Should we do Medicaid moving forward

[doneby35]

Note: I’m FIRE’d and the only income considered is from dividends, interest, capital gains and IRA conversions.

My wife and I are currently using ACA for health insurance. It’s pretty affordable as it costs $60/month for both of us for a silver plan with a family deductible of $1400 and out of pocket max of $6000.

Starting next year, my core living expenses are going to drop to $15k/year and I’m planning another 10k for any wants and desires. So we’ll definitely be under 138% FPL (in a state that has expanded Medicaid) for a couple to be eligible for Medicaid.

My questions are:
1. Is Medicaid free? Are there any deductibles or out of pocket max?
2. Does a state that has expanded Medicaid mean that we wouldn’t have an issue finding doctors and medical facilities accepting Medicaid? Would I be restricted in choosing doctors?
3. Is there any reason someone who is eligible for Medicaid to go with ACA instead?
4. I believe I read somewhere that you report income on a monthly basis? Is this correct? If so, as long as monthly income does is between 0 and 138% FPL, then we are good for that month?

[lhamo]

I have been on Medicaid in Washington State (it's called Apple Health here) pretty much since 2016 (had a 3 month period where we had to go on ACA due to our son's tech internship salary -- he was still living at home at the time).

The way it works here is you pay $0 for covered services, which is pretty much everything -- including mental health services (if you can find a provider).  I've had cataract surgeries in both eyes, another eye surgery to repair a retinal tear, and a Mohs procedure to remove a basal cell carcinoma -- didn't pay anything out of pocket for any of them.  I had a scare with the skin cancer thing because the provider didn't code something correctly and I thought I might be on the hook for not getting pre-approval, but it ended up being on them. 

I use a plan provider that contracts with the largest local medical practice (UW Medicine) and includes most of the specialty clinics at the biggest regional hospital (Harborview).  Here in Seattle there doesn't seem to be a huge issue with accessing care -- at least no more serious than any other person using an insurance network.  If anything, I think I may have MORE choices with Medicaid coverage than with a PPO or Kaiser.  But Seattle may be unusual so you will want to research what facilities are available to you in your state/city.

I can get an eye exam every other year -- glasses didn't used to be covered for adults, but  they recently added Zenni and you can get one free pair from them (limited frame options).

They only cover dental cleanings once every 12 months.  I should be getting them every 3-4 months, so that is something I might eventually start paying out of pocket for.

YOu can get Amazon gift cards for certain preventative care procedures -- many of them are for kids.  Women can get one for mammograms and certain other tests.

Here in Washington, once you qualify for Medicaid they will NOT kick you off if you have a one month jump in income, say cashing in LTCG or withdrawing a large lump sum from traditional retirement accounts.  You have to report if your income goes up significantly two months in a row.  And you don't want to take large bumps in income in the two months prior to your renewal period. 

I have verified all of this time and time again with our Healthcare Navigator, who I have been working with since 2016. Was expecting to have to sign up for an ACA plan in 2017 when we sold our condo in Beijing and had a HUGE capital gain, but she verified with the state that income bumps in a single month don't count. 

For those that might bristle at this, I'm probably actually saving the taxpayers money by being on medicaid as opposed to taking a large ACA subsidy.  I don't take prescription meds and even with my surgeries my healthcare costs probably average under $200/month.

[frugalnacho]

Note: I’m FIRE’d and the only income considered is from dividends, interest, capital gains and IRA conversions.

My wife and I are currently using ACA for health insurance. It’s pretty affordable as it costs $60/month for both of us for a silver plan with a family deductible of $1400 and out of pocket max of $6000.

Starting next year, my core living expenses are going to drop to $15k/year and I’m planning another 10k for any wants and desires. So we’ll definitely be under 138% FPL (in a state that has expanded Medicaid) for a couple to be eligible for Medicaid.

My questions are:
1. Is Medicaid free? Are there any deductibles or out of pocket max?
2. Does a state that has expanded Medicaid mean that we wouldn’t have an issue finding doctors and medical facilities accepting Medicaid? Would I be restricted in choosing doctors?
3. Is there any reason someone who is eligible for Medicaid to go with ACA instead?
4. I believe I read somewhere that you report income on a monthly basis? Is this correct? If so, as long as monthly income does is between 0 and 138% FPL, then we are good for that month?

I am in Michigan.  I quit my job January 2021 and started a business.  I have not taken a salary yet, and have been dumping all our earnings right back into expenses for the business, so I've had basically no income from then until now.  I've been on Medicaid that entire time.

1. Yes it's free.  There are some nominal cost sharing copays for people in the higher end of the bracket, but our care has been literally 100% free.
2. It's a smaller pool of available doctors, and you probably won't get your perfect choice.  But you will be able to find someone.  We had to change pediatricians, and I had to change my doctor, and I had to change my specialists, but we did find everything we need and get all the care we needed.  My son has had some medical issues and has needed to see a number of doctors and specialists, and some of them have been a little difficult to find and coordinate. But the price has been very right.
3. You likely can't.  If you qualify for Medicaid then you are ineligible for any ACA subsidies.  It's either Medicaid or full price market plans.  Or engineer your income to be where you want to qualify for ACA subsidies (while simultaneously NOT qualifying you for medicaid during any individual months).
4. My experience was that I reported my income as close to zero for the entire year.  Once I was accepted into the system I only had to report substantial changes in income.

It was a bureaucratic nightmare dealing with them initially, and again 2 years later for my renewal when I lost coverage for 2 months.  I documented my frustrations in real time in these threads:

https://forum.mrmoneymustache.com/ask-a-mustachian/help-understanding-aca-subsidies-and-medicaidchip/

https://forum.mrmoneymustache.com/ask-a-mustachian/understanding-aca-subsidies-and-income/

I apparently never updated the last thread, but the application was approved.  We were without coverage for 2 months, but the coverage was made retroactive, so we were able to recoup most of the money spent at urgent care and doctors visits during that period.

[Sanitary Stache]

I’ve been on Medicaid in my state for a month so far. We’ve had one emergency room visit and there was no cost. We had a dentist visit and found that our dentist is not in Network for Medicaid so we are planning to buy separate dental insurance on the market, which my Medicaid contact person said is possible. There are dentists that take Medicaid but we’ve had such a hard time finding a dentist we like that we are willing to pay to stay with them.

I had to buy bandages out of pocket after the ER visit, but I wasn’t expecting health insurance to cover bandages. Maybe if I had asked the ER for more when we were leaving?

I had an interview with a Medicaid person after signing up where all of my questions about providers were answered. This person seemed to be on top of which providers accept Medicaid and I feel good about calling them back with any questions. 

My income will go up in September. It I think it will stay in the Medicaid range. I do feel a slight pull to not earn too much in a season so that I don’t have to keep switching insurance coverage. As I plan to work seasonally.

[doneby35]

Great info from everyone. Sounds like Medicaid is the way to go, unless you are picky with doctors. Thanks!

[lhamo]

For anyone else who is considering this, a point to remember:

If you try your state's Medicaid program and find out it doesn't work well for you or your family, you can always just manufacture two months of income that puts you over the monthly Medicaid income limits.  You should then be able to switch over to an ACA plan due to the change in income.

[doneby35]

For anyone else who is considering this, a point to remember:

If you try your state's Medicaid program and find out it doesn't work well for you or your family, you can always just manufacture two months of income that puts you over the monthly Medicaid income limits.  You should then be able to switch over to an ACA plan due to the change in income.

Does that mean that if the max annual income to qualify for Medicaid was 20k, divided by 12 months equals $1666 per month, so I’ll need to show 2 months of let’s say $1700 income?

[yachi]

For anyone else who is considering this, a point to remember:

If you try your state's Medicaid program and find out it doesn't work well for you or your family, you can always just manufacture two months of income that puts you over the monthly Medicaid income limits.  You should then be able to switch over to an ACA plan due to the change in income.

Does that mean that if the max annual income to qualify for Medicaid was 20k, divided by 12 months equals $1666 per month, so I’ll need to show 2 months of let’s say $1700 income?

You have the math correct, but Medicaid is a *Monthly* program.  There really isn't an annual income that allows you to qualify, as it's based on your monthly income.

So,
If the max monthly income to qualify for Medicaid was $1666, you'll need to show 2 months of let's say $1700 income.

But you'd likely want to be over by more than just $34.   Maybe to get some Roth conversions to save in future taxes, or just to ensure you're set to be taken seriously in the ACA application. 

By the way, if someone paid biweekly is right at the max income based on 26 paychecks divided by 12 months.  Then 2 months out of the year they will be above the monthly max.  That's because most months will have 2 paychecks, but 2 months have 3 paychecks in them.  We used to call these bonus paychecks at one of my jobs.  Luckily for working people on Medicaid, those two months are never sequential.

[doneby35]

For anyone else who is considering this, a point to remember:

If you try your state's Medicaid program and find out it doesn't work well for you or your family, you can always just manufacture two months of income that puts you over the monthly Medicaid income limits.  You should then be able to switch over to an ACA plan due to the change in income.

Does that mean that if the max annual income to qualify for Medicaid was 20k, divided by 12 months equals $1666 per month, so I’ll need to show 2 months of let’s say $1700 income?

You have the math correct, but Medicaid is a *Monthly* program.  There really isn't an annual income that allows you to qualify, as it's based on your monthly income.

So,
If the max monthly income to qualify for Medicaid was $1666, you'll need to show 2 months of let's say $1700 income.

But you'd likely want to be over by more than just $34.   Maybe to get some Roth conversions to save in future taxes, or just to ensure you're set to be taken seriously in the ACA application. 

That’s good to know, I’ll keep that in mind. I do have some chronic issues and since some people have a negative view of Medicaid, I’m not so sure how I feel about it, but I guess it would make sense to enroll, and if it does not work as well as the ACA plans, then create some taxable income for a couple of months.

[jim555]

1. Is Medicaid free? Are there any deductibles or out of pocket max?
Yes.  Max OOP per year is $200, includes small co-pays for Rx $1 or $3.

2. Does a state that has expanded Medicaid mean that we wouldn’t have an issue finding doctors and medical facilities accepting Medicaid? Would I be restricted in choosing doctors?
Depends on your state.  All the doctors from my work plan are in the managed care plans in my area.

3. Is there any reason someone who is eligible for Medicaid to go with ACA instead?
If your doctor is in ACA and not in any Medicaid plans.

4. I believe I read somewhere that you report income on a monthly basis? Is this correct? If so, as long as monthly income does is between 0 and 138% FPL, then we are good for that month?
In my state it does 12 continuous months of coverage so high months don't knock you off.  $1,732 is the current limit for MAGI Medicaid house of 1.

[BuffaloStache]

This thread has me intrigued, so I'm posting to follow but also ask a follow-up question.

Many folks above mention a "Medicaid person" or a "Healthcare Navigator". How did you all go about finding one? I've heard stories of scams and people that were dragged through hell because they signed up with disreputable people that were supposed to help them. Do you pay these "Healthcare Navigator"s? Are there any certifications or something that you should look for when trying to find one?

...And oddly, because I just thought of this- would being a "Healthcare Navigator" be a good part-time/Coast type job?

[jim555]

There are actual valid navigators and then you have sharks who are insurance salesmen.  Honestly, just stick to the official websites and DIY.

[lhamo]

I am the person constantly harping about the benefits of Healthcare Navigators. 

Here in Washington state, you can find them through the ACA/Medicaid signup platform (Washington Healthplan Finder).  Here is the page that came up when I looked for mine (used her employer, which is a chain of low income health clinics in Seattle):

https://www.wahealthplanfinder.org/HBEWeb/Annon_DisplayBrokerNavigatorSearch.action;jsessionid=0jO49HhiqDxi2PVqI32MWLXph_O0LFydxd4_tPJO.hbeapp-76bf87f767-9h429

[doneby35]

I’ve also been reading that what Medicaid pays to doctors is extremely low, compared to ACA, that’s why a lot of doctors don’t accept Medicaid because it does not cover their costs.
This website shows acceptability percentages by state, it’s a little outdated though (2017).
https://www.shadac.org/news/14-17-physician-Mcaid-SHC

It seems that based on what I’m reading, even if a doctor accepts Medicaid, they prefer patients with private insurance instead, so they rarely take Medicaid patients.

[jim555]

I have noticed no difference in how I am treated.  If the office takes the plan they take it.  I doubt my docs even know what plan I have.

[frugalnacho]

I second that there is no difference in how I'm treated. 

[doneby35]

That’s good to know. I had concerns that if I was toncall a certain place to schedule an appointment and they know I’m on Medicaid, then either they would say they have no availability anytime soon or provide worse service

[jim555]

That’s good to know. I had concerns that if I was toncall a certain place to schedule an appointment and they know I’m on Medicaid, then either they would say they have no availability anytime soon or provide worse service

Managed Care plans run most Medicaid these days.  Providers agree to be in these plans.  The list is published by the MCO and sometimes a state will have a search site for them.

[yachi]

That’s good to know. I had concerns that if I was toncall a certain place to schedule an appointment and they know I’m on Medicaid, then either they would say they have no availability anytime soon or provide worse service

I can say that my daughter's therapist covers only a level above medicaid.  For us it means she's on a program called CHIP.  So it's important to us to keep her with the same person.  But also, even though our spending rate is below Medicaid, our income is not.  I had too low a taxable account balance when I FIRED, so I'm doing some extra IRA conversions.

[doneby35]

That’s good to know. I had concerns that if I was toncall a certain place to schedule an appointment and they know I’m on Medicaid, then either they would say they have no availability anytime soon or provide worse service

I can say that my daughter's therapist covers only a level above medicaid.  For us it means she's on a program called CHIP.  So it's important to us to keep her with the same person.  But also, even though our spending rate is below Medicaid, our income is not.  I had too low a taxable account balance when I FIRED, so I'm doing some extra IRA conversions.

I’m estimating 10k/year from dividends and any capital gains, that will leave me with 18k or so for the annual Roth IRA conversion to stay under the Medicaid limit. I can do bigger IRA conversions if I go with ACA and no monthly premiums (but will still have OOP max of $6000), so I’ll have to evaluate which one would be better long term.

[yachi]

That’s good to know. I had concerns that if I was toncall a certain place to schedule an appointment and they know I’m on Medicaid, then either they would say they have no availability anytime soon or provide worse service

I can say that my daughter's therapist covers only a level above medicaid.  For us it means she's on a program called CHIP.  So it's important to us to keep her with the same person.  But also, even though our spending rate is below Medicaid, our income is not.  I had too low a taxable account balance when I FIRED, so I'm doing some extra IRA conversions.

I’m estimating 10k/year from dividends and any capital gains, that will leave me with 18k or so for the annual Roth IRA conversion to stay under the Medicaid limit. I can do bigger IRA conversions if I go with ACA and no monthly premiums (but will still have OOP max of $6000), so I’ll have to evaluate which one would be better long term.

I had a plan while working where there was no conceivable way to meet the OOP max because once the deductible was met, the plan covered 100% (no coinsurance) except for a $20 or so per visit copay.  I wouldn't have imagined a plan like that existing if I didn't experience it myself.  It was a HDHP so we were on the hook for most everything until the deductible though.

[doneby35]

That’s good to know. I had concerns that if I was toncall a certain place to schedule an appointment and they know I’m on Medicaid, then either they would say they have no availability anytime soon or provide worse service

I can say that my daughter's therapist covers only a level above medicaid.  For us it means she's on a program called CHIP.  So it's important to us to keep her with the same person.  But also, even though our spending rate is below Medicaid, our income is not.  I had too low a taxable account balance when I FIRED, so I'm doing some extra IRA conversions.

I’m estimating 10k/year from dividends and any capital gains, that will leave me with 18k or so for the annual Roth IRA conversion to stay under the Medicaid limit. I can do bigger IRA conversions if I go with ACA and no monthly premiums (but will still have OOP max of $6000), so I’ll have to evaluate which one would be better long term.

I had a plan while working where there was no conceivable way to meet the OOP max because once the deductible was met, the plan covered 100% (no coinsurance) except for a $20 or so per visit copay.  I wouldn't have imagined a plan like that existing if I didn't experience it myself.  It was a HDHP so we were on the hook for most everything until the deductible though.

That would’ve been great, the only silver plans I see in the marketplace with no monthly premium and the max cost sharing subsidies bring the deductible down to $700/$1400 for individual/family, covering 80% after deductible is reached and then OOP of $3000/$6000.

[Telecaster]

For those that might bristle at this, I'm probably actually saving the taxpayers money by being on medicaid as opposed to taking a large ACA subsidy. 

Yep, this came out during ACA legislative process.   Republicans opposed the Medicaid expansion because it was cheaper than private insurance.  The worry is that the gummit would take over health care instead of those nice insurance company execs.