The ACA (aka ObamaCare) & Its Impact on FullTime RV Health Insurance
This is one of those posts I’ve been meaning to write for a long time. I’ve been both looking forward to it and dreading it. One the one hand it’s a really important post, on the other hand it’s a really complicated subject mostly because there is no easy answer to health insurance for fulltime RVers on the road. Alot depends on your situation, your age, your personal health and your finances. So, if you’re ready to take this ride take a deep breath, fortify yourself and get reading on my longest post ever….
Things Are A-Changing….
For the past 4 years we’ve carried a high-deductible ($10,000 deductible) insurance backed by a HSA (Health Savings Account) from Coventry in South Dakota that we bought online from ehealthinsurance.com and which I detailed in this post. It’s suited us perfectly because it has a strong nationwide network and it’s inexpensive, plus we are in good health and we pay most of our regular expenses out-of-pocket. What we’ve needed was a health insurance that would cover us in catastrophic terms (i.e. if something really bad happened) and for less than ~$200/mo this insurance fit the bill.
All that changed with the ACA (Affordable Care Act aka ObamaCare) which went into effect this year.
Now, I’m going to say up-front that I do not want this post to be about politics, and I will moderate comments the same way. This is a purely a practical interpretation of what ACA provides (or doesn’t provide) fulltime RVers and how it may (or may not) change the decision you make on where you domicile and what insurance you buy. Also, I’m not going to discuss Medicare or Medicaid (a whole other topic!) just to keep things simple. This post is really targeted towards younger (pre-Medicare) RVers who need to buy their own insurance. Finally keep in mind I am not a qualified insurance agent, so this stuff is only my personal opinions and understanding. With that said, let’s get started:
What Is The Affordable Care Act (ACA)?
The way I look at it, the ACA is basically an insurance bill. It regulates who insurances can sell to and what minimum coverage they must include, plus it requires everyone to have insurance or pay a penalty fee (there are certain exemptions). Also it created a centralized spot (the Health Care Exchange) where you can buy and compare insurance plans. In a way it levels the playing field, in that all insurance companies must now conform to specific minimum requirements and if you buy a particular level of insurance (say, Bronze level) from one guy, you can be pretty sure it’ll cover the same basics as the same level of insurance from another guy. In other ways it’s not so simple.
Certain things are now a requirement -> for example insurance companies can no longer differentiate between sick and healthy people (you ALL pay the same), they are no longer allowed to have lifetime caps (personally I like this) plus there are very basic heath checks (called “preventative care“) which are now included in all plans (Note/ you can read my take on preventative care here).
Other things are not regulated at all -> for example network sizes and out-of-network costs, which can be a potentially really important thing for fulltime RVers, except for emergency care (there’s a gotcha in here which I will explain below). Plus costs can vary substantially from state to state (e.g. the BCBS insurance you buy in one state might be a completely different price in another state). Also, the ACA does nothing to regulate the healthcare side of the equation (what hospital & doctors charge, prescription costs etc.)
The other major thing ACA has done is implement subsidies. What that basically means is that if you earn below certain levels (based on something called MAGI or Modified Adjusted Gross Income -> this year for a couple of two it’s less than $62,040), you can get a tax credit to help pay for insurance costs. The less you earn, the bigger your subsidy, down to a limit. An important thing to understand is that in order to get these subsidies you MUST buy your insurance through the Federal (or your State’s) Health Insurance Exchange or work with an ACA-qualified agent who can help you navigate the exchange.
There’s alot more to this ACA stuff, but in my mind these points are the most important ones for young fulltime RVers. If you want to read more about the intricate details of the ACA law this write-up from RV Dreams is an excellent summary -> The Affordable Health Care Act & RVers. Or check out Kyle’s equally fine summary here -> Affordable Care Act
How Does This Affect My Current Health Insurance?
Now, here’s the rub. What does all this mean for me, specifically?
Well, the very first thing that has affected us is that our current insurance plan (the one we’ve had for 4 years) may no longer be available to us at the end of this year. Our plan was “grandfathered in” (which basically means we bought it before March 2010 and have never changed it), but our insurance company has told us they will no longer support it after the end of this year. This may of course change (you never know), but that’s our current information. Once our insurance expires this Sept we’ll be forced onto an ACA-compliant plan. Our current plan costs around $260/mo for the both of us combined (it went up this last Sept), whereas a new ACA plan will cost around $550/mo (for the same $10,000 deductible), and since Coventry is not on the SD exchange we won’t be able to get any subsidies for it. The big jump in price is a direct result of additional minimum regulations as well as sick people being forced into the same insurance pool at the same level as healthy people (no judgement here…those are just the consequences). Also in the background of all this (and to save costs, I presume) alot of insurance companies are now also changing their coverage networks (many have limited them), plus not all the options out there are “fulltime RV” friendly.
We need to be pay attention to all these things when we go shopping for insurance again later this year.
Key Tips For Shopping For Insurance As A Fulltime RVer
So, how in the world do I chose what to buy? These are the most critical points I think that any new fulltimer (or current fulltimer who is being forced into buying new insurance) should consider:
1/ Should I Buy On The Exchange Or Not?
There’s no doubt the insurance subsidy is a huge benefit and will save significant $$ for those that qualify. If you DO qualify (you can check on this calculator) you *must* buy your insurance off your State’s Health Insurance Exchange, or work with a qualified agent who is certified to help you enroll in the government exchange. For the “big 3” fulltime RV states (TX, SD, FL) that means you buy it HERE. If you don’t qualify for a subsidy you can buy your insurance from any company, even those not on the exchange.
2/ What Are The Important Things To Look For?
Coverage is now limited to 5 categories -> Bronze, Silver, Gold & Platinum levels (Catastrophic is still available if you’re under 30 or qualify for a hardship exemption). When you buy on-line you should be looking at those categories and comparing deductibles and out-of-pocket expenses. I’m not going to go through those particular details, but my advice is that you should pay special attention to the things that are not regulated by ACA such as:
Network Size -> Alot of companies have chosen to reduce network size especially for offerings on the exchange. Limited networks mean you don’t have alot of choice of doctors and services outside of your given state. This is a big deal for fulltime RVers, in my opinion. Many folks have cited the new emergency care regulations as covering you. The ACA law says your insurance can’t charge you more for out-of-network emergency care. So, if I get in an accident out-of-network I’ll just go to the ER and then drive back to my home state for regular care, right? It’s actually not so simple. Although the ACA regulates how much your insurance company can charge in this case, it does not protect you from “balance billing” by the hospital (which basically means if the hospital didn’t feel they got paid enough by your insurance they can charge you directly for the balance!) Unless the State specifically prohibits this, there are NO limits to it and it can mean thousands of additional $$ out of pocket. Also, what if it’s the middle of winter and you can’t get back to your state of residence for follow-up care? Or, the nearest “in network” hospital is days away? For these reasons I think choosing an insurance with a STRONG nationwide network is critical for fulltime RVers. Personally I will only consider PPO plans with big networks (no EPOs, no HMOs). Staying in-network will always reduce your costs and protect you from balance billing.
Out-Of-Network Caps -> Our goal is always to try and stay in-network, but sometimes it can’t be helped. I think it’s good practice to chose insurances that limit out-of-network costs, just in case. This is something ACA doesn’t regulate, so you need to check for it specifically.
Friendliness To Fulltime RVers -> Another thing which is really key to us nomads is that some insurances are not fulltime RV friendly. For example they might require you to be “in state” a certain number of months per year, or they simply won’t accept mail forwarding addresses as proof of residence. This is a particular problem in South Dakota, for example where two out of the three insurance companies on the official exchange (Sanford & DakotaCare) require 6-month residency proof. This is HUGE! I personally know at least 3 RVers who were accepted, and then subsequently rejected for insurance in SD because they couldn’t provide proof of permanent residence, despite all of them having established legal domicile in the state.
Basic Costs -> One of the things us fulltime RVers have as a benefit is that we are not necessarily tied to a given state (for the most part). That means we can truly “shop around”. Trying to do this on the official exchange is a bit of a bear, but you can use HealthSherpa.com to shop around exchange-based insurances with total ease or try something like ehealthinsurance.com or a good, qualified broker for a wider range of choices. In our case, comparing equivalent insurances across TX, FL & SD has revealed costs of several hundreds of dollars of difference. Health insurance should never be your only consideration for domicile, but it’s an important one.
Support For An HSA Account -> We’ve had a Health Savings Account for many years and we really, really like the benefits. The money you put away each year for medical care is tax-free, plus you don’t pay taxes on the interest you earn in that account and you get to spend it tax-free. It’s like a triple-tax benefit. We keep the $10,000 deductible for our health care in this account and try to max out contributions each year. Not all insurance plans offer this, so you have to look specifically for it.
Holey Moley I Need HELP!!
Believe me, you are not the only one. I have personally spent hours (weeks, months) looking at ACA and trying to understand what impact it has for Paul and me. I’ve run 10-page long threads on forums & FaceBook and called slews of insurance companies and I still don’t understand everything. This is why I was overjoyed when I heard about Kyle and his new RV site RVerHealthInsurance.com. Here was finally a site run by a fulltime RVer with actual health insurance experience who completely understands our issues. I don’t usually recommend sites unless I really love them, as you know, and this one definitely qualifies. This guy has good articles on things to consider (whether pre-Medicare or post-Medicare) and can help you walk through your insurance choices, including those on the Government Exchange (Kyle is “ACA-certified”). I’ve actually corresponded with him several times and learned details I would not otherwise have figured out. Given that the ACA law is brand new and that things are likely to change alot in the next few years as insurance companies figure it out (the whole landscape will probably look totally different in 5 years time), knowing someone who is actually keeping ontop of all these changes will be really helpful. I like his site so much I signed up to be an affiliate, so if you click our link or let him know WheelingIt referred you, we get a small referral fee. Even if you never get a quote from him, I highly recommend browsing the site. It’s been invaluable for us.
What This Means For Paul And Me
So, this brings us back finally to Paul and me. What in the world are we going to do?? Since we’re still young and still healthy our plan is to continue to pay basic health care out-of-pocket and keep a (hopefully low-cost) high-deductible insurance plan with support for an HSA account as our back-up in case something goes wrong. But after Sept the plan we have now will likely no longer be available.
When this whole ACA thing launched the very first thing I figured out was that if we wanted to buy a plan on the exchange in SD we were going to be in trouble. There are currently only three companies on the SD exchange -> Avera, DakotaCare & Sanford. Two of those guys (Sanford & DakotaCare) won’t accept fulltime RVers, while the third (Avera) had an astonishingly crappy network, at least at the time I looked at them (thanks to Kyle I now know this may have recently changed). We could chose to buy off the exchange of course, but the costs are 2-3 times what we pay now even for the $10,000 deductible plans. All this means is that unless something changes between now and Sept we will probably choose to change domicile to another state.
From everything I’ve looked at, and everything I’ve learned from Kyle the most likely candidate is Texas (Escapees address). The change would be easy, there are no domicile issues in TX, I like the BCBS option offered on the exchange there (it has out-of-network caps and very strong nationwide network) plus it’s cheaper than anything I can get in SD. Also Texas is still a tax-free state with good costs for RV insurance, registration, mail forwarding etc. Lastly, since moving state is considered a “qualifying life event“, we will be able to enroll in a new health plan outside of the standard enrollment period.
But honestly at this point I’m still not 100% sure. I’m keeping informed of all the choices and by Sept will let you know of our final decision.
Did You Make It??
Did you survive the post??? I barely did. Hopefully it’s been helpful and will give some of you clarity on what to do with insurance under the new ACA law. Feel free to comment and post questions below (just keep it non-political please).
Good, Related Blog Posts & Links
- Technomadia -> Picking A Domicile State, Getting Mail & Voting As A Nomad (great intro to choosing domicile)
- RV Dreams -> The Affordable Health Care Act & RVers (good overview of the ACA law details)
- The Federal ACA Exchange -> HealthCare.gov (SD, TX & FL are all on this exchange)
- The “Shopping Around” Link -> HealthSherpa.com (get ACA quotes from any state. Great comparison link)
- The “Help Me” Link -> RVerHealthInsurance.com (Kyle’s excellent website for fulltime RVers)
- Self-Medical Care -> My Three-Part Series on self-medical care & cash pay