ACA vs. Medicaid vs. Ethics

[KitchenSink]

TL;DR - We are FIRED with a net worth of ~$5M, yet we qualify for both ACA ($12,500 cost per year) and Medicaid (~$0 cost per year) ... Is it ethical to accept Medicaid, when Medicaid is "intended" for people with low income?  How does the funding work, and would accepting Medicaid be "taking away" from people in greater need?

-------

Background:
We FIRE'd several weeks ago. We were SINK, and are 45 and 38.  Our NW is something like ...
   $2.3M retirement accounts (maybe 40% Roth)
   $1.7M Taxable investments (maybe 60% basis)
   $110k HSA
   $800k Primary home

Our annual spending (without healthcare) is ~$80k.
When planning for FIRE, I had estimated/budgeted that we might spend $15k/yr for everything (premiums, deductibles, co-pays, etc.).

My plan for income was to spend dividends & interest (~$20k/yr) spun off from the taxable account + cash on hand for the first 11mo of the year.  At the end of each year I would do some combination of capital gains in our taxable accounts (to generate spending money for the next year) and Roth conversions (to slowly do a "Roth Pipeline").  I'd probably aim for ~$100k of income (~$80k after standard MFJ deduction) to stay within the 0% cap-rate / 12% earned income tax brackets.

I didn't expect much in terms of ACA subsidies, at least not for the first many years, because of the Roth conversions and aiming for $100k of income.

Present Situation:
It's time to select new health plans, both due to the recent change in employment status, and because of the current open enrollment period.

When browsing the available plans, you need to estimate your income so that they can tell you what your premium will be.  It wasn't clear to me how they wanted that estimate (is it annual? For 2023?  Or 2024?  Or from Nov->Nov? etc.).  So I read a fair amount about how the marketplace treats income.  While doing that reading (including posts here on the forum by  @seattlecyclone and @lhamo), I discovered quite to my surprise  that we qualify for Medicaid ("Apple Health" here in WA, I'll use "Apple Health" and "Medicaid" interchangeably).

How could that be?  Well, Apple Health (and perhaps all of Medicaid? I'm not sure) bases eligibility on monthly income rather than annual.  We currently have low income (~$1500/mo from dividends & interest in taxable accounts), so we met eligibility for the present month.  And subsequent eligibility is determined by your income not exceeding the limits for two consecutive months.  This means that the capital gains and Roth conversions I planned to do each December would be considered a "lump sum" and wouldn't disqualify us from the program.  I would have to report that change of income for December, and then go back to reporting "low" income for January -> November.  Because our income would never exceed the limit for two consecutive months, we'd remain eligible.

This was quite a surprise to me.  I called a "Healthcare Navigator" to verify my understanding of the way income-based qualification worked.  I explained our situation of 11mo of "low" income followed by 1mo of high income.  She confirmed my understanding that we do indeed qualify for Apple Health.  I expected her tone to be ... reproachful, perhaps?  But no.  She seemed enthusiastic that she could confirm the eligibility.  She even pointed out that Apple Health includes Dental and Vision coverage, so it's "really great".

I did more research.  I went back to the ACA Marketplace, and based on our estimated (annual) income, doctor visits, prescriptions, desire to keep our primary docs, etc.. the plan that I'd choose from there would be an estimated $12.5k/yr (premiums plus estimated deductibles, co-pays, etc., including ~$150/mo of premium subsidies).  It turns out that that plan uses the same network (Molina) as would be available through Medicaid / Apple Health.  In fact, other than cost, I didn't really see any difference between the Medicaid and ACA offerings.

I reached out to a couple friends who (or whose family) use Apple Health, and they had had good experiences.  Two people were in a similar situation -- high enough NW to be FIRE, and low enough monthly income to qualify -- and were indeed enrolled in Apple Health.

The Choice:
Do we take the ACA plan for ~$12.5k/yr, or the Medicaid/Apple Health plan for ~$0/yr?

My wife and I talked about it today.  She had a moderately strong negative reaction, feeling that Apple Health is intended for low-income people, and that we aren't low-income (she knows she's conflating income and net worth, but doesn't care to distinguish).  She also wouldn't want to "take it away" from someone more deserving.  As for me, I tend to be logical & value optimization/efficiency, but also haven't fully escaped the guilt of my Catholic upbringing.  I don't think I would have gone out of my way to intentionally structure my income to meet the Apple Health eligibility requirements, but since it was already what I was planning on doing anyway, I'm less averse to accept the offer of Medicaid.  I also support socialized healthcare, and historically have voted for tax increases/etc. to that end -- I think everyone should have this option.  If I were single I'd probably accept Medicaid, and increase my charitable giving by $5k or so.  Or maybe track what our actual usage of healthcare was, and then donate that amount.  My wife feels like that is too much bookkeeping, and splitting hairs.

(FWIW, she has no concern with Medicare or Social Security in our future, because "everyone uses it" and "we paid into it".)

We ended up agreeing that more research is needed.  Specifically into how the two systems are funded, and whether being on Medicaid would "take away" from people in need more than being on a (lightly) subsidized ACA plan would.

Questions for you:
- What would you do?
- What is your take on weighing the "intent" of Medicaid being for low-income people vs. the actual qualifications allowing for occasional high income?
- What do you know about how Medicaid is funded, and whether our enrollment would "take" from someone in need?  Is it characteristically different than the $150/mo of premium subsidies we'd receive on ACA?  Or only different in scale?  Does it all just accrue against the big national budget/deficit in the end?

[seattlecyclone]

I'm on the record in this other recent thread saying that I see nothing morally questionable about availing yourself of any government funding you qualify for, nor in arranging your affairs so as to maximize the chances you qualify. I stand by that. This is true of Medicaid especially; pre-ACA there were asset tests, the ACA eliminated those on purpose, so if your income meets the standard you are explicitly in the group of people intended to use this program.

I will say that it's relatively easy for many early retirees to "game" the difference between Medicaid's monthly income standard and the annual income standard used for the Marketplace tax credits. It's conversely very easy for us to fall into the trap where we unexpectedly qualify for Medicaid because we didn't realize this difference existed! This happened to me a few years back, and now you've been caught up in it too.

Further complicating things is that once the state says you've qualified for Medicaid you're ineligible for whatever Marketplace premium tax credits you may have been expecting, at least until you've shown multiple consecutive months of higher income and the state officially decides you're no longer Medicaid-eligible. So it's not as simple as "turn down Medicaid, buy a subsidized plan from the Marketplace." If you want to turn down Medicaid to pay full price on a Marketplace plan that's always an option, but the $150/month subsidy you were expecting is only available if you have no other qualifying coverage available outside the Marketplace, and Medicaid counts as qualifying coverage. For this reason if you do decide to eschew Medicaid you would be wise to ensure that you realize income each and every month that is above their qualifying standards. However doing this is arguably just as much "gaming the system" as it would be to do your annual Roth conversion with little income the rest of the months, since that's what you would have naively done without knowing about this issue in the first place!

[Morning Glory]

You can't be on ACA with subsidies if you qualify for Medicaid.  You will have to increase your income  or get a Medicaid rejection letter if you want to not qualify. Also Medicaid costs the taxpayers less than paying subsidies for you to be on aca through a third party insurer.  I don't really understand why one is considered somehow shameful and the other not.

https://pnhp.org/news/aca-subsidies-cost-more-per-person-than-medicaid/

"The CBO’s latest projections from earlier this year show government paying out an average of $6,300 annually for every subsidized enrollee in fiscal 2018. It estimates that number will rise to nearly $12,500 in 2028. In contrast, Medicaid spends $4,230 per non-disabled adult, set to inflate at 5.2% annually to just over $7,000 per person in 2028."

[KitchenSink]

I'm on the record in this other recent thread ...

Thank you, I hadn't noticed that thread.  Probably skipped over because of "SNAP" being the focus.

Pre-ACA there were asset tests, the ACA eliminated those on purpose, so if your income meets the standard you are explicitly in the group of people intended to use this program.

This is a good point!  I had read about the elimination of the asset test back when ACA was being proposed & passed, but I'd forgotten about it in the intervening years.
I'll need to do some more reading here.

Further complicating things is that once the state says you've qualified for Medicaid you're ineligible for whatever Marketplace premium tax credits you may have been expecting, at least until you've shown multiple consecutive months of higher income and the state officially decides you're no longer Medicaid-eligible. So it's not as simple as "turn down Medicaid, buy a subsidized plan from the Marketplace." If you want to turn down Medicaid to pay full price on a Marketplace plan that's always an option, but the $150/month subsidy you were expecting is only available if you have no other qualifying coverage available outside the Marketplace, and Medicaid counts as qualifying coverage.

Thank you.  I hadn't realized that was the case.
Looks like we'll be on the Apple Health plan for at least a couple months, no matter which way we ultimately decide to go.

For this reason if you do decide to eschew Medicaid you would be wise to ensure that you realize income each and every month that is above their qualifying standards. However doing this is arguably just as much "gaming the system" as it would be to do your annual Roth conversion with little income the rest of the months, since that's what you would have naively done without knowing about this issue in the first place!

Ugh.  That's a pain.  Doesn't feel good to have to take extra steps that I wouldn't have otherwise, just to earn the ability to pay more.  :^\

[KitchenSink]

You can't be on ACA with subsidies if you qualify for Medicaid.  You will have to increase your income  or get a Medicaid rejection letter if you want to not qualify.

Thank you, yes, this is in-line with seattlecyclone's post as well.

Also Medicaid costs the taxpayers less than paying subsidies for you to be on aca through a third party insurer.  I don't really understand why one is considered somehow shameful and the other not.

https://pnhp.org/news/aca-subsidies-cost-more-per-person-than-medicaid/

"The CBO’s latest projections from earlier this year show government paying out an average of $6,300 annually for every subsidized enrollee in fiscal 2018. It estimates that number will rise to nearly $12,500 in 2028. In contrast, Medicaid spends $4,230 per non-disabled adult, set to inflate at 5.2% annually to just over $7,000 per person in 2028."

Like Fox Mulder, I want to believe.  I think it would be very convincing, even determining, if the net costs are truly less under Medicaid.

While I wouldn't suggest the CBO is wrong in the aggregate terms they are using, I'm skeptical that the same cost savings would apply to our case specifically.  With an estimated $150/mo of premium subsidy, and no cost-sharing, I would think that we'd be less costly to the state than the average ACA enrollee.  And therefore the comparison of the cost of ACA vs. fully state sponsored Medicare for us would be worse than average.

But this is something to look into further.  There are likely other costs (not presented to the end user on the marketplace) that go into the calculus.  Maybe I'll dive into more CBO reading, if I can find anything relevant.

[Morning Glory]

Yes I am one of the most expensive aca participants but my income is too high to put adults on Medicaid in North Carolina (spouse works but is not offered insurance). Cutoff for children here is higher so kids are on it. The only hiccup I have is that I can't get them into a dentist that takes it and also can't put them on my aca dental because Medicaid technically covers it. 

This is a little harder to measure but I think that having more educated, well off folks on Medicaid might help to counter stereotypes, reduce stigma, and get more political will behind expanding the program further (kind of like riding the bus even if you can afford a car).

Over the years working in hospitals I have heard sneering from staff about those people with the "free card" who are lazy, don't work, overuse the ER, whatever other stereotype they heard on cable news.  Certainly I've heard an air of superiority from those who "work to have insurance ", including from my mom*, who is ironically on Medicare and a state pension. I was legitimately afraid of being treated differently at the children's appointments but it has not happened so far, although I had one doc do a double take when I said I've never brought either kid to the emergency room.

Matthew Desmond's book Poverty by America talks about why some programs are stigmatized and others are treated as nbd. The mortgage interest deduction is just as much a handout as SNAP is, for example.

*My mom gave me crap for being lazy or abusing the system or whatever because my children have Medicaid I had to invoke President Obama and explain the whole ACA system to get her to calm down. She had no qualm about me and my husband being on Blue Cross through Obamacare even though it costs the government more than Medicaid would, so I suppose this is anecdata about the stereotypes being real.

[sonofsven]

I'm in the position of being able to qualify for medicaid, but I'm not sure that I want to be on medicaid, or the Oregon Health Plan as it's known here.

My concern is that in my rural location the number of available pcp providers is small, and after years of simply choosing the HSA plan and needing very little health care services, now I'm looking at needing at least one surgery, and possibly more.

I have been with my pcp for a number of years, but would have to change. I already have a referral for the first surgery, with my initial appointment in late December, so the surgery would be in 2024 and under  the auspices of whatever new coverage I have.
I'm concerned about switching coverage in the middle of this.

I'm looking at silver aca plans because of their lower max out of pocket compared to the high deductible HSA plan. I registered my income at Healthcare.gov as $2100 per month to realize a large subsidy. I'm not working much now (self employed carpenter) and I  can use Roth conversions to make up any shortfall to stay off medicaid.

I'm going to stop by my local hospital and talk to the folks that send the referrals on to the insurance companies and see which ones are the best at approving claims.

The company I've been with for my HSA plan has four different silver plans that are all virtually the same price, so I need to dig down and discover what the actual differences are. Or maybe go with a different provider.

I would actually like to use medicaid to save money on my upcoming expenses, but I fear the byzantine bureaucracy might drag it out longer. My goal is to recover enough to eventually return to work, since I enjoy it (and the money).

This forum ( this thread and others) has been very helpful to see what options folks are using, so thanks to all who contribute.

[jim555]

I don't see the problem, you qualify take it.  Monthly based eligibility creates situations that can seem unintuitive, but legal.

[Morning Glory]

@sonofsven you can ask to speak with a hospital social worker at the place you plan to have surgery and they should be able to tell you pretty quickly which insurance companies play nicely with their system and which ones to avoid

[lhamo]

FWIW, our experiences being on Apple Health with Molina since 2016 have been mostly great.  Have had delays getting specialist referrals at certain points, but that is because the whole system is bottlenecked, not specific to Apple Health. 

Glad your Navigator was able to help you!  Ours has been such a valuable resource.

[eostache]

Well, Apple Health (and perhaps all of Medicaid? I'm not sure) bases eligibility on monthly income rather than annual.  We currently have low income (~$1500/mo from dividends & interest in taxable accounts), so we met eligibility for the present month.  And subsequent eligibility is determined by your income not exceeding the limits for two consecutive months.  This means that the capital gains and Roth conversions I planned to do each December would be considered a "lump sum" and wouldn't disqualify us from the program.  I would have to report that change of income for December, and then go back to reporting "low" income for January -> November.  Because our income would never exceed the limit for two consecutive months, we'd remain eligible.

I'm low income and on ACA Medicaid in Colorado. (I love my Medicaid coverage!) I got a part time job a few months ago, my hours vary depending on what projects the company gets from week to week. My monthly income will be low enough most months to stay under the limit, but may occasionally go over the limit. My yearly income will stay below the limit. I have been trying to find information specific to Colorado Medicaid about what happens when my income goes over. How do they account for irregular, but overall low, income? I'm not sure if Colorado also follows the two consecutive months rule, does that come from the federal ACA rules?

[jim555]

Well, Apple Health (and perhaps all of Medicaid? I'm not sure) bases eligibility on monthly income rather than annual.  We currently have low income (~$1500/mo from dividends & interest in taxable accounts), so we met eligibility for the present month.  And subsequent eligibility is determined by your income not exceeding the limits for two consecutive months.  This means that the capital gains and Roth conversions I planned to do each December would be considered a "lump sum" and wouldn't disqualify us from the program.  I would have to report that change of income for December, and then go back to reporting "low" income for January -> November.  Because our income would never exceed the limit for two consecutive months, we'd remain eligible.

I'm low income and on ACA Medicaid in Colorado. (I love my Medicaid coverage!) I got a part time job a few months ago, my hours vary depending on what projects the company gets from week to week. My monthly income will be low enough most months to stay under the limit, but may occasionally go over the limit. My yearly income will stay below the limit. I have been trying to find information specific to Colorado Medicaid about what happens when my income goes over. How do they account for irregular, but overall low, income? I'm not sure if Colorado also follows the two consecutive months rule, does that come from the federal ACA rules?

Each state has its own way to handle irregular income.  My state they give it to you for a year block and you keep it until the annual date.

[DirtDiva]

I have Colorado Medicaid ("HealthFirst") and it has been seamless.  Same providers, same wait times, same referrals (I use the University for tertiary care).  No complaints.  Prescriptions cost $4/month each. 

I do worry a little about what people are thinking when they see Medicare (I also receive SSDI for metastatic cancer) and Medicaid as my payors. I live in a small town and I work a few hours a week at the hospital. 

I wouldn't recommend my route for receiving benefits. :/

[Trifle]

For those of you on Apple Health/Colorado Medicaid/other state Medicaid plans -- do you know if your state's program recoups Medicaid health insurance costs from your estate down the road?

Here in North Carolina, the state just expanded Medicaid.  My only real hesitancy to use the state Medicaid insurance is the possibility of estate recoupment later.  So far it looks like the state hasn't addressed the question. 

My understanding is that states are required to recoup Medicaid nursing home care from people's estates, and they are allowed to recoup other Medicaid expenses (like the health insurance).  My brother (who is under 55 y.o.) is a FIREee on Iowa Medicaid and just this year got the letter stating that there would be estate recoupment for his health insurance.   

 

[jim555]

"In other Medicaid expansion states with non-LTCR Medicaid estate recovery just prior to the ACA main provisions, such as Massachusetts,[8][21] New Jersey,[20] Iowa,[25] Nevada,[26] New Hampshire,[27][28] North Dakota,[29] Ohio,[30] Rhode Island,[31] Indiana,[32] Idaho,[53] Utah,[33] and Maryland,[34] as well as in the District of Columbia,[22] the recovery of non-LTCR persists. "

https://en.wikipedia.org/wiki/Medicaid_Estate_Recovery_Program

[Trifle]

Thanks for that link @jim555 — very interesting.  It seems that the states have very different philosophies on this.  My state has yet to say whether their current attitude of no recovery will change now with Medicaid expansion. 

After reading this article I still question what the hell is Iowa doing …  estate recovery is supposedly limited to people over 55.   But my brother is younger than that (he’s 52 now) and they still sent him the recovery notice letter.   

[kite]

Thanks for that link @jim555 — very interesting.  It seems that the states have very different philosophies on this.  My state has yet to say whether their current attitude of no recovery will change now with Medicaid expansion. 

After reading this article I still question what the hell is Iowa doing …  estate recovery is supposedly limited to people over 55.   But my brother is younger than that (he’s 52 now) and they still sent him the recovery notice letter.

States *MUST* recover from the estate for those recipients over age 55 who needed custodial care. They *MAY* recover assets for other Medicaid expenses from younger recipients.   

[CrustyBadger]

I'm confused - isn't there an asset test for Medicaid eligibility?

[jim555]

I'm confused - isn't there an asset test for Medicaid eligibility?

Traditional Medicaid (elderly, disabled, blind) does have an asset test is all states.

[Trifle]

Thanks for that link @jim555 — very interesting.  It seems that the states have very different philosophies on this.  My state has yet to say whether their current attitude of no recovery will change now with Medicaid expansion. 

After reading this article I still question what the hell Iowa is doing …  estate recovery is supposedly limited to people over 55.   But my brother is younger than that (he’s 52 now) and they still sent him the recovery notice letter.

States *MUST* recover from the estate for those recipients over age 55 who needed custodial care. They *MAY* recover assets for other Medicaid expenses from younger recipients.

Hmm.  I dug a little deeper and I don't think so . . . The Federal Medicaid office which permits the non nursing home recovery says:

"State Medicaid programs must recover certain Medicaid benefits paid on behalf of a Medicaid enrollee. For individuals age 55 or older, states are required to seek recovery of payments from the individual's estate for nursing facility services, home and community-based services, and related hospital and prescription drug services. States have the option to recover payments for all other Medicaid services provided to these individuals, except Medicare cost-sharing paid on behalf of Medicare Savings Program beneficiaries."  https://www.medicaid.gov/medicaid/eligibility/estate-recovery/index.html 

And Iowa's own estate recovery website says:

"Who does estate recovery impact?
Estate recovery only applies to Medicaid recipients who:
 Are age 55 or older, or
 Are under age 55 and live in a medical facility and will probably not return home."   
https://hhs.iowa.gov/media/8542/download?inline#:~:text=In%20Iowa%2C%20the%20estate%20recovery,will%20probably%20not%20return%20home.

Looks like the wider estate recovery is always supposed to be limited to over-55s.   From what I can see for under-55 y.o.s it's supposed to be limited to recovery of nursing home care costs, not health insurance.  I guess Iowa has gone rogue and decided to push the envelope.

Anyway, thanks for the input and sorry to derail the thread y'all.     

[jim555]

I believe the Federal law is 55 or older only for estate recovery.  54 or lower not subject to recovery.  I don't think states can do more than the Federal rules, but I'm no expert.

[kite]

Thanks for the clarification. Quite interesting.

We got the letter about my brother's estate. He was never in a nursing home. His chemo & radiation was probably well over a million.
There was so little in his bank account that it would have cost me more in postage and county probate office fees than the entire estate was worth. I'm not going to spend $200 to send $100 back to the state. They can just take it.



As it relates to my experience of his treatment under Medicaid, I would never select Medicaid if I could afford not to.  It's not a question of ethics. I'll pass no judgement about that. It's not a question of the quality care or treatment from providers themselves. The care he did receive once diagnosed was also great. No one treated him any differently face-to-face because he had Medicaid and there was nothing but the highest praise for doctors, nurses & hospitals, etc.

The issue is wait times and rejections.
It took months to get approval for a CT Scan when he had definite symptoms that cancer had returned. Palpable lump in the lymph node close to where the original tumor had been. When it was marble size - test denied. Walnut sized - test denied. Orange size - test denied. Finally about the size of a grapefruit and it was approved because it was forcing his head to one side and curving his neck.

Once approved, it takes longer to schedule as a Medicaid recipient. Wait again.

There is every indication it would have been curable when it was first felt. By the time it grew, surgery wasn't an option and immunotherapy only worked for so long. Even in those years, about half of all the scans the doctors ordered were rejected. Then at the end of his life when the tumor in his neck left him paralyzed I was once again begging CMS to approve the home health aide to which he should have been entitled. They told me there'd be another 30 day wait for a hearing. In the meantime he died.

If I didn't have other loved ones with the same disease but better insurance, I'd have no basis for comparison. But I do. Another relative with more superficial melanoma got PET scans regularly to check for recurrence, despite hers never being as advanced as his. I needed a CT Scan on the same area. Doctor ordered it and I was in the testing center within 30 minutes; no 6 month wait for me.  My brother had the same metastatic melanoma as Jimmy Carter.  President Carter's cancer spread to his liver & brain but was cured with immunotherapy.  The MRI of my brother's brain was denied. Retired federal employees can get an MRI.
Sure, my brother's med's were "Free" on Medicaid, but Medicaid also put a limit on the number of pills, covering about 1/4 of number of pain med's his doctors prescribed. Cancer death is brutal, messy and takes an unbelievable toll. Medicaid definitely helped to make things worse at random points along the way.

I try not to be paranoid, but if the thing that is giving you back pain is bile duct cancer or an abdominal aortic aneurism, delayed testing dictated by CMS as a matter of policy or because of the paltry number of Medicaid providers can mean the difference of a decade worth of living.  If you have the money for a gold plan, get a gold plan.

[jim555]

YMMV, I haven't found any problems getting scans or appointments.  I live in a doctor rich county of NY, so that may explain it.

[Trifle]

I'm so very sorry about your brother @kite.  That's terrible. 

[Davids]

My opinion is this, if you do qualify for it then take it. There is nothing illegal about what you are doing. So yes if you qualify for Medicaid even with a net worth close to $5M then take it.

[iluvzbeach]

I'm in the position of being able to qualify for medicaid, but I'm not sure that I want to be on medicaid, or the Oregon Health Plan as it's known here.

My concern is that in my rural location the number of available pcp providers is small, and after years of simply choosing the HSA plan and needing very little health care services, now I'm looking at needing at least one surgery, and possibly more.

I have been with my pcp for a number of years, but would have to change. I already have a referral for the first surgery, with my initial appointment in late December, so the surgery would be in 2024 and under  the auspices of whatever new coverage I have.
I'm concerned about switching coverage in the middle of this.

I'm looking at silver aca plans because of their lower max out of pocket compared to the high deductible HSA plan. I registered my income at Healthcare.gov as $2100 per month to realize a large subsidy. I'm not working much now (self employed carpenter) and I  can use Roth conversions to make up any shortfall to stay off medicaid.

I'm going to stop by my local hospital and talk to the folks that send the referrals on to the insurance companies and see which ones are the best at approving claims.

The company I've been with for my HSA plan has four different silver plans that are all virtually the same price, so I need to dig down and discover what the actual differences are. Or maybe go with a different provider.

I would actually like to use medicaid to save money on my upcoming expenses, but I fear the byzantine bureaucracy might drag it out longer. My goal is to recover enough to eventually return to work, since I enjoy it (and the money).

This forum ( this thread and others) has been very helpful to see what options folks are using, so thanks to all who contribute.

@sonofsven - IIRC, you live somewhere along the coast, but I'm not sure if it's on the northern coast, central or much further south.  Anyway, we're in the SW part of Oregon (just west of I-5) and one of our options is Moda.  We've been on Moda for all of 2023 and we've been very happy with it.  We intentionally manage our income to keep us at the silver level with the lower deductibles.  Our plan is the one with 6400 in the title.  We chose to sign up for it again for 2024 and our plan next year will be even better than what we've had this year.  We don't have many medical expenses but we've not had any difficulty whatsoever with getting prescriptions approved, we don't need referrals to see a specialist and they have been quick to process claims.  I have had melanoma twice, so I regularly see a dermatologist to ensure no further issues.  They haven't given me any issues about this and, again, have been quick to pay.  Our premiums (for DH & me) are less than $60/month and our deductibles this year were $750 each, but office visits (even the specialty docs) only cost us a co-pay amount.  We've been very happy with our plan; it's worth taking a look at, if it's one of your available options.


@kite It is absolutely horrifying what your brother had to go through.  I am so very sorry your family had to deal with such a terrible experience, on top of his illness to boot.

[sonofsven]

I'm in the position of being able to qualify for medicaid, but I'm not sure that I want to be on medicaid, or the Oregon Health Plan as it's known here.

My concern is that in my rural location the number of available pcp providers is small, and after years of simply choosing the HSA plan and needing very little health care services, now I'm looking at needing at least one surgery, and possibly more.

I have been with my pcp for a number of years, but would have to change. I already have a referral for the first surgery, with my initial appointment in late December, so the surgery would be in 2024 and under  the auspices of whatever new coverage I have.
I'm concerned about switching coverage in the middle of this.

I'm looking at silver aca plans because of their lower max out of pocket compared to the high deductible HSA plan. I registered my income at Healthcare.gov as $2100 per month to realize a large subsidy. I'm not working much now (self employed carpenter) and I  can use Roth conversions to make up any shortfall to stay off medicaid.

I'm going to stop by my local hospital and talk to the folks that send the referrals on to the insurance companies and see which ones are the best at approving claims.

The company I've been with for my HSA plan has four different silver plans that are all virtually the same price, so I need to dig down and discover what the actual differences are. Or maybe go with a different provider.

I would actually like to use medicaid to save money on my upcoming expenses, but I fear the byzantine bureaucracy might drag it out longer. My goal is to recover enough to eventually return to work, since I enjoy it (and the money).

This forum ( this thread and others) has been very helpful to see what options folks are using, so thanks to all who contribute.

@sonofsven - IIRC, you live somewhere along the coast, but I'm not sure if it's on the northern coast, central or much further south.  Anyway, we're in the SW part of Oregon (just west of I-5) and one of our options is Moda.  We've been on Moda for all of 2023 and we've been very happy with it.  We intentionally manage our income to keep us at the silver level with the lower deductibles.  Our plan is the one with 6400 in the title.  We chose to sign up for it again for 2024 and our plan next year will be even better than what we've had this year.  We don't have many medical expenses but we've not had any difficulty whatsoever with getting prescriptions approved, we don't need referrals to see a specialist and they have been quick to process claims.  I have had melanoma twice, so I regularly see a dermatologist to ensure no further issues.  They haven't given me any issues about this and, again, have been quick to pay.  Our premiums (for DH & me) are less than $60/month and our deductibles this year were $750 each, but office visits (even the specialty docs) only cost us a co-pay amount.  We've been very happy with our plan; it's worth taking a look at, if it's one of your available options.


@kite It is absolutely horrifying what your brother had to go through.  I am so very sorry your family had to deal with such a terrible experience, on top of his illness to boot.

I'm so far north I see another state from my house ;-)
Moda is who I've been using. I spoke with a "navigator" on the phone yesterday. They suggested Pacific Healthsource as they don't require referrals, so I'm looking into that option. My pcp, local hospital, and OHSU are all in network with both insurers

I was inputting different low incomes into the healthcare.gov site and looking at the results. It didn't change the HSA bronze plans at all, but there's pretty big consequences in the Silver plans regarding the maximum out of pocket costs. All these low income levels have a large subsidy on the cost of the premium, but the max oop changes drastically.
Example: at annual income estimate of $22k, just enough to stay out of medicaid, the premium subsidy is $987. On a Silver plan with CSR's, I'll use Moda as an example, the deductible is $1325 and the max oop is $3150.
On a $29k income, subsidy is $940, deductible is still $1325, max oop $3150
Change the income to $30k annually: subsidy is $932, deductible is now $5500 and max oop $7550, which is higher than the HSA plan I've been using.

I'm going to email the navigator this, but what happens if I estimate my income at $22k but it ends up closer to $30k? Can the insurer change my deductible and max oop after the fact?

[seattlecyclone]

Incomes can be unpredictable sometimes. There's no clawback of the CSRs if you happened to estimate a bit low. It has to be a real estimate though, not a lie.

[Jaybo]

For those of you on Apple Health/Colorado Medicaid/other state Medicaid plans -- do you know if your state's program recoups Medicaid health insurance costs from your estate down the road?

Here in North Carolina, the state just expanded Medicaid.  My only real hesitancy to use the state Medicaid insurance is the possibility of estate recoupment later.  So far it looks like the state hasn't addressed the question. 

My understanding is that states are required to recoup Medicaid nursing home care from people's estates, and they are allowed to recoup other Medicaid expenses (like the health insurance).  My brother (who is under 55 y.o.) is a FIREee on Iowa Medicaid and just this year got the letter stating that there would be estate recoupment for his health insurance.

No, there is no recoupment in any state.  In regards to long-term care which is under Medicaid but a completely different program, yes, the state is required to attempt to recoup funds used for long-term care once you pass.  But again, this does not apply to the medical/dental/vision coverage and ONLY applies IF near end of life you utilize Medicaid for long-term care.  In addition, in order to qualify for long-term care under Medicaid your estate will have to be damn near depleted to next-to-nothing anyway.

[Jaybo]

I see no issue in you taking it.  The Medicaid program was somewhat revamped when the Affordable Care Act was fully implemented and purposely did away with the means/asset testing.  Its paid for as a joint program between the Federal Government and the applicable state government.  For each adult on Medicaid the Federal Government pays 90% of the cost with the state paying 10%.  There is no set number of slots for people to be on Medicaid so it’s impossible for you to be taking it away from somebody else who needs it.  It’s designed to be a fluid system with people coming on to Medicaid each month and some people coming off of Medicaid each month.  I understand your wife’s trepidation; I was a marketplace Navigator back in the day and there was mass misunderstanding about how the program works; still is today. 

Bottom line, you’ve paid for this program through taxes since you started working; there’s nothing wrong with you utilizing a government program that exists for you to use and that you’ve been paying for.

[jim555]

...  The Medicaid program was somewhat revamped when the Affordable Care Act was fully implemented and purposely did away with the means/asset testing.  Its paid for as a joint program between the Federal Government and the applicable state government.  For each adult on Medicaid the Federal Government pays 90% of the cost with the state paying 10%.  ...

This is only true for the expansion group, there is still a resource test for elderly Medicaid in all states (except CA), and the Feds only pay 90% for the expansion group, around 50% for elderly (Traditional) Medicaid.

[Trifle]

For those of you on Apple Health/Colorado Medicaid/other state Medicaid plans -- do you know if your state's program recoups Medicaid health insurance costs from your estate down the road?

Here in North Carolina, the state just expanded Medicaid.  My only real hesitancy to use the state Medicaid insurance is the possibility of estate recoupment later.  So far it looks like the state hasn't addressed the question. 

My understanding is that states are required to recoup Medicaid nursing home care from people's estates, and they are allowed to recoup other Medicaid expenses (like the health insurance).  My brother (who is under 55 y.o.) is a FIREee on Iowa Medicaid and just this year got the letter stating that there would be estate recoupment for his health insurance.

No, there is no recoupment in any state.  In regards to long-term care which is under Medicaid but a completely different program, yes, the state is required to attempt to recoup funds used for long-term care once you pass.  But again, this does not apply to the medical/dental/vision coverage and ONLY applies IF near end of life you utilize Medicaid for long-term care.  In addition, in order to qualify for long-term care under Medicaid your estate will have to be damn near depleted to next-to-nothing anyway.

That's not accurate @Jaybo.  States ARE allowed to recoup Medicaid costs beyond long term care and there are about a dozen states doing it.  They are recouping for Medicaid health care coverage and expenses.  Usually that's for over-55s, but I know for a fact at least one state (Iowa) is recouping the health care coverage for able-bodied under-55s.  (My brother lives there, is FIREd, on Medicaid, and was notified by the state of the recoupment).  Not sure how far under age 55 they are going; maybe it's everyone. 

Check out this article which @jim555 linked to above:  https://en.wikipedia.org/wiki/Medicaid_Estate_Recovery_Program

[ender]

You can't be on ACA with subsidies if you qualify for Medicaid.  You will have to increase your income  or get a Medicaid rejection letter if you want to not qualify. Also Medicaid costs the taxpayers less than paying subsidies for you to be on aca through a third party insurer.  I don't really understand why one is considered somehow shameful and the other not.

https://pnhp.org/news/aca-subsidies-cost-more-per-person-than-medicaid/

"The CBO’s latest projections from earlier this year show government paying out an average of $6,300 annually for every subsidized enrollee in fiscal 2018. It estimates that number will rise to nearly $12,500 in 2028. In contrast, Medicaid spends $4,230 per non-disabled adult, set to inflate at 5.2% annually to just over $7,000 per person in 2028."

Something I would definitely consider in this comparison is the growing number of medical providers no longer accepting medicaid patients because of medicaid basically doesn't pay enough to even break even.