to establish domicile in Montana and we have a state income tax, a real bummer for some people.
I have a Grandfathered PPO through BCBS of NC with a $10000 deductible. I recently had a bicycle accident in Idaho that resulted in a trip to the emergency room where they had to put in stitches. I was in the emergency room for an hour or so. As you can imagine, I was terrified to look at the bill when it arrived. To my complete surprise, the entire bill was $1200. After the BCBS reduction, the bill was $1000. I called the billing department at the hospital to see if I qualified for any other adjustments. When I mentioned that I had a high deductible plan, they gave me another 25% off so the bill was further reduced to $800. I did the same with the doctor’s office where I had the stitches removed, and they also gave me 25% off. Major happy dancing commenced that day 🙂 Moral of the story … ask questions before paying anything! We also always ask if there is a discount for cash payment (which can often be paid by credit card) and there usually is.
Like the rest of you, I feel this whole insurance thing is so frustrating and scary especially for us pre-medicare folks. My premium for the $10000 deductible plan goes up every year – for 2016 $40 a month more. Someone is getting the benefit of my money! You have to be a lawyer anymore to try and figure out all the details and the onus is on you.
One other thing I neglected to mention, don’t neglect the Public Health Centers. Most of us have the preconceived notion that they are all dirty, with rude staff, and long waits. We thought so too until we checked out some in smaller towns. They are usually multi-tasking including, say, land management, in the same office. We have found them to be clean with wonderful people and little to no waiting. Both my husband and I received Shingles shots for $20 through a program Merck offers to people who haven’t met their deductible. None of the big box stores (Costco, Walmart, Walgreen, etc) even mentioned this program to us!
Yup. There are lots of little clinics around that offer inexpensive services such as shots and basic blood tests. It’s worth taking advantage of these deals when you see them.
Nina
Good advice. It definitely always pays to ask for a discount. I’ve been able to negotiate discounts on most of my hospital bills including emergency, even after-the-fact.
Nina
Great post Nina! Thanks for sharing all of your research with us. It is a painful process, one made a bit easier by you sharing!
Ok. I have an interesting one. Due to our cyclical income, we tend to do projects and get the bulk of our income about every 3 years. In the off years, we have rental losses that makes our modified income close to zero. So based upon my review it looks like I make too little income to qualify for any subsidy and too much in the big years. So, as I prefer not be on medicaid my options are odd. We had a grandfathered PPO that was dropped this year. I assume I am SOL on this issue. I have considered an IRA to Roth conversion to move funds into the tax free catagory and bump my income up to get a subsidy. Not sure its worth the trouble but probably. Crazy system we have evolved into.
Honestly your best bet may be to incorporate, deposit the big cash years into the company and pay yourself a more “regular” salary so you can smooth out your income stream and stay within the subsidy limits. We’ve considered this ourselves and may go that route in the future. Large revenue fluctuations are hard.
Nina
I’ve been a tax accountant for over 30 years. I sold my tax practice in 2008, but in 2015 have gotten back into doing taxes for $$ and may incorporate again. If you are an “S” corp your wages PLUS corp profit will both carry to your personal return. If a “C” corp you could be subject to double taxation if you leave a lot of profit in the corp at the end of the year. And make sure you follow the rules for a “C” corp or “S” corp as to the correct ways to get a health insurance deduction.
Hmmm…clearly I have a lot more to learn here and my “solution” for smoothing out income may not be as simple as I thought. Large variations in income are a common problem for self-employed and it really makes it tough on the health-care side, specifically because of the subsidy limits. Wonder if there’s another easy solution here? Teri given your expertise, do you have any thoughts?
Nina
There’s a fairly simple way to “create” enough income to qualify for the ACA subsidies as long as you’ve got money in a traditional IRA. Simply do a ROTH conversion (which counts as taxable income) to get your AGI income up to the minimum necessary to qualify for ACA subsidies. Since this amount is only around $11,xxx for singles, your taxable income ( after deductions) will still be low enough that you’ll owe minimal if any tax.
The Obama Health Care is a crazy system. I don’t have a retirement and all of my money is either in my checking and saving accounts or stock market. So when I try to sign up for insurance through the “insurance market” I can’t show an actual income and they will not recognize my money I have sitting so they keep telling me I need to be on the Oregon Health Plan which is free insurance. (I use Oregon as my domicile).
I keep telling them that I don’t need “free” insurance and I don’t mind paying my way and that even if I did “play the system” and take free insurance it would do me no good being fulltime and mostly not in Oregon.
I hope this isn’t considered a political statement but giving stuff away for free to people that don’t need or deserve it is part of the US’s problem.
So, for the last 3 years I have been buying a high deductible short term insurance. Just because I say I have money set away does not mean I can afford crazy high costs.
I guess I need to time out stays in Oregon for when my short term’s run out and have Oregon Health Care at my disposal until we leave Oregon again and then sign back up for short term and just life with it. Any suggestions?
If you’re making money in the stock market (gains, dividends etc.) that counts as income (MAGI income) for the purposes of health subsidies, so it depends how much you’re making there. Also retirement income counts too (if you’re making that). If both of those are under the subsidy levels then you either qualify for Medicaid (if your domicile state was part of the expansion) or you are in the gap. You can certainly continue to buy short-term insurance too if that’s within your means. Medicaid is very local, but short-term insurance should have options/plans that allow you to travel.
Not sure if that answers your question, but that’s understanding of the options.
Nina
So i had a thought on insurance cost and such. If you don’t have any real property and get put in hospital for a couple weeks with the short term type insurance you guys carry what type of collection avenues will a hospital have in trying to collect money from you.
I was thinking about putting my 2 rental properties we will have when we go full time in 5ish years in a real estate trust with me being the trustee. Would that not shield your property from being sold to satisfy the collection efforts of a hospital?
just thinking out loud, with a beer in my hand. 🙂
That I can’t answer. I have no experience on hospital debt collection.
Nina
The trusts don’t do much of anything anymore when it comes to protection. They changed many laws in 2012-13 because people use to hide assets in trusts (avoiding collections and inheritance taxes). Now a trust has to have owners listed and depending on the percentage of your ownership, those are your assets that any one can go after. 401K is the only way to truly protect your money from creditors.
I think we should be careful of unintentionally providing misinformation. There are MANY different types of trusts, all of which are generally governed by individual states, aside from IRS federal tax considerations. Aside from the different TYPES of trusts, the same type in one state MAY be governed/structured differently between states. Additionally, certain trusts have no “owners” per se, only trustees and beneficiaries. The Trust is essentially the “owner”….kind of.:)
Thank you, Nina for the time you spend putting these posts together. I don’t know yet what I’m doing re insurance. All I can think is, boy, what a mess this all is.
Many states do have nationwide health insurance plans. Blue Cross Blue Shield for example provides one that includes 95% of doctors and hospitals nationwide. The trick as a fulltimer is to domicile in a state which offers these nationwide plans. Ours also includes coverage for when we travel abroad.
The issue is what it takes to establish domicile. Many states require a physical address for domicile which means either renting a spot or buying land. For fulltime RVers this can be tricky and it’s why most folks end up in either FL, SD or TX. They are fulltime RV-friendly states with fairly easy domicile requirements.
Also Blue Cross Blue Shield varies tremendously in what they offer from state to state on the individual marketplace. In SD they require proof of 6-month in-state residency (we were rejected for this very reason by them several years ago). In TX the on-exchange plans no longer offer access to the extended Blue Card network out-of-state, as of 2016. So they’ve lost that great network of docs. As of this year FL is the only one of the “big 3” fulltime states that still offers Blue Card access, but who knows if they’ll keep that for 2017?
I’m curious about your specifics. Which state are you domiciled in? Do you have land there? Mail service? What did it take to establish domicile for you? Which health exchange plan do you have? Many fulltime RVers are looking for alternatives, so please do share your details.
Nina
OK, so if the main catch of a state as a domicile is to have land there why couldn’t someone just pick out a small town in that state and buy a small vacant lot? A small vacant lot in a small rural town usually isn’t that expensive and neither are the taxes. Now, I’m talking really small town, like less than 500 pop. in an area that doesn’t serve as a bedroom community for a larger nearby town. Sure, it would be a cost up front & real estate taxes each year, but with the outrageous cost of health insurance it could just be the way to go.
You also need a physical address to go with it which sometimes involves more than just getting a vacant lot, but it’s a potential. Also *some* states require you to spend a certain amount of time in state each year. Then of course you need to register your car/RV, get drivers license, pay taxes there etc. Domicile laws vary cross-country, so you have to look into it for whatever state you decide on.
Nina
Hello Nina,
thanks for all the valuable info. Just a short question:
How does one achieve 6 months residency in SD? Is the date of issuance of ID (driver license) sufficient?
sean
No the drivers license is not enough. You need a physical address which cannot be a mail forwarder. Most folks buy a lot or land there. When we got a rejected by BCBS a few years ago they were also requiring additional proof such as mortgage or rental agreement, phone bills etc.
Nina
Excellent write up! Thanks for doing the research. I’m a some-time RVer and still have a home in New England. One major reason for that is wanting to keep seeing my regular doctors who know my health condition. A decision factor in selecting a health plan is assessing the state of your health (i.e., your needs). I agree with you that the on exchange plans can be limited. I have a chronic illness and my wife is a cancer survivor. We want to be able to see certain doctors outside of a certain area and be able to go to the best hospitals. I went off exchange for that reason. I pay a lot more for that, but for me it was worth it. Thanks again.
I’m glad you are able to have a plan that serves your needs. If you’re ill it definitely changes the landscape, and thankfully there are still options (especially off-exchange) to get good coverage plans, even if they are expensive. The ability to get coverage with pre-existing conditions is a huge benefit of ACA.
Nina
Nina,
I have been reading your blog for eons and have never made a comment. It’s now time to say thank you for the countless hours you have saved me as I shop for health insurance as a part time RVer living in South Dakota. There are no words to truly express my gratitude for this information and the wealth of other knowledge you share on your site that make life easier. Kudos!
Signed,
Shampooing with Baking Soda
Glad I could help out. Navigating the individual health care marketplace is NOT easy and I feel us RVers have to stick together and help each other to figure this out. I also have to give a lot of Kudos to Kyle (rverinsurance.com) who’s helped me understand much of this too. Good Karma all around.
Nina
These (and your campground/boondocking reviews) posts are fantastic. Thank you!
Thanks for your research and great observations regarding ACA. Fortunately, I am on Medicare (almost age 80) but there are similar characteristics in both worlds based on my latest visit with our health insurance advisor. We have been on Health Net Violet 2 PPO for the past four years with zero monthly premiums. As full-time RVers with address in Oregon for seven years (30 year resident no longer owning any property). Health Net has served us well. We have had several chances to use it including a Heart Event in Alaska where an emergency helicopter flew me into Anchorage to see a cardiologist who placed a stent in one of my arteries the next day. The overall billing came to about $90,000 for two days in the hospital including surgery and helicopter. We paid about $1000. Thank God for insurance and the PPO.
About three weeks later we were preparing for a three day kayak/camping trip on the Bowron Lakes in B.C. when I had a complication from the medication and I ended up in a hospital in Prince George for two days for an emergency bladder cautizeraton. Billing was about $10,000 and the staff and doctors were outstanding.
I called Health Net about the emergency operation and they reimbursed all of my expenses over six months less about $500. To get out of the hospital I had to pay $2000 on my credit card and they billed me for the next six months. Just sharing this history as to the realities and importance of health insurance.
After a thorough review of Oregon medicare policies this month, Health Net Violet 2 was one of the very few, and maybe the only one, as a PPO. It seems that everything else is going the way of HMOs. And…the rumor, as you have stated, is that Medicare and ACA may only offer HMOs in the future. That’s a bummer for all of us travelers regardless of age.
We now have a lovely, cozy apt overlooking a small golf course in Eugene and sold our motorhome a few months ago. My wife said…”time to reunite with our famly and commnunity in Eugene.” “Happy Wife, Happy Life”, as the saying goes. After less than a year, I am now looking for a cargo van to convert for part-time travels. Gotta add…”Happy Travels, Happy Life”, also applies. Love your blog. Outstanding writing!
One other item. One of the best kept secrets about Oregon is that it has the reputation as a heavy tax state for retirees because of property and personal income taxes. Maybe for some. In truth, I have not paid taxes (federal or state) since I retired over 20 years ago because of many exclusions for seniors in Oregon. We used the address of one of our good friends for our 12 years of traveling and working in the Middle East (five years) and RVing for seven years. We rented one of her spare rooms for approximately $1 a month plus dinners and stories upon our annual visits. She was a wonderful postmistress! Our intention was always to return to Oregon again for retirement residence (to keep things legal).
Indeed Insurance is critical. If there’s ONE piece of advice I can offer folks, it’s to get insurance even if it’s the cheapest kind. One simple emergency event can bankrupt you, and it’s not worth the risk IMHO to go without.
I’m glad you guys have decent options in OR. One day, when we “settle down” Oregon is very likely to be high on our list.
Nina
Thank you so much for your wonderful information. Yours along with Kyle’s have been the easiest-to-understand explanations we have found. We are not full-timers so much of it does not apply, but all information is helpful when trying to make decisions. Thank you again!
Nina – great write up! I’m sure you’ve saved many people countless hours of research.
I came across something I hadn’t considered in a while (since my son was in college) – many Blue Cross HMOs have a program called “Away from Home Care Plan.” If one is outside of one’s HMO area for an extended period of time (at least 90 days) and happens to be in another HMO area that participates during that time, one can enroll in the other HMO at no additional cost. For snowbirds or work campers, this might be an option. I know New York, Maryland, and Florida work but I haven’t checked into other states yet.
Anyway, thank you for all the work you put into getting information out.
Yeah, I too read something about this BCBS “Away from Home Care Plan” in one of Nina’s posted links. I wonder if it could be used at least by atleast snowbirds/winter visitors?
Here’s the link:
http://www.bcbs.com/already-a-member/for-students-travelers-and.html
I must admit this looks like a great option for folks who part-time in specific locations or stay multiple months in a given location. Doesn’t look like you can change HMO’s “on the fly” so it wouldn’t work for constant travelers, but it would certainly work for people who snowbird and such.
Thanks for posting about it!
Nina
So bad news on this for TX domicile residents. I got confirmation from Kyle that the HMO “Away From Home Care” plan is NOT available to BCBS of TX HMO members. So, unfortunately it won’t be an option for any our our TX domicile RVers.
Nina
I spent hours in 2014 trying to understand obamacare. It was too expensive for the high deductibles. Fortunately we are healthy, no medications, or chronic illness. So we went with Samaritans who have $300 deductible per illness, accident or surgeries, hospitalization, etc. We are expected to pay for our own routine care. For the two of us we pay $360 directly to members who submit their receipts to samaritan’s office. One month a year goes directly to office expenses. This program is as dependable as any insurance company. Member monthly dues pay for member medical issues. Samaritans isn’t getting rich. Medical insurance is important but marketed to make us fearful. I am glad these plans were mentioned in this article as an option.
Glad to hear the Samaritan Healthshare plan has worked out for you. For Christian folk it is a viable alternative to ACA.
Nina
Brenda,
One, humble, question: Does Samaritan’s require letters from the leadership of your local (= “domiciled”) congregation? If a full-time RVer is on the road traveling all the time, they may eventually lose that local connection over time.
Did you need to get recommendation letters from your minister or elders?
That one reason is why Liberty seems a “more open” option for those on the road 24/7, among the faith-based options. Unless I read it wrong, it seems they don’t require confirmation of membership (attendance) at one, local congregation.
Did Samaritan’s require you to submit recommendation letters?
Just wanted to let you know how it is in certain parts of PA. Pennsylvania has presently a 3.07% state income tax. Rather low compared to those states with income tax(however our present governor is trying to change that). 6% sales tax as long as you don’t live in Philadelphia nor Pittsburgh and a few other burbs. Highmark Blue shield and Capital Blue Cross offer several PPO’s based on your domicile. These PPO’s are also included in the Blue Card plan that offers in-network insurance rates across the country. We travel for about 6 months per year in our motorhome so that is very important to us. They told me that if you need physician or other medical services to call your member services to find in-network services anywhere in the country. We will best subscribing to one of these. We have been with Highmark BlueShield for several years and have been satisfied, however, like all the other plans, the deductibles, co insurance and premiums have gone up. They told me that as long as anyone subscribes to a Blue Cross or Blue Shield plan anywhere, they will be covered with the Blue Card plan(may be called something else in other areas of the country). Good luck to everyone in this difficult “root-canal like” process!
Sounds like you still have great options in PA. That’s good news for any RVer who is able to maintain domicile there.
Nina
Great writeup. I am very thankful for my employer-sponsored PPO right now. Every year I wonder what health insurance changes will mean for our budget and what I see here is that I won’t be shopping for alternatives this year. Thanks for all the research and the great comments in response! I hope we get some simplified choices for us full timers in future years.
Yup, I would certainly stick with the employer-sponsored plan. Coverage is generally better through company plans.
Nina
For someone who says they do not want to bring politics into the discussion but prefaces all that with calling the ACA “ACA (AKA Obamacare)”; well you lost me. That’s like calling the IRAQ war BUSHWAR and then saying you don’t want to politicize things. Be consistent.
“Obamacare” is more a colloquial term than a political one. Everyone knows what Obamacare is. Few know it is as the ACA. Although intended to be derogatory, the term has since been embraced by President Obama himself. He even said, “I don’t mind it being called Obamacare because, it’s true, I do care.”
Exactly what Doug said. It’s a colloquial term that’s been accepted by the President himself. Not everyone understands or knows the term ACA. If that’s the only thing you got out of my ~2,500 word article, I suggest you unsubscribe from my blog.
Nina
We are considering one of the healthcare ministry plans this year (and yes, we are Christians). In a response above you mention, “for Christian folks, it’s a viable alternative”. Like politics, I don’t want to get into religion either….but if the beliefs, etc. were out of their equation, would you go with a plan like these? I guess I’m trying to figure out why not to go with one….
Outside of the religious requirements (which vary by Ministry) most of the Healthshare plans do exclude pre-existing conditions, so if you are already ill they are not a good choice. Also it’s important to understand that these are share cost plans (each member contributes to sharing the medical costs of other members), and not regulated insurances. The payment of bills is ultimately up to the Ministry and there are no guarantees or legal requirements for them to pay. This is a risk that you have to be comfortable with. Lastly there may be other limitations such as lifetime caps and certain medical procedures which may not be covered (on moral grounds).
That said most folks who’ve signed up to these plans seem to be very happy with them. Payment seems to be prompt and people are satisfied with the coverage. I have no actual data on how well they function except for forum/blog comments from people who’ve decided to go this route, but they do seem to satisfy a lot of folks needs. And although it may not mean anything, I have yet to hear from someone who signed up and was disappointed. I think if you’re healthy, and comfortable with the premise of the Ministry and how these plans function, they are worth a look.
Nina
I found another article on Healthshare Ministries that explains a little more detail on their limitations and benefits. Maybe this will help with your decision:
http://www.thesimpledollar.com/what-is-a-health-care-sharing-ministry/
Nina
Thank you for the feedback. I have a medical background and am just a little leery of anything “different”. I appreciate your help.
Thanks for taking time to pull all this great information together. I began full timing this year but took the COBRA plan from my former employer to finish out 2015. Currently I am an Oregon resident but really need to consider my other domicile options. Lots to consider and your info – and Kyle’s – helps a lot.
Thanks a ton!
Peter
Don’t rule out Oregon ACA options either. As an Oregon resident you may be able to keep your domicile there and become a “continuous traveler” (legal designation specific to OR) when you fulltime RV. So, you could get health insurance through their exchange. I don’t know anything about the ACA options in OR, but if they’re good it may be worth keeping your domicile there.
Nina
Thanks for the great write up! Although I am not (yet) a fulltime RVer, I’ve had plenty of experience with getting health insurance b/c I’m self employed and have been for many years. I live in Texas and have the BCBS Bronze PPO and I realized straight away that the future of traveling full time will be difficult. Even now, I want a nationwide network b/c we travel quite a bit, but it’s not as crucial as it is for full time travelers. It does indeed seem that they are going for a more localized approach, at least here in Houston (where we can get a plan that’s tied into a local hospital network). Thinking ahead, one plan we had was sticking with a plan like that and rolling through Houston for our routine care – we’d be here fairly often anyway to visit family and friends. The catch is the emergency care as you’ve detailed above. I guess when the time draws nearer for us to cut ties and travel full time, we’ll tackle that aspect!
Your plan is actually exactly what a lot of fulltime RVers end up doing. They pass through their home state once/year and get all their medical work done at that time.
Like you mentioned the “gotcha” is when you need care out of your home state. The easy answer is to get a solid nationwide plan, but sadly this is becoming more difficult (and/or too expensive). I do think the general “trend” is towards more localized insurance.
Nina
I may have missed it, but just from an initial perusal of the off exchange plans in Texas, I didn’t even see one with nationwide coverage ….
Unfortunately that’s also possible. The health plan offerings (and prices) not only vary by state, but they ALSO vary by county. So, what’s offered in say Polk County, TX (which is where most fulltime RVers domicile thro’ Escapees) may not be offered in your county (same state). I discovered this last year when I was pricing out ACA plans thro’ different counties across TX, FL & SD. I haven’t researched the off-exchange offerings so can’t really comment more. But basically yes -> there may or may not be any nationwide ACA-compliant offerings in your particular area, even off-exchange.
Nina
Nina
Thanks for your many posts with great info for us full timers. We happen to be in the Medicare crowd now, thank God.
I had a thought as I was reading this post. If one’s income is low enough to qualify for subsidies, is state income tax really an issue? And if not, are there states besides the big three (SD, TX, FL) that would serve equally well for domicile?
We lived in NM prior to going full time and we decided to keep our NM residence as it was nearly as good as any of the big three and far better for us than the trouble/expense of switching. We have a local mail handling service that works just fine and is run by people we know. The fees for auto insurance and plates are tolerable. There is a state income tax, but we pay little or none with our income that I would call middle class.
Where I am going with this is, “Aren’t there other options for those of us with modest incomes besides the big three? If so, the options for Health Insurance open up dramatically. Just a thought or two. Maybe I am missing something.
Anyway, we love your blog and usually don’t stick our nose in, but do appreciate all your work and info.
Monte and Mary Kern
Yes…and no. The biggest issue with states outside the “big 3” are what it takes to establish domicile there. Since you were already NM residents before you went RVing this likely made things easier for you. As an outsider coming in from another state, the rules to establish domicile can be more difficult. There may be physical address requirements, stay requirements (certain number of months) and other things which might or might not be easy to do (esp. on a low income).
We actually looked at doing this a while back in OR, but we needed to have a physical address and be in Oregon for at least 6 months and even then we couldn’t get the coveted Oregon “continuous traveler” designation until we’d been there more than a year. We also looked at WA, but we had to buy (or rent) land there to establish domicile. So, it ended up not being realistic for us.
That’s not to say it’s impossible to establish residence in states other than the “big 3”. It’s just more difficult and may or may not be realistic for someone who is essentially traveling fulltime. There’s definitely compromises to be made as a fulltime RVer 🙂
Nina
Hey, thanks for the clarification. I was not aware of the issues of establishing residence. I learned something new reading your blog, again.
Monte
Oregon was one place I was looking to setup a domicile if I had a seasonal job offer with a physical address. But sounds like I would still have to have insurance from another state domicile for 6 months that would cover me out of state before I could have a domicile and setup Oregon insurance?
I think this is one of those unintended issues that those involved with setting up the ACA did not think about
I’m not a full timer yet, and this is scary. I am retiring in 7 years and will go full time then, I’ll be 54. Not sure if this would help anyone but by Fl law and retired or current type of officer is permitted to have a fictional address in the state. As my insurance is through work still not sure what is needed other then a drivers license to prove residency.
We live on a boat full time instead of an RV but the difficulties are the same. Good info here in your post but one thing I don’t see covered is the issue that those of us have who have no income and are living on assets. We don’t make ENOUGH money to qualify for subsidies and MO, our official domicile, opted out of Medicaid. We bought private insurance, our only option, which was reasonably priced but has a very high deductible which has bitten us more than once.
Yeah, I did not directly address those people who earn below the income subsidy levels. This is a significant problem for fulltime travelers living on limited means. If you opt out of Medicaid or (even worse) your domicile state was not part of Medicaid expansion (which includes FL, TX & SD!) you may well find yourself in the “Medicaid Gap” with no reasonable ACA options available. Private insurance (off exchange) is an option, but it’s super expensive and deductibles are high. Two of the other items I listed in my post (= Short-Term Insurance & Ministry Healthshare plans) are also potentials and may be better suited for those of limited means. Sadly, there are not a lot of other choices.
Nina
As long as you have money in a traditional IRA your can convert money to a ROTH to “create” enough AGI to qualify for ACA subsidies. If you convert just enough to meet the ACA requirements your tax on the converted amount will be minimal or nil after taking deductions into account.
Steve,
I saw your response, but it took me a while to look into it. I’m actually not sure your plan works. According to what I’ve read money that is converted from a Traditional to Roth IRA counts as part of your AGI (= it increases your AGI), but is EXCLUDED from MAGI (which is what ACA subsidies are based on). As a specific example read the last paragraph in this link:
http://fairmark.com/retirement/roth-accounts/contributions-to-roth-accounts/modified-adjusted-gross-income/
Have you actually seen MAGI include converted money this way? Do you have any other links?
Nina
Nina,
I’ve actually been doing this every year since ACA started, and it works fine, at least according to turbotax. I haven’t had any questions from the IRS yet, either.
I just looked at the link you included, and it’s a different context. The link talked about MAGI from the point of contributing to an IRA, NOT converting a tradional IRA to a ROTH.
Steve
I’ve just spent a lot more time reading into this and I think we may BOTH be right.
-> The confusion lies in the fact that the IRS “seems” to have DIFFERENT definitions of MAGI for different purposes!
For the purposes of making Roth contributions, MAGI calculations *exclude* any money that is converted from a traditional to Roth IRA. This is what the example I linked to in my first response showed (here’s the snapshot pic of that):
This is confirmed by the IRS publication worksheet (P590A):
https://www.irs.gov/publications/p590a/ch02.html#en_US_2014_publink100025085
In the “worksheet” example (see item 2.1) conversions from traditional to Roth are clearly *subtracted* from the MAGI income calculations:
BUT…when I look at MAGI calculations for ACA income purposes (and the IRS info totally sucks on this) I do *not* see traditional to Roth conversions deducted. In fact, IRA conversions aren’t mentioned anywhere in any of the info I can find. So, from what I can see the conversions add onto your AGI AND count towards your MAGI income **for the purposes of ACA**, which implies your method for “manufacturing” income for the purposes of ACA subsidies works. Here’s an example of how MAGI is calculated for ACA purposes:
http://laborcenter.berkeley.edu/pdf/2013/MAGI_summary13.pdf
Very confusing stuff, but I think I got to the bottom of it. The end result is that your idea seems to work for the purposes of ACA subsidies specifically (cheers for the idea!). Oh and if there are any real tax attorney’s on the blog readership who can confirm my layman’s analysis PLEASE do chime in.
Nina
I think you’re right Nina. The confusion is that the IRS uses the term MAGI to mean 2 different things in 2 different contexts.
Steve
The following appears in Wheelingit November 4, 2015 by libertatemamo:
“the Blue Advantage PLUS Silver HMO 102 plan has a similar set-up with 50% co-insurance for out-of-network care”
I have read all the docs I could find about this plan including the Summary of Benefits, Plan Details and the plan policy or document at https://www.bcbstx.com/pdf/policy-forms/2016/33602TX0460238-04.pdf. None reference the 11/4/15 Wheelingit statement about 50% co-insurance for out-of-network care. All I see in the documents is “If you use an out-of-network provider under this plan, you will pay for the entire cost out of pocket, with the exception of Emergency Room services.”
What plan documentation for the Blue Advantage PLUS Silver HMO 102 plan supersedes the existing docs in support of the Wheelingit reference to non-emergency non-network 50% coinsurance?
Thanks.
First of all, in case I didn’t already make this *abundantly* clear I am not an insurance agent and ask that you address all detailed questions to a qualified one. That said I got this information directly from an agent and the info references a document called “Blue Advantage Plus Silver HMO 102, Summary of Benefits and Coverage“. Since I’m not an agent I cannot send this document to you, but the particular reference is on Page 3 of the document and looks like this:
I recommend that you not rely solely on the docs that are posted on the web (including my blog!) and suggest that you speak to a qualified BCBS Texas agent for the specific details of each plan.
Nina
The other poster’s document link does not refer to the “PLUS” version of the Silver plan—it’s the “PLUS” plans that provide the additional out-of-network coverage.
Ah, very good catch Doug. So, Joellen (the OP) is looking at the wrong docs. The 50% co-insurance for out-of-network benefit is *only* for the PLUS plan.
Nina
Thank you for the article, and in particular for bringing up out-of-network coverage as a factor to consider. We’re Texas residents (but not Livingston). One half of us has an apparently grandfathered BCBS PPO policy (well, for 2016, anyway), while the other half has a now-eliminated on-exchange BCBS PPO policy.
Because you mentioned out-of-network coverage, I evaluated the plans I’m offered on the exchange and found that only one company out of six offered any out-of-network coverage at all. It’s 50% coinsurance, and there’s a separate deductible, but there IS an out-of-pocket cap (which doesn’t include balance billing, of course). I never gave out-of-network coverage much thought before because I figured if I’m traveling anyway, it’ll be easy enough to go in-network if I need a doctor. But now, going in-network means going to Texas, and that’s not easy at all.
And since I don’t have a doctor that I need to be in-network, there was nothing among the various companies to differentiate them. (What a great system, for the single highest expense I have in my life.)
So I’m thinking of going with the one that offers something when it comes to out-of-network coverage, which I think is he same thing you’re considering, only in Texas instead of South Dakota. Plus, that might help when an in-network provider brings in an out-of-network provider, and certainly can’t be any worse than no out-of-network coverage at all (but every time I say, “It can’t be any worse than…,” it always is).
Yeah, I think this is the route we’ll take for SD. The plan to look at in Texas for out-of-network co-insurance (50%) is the Blue Advantage PLUS Silver HMO 102 (make sure you look at the PLUS, not the regular version). It’s not ideal, but like you said at least there is *some* out-of-network coverage, as opposed to none w/ the other options. I hope it works for you.
Nina
Well, this certainly doesn’t help matters. Blue Advantage PLUS Silver HMO 102 is included in the plans offered to me on the exchange, and when I click on PLAN DETAILS I get (copy and paste):
Blue Advantage Plus Silver? 102 – Three $0 PCP Visits
with this under OUT OF NETWORK:
“If you use an out-of-network provider under this plan, you will pay for the entire cost out of pocket, with the exception of Emergency Room services. ”
So I had decided not to look into that one. But if I drill further down and download the SUMMARY OF BENEFITS, the 50% coinsurance for out-of-network is there (in the format you screen-shotted above).
However, I compared the Blue Advantage one with the Scott & White ones I am offered, and am unimpressed with Blue Advantage. Of course, if it’s the only one someone can get with any out-of-network coverage, and if that’s important to a person, then there’s no choice to be made. But fortunately, it looks like my zip code is saving me from being in that boat. This year, anyway.
But I did notice that in the version of Blue Advantage that’s offered to me, the deductibles are:
in-network deductible $3,250
in-network out-of-pocket maximum $6,850
out-of-network deductible $15,000
out-of-network out-of-pocket maximum $unlimited
Is that what you’re getting? Because an out-of-network deductible almost 5 times the in-network deductible is kind of outrageous (it’s usually about double), and not having any cap on the out-of-pocket is scary. And I’m going to be hit with unlimited balance billing, too.
Heh–maybe in their plan details when they said I’d be paying the entire cost of out-of-network care out of my pocket, they were taking into consideration the actual plan coverages because it’s not far from the truth.
I don’t think you’re seeing it wrong. The in-network deductible is lower on the Silver Plan (in the docs I have), but the out of network deductible is listed at $15,000 and there are no limits on max spend.
Sadly the options on exchange in TX are not great. You’re basically looking at a Bronze HMO plan with zero out-of-state (= out of network) coverage (except Emergency) versus a Silver HMO plan with *some* out-of-state coverage albeit with high deductibles and no caps (both of which are horrible). It’s a choice between super scary and slightly less scary IMHO. I truly wish the options were better.
If your zip code is offering you other options with better out of state deductibles and limits that’s good news.
Nina
Ten days ago the Colorado exchange, Connect for Colorado, was showing several Anthem Blue Cross Blue Shield Plans with the coveted Blue Card. Today the Blue Card designation from these plans has disappeared. I called the exchange and couldn’t get anyone who even knew what the Blue Card was let alone give me an answer as to what happened.
Then I saw a plan called BCBS Anthem Silver Direct Access Multi-State Plan and thought this might be the answer. After doing some research to try and find state and network information, I came across this little gem: “In a July 17 news release, New Hampshire Insurance Commissioner Roger Sevigny described what a multistate plan was not. “A resident who purchases a health insurance plan labeled ‘multistate’ through HealthCare.gov should understand that the term does not refer to coverage in other states but rather to the contractual arrangement between the U.S. Office of Personnel Management … and a health insurance company that offers a plan or plans in more than one state.”
It seems people who bought this exact plan turned out to not have coverage out of New Hampshire. In one case a BCBS customer service rep, also believing this plan provided for out of state coverage, gave a patient the name of an in network doctor she could see in California. The claim was later denied.
Back to the drawing board.
What a horrible situation for you!
And yes, that “multi-state” designation is very, very misleading. Any normal person would take that name to mean you can use the plan across multiple states. Seems logical, right? Not so at all!! Sadly, like you discovered it’s just a specific type of plan that’s been formed under contract between the US Office of Personnel Management and the insurer. The designation provides NO guarantee of care outside of your home state (you have to read plan details to see what counts as in-network care), and has absolutely nothing at all to do with travel. They should have called these plans OPM plans or something else entirely less misleading in name IMHO.
Sorry your options have narrowed so much in CO. I hope you find a viable alternative.
Nina
Thank you for all the work you have done researching this subject. I wish there was a way for ALL full time RVers to band together to fight this assault on our chosen way of life. This insurance issue is a huge overwhelming problem. Combine it with ALL the issues for the best state to domicile and it certainly has become a difficult choice. I have not seen any discussion of Nevada. I would love to see your comments on that state as it does not have a state income tax but I do not know of other pros and cons. Again, thank you so very much for your posts on this topic.
The biggest thing with Nevada is that RV registration can be very pricey, especially if you have a newer (and larger) rig. I think that’s the main reason most folks avoid it. But I do believe there are mail forwarding options, and the lack of income tax is a definite bonus. I’m not familiar with either domicile requirements or the health insurance options in that state, so you’d probably need to do some research in both those areas. If you have an older RV (where the registration costs are more reasonable) then it’s probably worth a look.
Nina
You have to remember that the vast majority of fulltimer RVers are on Medicare, so this isn’t an issue for them, making the number of fulltimers wrestling with this insurance problem relatively small. And we ARE scattered about: mainly South Dakota, Texas, and Florida, but random other states as well, making it harder to find a focus point.
Add to that the fact that most young RVers probably don’t have a constant need for doctors, so health insurance is more of a contingency thing than something concrete like income tax or vehicle registration costs. That makes comparing domicile states tougher for us than for people who know, for example, that they absolutely must have a nationwide network of non-emergency care available because of a chronic condition. Domiciling in a state with an income tax might be okay if, for about 5% of their income, they’re able to fulfill their health care needs.
Those of us working on the road, especially via computer have to pay income tax(es) where ever our employer(s) are located so where our domicile is may not have an impact on income taxes
Nina, Thanks for your thorough post and your patience with the many questions. I appreciate your integrity in approaching this issue.
I wanted to do a sanity check. We are newly retired and still have insurance thru my wife’s company, but cost for next year will go up to $970/mo for the two of us. It’s great insurance for sure, but it’s eating up our budget. We are 52 & 56 and very healthy. What are others spending for coverage?
BJ,
I can’t answer your question off-hand, but you can easily get a quick no-hassle quote here: https://www.healthsherpa.com/
Nina
I’ve been reading this post and all of the comments and can tell you it has me worried. I plan on retiring in 7 years, I’ll be 54. My dream has been to rent out my TownHome and live full time in a Haulmark or Renegade Super C. I am beginning to thing the 70-75K income that I plan for won’t nearly be enough.
I honestly think you’ll be fine with that income level. It’s already higher than many retired folks on the road today. Health Insurance will likely be expensive, and I have no idea what the landscape will look like by that time (a lot can change in 7 years), but you’re starting with a solid base and there are always plenty of options to save in other areas of RVing (camping costs, driving costs etc.). I have confidence you can still achieve your dream.
Nina
Scott,
we are planning the same type of plan ourselves in 5-6ish years.. the house will be paid off, and a rental property as well which will be some $2000 a month more or less in 2020.
I was trying to figure out your income number of 70-75K and wondering if that was yearly or total.. I hope to god it does not take 70K to live in an RV a year as i do it in a 1900 sf house with 6 cars/trucks, college, 2 kids etc for 54K.
I believe I have seen a average of 3000 a month to 7K a month depending on how you like to live.
I know our Health Insurance cost this year remained mostly stable and detectable went from 5K to 10K but we do not get sick or go to doctors a lot except the chiroprators office 🙂 .. and this is a Blue Cross Blue Shield NC ACA, HSA type policy covering the family of 4 for $370 a month with subsidies.
I am afraid it will take a couple of years to get this issue straightened out by washington DC as they do not have health care on the front burner will that that happened in Calf last week or so, unless Bernie Sanders gets elected to office.
To Paul and Nina (i know you are traveling) I wish you both a merry christmas, happy new year and safe travels.
Carl,
Yes the $70-$75 will be my yearly total before taxes . I have a TownHome now that I plan on turning into a rental. The homes that are rentals there now are paying for themselves with rents increasing. Hopefully this trend will continue and I will be able to just let a property manager pay the mortgage/HOA/Taxes, and maybe send me a tiny bit to save for eventualities. If I had to I could sell, but would rather keep it as a rental.
My plan this far is something like a Dynamax DX3 to Renigade Icon or similar, basically $200-$250 range, with a Jeep as a tow along.
I estimated a $4500 a month after taxes with an RV payment at around $1700.
I don’t think I love extravagantly, would rather spend 5 days hiking the AT then 5 days in a Hilton.
Thank you for sharing so much useful information on this site! I just found you two nights ago and am slowly working my way through all of the material. My husband and I are planning early retirement in 2017 when we will both be 46. This is our planning year before we finally pull the plug and we are trying to learn as much as possible to make our new adventure our best one yet! Part of our retirement plan is for long stretches of domestic travel. Due to family commitments we don’t think we will initially be able to go out full-time so we may tip-toe into it as we can. Since we already have a low miles paid for pick-up we plan to do some fairly rough truck camping initially to see what we like and to develop some camping skills that should be beneficial even if we end up with a much more comfortable “rig” in the end. Thanks again!
Hi Nina,
I was just looking at Kyle’s website, and it looks like there’s nothing available for pre- Medicare nomads anymore, other than the faith-based plan. I’m already a Florida resident, but it doesn’t look like that’s going to do me any good. I was wondering what you guys had in mind, as a Florida domicile won’t help.
As far as I know Florida Blue still offers a proper nationawide plan on the ACA exchange, at least until the end of this year 2016 (No-one knows what will be on offer for 2017. We won’t know until Open Enrollment in November). Look at their EPO plans (Blue Select and Blue Options, specifically). Although not “technically” PPO these plans actually allow you to use the extended nationwide BCBS network (= Blue Card) outside of Florida. So, you get nationwide coverage.
You can quickly check which plans are available on healthsherpa: https://www.healthsherpa.com/
NOTE/ If you are ALREADY a resident of Florida and did not sign up for an ACA plan this year then you have to wait until Open Enrollment in Nov unless you qualify for a “life event”. A “life event” includes losing health care coverage (e.g. from a job), getting married, moving etc. You can see all qualifying life events in this link:
https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/
Nina
Hi Nina,
I guess you’ll be working on your 2017 decision soon. Today, I’ve run into this:
http://www.nytimes.com/2016/08/20/upshot/obamacare-options-in-many-parts-of-country-only-one-insurer-will-remain.html?mtrref=undefined&_r=0
It may be of interest to you (and others).
sean
Yeah, I saw that post when it came out a few weeks back and I’m certainly not looking forward to Open Enrollment. Hopefully we’ll still have some choices, but I really don’t know. We’ll see the final tally when Nov rolls around. I’ll certainly share with my blog readers whatever we decide to do.
Nina
Are you going to update this information for 2016?
We live in new jersey and i am on Medicare, my wife is on Horizon blue cross which only cover her instate, and will not be able to go on medicare until June of 2018. This is holding us back from going full time.
Without changing our domicile is ther any plan that will cover her for the net 18 months till medicare kicks in?
Yes, I’ll be updating the post after Open Enrollment starts (Nov 1st), but I’ll give you a brief run down here too.
If you don’t want to change domicile I’d recommend looking at either short-term insurance (if it’s offered in your state) or at Silver plans on the ACA. I’m not familiar with your location, but many Silver plans will offer co-insurance out of network. It’s not perfect, but it’ll at least offer *some* coverage when you’re not in State. That’s what we chose last year.
If you DO decide to switch domicile my preliminary info shows that nothing has changed in SD or TX, (that I know of) for 2017 so they are not great options for pre-Medicare at this time. However Florida is still offering the same plan (with nationwide network) that I talked about in this post for 2017. So FL domicile still looks like the best option for pre-Medicare newbie fulltimers going on the road.
That’s my quick preliminary take. I’ll know more once Open Enrollment comes around and will update the full post at that time!
Nina
I just found info that helps RVers earning incomes in multiple states and allows you to change insurance in states you live without worrying about it being your domicile
https://rvseniormoments.com/2016/11/15/state-residency-and-aca-obamacare-health-plans/
Nina,
You haven’t updated what you did for insurance in 2017. We are Texas residents and looking at starting our fulltiming again next year. I was interested in what you chose for this year. Also, have you had to use the benefits… doctor visits, ER or hospital stays?
Thanks Nina. I love reading your site.
I did a quick post on our 2017 health insurance choices back in mid-Nov here:
https://www.wheelingit.us/2016/11/01/a-few-updatesannouncements-our-accident-health-insurance-lithium-video-chat/
Basically we decided to stick with the same Avera Silver plan we had last year. It’s not anywhere close to ideal since it offers zero network outside of SD, but it does offer co-insurance on non-network care. And no, we’ve not had to use it yet so can’t comment on how well it actually works.
Nina
Thanks Nina!!