ACA Alternatives

[MissAnna]

I can only speak for my state, CA. No recovery.

 

[pjigar]

If premiums keep going up the way they are, we are seriously considering self-insurance. We should be able to afford self-pay when I retire. If we go this route then here is the game plan:
* Self pay office visits and medication. Most doctors and our pharmacist offer palatable price tag for routine services. We kind of already self-pay with a high-deductible plan anyway.
* Any out patient surgeries or planned hospitalization, use medical tourism.
* Currently we have no chronic pre-existing condition but if we do end up with a chronic condition then go back to ACA.
* Emergency care: Bite the bullet, negotiate with hospital directly and pay up!

Am I missing something?

 

[Just_Steve]

I think Wikipedia is a good place to start on the whole "expanded Medicaid estate recovery" thing: Medicaid estate recovery - Wikipedia

TLDR: Some (most?) "expanded medicaid" states don't have clear laws differentiating ACA Medicaid and asset based Medicaid. So, IMHO, you are playing with fire if you have significant assets and go on Medicaid due to a low MAGI.

Not only that but it should be illegal.

 

[flyoverstate]

Estate recovery provision for Medicaid were written pre ACA days, and targeted for recipients of Medicaid nursing home stays.

While you may be correct, the fact is that *some* states still invoke estate recovery on ANY Medicaid recipient (ACA expanded Medicaid or not), for ANY Medicaid-covered expenses. Colorado does for sure. They contract with a third party company that is paid on commission. That company is so abusive that CO passed a law this year to rein them in a little, but they did NOT change the law around what is eligible to be recovered.

I saved a few people from the Medicaid trap here. I was only interested in the whole thing because I couldn't believe how crazy it is.

It varies state to state, but CO is the worst case scenario.

 

[RetiredHappy]

While you may be correct, the fact is that *some* states still invoke estate recovery on ANY Medicaid recipient (ACA expanded Medicaid or not), for ANY Medicaid-covered expenses. Colorado does for sure. They contract with a third party company that is paid on commission. That company is so abusive that CO passed a law this year to rein them in a little, but they did NOT change the law around what is eligible to be recovered.

I saved a few people from the Medicaid trap here. I was only interested in the whole thing because I couldn't believe how crazy it is.

It varies state to state, but CO is the worst case scenario.

Do you have an actual case that CO state went to recover money from the estate for an ACA recipient? Unless you have an actual case to quote, it is at this point, fiction, because ACA is written such that it is only income based to determine if one ends up in Medicaid or not.

 

[Aerides]

If premiums keep going up the way they are, we are seriously considering self-insurance. We should be able to afford self-pay when I retire. If we go this route then here is the game plan:
* Self pay office visits and medication. Most doctors and our pharmacist offer palatable price tag for routine services. We kind of already self-pay with a high-deductible plan anyway.
* Any out patient surgeries or planned hospitalization, use medical tourism.
* Currently we have no chronic pre-existing condition but if we do end up with a chronic condition then go back to ACA.
* Emergency care: Bite the bullet, negotiate with hospital directly and pay up!

Am I missing something?

Yes. Whatever your health situation is before retirement cannot remotely be counted on as you age. For many, their 40's are very bad predictors of their 50's and even less so their 60's.

But here's just a few things:
Chronic conditions are expensive even if you don't have one now, even for one year. Jan 5 you feel a lump and go to the doctor and ... uhhh, well, good luck with that.
Some places won't take you without insurance for any price.
Emergency situations often mean you are incapacitated at the time of the event. Lack of insurance won't be an issue while they stabilize you, but it will if you need more than a day or 3 of in-patient care - ie, a heart attack or bad accident. Plan on $50k per day.

A few years ago, DH had a pulmonary embolism that appeared out of nowhere, at 50. After he was admitted the administrative office called me. They needed to transfer him to the hospital "proper" but our plan didn't cover them, only their ER in our plan. But his doctors didn't recommend we move him to an in-network hospital. I was glad we had the finances to let him stay put, that was extra stress we didn't need.

We got lucky and they submitted the whole thing under the in-network ER codes, but the total charge for less than 48 hours was about 75k, and we fortunately only had to pay our deductible.

 

[flyoverstate]

Not only that but it should be illegal.

It is a trap that many people have fallen into. They raised the income limits for Medicaid eligibility and removed asset checks. People get laid off from their jobs, they go on their ACA Marketplace, and they choose a plan. If the number they put in for projected income the next year is below the expanded Medicaid upper limit, THEY ARE PUT ON MEDICAID. They have no choice. A lot of people just shrug and say "free premiums", and click through, not knowing the implications. I saved a several former co-workers from this. People just don't know.

What is crazy to me is that if you are under 55 years old, estate recovery doesn't apply. So someone 54 can get Medicaid with no repercussions, but 55 or older are zapped. I told people over 55 to project the lowest amount of income that gets them over the Medicaid maximum for the next year, and pay the ACA level premium. Then, at the end of the year, if they haven't made that much, pull out of 401K/IRA to be sure MAGI is high enough. These were all tech workers, and I didn't know any that had no 401K/IRA at all. If someone had no means to get MAGI up, I guess they would have to find whatever job they could.

 

[flyoverstate]

Do you have an actual case that CO state went to recover money from the estate for an ACA recipient? Unless you have an actual case to quote, it is at this point, fiction, because ACA is written such that it is only income based to determine if one ends up in Medicaid or not.

I don't know anyone personally, but it is widely known that Colorado collects from ALL Medicaid recipients and does not exclude those under "expanded" ACA Medicaid. Google is your friend.

 

[Pluperfect]

And if you accept Medicaid, you are subject to estate recovery, period.

Colorado Recovery

mru.hmsy.com

"The acceptance of public assistance creates a debt of the person accepting assistance which is enforceable only after the death of the client. Estate recovery applies to those Medicaid clients who have received services at any time on or after July 1, 1992 and who were age 55 or older at the time of provision of the service or who were institutionalized."

While you may be correct, the fact is that *some* states still invoke estate recovery on ANY Medicaid recipient (ACA expanded Medicaid or not), for ANY Medicaid-covered expenses. Colorado does for sure.

I don't know anyone personally, but it is widely known that Colorado collects from ALL Medicaid recipients and does not exclude those under "expanded" ACA Medicaid. Google is your friend.

Just to be clear--the portion you quoted says recovery doesn't happen if the person was age 55 or over when the service was provided. But that doesn't square with "any" Medicaid recipient or "all" Medicaid recipients. Should it be "any Medicaid recipient under 55" or "all Medicaid recipients under 55"?

 

[MissAnna]

CA addressed this specifically in 2017, the year I was about to turn 55 and prepared to increase income to ACA levels. I know several states, including NY, were looking to do the same. I’m not sure if they did. Easy google search, as pointed out above.

 

[MissAnna]

Not only that but it should be illegal.

The One Big Beautiful Bill will make this strategy much harder to implement with new work requirements for those under 65, starting in 2027.

 

[Fermion]

The One Big Beautiful Bill will make this strategy much harder to implement with new work requirements for those under 65, starting in 2027.

For some people. I think our county is exempt because it is a farm community with no jobs available. Not that I suggest Medicaid when cost sharing silver plans are still really really good.

 

[jim584672]

Colorado does NOT recover from the ACA expansion group. The altered their state plan to in 2014 to limit recovery to aged 55+ and in nursing facilities or HCBS (home care).

 

[jim584672]

For some people. I think our county is exempt because it is a farm community with no jobs available. Not that I suggest Medicaid when cost sharing silver plans are still really really good.

High unemployment is not an exception to the work requirements for Medicaid in the OBBB.

 

[RetiredHappy]

High unemployment is not an exception to the work requirements for Medicaid in the OBBB.

Some counties like farm community where unemployment are high are exempt from work requirements for Medicaid in OBB.

 

[Fermion]

High unemployment is not an exception to the work requirements for Medicaid in the OBBB.

A Look at the Potential Impact of the High Unemployment Hardship Exception to Medicaid Work Requirements | KFF

This issue brief describes the hardship exception for individuals living in counties with high unemployment, and using the most recent available county-level unemployment data, estimates the number of counties that could meet the criteria for this exception and the number of expansion enrollees...

www.kff.org

Excerpt: "The law exempts certain individuals from the requirements, including parents of children ages 13 and younger, people who are medically frail, and people who meet similar work requirements in the Supplemental Nutrition Assistance Program (SNAP). The law also permits states to allow for short-term hardship exceptions for individuals who live in areas of high unemployment, where it may be more difficult to find a job."

 

[jim584672]

A Look at the Potential Impact of the High Unemployment Hardship Exception to Medicaid Work Requirements | KFF

This issue brief describes the hardship exception for individuals living in counties with high unemployment, and using the most recent available county-level unemployment data, estimates the number of counties that could meet the criteria for this exception and the number of expansion enrollees...

www.kff.org

Excerpt: "The law exempts certain individuals from the requirements, including parents of children ages 13 and younger, people who are medically frail, and people who meet similar work requirements in the Supplemental Nutrition Assistance Program (SNAP). The law also permits states to allow for short-term hardship exceptions for individuals who live in areas of high unemployment, where it may be more difficult to find a job."

I stand corrected, found the law and looked it up...

(B) Optional exception for short-term hardship events-

(II) such individual resides in a county (or equivalent unit of local government)—

(aa) in which there exists an emergency or disaster declared by the President pursuant to the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act; or

(bb) that, subject to a request from the State to the Secretary, made in such form, at such time, and containing such information as the Secretary may require, has an unemployment rate that is at or above the lesser of—

(AA) 8 percent;

or(BB) 1.5 times the national unemployment rate;

 

[Fermion]

Actually, I think our county might have slipped under the 1.5 times thing now. It will be interesting to see which counties Washington files for this exemption. Managing this stuff is going to be a nightmare for them and anyone on Medicaid. Like I said, I recommend silver plan if at all possible.

 

[jim584672]

Actually, I think our county might have slipped under the 1.5 times thing now. It will be interesting to see which counties Washington files for this exemption. Managing this stuff is going to be a nightmare for them and anyone on Medicaid. Like I said, I recommend silver plan if at all possible.

It basically is a dumb tax. If you don't know the rules and fall under 138% you have to go through all this nonsense. But smart people know to get over 138% and all this goes away with a Silver plan.

There is a trap, if you fail the work requirements then you are barred from ACA subsidies.

 

[Fermion]

I am thinking about all of the people in our county on Medicaid and imagining them pondering how to correctly time Roth conversions of their IRA to give them 139% of FPL. I just can't visualize it. Maybe I should teach a class at the community college on how to manage your MAGI and then by enrolling in this they could qualify for an educational exemption.

 

[jim584672]

CA addressed this specifically in 2017, the year I was about to turn 55 and prepared to increase income to ACA levels. I know several states, including NY, were looking to do the same. I’m not sure if they did. Easy google search, as pointed out above.

NY has the Essential Plan that goes up to 250% FPL @ $0 a month. That will reduce to 200% FPL in July 2026 due to cuts from the OBBB.

 

[GenXguy]

If the number they put in for projected income the next year is below the expanded Medicaid upper limit, THEY ARE PUT ON MEDICAID. They have no choice.

They will decline enrolling you and direct you to Medicaid if your current month's income is too low, also, even if your estimated annual income is high enough for ACA eligibility.

ACA Open enrollment frustrations

I'm currently still working but would like to retire soon as I can get ACA coverage, so that I have no gap in health insurance coverage. Along with that I plan on taking a distribution this month that I will use in the next 4 years to keep my MAGI below the 400% threshold. So going through...

www.early-retirement.org

 

[TripleLindy]

If premiums keep going up the way they are, we are seriously considering self-insurance. We should be able to afford self-pay when I retire. If we go this route then here is the game plan:
* Self pay office visits and medication. Most doctors and our pharmacist offer palatable price tag for routine services. We kind of already self-pay with a high-deductible plan anyway.
* Any out patient surgeries or planned hospitalization, use medical tourism.
* Currently we have no chronic pre-existing condition but if we do end up with a chronic condition then go back to ACA.
* Emergency care: Bite the bullet, negotiate with hospital directly and pay up!

Am I missing something?

I’ve definitely considered self insuring. My wife and I are both in good health and rarely meet our deductible. But it’s the high dollar unexpected expense that we’re insuring for. My wife had knee surgery last year and that was just under $30k using the insurer’s contracted rates. Heart attack? Cancer? You can’t just go and jump into the ACA outside of open enrollment.

I’d love to see a plan that had something like a $50k deductible but a very low premium - maybe $3k-$5k. I’d take that risk since we rarely hit our deductible.

 

[GenXguy]

The One Big Beautiful Bill will make this strategy much harder to implement with new work requirements for those under 65, starting in 2027.

States can get waivers to delay the work requirements until 2029.

 

[jim584672]

States can get waivers to delay the work requirements until 2029.

HHS has to approve the delay and it is for states with implementation problems. So I can guess some states will never get that HHS permission.