Author Topic: Case Study - FIREed, Nomadic, Pregnant: Picking Health, Drawdown (and Life) Plan  (Read 11309 times)

CanuckExpat

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Overview: Recently FI/RE'd and want to harvest the collective wisdom here to analyse and critique our draw down strategy, immediate health care plans and how they will interact. Please help me with brainstorming, pointing out anything I missed, and making sure I understand the situation fully in terms of financial implications and possible optimizations.

Background: Wife (34) and I (33) quit our jobs earlier this year and we are travelling through the USA and Canada in an RV. We have a son (2) and it appears my wife is pregnant (to be confirmed) and expecting next summer. Healthcare will be important through her delivery, and ideally it would be nice, but not necessary, to have health insurance that would cover us as we move around the US.

Currently, all three of us are covered under my wife's employer plan through the end of 2016, in January we have the option of continuing that under COBRA, or finding new insurance. Our last fixed address was in California but we don't currently plan to physically return to California anytime before my wife gives birth. We anticipate that as part of selecting a health plan we will choose our state of domicile strategically. We are Canadian citizens, and US permanent residents of less than five years, I note that as it can affect healthcare options, namely Medicaid, on a state by state basis.

Estimated Expenses: $40,000, but we're not really sure. We have sufficient cash cushion, taxable investment account balance, and Roth principal to meet this amount for several years as long as our ballpark estimate of expenses is not totally off. So our "income" can be optimized for tax and health subsidy optimization and not driven by our expenses.

Relevant Assets and Estimated Income: Estimate baseline $20,000 - 25,000 Gross Income as follows.
$200,000 in cash. At 1% average interest, I expect this will generate $2000 interest income.
$500,000 taxable investment account, essentially Total US and Total International with small and value tilt (approximate as VTSAX and VTIAX even split). Assuming 2.5% average yield, I estimate $13,000 dividend income
No plans for serious earned income, but allow buffer of $5,000 - 10,000 for other income, which can as needed be filled in with Roth conversions or capital gains as required for some time.

Other assets:
$300,000 in pretax 401k and IRA which can be converted to Roth to generate income as required (and provide spending money in five years).
$100,000 in Roth (mainly principal) and HSA which can be tapped if tax free income is needed, but I do not anticipate doing this and currently plan to spend down cash cushion and taxable first.

Note: Large cash balance is due to sale of principal residence. If we settle down, we may use this towards purchasing a new residence in the future, otherwise currently plan to spend down cash buffer without replenishing, as a lazy approximation to rising equity glide-path <-- Question: Reasonable strategy for cash buffer?

Note: Taxable investment account is mainly principal, less than $50,000 of capital gains. Provides a ceiling on taxes from liquidating investment account holdings and room for tax gain harvesting.

For ease of reference, the relevant Federal Poverty Level for a family of three and four is approximately $20,000 and $24,000 for calculating ACA subsidies, etc.

Current Assumptions:
1) If wife is indeed pregnant, we will be heavy healthcare users next year with prenatal care and delivery costs meeting out of pocket maximum on any chosen healthcare plan. I'll estimate costs as total of premiums for year + out of pocket maximum. Is it most sensible to minimize gross income in order to either qualify for medicaid if desired, or maximize ACA subsidies and cost sharing, or are there other tax optimizations we miss out on by going that route?

2) We can and will choose to remain relatively mobile until three months before delivery date. Starting in April 2017, we stay at fixed location through delivery. This will be period of highest healthcare utilization, assuming healthy pregnancy before.

3) Since we have essentially broken all ties with California, we can and will choose state (or country) of domicile based on health care choices and/or where we would like birth to happen. I estimate $500 in costs for taking up new state of domicile (driver and vehicle registration, any notarization, mail forwarding, etc).

4) Not sure if ACA marketplace would accept our stated low income given that previous years tax returns shows high income. If not accepted, tax credits would be reconciled when we filed taxes, but cost sharing reduction would be lost, making ACA plans much less appealing. Perhaps same problem with medicaid, and they have 30-60 days before acceptance or not is known.

Considerations:
1) We haven't decided where delivery location will be. This will impact healthcare options greatly, but we have no strong criteria to pick that location yet. Western NY is the only current contender as it is close to home, we have family in the area, and by April the weather shouldn't be horrible. No strong attachment to this choice though.

2) Given consideration 1, and our desire to be mobile, a nationwide PPO plan with large selection of doctors would be ideal. These tend to be expensive, not readily available on the ACA marketplace, and I am nervous that we would pick one and then find out certain doctors or out of state care is not really covered.

3) At our proposed income levels, and given wife's pregnancy, it may be hard to avoid Medicaid eligibility. This might be a fine option, but would give us no out of state coverage, and enrolling might require more bureaucracy.

4) We are mainly looking at giving birth in the US, but Canada (and Mexico less so) are also options. This would affect future child's citizenship possibly, and maybe raise questions about our residency if we have to explain on re-entry that yes we're permanent US residents but decided to give birth outside of the country because we are retired, lazy, cheap and find navigating the US healthcare expensive and frustrating.

5) If we need to change healthcare mid-year, we have a lot of flexibility to generate a life event: take up a new state of domicile, generate income to take us from Medicaid to ACA, etc. But this would be cumbersome and expensive, prefer to pick plan and not change it.

Current Health Care Options:
1) Maintain current insurance at COBRA rates. Very expensive. Cost for 2017: $23,000. It is nationwide PPO, should have no problems finding providers in any state. Paperwork should be minimal, no need to change state of domicile.
Easiest option, but price is not appealing.


2) Currently can not find ACA subsidized PPO with nationwide network available on California marketplace. Any suggestions? Would avoid hassle of changing state of domicile, while having reduced costs due to premium tax subsidies.

3) Establish domicile in NY state and enroll in NY Essential (ACA basic plan) and/or NY Medicaid plans in county we would plan to give birth. Cost for 2017: $200 - $2,000. At proposed income levels, would be close to free care. No care out of state except emergencies. Some questions of establishing eligibility since we are going from high income year to low income year. NY is in immediate travel plans, having family in area would make establishing domicile easier
Open question: verify eligibility
Open question: verify if can enroll while still on current insurance, to expedite approval, or must we wait until Jan 1st

4) Establish domicile in FL, enroll in EPO which appears to have nationwide network: Florida Blue (BlueCross BlueShield FL) · BlueSelect Silver 1456C for example. Cost for 2017: $2,200. This has been recommended as ACA subsidized alternative to nationwide PPO. I have some concerns if we later can't find a provider out of state (don't intend on delivering in FL). FL was on travel plans, until pregnancy, now not sure due to Zika and all. Florida is popular state for RV'ers to domicile, and as such there exist more services that could help with establishing domicile, providing an address, and mail forwarding all in one.

5) Any state in the approximate NY - FL area I'm missing that would be worth establishing domicile, either for ACA market with nationwide network, or good local health plan and that would be a cool place to hang out starting in April and then deliver baby in?

6) Say fuck-it. Establish residency in a Canadian province of our choosing, meet minimal physical requirement to qualify for healthcare, and deliver for essentially free. I understand requirements easily, bureaucracy should be minimal as is cost, finding participate provider problem, balance billing, all those problems disappear. Possibly not provide US citizenship for future child. Physical presence requirements would mean spending most of winter in Canadian province. Was not in our travel plans. Might provide problems with our US residency, but could be worked around. Some locations in Canada would provide us strong network of friends/family/etc at time of birth. We probably plan on establishing Canadian tax residency anyways for other reasons so no added cost, but being eligible for healthcare would have added physical presence requirement.

7) Say fuck-it. Deliver in Mexico and pay cash. Mexico was tentatively in original travel plans, but mainly scrapped due to pregnancy, so probably not considering this option. Would be fun and interesting, language, Zika, and residency issues aside. Child might end up with triple citizenship which would be kind of neat.

Questions
1) Is my understanding of healthcare options, medicaid, vs nationwide PPO, and cost/benefit trade-offs about right? Several open questions on optimizing income for ACA subsidizes based on chosen health plan

2) Draw down plan reasonable?: spend cash buffer first, then brokerage account. Is there anything I might be missing with that. For example, I recently got curious about earned income tax credit, but we would not be eligible due to investment income, spending down taxable account faster would deal with that..

3) General input and feedback? Should I be considering anything otherwise in our draw down plan or for healthcare?

This is all kind of a moving target, I appreciate the help in brainstorming.

Edited to fix multiple typos
Edited to update income/asset numbers
Edited to rule out non-US healthcare options
Edited with updates
« Last Edit: December 30, 2016, 12:17:06 AM by CanuckExpat »

Dicey

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What about other countries with both sophisticated and relatively inexpensive healthcare? I'm thinking Asia, but have no personal experience. Surely there are medical arbitrage experts here in forumland. Go Curry Cracker comes to mind; have you devoured his blog yet?

Anatidae V

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Arebelspy had his kid somewhere in Europe. Also, on the baby thread someone was gushing about a zero-cost medical cover in a particular Canadian provinces, but I can't remember which one.

Rubic

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Arebelspy had his kid somewhere in Europe.

Istanbul, Turkey.  From the podcast with MadFientist, I recall the medical costs
were $4000.

KCM5

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If I were you, as I can see you've discussed, I'd try pretty hard to give birth in the US only because I hate dealing with USCIS so much. Given that it appears that you would like to be able to easily live in the US in the future, that's pretty valuable.

I have no other advice, though. Since you've done the research on New York it looks like a good option. Rent a sweet cabin in Dec to start establishing residency, spend the winter skiing (maybe not the female half so much?), and give birth in the summer.

CanuckExpat

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If I were you, as I can see you've discussed, I'd try pretty hard to give birth in the US only because I hate dealing with USCIS so much. Given that it appears that you would like to be able to easily live in the US in the future, that's pretty valuable.

This is unfortunately a big consideration for us, and part of the reason we'd mainly only consider USA, Canada, and Mexico, roughly in that order.

If push comes to shove, the US has a "commuter" program which allows one to live in either Canada or Mexico while maintaining permanent residency, that benefit is not extended to other countries. Even the commuter program is more hassle then we'd ideally like to encounter, but at least it is good to know it's there.

(The dogs also make other long term international travel a pain, but for now let's blame USCIS)

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Dogs are a valid consideration.

Personally, I'd go the NY option. Family, possibility of Medicaid, etc.

seattlecyclone

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$500,000 taxable investment account, essentially Total US and Total International with small and value tilt (approximate as VTSAX and VTIAX even split). Assuming 3% average yield, I estimate $15,000 dividend income <-- Question: assuming too aggressive yield?

VTSAX yields right around 2%, VTIAX is nearly 3%. Given your even split between the two, I'd probably assume 2.5%.

Quote
$100,000 in Roth (mainly principal) and HSA which can be tapped if tax free income is needed, but I do not anticipate doing this and currently plan to spend down cash cushion and taxable first. <-- Question: Large portion of Roth balance is from "mega back door Roth", once turned into Roth IRA, can it be spent immediately if desired, or do we wait five years as for conversion?

This went straight from your after-tax 401(k) to your Roth IRA? The way it works is that this money counts as a conversion. The ordering for Roth IRA withdrawals is direct contributions come out first, then conversions (oldest first), then earnings. When you withdraw conversions less than five years old, you owe the 10% early withdrawal tax on any part of that money you paid tax on when you converted it. For the mega backdoor Roth, this amount should be relatively minimal. You paid tax on the principal when it went in the 401(k). The only part subject to the early withdrawal tax would be any growth that happened within the after-tax 401(k) before you moved the money to the IRA.

Quote
Note: Large cash balance is due to sale of principal residence. If we settle down, we may use this towards purchasing a new residence in the future, otherwise currently plan to spend down cash buffer without replenishing, as a lazy approximation to rising equity glide-path <-- Question: Reasonable strategy for cash buffer?

Seems rather conservative but reasonable. You might want to consider buying some Series I savings bonds; the latest interest rates are much more favorable than a savings account. Limit $10k in purchases per person per year.

Quote
1) Is my understanding of healthcare options, medicaid, vs nationwide PPO, and cost/benefit trade-offs about right? Several open questions on optimizing income for ACA subsidizes based on chosen health plan

Looks like you've done your research. All these options vary so much by state, so there's a lot to wade through. Do you know what income level triggers Medicaid for pregnant women? I know we were talking about that in your other thread. The cost sharing subsidies below 200% of the poverty line seem very worthwhile to get if you can make it work, but I don't know if that triggers Medicaid or not. And it sounds like Medicaid makes travel harder due to restrictions on out-of-state care, so you might then have to choose between manufacturing some income to qualify for a more expensive ACA plan that lets you keep your mobility or settling down for a few months somewhere to get some free Medicaid coverage.

Quote
2) Draw down plan reasonable?: spend cash buffer first, then brokerage account. Is there anything I might be missing with that. For example, I recently got curious about earned income tax credit, but we would not be eligible due to investment income, spending down taxable account faster would deal with that..

I'd say forget about the EITC. It requires investment income to be below $3,450, which even at a 2% dividend yield means you need to have less than $172,500 invested. It will take you some years to draw down your taxable account that much. Or you could convert it all to cash, but that hardly seems like a good tradeoff. I guess if you really want the credit you could look into buying a rental house or two, and hoping the depreciation gives you a loss on paper.

jim555

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NY Medicaid and Essential plans have no open enrollment periods, you can get it as soon as you domicile.  Medicaid is $200 max OOP per year.  The ACA should be around through 2017 at least.
Also do you have to worry about the citizenship of the baby as far as birth location?  I would try to get US and Canadian citizenship for the baby.
NY doesn't seem like it is too rigorous on proving an income estimate unlike the regular Fed website.
Medicaid is based on current monthly income which is annualized.  So if you had a windfall of say $50,000 last month it should not be included in your estimate because it was last month.  Only current monthly income counts.  NY does an annual redetermination so fluctuations in income do not trigger a churn, being pushed back to a ACA plan.

You mentioned Silver cost sharing is is reconciled at the end of the year.  This is not the case.  The CSRs are not reconciled, only the premium subsidy based on yearly income, and that is capped to certain max amounts.

Fortunately NY does not require a 5 year waiting period for Medicaid eligibility (for pregnant women and children) for lawfully present (green card) holders.
« Last Edit: November 18, 2016, 06:20:28 PM by jim555 »

Paul der Krake

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I second the idea of avoiding filing paperwork with USCIS at all if possible. If you had to put a dollar value on not having to do it, take the filing fees and multiply by 2 or 3.

CanuckExpat

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VTSAX yields right around 2%, VTIAX is nearly 3%. Given your even split between the two, I'd probably assume 2.5%.

Thanks. For some reason I was having trouble finding the yield for VTIAX. I was over estimating, assuming it wouldn't be larger than the buffer I left for unplanned earned income. I'll update that in the original post, along with some other numbers I double checked.

Quote
This went straight from your after-tax 401(k) to your Roth IRA? The way it works is that this money counts as a conversion. The ordering for Roth IRA withdrawals is direct contributions come out first, then conversions (oldest first), then earnings. When you withdraw conversions less than five years old, you owe the 10% early withdrawal tax on any part of that money you paid tax on when you converted it. For the mega backdoor Roth, this amount should be relatively minimal. You paid tax on the principal when it went in the 401(k). The only part subject to the early withdrawal tax would be any growth that happened within the after-tax 401(k) before you moved the money to the IRA.

The money is still in wife's after-tax 401(k), to be rolled over next tax year (January 2017). Her employer plan indicated that they track contributions and gains in after-tax 401(k) separately and would allow her to split the rollover so that contributions can be sent to a Roth IRA and gains sent to a traditional IRA. That seemed ideal, and assuming they actually will allow that, we are waiting until next year to do the rollover as she performed a backdoor Roth this year and thus would not want any funds in a traditional IRA at the end of the tax year.

If I'm understanding you correct, and the split rollover is allowed, then it appears that we would be able to withdraw her rolled over mega-backdoor-Roth funds tax free without waiting the five years if we needed (after withdrawing her original contributions, which should also be withdrawn tax free).

Also, if I am reading that correct, it appears the ordering of rollovers will be important for us: roll after tax 401k funds before any traditional IRA rollovers. That is good to keep in mind. Thank you.

Is the record keeping for all of us this on us, or does the information get transmitted along from 401k provider to IRA/Roth account automatically?

Quote
Seems rather conservative but reasonable. You might want to consider buying some Series I savings bonds; the latest interest rates are much more favorable than a savings account. Limit $10k in purchases per person per year.
Agree with conservative, but don't mind paying a bit of a price for sleeping at night.
I've already maxed out my I bond allotment in the spring, wife has her purchase scheduled this month for the fall period. The original plan had been to put as much as possible into the five percent prepaid accounts (i.e. Netspend) and then invest the rest, but those deals died around the same time we planned to do that.

Quote
Looks like you've done your research. All these options vary so much by state, so there's a lot to wade through. Do you know what income level triggers Medicaid for pregnant women? I know we were talking about that in your other thread. The cost sharing subsidies below 200% of the poverty line seem very worthwhile to get if you can make it work, but I don't know if that triggers Medicaid or not. And it sounds like Medicaid makes travel harder due to restrictions on out-of-state care, so you might then have to choose between manufacturing some income to qualify for a more expensive ACA plan that lets you keep your mobility or settling down for a few months somewhere to get some free Medicaid coverage.

Of the two I've checked:
NY: Pregnant women eligible for Medicaid at 218% FPL
FL: Pregnant women eligible for Medicaid at 191% FPL
Based on Medicaid and CHIP Eligibility Levels

You are right, varies a lot state by state. Interesting some are below the 200% FPL and some are above.

Your question made me check something else, more specific to us Medicaid and CHIP Coverage of Lawfully Residing Children and Pregnant Women. Based on that, I think it's possible for us to avoid Medicaid in Florida without generating extra income. That might be pretty relevant.

At our income levels, not sure how we could avoid Medicaid in any state for son, but that was kind of expected.

It's the state by state variance when we have no specific ties that make it trickiest.

CanuckExpat

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NY Medicaid and Essential plans have no open enrollment periods, you can get it as soon as you domicile.  Medicaid is $200 max OOP per year.  The ACA should be around through 2017 at least.

Essential plan is also $200 max OOP if family income is below 150% FPL. That is part of what made it so interesting, paying $200 is a lot nicer than paying $2,000 or $20,000...

The no open enrollment is interesting for people who already live in state and FIRE that year, but I wasn't sure if that was relevant to us, since taking up domicile in a new state (moving) would qualify as a life event. Anything I am missing, only less paperwork, or some other advantage? 

Quote
Also do you have to worry about the citizenship of the baby as far as birth location?  I would try to get US and Canadian citizenship for the baby.

Maybe. Under current laws, any children we have would get Canadian citizenship no matter where they are born.
As for having a child outside the US .. actually, I just checked that, and maybe the best thing is to plan to have the child in the US :)

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Fortunately NY does not require a 5 year waiting period for Medicaid eligibility (for pregnant women and children) for lawfully present (green card) holders.

Yes, from what I saw, it seemed like in that scenario child and pregnant wife would end up on Medicaid, and I would be on essential plan. Seemed slightly more confusing to have everyone on different plans, but I think we could survive.

azure975

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I'm trying to keep an open mind about this and not be judgmental, but my gut reaction is that medicaid should be for people who truly cannot find a way to pay for health insurance, not people who voluntarily choose not to work. I feel like this is the reason Republicans want to find a way to gut the ACA and roll back Medicaid expansion. Anyway, I'm not doing a good job of not being judgmental, so everyone please feel free to present other viewpoints.
« Last Edit: November 21, 2016, 10:27:08 PM by azure975 »

seattlecyclone

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If I'm understanding you correct, and the split rollover is allowed, then it appears that we would be able to withdraw her rolled over mega-backdoor-Roth funds tax free without waiting the five years if we needed (after withdrawing her original contributions, which should also be withdrawn tax free).

Yep, there's no early withdrawal penalty for converted funds that were after-tax to start.

Quote
Also, if I am reading that correct, it appears the ordering of rollovers will be important for us: roll after tax 401k funds before any traditional IRA rollovers. That is good to keep in mind. Thank you.

Yes, ordering matters. If you convert both pre-tax and post-tax amounts in the same year, the pre-tax part (which would be subject to an early withdrawal tax if withdrawn within five years) comes out before the post-tax part (which would not have the tax). For this reason you may wish to avoid converting any of your wife's pre-tax money in 2017; if you want to do any pre-tax-to-Roth conversions next year make them be in your own name instead.

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Is the record keeping for all of us this on us, or does the information get transmitted along from 401k provider to IRA/Roth account automatically?

You'll need to keep some records. Anytime you withdraw from a retirement account (including rollovers) you should get a 1099-R at the end of the year reporting the amount withdrawn. For 401(k) withdrawals and rollovers you'll copy the amounts withdrawn onto your Form 1040, Line 16a for the entire amount and Line 16b for any taxable part of the amount on Line 16a. Keep statements from your Roth and traditional IRAs showing the rollover deposits. You won't need to report your Roth basis to the IRS until you eventually withdraw from the account, so keep good records.

jim555

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I'm trying to keep an open mind about this and not be judgmental, but my gut reaction is that medicaid should be for people who truly cannot find a way to pay for health insurance, not people who voluntarily choose not to work. I feel like this is the reason Republicans want to find a way to gut the ACA and roll back Medicaid expansion. Anyway, I'm not doing a good job of not being judgmental, so everyone please feel free to present other viewpoints.
Don't worry the ACA will not survive the Republicans.  You can sleep better knowing that a few people will not be "getting over" on the system.

azure975

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I'm trying to keep an open mind about this and not be judgmental, but my gut reaction is that medicaid should be for people who truly cannot find a way to pay for health insurance, not people who voluntarily choose not to work. I feel like this is the reason Republicans want to find a way to gut the ACA and roll back Medicaid expansion. Anyway, I'm not doing a good job of not being judgmental, so everyone please feel free to present other viewpoints.
Don't worry the ACA will not survive the Republicans.  You can sleep better knowing that a few people will not be "getting over" on the system.

I don't want the ACA to be repealed--I need the pre-existing conditions clause in order to FIRE myself. But I think the Republicans use the justification that people are gaming the system in order to bring it down. Which is very unfortunate.

jim555

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I'm trying to keep an open mind about this and not be judgmental, but my gut reaction is that medicaid should be for people who truly cannot find a way to pay for health insurance, not people who voluntarily choose not to work. I feel like this is the reason Republicans want to find a way to gut the ACA and roll back Medicaid expansion. Anyway, I'm not doing a good job of not being judgmental, so everyone please feel free to present other viewpoints.
Don't worry the ACA will not survive the Republicans.  You can sleep better knowing that a few people will not be "getting over" on the system.

I don't want the ACA to be repealed--I need the pre-existing conditions clause in order to FIRE myself. But I think the Republicans use the justification that people are gaming the system in order to bring it down. Which is very unfortunate.
I have never heard a Republican make that argument myself.  They usually don't like the individual mandate and the way the insurance policies are defined.

goatmom

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I am in New York.  Many people here are not happy with people moving here and getting Medicaid.  I hear it often.

arebelspy

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Following!  We may be in a very similar (shockingly similar) situation in the next year or two.  :)
I am a former teacher who accumulated a bunch of real estate, retired at 29, spent some time traveling the world full time and am now settled with three kids.
If you want to know more about me, this Business Insider profile tells the story pretty well.
I (rarely) blog at AdventuringAlong.com. Check out the Now page to see what I'm up to currently.

CanuckExpat

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I'm trying to keep an open mind about this and not be judgmental, but my gut reaction is that medicaid should be for people who truly cannot find a way to pay for health insurance, not people who voluntarily choose not to work

I'll probably only respond to this aspect once, because there's been a lot of good actionable advice and helpful input, and I selfishly don't want to see the thread derailed into pointless and non-actionable arguments (there's a whole off-topic sub-forum for that...)

But to stay on topic, not sure if you read the entire post, or if I wasn't clear: there are a few reasons I would like to avoid Medicaid if feasible, including wanting care out of state, and avoiding some bureaucracy. However, given our spending levels (which translates to income) and that wife is pregnant, it might not be very easy to avoid qualifying for and probably taking Medicaid, given the way the current laws are written. The situation as I as see it is that currently:
You are required to have insurance, possibly quite costly insurance.
At certain income levels, you are offered tax credits to subsidize private insurance
At even lower income levels it is assumed you will be on Medicaid (which now has no asset test) and the subsidies disappear, making it very undesirable to take the mandated private insurance.

If/when you retire,  you might choose to turn up your nose at Medicaid for whatever reason if your income/spending levels put you there, but that is not a cross I am willing to die on.

The word should is a funny because it can be used to state things without citation.
The word game is funny also, because it can be used to label things negatively, where you could say optimize to label it positively. Different strokes for different folks and all that.

If any laws are changed that impact my strategy, then I will happily or unhappily comply and adapt.

I am fine with "tax avoidance legal, tax evasion illegal"

I'd have more to say, but it will quickly get off topic

Hope that clears up my views on the topic.
« Last Edit: November 24, 2016, 08:02:34 PM by CanuckExpat »

jim555

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To see the NY Medicaid plans by county:
https://www.nymedicaidchoice.com/

The enroll section would not apply, that would be done from https://nystateofhealth.ny.gov/.

There is no more bureaucracy involved for Medicaid vs. Essential vs. Metal plans.  They all go through the web site.


**To all - Please don't derail this thread.***
« Last Edit: November 24, 2016, 04:08:23 AM by jim555 »

myhotrs

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Following, we'll be in a very similar situation next year (with only one kid and cats instead of dogs.)

Laura Ingalls

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Maybe medicaid should be the goal😉.   Call around to any states that expanded medicaid and see if obs, midwives, birth centers will take new Medicaid patients.  My family is ER with older kids with no ongoing health concerns in a expansion state.  We have been very happy with the Medicaid for about two years.  For use the best part is the dental coverage which we wouldn't have with an ACA plan.

CanuckExpat

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For those in, or going to be in similar situations, here is another thread that was helpful: ACA Subsidies: Pregnancy During Open Enrollment about the interaction of ACA, medicaid, and handling open enrolment period. Not sure if there was a definate answer, other than some things vary state by state

The Guide to Health Plan Options for RVers was helpful at least in identifying what nationwide PPOs exist. They seem to concentrate now on selling different barely ACA compliant plans, so don't know if it will continue to be useful in the future.

And I think most of you are right, in that the best option on most accounts might be to stay put in NY and take the Essential and/or Medicaid plan.. but wife is really gritting teeth at thinking of spending winter somewhere cold.. so gotta make do with that.

arebelspy

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Does NY just flat out have the best plan?  No other states with similar ones?
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CanuckExpat

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Does NY just flat out have the best plan?  No other states with similar ones?

For us NY is more for personal reasons and geographical reasons. Close to family, and it we are passing through on the beginning of the trip and again around delivery time, but we don't necessarily want to spend winter there.

I think other states might be similar in terms of Medicaid plans, but hard to compare.

The one interesting thing about NY is their Essential plan, it's an ACA Basic Plan. ACA allows any state to implement them with federal funding, so far only NY and MN have them.

jim555

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Ran across this about pregnancy:
"Pregnant women are NOT eligible for Essential Plan because they will qualify for Medicaid.  Consumers are required to report their pregnancy and the NY State of Health will re-determine their eligibility for Medicaid."
http://info.nystateofhealth.ny.gov/sites/default/files/Essential%20Plan,%2010-7-15.pdf

CanuckExpat

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Quick updates, and thanks again for all the input.

We enrolled in a Florida Blue ACA plan. Seemed to be no problem (yet) with using our mailbox address, and no questions were asked about income. We were approved for premium tax credits and cost sharing subsidies: $0 premiums out of pocket, roughly $1000/$2000 individual/family OOP maximum. As expected, son was not eligible as he is considered eligible for Medicaid due to his age, citizenship, and our "income". The plan seems to have out of state providers, we'll have to wait to see in practice if that works out.

One wrinkle I didn't consider is what we will done once new baby is born, since she will probably also fall into medicaid eligible range for same reasons, but will likely be born out of our domicile state...

vanderstache

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First time post - finally got registered after 2 years of lurking so I can add my 2 cents to this conversation . . . .

Unless I've missed something, Medicaid is off the table. There are both income and asset limits. While one may qualify based on income, it is quite difficult to qualify based on assets and limits can be very, very low. Not certain what they are in this particular situation but asset limits in FL appear to be $2000 after certain exempt assets.  These asset limits exist so that people spend their assets before qualifying and the money goes to the most needy.

jim555

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You are correct in Florida Medicaid is off the table for childless adults 18-64 since they did not expand.  You would have to be classified as disabled and spend down almost all your assets for it to kick in.

Children under the Florida CHIP program are covered based on an income test and lawful residence status. 

NY expanded Medicaid so the only test is an income under 138% FPL.

CanuckExpat

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Asset tests for Medicaid eligibility are no longer allowed under the ACA in most cases and I think that applies whether or not a state expanded medicaid

https://www.medicaid.gov/medicaid/eligibility/index.html
http://theincidentaleconomist.com/wordpress/bye-bye-medicaid-asset-test/
https://www.newamerica.org/asset-building/the-ladder/hello-2014-goodbye-medicaid-asset-limit/

(There are exceptions where asset tests are allowed for groups who qualify for medicaid based on reasons other than income such as disability or age)

jim555

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The expanded group (18-64) has no asset test.  All other groups (disabled, blind, elderly) still have asset tests, aka "old" Medicaid.

Cassie

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All of Medicaid should have assets tests.  I spent my life working with people in various human service programs but the intent is to help the poor and not having assets tests is ridiculous.   Hopefully there are not that many people exploiting the loophole when they can afford to pay for insurance.

Peony

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If we're making pronouncements on what "should" be the case, IMO, Medicaid and/or Medicare should have neither asset tests nor income tests, but simply be available to all Americans. I care a great deal for the poor and I don't care a whit about people "exploiting loopholes" to get health care. I want my tax dollars to pay for everyone's health care (including Paul Ryan's, even though he wants to take mine away).

jim555

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People shouldn't have to go broke for healthcare.