Brand new to ACA, have a few questions

[EnjoyTheJourney]

To provide a few background facts ...

1. We're FIRE'd in New Jersey, currently, and considering moving to Canada sometime after we sell our home. We're likely to leave toward the end of June, but we can't be certain quite yet.
2. We have a lot of flexibility to set our income at a level that gives us the maximum premium subsidy for ACA coverage.
3. We know relatively little about the ACA, which is being purchased to ensure the four of us have health insurance for the remainder of our time here. COBRA seems likely to be far more expensive.
4. One of our sons is receiving ABA therapy and that's scheduled for 4 times per week. Currently we pay $5 per day he receives services. We'd like that copay to continue under ACA, although it's not a disaster if it's say, $25 per day. None of the rest of us have an ongoing need for regular health services.
5. I've contacted a health insurance broker and confirmed that insurance companies pay for her services, and not us. It's a simple process to add her to our application. She seems competent and motivated.

Is there some not-so-easy-to-see reason to avoid a health insurance broker and DIY the application process instead? Also, are there ACA plans that offer $5 copays for ABA services in New Jersey? What are the provider names and plan names for those that offer $5 copays (or similar) for ABA services? Should we buy separate plans for each of us, say silver for the rest of us and gold for our son who receives ABA therapy? Is that possible? Is a short term ACA plan better than a full year plan, given our circumstances?

February 1st is our start date for new coverage, and so we're hoping to get things set up this week. Thank you in advance for any information and suggestions offered.

[Loren Ver]

Hello!

Been on ACA since 2019, so I know some things but totally not an expect.  Also I'm in the midwest so YMMV.

Never used a broker, but I've heard others on the forums mention they have had luck with them, especially early on with the ACA.  I've always DIY and it's been fine, but mine and DH's is simple.  So can't really help you there.

You should be able to search the plans available to you specifically from the ACA site (without signing up).  Go through their paperwork.  You should be able to find each plans co-pays, deductibles etc.  There you can find the cost of each treatment etc.  This link should help: https://www.healthcare.gov/see-plans/#/
When searching for plans, you can search be covered doctors, medications, etc.  That might help.

When filling out the forms, I've been given the option to put DH and myself in different groups for health insurance, where I can give each of us a different plan.  If I recall correctly, the example they give on the website is one of us getting a gold plan and one getting a bronze or silver.  I believe this what what you are asking to do.  If so, then yes, you can do this.  I have never done it, but the website seems to give an example of it, so it is theoretically possible assuming I read it correctly. 

I have never heard to a short term plan.  You are on the ACA until you no longer qualify (i.e. get a job with insurance, leave the country), I've never had to pick an end date.  Once you no longer qualify, you inform them.  I've never don't this, but they make it clear that it is something you need to do if your status changes.

Hope this helps,
Loren

[secondcor521]

General comments:

Since you live in New Jersey, if you choose to go with an ACA plan you'll need to look at the New Jersey ACA marketplace, which is at https://www.nj.gov/getcoverednj.  The site mentioned by Loren Ver above is the federal site, which New Jersey doesn't use.  I don't live in New Jersey, so I'm not familiar with the site, but usually you're able to look at plans, doctors, costs, copays, etc. on the site before signing up for a plan.

The maximum premium subsidy would be at 138% of FPL, which the NJ site above says is $3,048 per month for a family of four.  Anything under 150% of FPL will get you maximum CSRs if you sign up for a Silver level plan.

The broker you refer to could be either a private market health insurance broker, or they could be an ACA navigator.  In either case, if you like them and think they're doing a good job for you, they can be pretty effective.  If you're a cynical control freak like me, then DIY can be a slower, less optimal way to go. :)

You can buy separate ACA policies for each person in your household if you want, and each plan can be a different metal level, or even a different health plan or different insurer if you want.  It does make the application process, billing, and tax process more complex because you have to apply four different times, pay four different bills, and receive four different tax forms.  But yeah, you can do that if you want - I've done it before when my family was spread out in different zip codes.  But in general I wouldn't do it if we were all living in the same house - I'd just pick the plan that worked best for all of us in aggregate because I'd prefer the simplicity of one application, one bill, and one tax form.

Short term plans are usually not bought on the ACA exchange, are cheaper, are not as full-featured as ACA plans, and you don't get any federal tax benefits if you buy one.  You can also just sign up for your ACA plan for as long as you'll be here, then cancel it when you get coverage in Canada.

As an aside, reading between the lines here, but you're not eligible to sign up for ACA in February unless you had a qualifying event (leaving your job and moving both qualify; there are more).

[secondcor521]

One other thing.

If you report an income under 355% of FPL, NJ says they will shunt your kids over to CHIP, which is generally speaking an insurance program sort of like Medicaid.  It's generally very cheap but the quality level varies from state to state.  The web site will probably point this out to you when you either go shopping or decide to apply for a plan.

If you do end up where you're on ACA and the kids are on CHIP, then your ACA subsidies will be based on a family size of 2 (the kids on CHIP get excluded).  So you'll see your ACA subsidized premiums change dramatically when you cross that 355% threshold, and that's why.  It can be a bit confusing at first if you're just focusing on the ACA subsidy dollar figure.

[stoaX]

Regarding which providers are covered for ABA services, that's a bit of a research project that the broker might help you out with. The providers covered by a BCBS plan might be different than those covered by another carrier's plan.

[EnjoyTheJourney]

This is all excellent advice and thank you all for providing it. Short term doesn't seem like the way to go and one plan for all seems most appealing, as two immediate takeaways.

As one question, what's a "CSR?"

I've been reading more about CHIP, which I didn't know about before. I'll consult with the insurance broker, as well, to understand the choices available to us better. Hopefully if our sons are shunted to CHIP they'd still be able to be covered as of February 1st, as long as we apply before January 15th.

On a connected point, although we can set our income pretty much where want, we have a high enough net worth to disqualify us for any asset-tested means tests. Are there asset-based tests used for CHIP?

I'll also need to figure out whether ABA services will be interrupted by the change in health insurance plans. I don't know yet if that is likely (or inevitable).

Edit & PS: I'm retiring effective January 31st, hence the eagerness to start coverage on February 1st for all of us.

[DaMa]

I suggest you talk to your ABA provider.  Make sure they accept the plan you are considering.  I'm not familiar with NJ, but in Michigan this is a major issue. 

For example, Blue Cross Michigan has about 15 different ACA plans.  A provider could accept none, some, or all.  My DME provider accepts the PPO plans, but not the HMO plans.  My doctor didn't participate with the lowest cost HMO plan.

[EnjoyTheJourney]

I suggest you talk to your ABA provider.  Make sure they accept the plan you are considering.  I'm not familiar with NJ, but in Michigan this is a major issue. 

For example, Blue Cross Michigan has about 15 different ACA plans.  A provider could accept none, some, or all.  My DME provider accepts the PPO plans, but not the HMO plans.  My doctor didn't participate with the lowest cost HMO plan.

After checking with my son's ABA provider, they take CHIP insurance and medicaid. Basically, they accept virtually any and all insurance plans.

We can set income at a level that would apparently allow all of us to qualify for medicaid. But, we know next to nothing about medicaid; is there an asset-based test for eligibility or is eligibility purely income-based? Also, is the network of providers reasonably good in New Jersey, or would we find that most providers steer clear of it?

[secondcor521]

"CSR" is Cost Sharing Reductions.  It is a separate benefit to people who buy ACA Silver level plans, and essentially what it does is reduces the out of pocket costs, usually by reducing the deductible and/or out of pocket maximum.  There are three levels, which are at 150%, 200%, and 250% of FPL.  It is not reconciled on your tax return like the premium subsidy is.  You can google more about it.

I don't believe there are asset-based tests for either CHIP or Medicaid in states with expanded Medicaid under ACA.  Which includes the state of New Jersey.  You can read more about it on the covered NJ site, or you can call your state marketplace people (in my state it's part of the state department of health and welfare) and they probably can answer your questions directly.

All medical services, especially if they're continuous like you're talking about, should be continuable when you switch coverages.  I don't know much about ABA, but I would call your son's ABA provider and explain the situation and see what they say.  I bet they've seen people switch insurance before.  The only hiccup I can see would be to make sure they bill the correct insurance based on the date of his visits.

I've had trouble in my state finding pediatric dentists who take Medicaid, but as far as doctors go it seems to be pretty good.  Again, the quality of Medicaid varies by state.

[EnjoyTheJourney]

After beginning the application process a key term showed up that we didn't know about, namely the estate recovery provision.

Since I am already over 55 and my spouse will be 55 quite soon, our estate would essentially have a lien placed against it to recover any money paid out by medicaid. There are also paperwork requirements that would carry forward well into the future and that could affect one of our sons. To avoid those kinds of issues and the associated complications it's probably better to avoid having my spouse and I arranging our health insurance through medicaid. It's probably still worthwhile to have our sons on medicaid or CHIP, but to purchase our own insurance through the ACA.

I'll need to sit down and carefully figure out how to thread the needle on declared income so our sons can be on CHIP / medicaid, while preserving ACA access for myself and my spouse.

[seattlecyclone]

4. One of our sons is receiving ABA therapy and that's scheduled for 4 times per week. Currently we pay $5 per day he receives services. We'd like that copay to continue under ACA, although it's not a disaster if it's say, $25 per day. None of the rest of us have an ongoing need for regular health services.

Plans will vary quite a bit from state to state. Around here (Seattle) the only way you're getting an ACA plan with copays that low is to have an income below 200% of the poverty level to get the really good CSRs (cost sharing reductions). Otherwise there are some gold plans with $10-20 copays, but those will cost a few hundred dollars more per month than a plan with a $25-50 copay.

If you do end up where you're on ACA and the kids are on CHIP, then your ACA subsidies will be based on a family size of 2 (the kids on CHIP get excluded).  So you'll see your ACA subsidized premiums change dramatically when you cross that 355% threshold, and that's why.  It can be a bit confusing at first if you're just focusing on the ACA subsidy dollar figure.

Technically the subsidies will still be calculated based on a four-person family size. They figure out what percentage of the poverty level you're at using the full family size, look that up in a table to see what percentage of your income you owe for premiums, and calculate the subsidy required to make sure that you're paying that percentage for the second-cheapest silver plan in your area. What changes when your kids go on CHIP is that the gross premium no longer includes the cost of the kids' coverage, so the amount of subsidy required to get your net premium down to the right percentage goes down accordingly. The net cost of the second-cheapest silver plan will be basically the same on either side of that threshold.

After beginning the application process a key term showed up that we didn't know about, namely the estate recovery provision.

I'd personally steer clear of Medicaid if estate recovery was looking like a possibility. Set your income at 140% of the poverty level to avoid this. Make sure you realize at least this amount of income each and every month. Medicaid eligibility is based on your ongoing monthly income. If you realize 150% of the annual poverty level figure all in one month and nothing the rest of the year, you're technically eligible for Medicaid those other months. If they find out that you are eligible for Medicaid they will offer you Medicaid, and that offer disqualifies you from ACA marketplace subsidies until they determine you are no longer eligible for Medicaid.

[secondcor521]

If you do end up where you're on ACA and the kids are on CHIP, then your ACA subsidies will be based on a family size of 2 (the kids on CHIP get excluded).  So you'll see your ACA subsidized premiums change dramatically when you cross that 355% threshold, and that's why.  It can be a bit confusing at first if you're just focusing on the ACA subsidy dollar figure.

Technically the subsidies will still be calculated based on a four-person family size. They figure out what percentage of the poverty level you're at using the full family size, look that up in a table to see what percentage of your income you owe for premiums, and calculate the subsidy required to make sure that you're paying that percentage for the second-cheapest silver plan in your area. What changes when your kids go on CHIP is that the gross premium no longer includes the cost of the kids' coverage, so the amount of subsidy required to get your net premium down to the right percentage goes down accordingly. The net cost of the second-cheapest silver plan will be basically the same on either side of that threshold.

Serves me right for not recalling the details and making it up a little.  You're right.  I just remembered there was a surprising dislocation when I was changing my estimated income around and my kids were going on/off CHIP and the subsidies started acting weird (my state tells me my subsidy amount before showing plans).

OP, to thread the needle all you have to do is estimate an income that is above the Medicaid number (officially 138% of FPL but 140% of FPL will work) to keep the parents off Medicaid but below 355% of FPL to keep kids on NJ's version of CHIP.

You can look up FPL for your family size and location, it can be a tad confusing because the FPL numbers used for 2022 ACA coverage (and Medicaid and CHIP I think) are actually the 2021 FPL numbers published by the government.  This one year offset is due to timing between when the government publishes the number and when people are signing up for ACA coverage (sometimes in November of the year prior).  The following is the easiest resource for getting the right info:

https://thefinancebuff.com/federal-poverty-levels-for-obamacare.html

It looks like to me that for 2022, for a family size of 4 in New Jersey, FPL is $26,500.  So you'd multiply that by the 138% and the 355% numbers to get the actual estimated income limits you'd need to stay between.  The CoveredNJ site, if it's anything like my state's site, should also make it clear to which programs it's shunting which applicants via a pop-up window or message or something.

[EnjoyTheJourney]

Thank you very much for your replies. They have been *very* helpful.

Now I'm a bit confused about how medicaid eligibility is determined for part year state residents. For example, if we leave the state of New Jersey at the end of June, and we have taken out 140% of annual FPL each month, do they cut everything in half and decide that we were still eligible for subsidies? As another wrinkle, if we leave the country at the end of June, would our monthly income to that point be doubled to find annual income, and would that total be used to determine ACA subsidy eligibility?

The logical response would seem to be to cut the FPL in half if we lived in state / in country for half a year and to then come up with 140% of FPL having been received as income in their calculations. Then we would still be considered eligible for subsidies received. Is this handled in a logical way?

We are not certain to leave New Jersey this year, but conversations are underway.

As a final wrinkle, I'm receiving my January salary from the job from which I'm retiring. It is over $10K for that one month. Do I still need to declare 140% of FPL each month from February onward to avoid medicaid, or does the January salary somehow count toward calculations for medicaid eligibility?

[secondcor521]

Generally speaking:

ACA premium subsidies are calculated based on estimated annual income.  You apply, provide your estimated annual income, they approve you, then sign up for a health insurance plan, and they deduct the subsidy from your premium and you pay the rest monthly.  You get the subsidies every month until you either decide to drop your plan, or a new year rolls around and things get reevaluated in November/December during open enrollment.

If you discover while on ACA that your income is going to be different from your estimate, then you're supposed to update it with them so they can adjust your subsidy.  It will also get trued up at tax time on a Form 8962 which gets filed with your 1040.

Expanded Medicaid and CHIP eligibility usually seem to be based on monthly income.  You apply, prove your monthly income for the previous month or two, they approve you, then you or your kids are on Medicaid or CHIP until something changes or you get reevaluated (which seems to happen once a year on your Medicaid/CHIP signup anniversary).

I believe it is @lhamo who is on Medicaid in Washington state and she says that a one month income blip is not enough to throw you off Medicaid.

If you start off applying for ACA and they figure out that you should be on Medicaid instead, then they may divert your application from one program to the other.  In my state, it does seem that if you somehow qualify for both at various times and have a preference, they'll work with you to get you on the plan that you want assuming you do qualify.

Because one is annual and one is monthly, there are some weird interactions that can happen, but the above is generally how it works as far as I understand it.