Author Topic: Health Insurance by state comparison  (Read 6281 times)

StetsTerhune

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Health Insurance by state comparison
« on: January 21, 2016, 08:22:00 AM »
I'm starting to investigate which state it is best to have residence in when I retire in a few months. (I won't actually have a residence, this is purely for tax/legal purposes). There's a lot of factors, but South Dakota seems to be the clear favorite based on what I've seen so far.

What I haven't gotten a clear picture of is how health insurance will work. I'm assuming I'll need to buy my (ACA) health insurance in the state I'm resident in. A. Can anyone confirm that? B. Has anyone seen a good (current) comparison of ACA costs by state?

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Re: Health Insurance by state comparison
« Reply #1 on: January 21, 2016, 09:11:52 AM »
Your income might be a factor. If you are low enough income to take Medicaid, you might want to select a state that does not practice zealous Medicaid Estate recovery.

Some states recover Medicaid costs for long therm nursing home care only. Others seek reimbursement for all expenses. It might be a factor to you if you wish to leave money to charity or individuals.

Also, how are you defining “residence”? You may run into trouble if you try using a post office box as a “residence”.

StetsTerhune

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Re: Health Insurance by state comparison
« Reply #2 on: January 21, 2016, 09:52:19 AM »
Your income might be a factor. If you are low enough income to take Medicaid, you might want to select a state that does not practice zealous Medicaid Estate recovery.

Some states recover Medicaid costs for long therm nursing home care only. Others seek reimbursement for all expenses. It might be a factor to you if you wish to leave money to charity or individuals.

Also, how are you defining “residence”? You may run into trouble if you try using a post office box as a “residence”.

No, I will not be low enough to get medicaid, I will be buying ACA health insurance.

At least for tax purposes, it varies by state how easy it is to establish residency. In SD for example you can declare yourself a permanent traveler and be a legal resident. How health insurance companies will feel about this is another question.

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Re: Health Insurance by state comparison
« Reply #3 on: January 21, 2016, 10:14:29 AM »
This might be useful. It turn out that rates vary city by city, as well as State to State.

http://kff.org/health-reform/issue-brief/analysis-of-2015-premium-changes-in-the-affordable-care-acts-health-insurance-marketplaces/

I would guess that it may even vary by zip code, due to variables like smoking, violent crime, obesity and the like. So the better educated, healthier and wealthier zip codes might get lower rates.

jim555

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Re: Health Insurance by state comparison
« Reply #4 on: January 21, 2016, 11:11:53 AM »
I didn't think South Dakota expanded Medicaid, so that wouldn't be an option.

brooklynguy

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Re: Health Insurance by state comparison
« Reply #5 on: January 21, 2016, 12:58:33 PM »
Has anyone seen a good (current) comparison of ACA costs by state?

By design, the ACA subsidization scheme smooths out the variability in health insurance costs across the country.  The size of the premium tax credits you will receive is a function of the cost of the second-cheapest "silver plan" in your area, such that your out-of-pocket premium cost (that is, net of the tax credit) will be equal to a fixed percentage of your income.  So if coverage is more expensive in your area, you will get a bigger premium tax credit, and pay the same net amount as someone in a cheaper area.  You don't have to purchase the second-cheapest silver plan, though, so, depending on the variability in the pricing of the other available plans, your out-of-pocket costs could vary based on where you reside if you select a different plan, but otherwise your out-of-pocket costs should be roughly the same no matter where you reside.

Eric

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Re: Health Insurance by state comparison
« Reply #6 on: January 21, 2016, 01:18:16 PM »
In SD for example you can declare yourself a permanent traveler and be a legal resident. How health insurance companies will feel about this is another question.

Are you just going to travel around the US?  Or around the world?  Because if you're in the US for less than 35 days in a 12 month period, you're exempt from purchasing ACA compliant insurance.

https://www.healthcare.gov/quick-guide/eligibility/


If you're planning to stay in the US, I'd make a list of states with zero income tax, and then go to each of their state exchange websites and price out plans.

StetsTerhune

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Re: Health Insurance by state comparison
« Reply #7 on: January 21, 2016, 01:27:44 PM »
By design, the ACA subsidization scheme smooths out the variability in health insurance costs across the country.

I will likely not receive subsidies (certainly not in 2016, and moving forward will likely still have enough consulting income to be above the threshold), so that point doesn't really apply to me.

Are you just going to travel around the US?  Or around the world?  Because if you're in the US for less than 35 days in a 12 month period, you're exempt from purchasing ACA compliant insurance.

Does this mean that there is non-ACA compliant insurance that I could buy, or just that I wouldn't have to pay the penalty for not having it? The penalty is small enough that it's a non-factor compared to needing to have some sort of insurance to protect myself from worst-case scenarios. I'd love to be able to buy an old-school 15k deductible plan.

brooklynguy

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Re: Health Insurance by state comparison
« Reply #8 on: January 21, 2016, 02:32:01 PM »
I will likely not receive subsidies (certainly not in 2016, and moving forward will likely still have enough consulting income to be above the threshold)

Quote
The penalty is small enough that it's a non-factor compared to needing to have some sort of insurance to protect myself from worst-case scenarios.

These two statements seem likely to be in conflict with one another.  Are you sure you're calculating the penalty correctly?

Eric

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Re: Health Insurance by state comparison
« Reply #9 on: January 21, 2016, 02:33:02 PM »
Are you just going to travel around the US?  Or around the world?  Because if you're in the US for less than 35 days in a 12 month period, you're exempt from purchasing ACA compliant insurance.

Does this mean that there is non-ACA compliant insurance that I could buy, or just that I wouldn't have to pay the penalty for not having it? The penalty is small enough that it's a non-factor compared to needing to have some sort of insurance to protect myself from worst-case scenarios. I'd love to be able to buy an old-school 15k deductible plan.

Both.  You would be exempt from the penalty.  Then assuming you'd still want some kind of health insurance coverage, you could tailor that to your specific situation.  If you were going to take up residency in another country, you could buy a policy from that country specifically. If you were going to perpetually travel, you could buy a travel policy.  I can't remember where, but I wrote it down after I read it on some travel blog (although haven't gotten around to researching for myself, so caveat emptor) that World Nomads is a good travel option.  Or there's Bupa and a few other companies that offer short term country specific policies.  If you google International Health Insurance, there are a lot of hits for both regular and travel insurance.  A lot of what you'd want depends on your plan.

Edit -- spelling
« Last Edit: January 21, 2016, 06:12:21 PM by Eric »

arebelspy

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Re: Health Insurance by state comparison
« Reply #10 on: January 21, 2016, 04:33:19 PM »
Has anyone seen a good (current) comparison of ACA costs by state?

By design, the ACA subsidization scheme smooths out the variability in health insurance costs across the country.  The size of the premium tax credits you will receive is a function of the cost of the second-cheapest "silver plan" in your area, such that your out-of-pocket premium cost (that is, net of the tax credit) will be equal to a fixed percentage of your income.  So if coverage is more expensive in your area, you will get a bigger premium tax credit, and pay the same net amount as someone in a cheaper area.  You don't have to purchase the second-cheapest silver plan, though, so, depending on the variability in the pricing of the other available plans, your out-of-pocket costs could vary based on where you reside if you select a different plan, but otherwise your out-of-pocket costs should be roughly the same no matter where you reside.

But if you don't get tax credits/subsidies, then it makes a BIG difference.  Nevada, for example, sucks.  :P
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brooklynguy

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Re: Health Insurance by state comparison
« Reply #11 on: January 21, 2016, 05:36:10 PM »
But if you don't get tax credits/subsidies, then it makes a BIG difference.  Nevada, for example, sucks.  :P

Not nearly as badly as NYC.  This is why I've long said ACA subsidies can be one of the biggest (if not the biggest) ticket items out there when it comes to financial optimization for early retirees.

StetsTerhune

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Re: Health Insurance by state comparison
« Reply #12 on: January 22, 2016, 07:08:08 AM »
Both.  You would be exempt from the penalty.  Then assuming you'd still want some kind of health insurance coverage, you could tailor that to your specific situation.  If you were going to take up residency in another country, you could buy a policy from that country specifically. If you were going to perpetually travel, you could buy a travel policy.  I can't remember where, but I wrote it down after I read it on some travel blog (although haven't gotten around to researching for myself, so caveat emptor) that World Nomads is a good travel option.  Or there's Bupa and a few other companies that offer short term country specific policies.  If you google International Health Insurance, there are a lot of hits for both regular and travel insurance.  A lot of what you'd want depends on your plan.

Thanks Eric! Things I didn't even know I should be looking into. Exactly why I posted on here.

Penny Lane

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Re: Health Insurance by state comparison
« Reply #13 on: January 22, 2016, 07:59:04 AM »
We pay 1081. a month for bronze with combined >$12 K deductable.  If either of us gets anything significant, it will be combined cost of $25,000.  So age makes a difference, too; I'm a few years from medicare.  I can afford this, but many,many could not. 

AdrianC

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Re: Health Insurance by state comparison
« Reply #14 on: January 22, 2016, 10:50:57 AM »
But if you don't get tax credits/subsidies, then it makes a BIG difference.  Nevada, for example, sucks.  :P

Must be the lifestyle ;-)

Ohio isn't good. We're at $994/mo for an HSA compatible plan. Family of 5.

jim555

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Re: Health Insurance by state comparison
« Reply #15 on: January 22, 2016, 02:59:11 PM »
In NY if you keep under 200 FPL, about $23,540, it is only $20 a month with very reasonable co-pays, $2,000 max OOP.  Up to 150 FPL $0 per month, $0 co-pays, $200 max OOP.

Reynold

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Re: Health Insurance by state comparison
« Reply #16 on: January 26, 2016, 08:27:10 AM »
This might be useful. It turn out that rates vary city by city, as well as State to State.
[snip]

Just as a warning, there is a rather steep increase in premiums based on age, the cheapest Bronze plan I found in NJ was barely under $1000/month for myself (54) and a spouse.   If I put in an age of 40, like the chart you linked, it is only $578/month for two of us.  At 65 it is close to $1500/month.  One thing keeping us on the fence about FIREing is health care costs, with a Silver plan, which is substantially inferior to what I have now at work, I would expect our premiums + health care costs to be running around $20k/year, based on our last few years experience with health care needs.  Out of network coverage just isn't very good with the Exchange plans, from what we have seen. 

Eric

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Re: Health Insurance by state comparison
« Reply #17 on: January 26, 2016, 10:44:38 AM »
This might be useful. It turn out that rates vary city by city, as well as State to State.
[snip]

Just as a warning, there is a rather steep increase in premiums based on age, the cheapest Bronze plan I found in NJ was barely under $1000/month for myself (54) and a spouse.   If I put in an age of 40, like the chart you linked, it is only $578/month for two of us.  At 65 it is close to $1500/month.  One thing keeping us on the fence about FIREing is health care costs, with a Silver plan, which is substantially inferior to what I have now at work, I would expect our premiums + health care costs to be running around $20k/year, based on our last few years experience with health care needs.  Out of network coverage just isn't very good with the Exchange plans, from what we have seen.

That's why it's important to stay below 400% of the poverty level.  If you receive subsidies, they also increase with age, so you end up paying the same amount year after year.

http://www.gocurrycracker.com/obamacare-optimization-early-retirement/

Laura Ingalls

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Re: Health Insurance by state comparison
« Reply #18 on: January 31, 2016, 07:22:29 PM »
I read rv message boards often.  I also have lived in SD.  The full-time rv crowd loves SD for tax purposes, but it is way more popular with folks of medicare age. South Dakota is a state with a small population and offers few Aca plans.  The plans have tiny networks and are based on the two big hospital systems in the state (Sanford and Avera).  They provide great care but you need to physically show up to get it.

jim555

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Re: Health Insurance by state comparison
« Reply #19 on: February 01, 2016, 06:01:20 AM »
One good thing about NY, no age rating is allowed for health insurance.  This means young people subsidize the old.  Good if your old, bad if not.