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Old 08-12-2013, 22:37   #1
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Maximizing the ACA

Sorry to bring this up again....

But the last thread ended a while ago, and I would love to get some input from people who have signed up for health insurance. Right now, my state's website is blocking IPs from outside the US, so that is a problem.

Here is where I see things:
1. If you are off sailing in a faraway place with no intention to go to the USA, you qualify for the "physical presence" exception (no more than 35 days in the USA a calendar year). Good for you.
2. Your income is low enough, you qualify for Medicaid.
3. You have an income somewhere between 16K and 90K, hence qualify for a tax break. Check your state website or healthcare.gov, if you can get it to work.

I imagine, most of us fall into the third category, hence I am trying to healthcare shop, but no luck yet.

Three questions:
1. How do you prove the "physical presence" exemption?
2. If I return to the USA after 6 months, can I sign up for insurance under the "just moved" exception, even though it is outside of enrollment?
3. According to the ACA, you can forego insurance for 3 months a year with no penalty. Also, the enrollment period is open until March 31. Since most of us are out of the USA from Jan 1 through March 31, can we simply not pay insurance until March 31, and if we need to repatriate after an illness or accident, simply sign up for same day or next day coverage? If so, I just saved myself 25% a year.

Thanks for the help.
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Old 08-12-2013, 23:26   #2
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Re: Maximizing the ACA

Don't know about this fiasco but I have outus for more than 20 yrs. I assume the immigration records show departure and return times.
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Old 09-12-2013, 00:49   #3
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Re: Maximizing the ACA

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Don't know about this fiasco but I have outus for more than 20 yrs. I assume the immigration records show departure and return times.
Wrong, there is no "official check-out" for anyone. Citizens or non-citizens. Only your entry is recorded.

This is not true in the 50 countries we have visited so far...immigration check-out in all of them, but not the US. I am guessing this is the reason that so many people overstay their visas...some by 50 years!

Bill
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Old 10-04-2015, 16:29   #4
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Re: Maximizing the ACA

Instead of starting a new thread lets try working this one.

Who is cruising with an ACA policy (meaning you are staying in 1 state as a resident)? Hows it working out? Are you on a plan with subsidy of because you don't have an income are you on Medicaid? What's is costing you after subsidy if that is what you have it? What would it be without the subsidy?

Yes this is a USA specific question. No we don't need to do any rants, just the facts.
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Old 10-04-2015, 17:30   #5
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Re: Maximizing the ACA

We have an ACA policy.

ACA has been super fantastic for us. Before ACA it was impossible for my family to buy health insurance. My 11 year old daughter has a pre-existing condition that completely excluded her from health insurance. They wouldn't even quote us a higher premium, they would simply reject us. Before ACA I had to either work for a company, or make my own company to work for, so that we could buy insurance through a group plan and get around her pre-existing condition.

We pay $750/month for a family of four. We do not get a subsidy.
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Old 13-04-2015, 05:45   #6
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Re: Maximizing the ACA

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We have an ACA policy.
You list your location as the Caribbean, how are you using your ACA policy? Are you traveling back to the US all the time to use it?
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Old 13-04-2015, 10:32   #7
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Re: Maximizing the ACA

We pay out of pocket for care in other countries. The most expensive thing so far was an ambulance ride and emergency room visit in Martinique for ~170 (I can't remember exactly).

I'm not worried about healthcare costs in other countries.

We bought ACA insurance before we left the country. I believe we remain official residents of the last state we lived in.

We are currently in Portland, Oregon for an unexpected year of medical complexity. We moved our insurance here when we decided to make Oregon our home state. It took two months because there is a very early cut off date to be insured the following month, something like you have to sign up by the 1st to be insured the following month. We missed that and had to effectively wait two months.

I completely disagree with the strategy to be uninsured and then reinsure with ACA when one gets sick. I feel it's immoral, like cheating welfare. But also impractical because, in our experience, health insurance doesn't turn on instantaneously. For some things -- a heart attack or stroke or aggressive cancer or whatever -- well, you could easily go bankrupt or die while waiting months for the insurance paperwork to go through. Without insurance our medical system will only "stabilize" you, which I do not believe includes cutting out a tumor before it spreads. I've been in the emergency room a lot with my daughter and see how the uninsured are treated: I would never want to be in that situation.

Is there actually a way to buy health insurance the same or next day?
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Old 13-04-2015, 11:34   #8
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Re: Maximizing the ACA

Oh, sorry, I ranted a little. I would edit it out but it's too late. I take it all back in the interest of not derailing any discussion.

Also, I was wrong -- we had individual insurance, not ACA, when we first started cruising. The first stage of Obamacare is that children couldn't be denied insurance because of pre-existing conditions. So we had normal individual policies for one year. Then switched to ACA. We bought that policy on the Internet while sailing.

As an anecdote, my step-dad is a semi-retired Australian physician. He has many stories of travelers getting major healthcare in Australia for reasonable cost. That, and our experiences in Mexico and the Caribbean with our kids, forms the basis of our strategy to self-insure in other countries. We keep insurance in America for if anything 'major' goes wrong-- as it did for us this past year-- that requires flying back or staying back.
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Old 13-04-2015, 12:48   #9
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Re: Maximizing the ACA

Did you investigate private insurance options when you were in Mexico? I am thinking of moving there from Costa Rica, where as residents we have access to the public health care system at minimal cost (about $100 a month). The boat is already in that country, on a temporary import permit. If my wife and I move there and rent or buy a house, we will have to do something about health care - just pay out of pocket, buy international or other insurance, or figure out options under ACA/Medicare. I have no idea what the #3 options are at this point - we relied on the stay-out-of-the-US strategy for 2014, but I joined Medicare in December having reached the necessary golden age. Since then I have been busy cruising and have not looked into ACA with Medicare options. Before Medicare, ACA would have doubled our pre-ACA insurance costs in the US, given our income level. So we just relied on the compulsory public system in CR, plus some use of private providers, paying out of pocket.
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Old 13-04-2015, 12:52   #10
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Re: Maximizing the ACA

Proving the physical presence exemption, i.e., that you were out of the US for at least 330 days: I filed using TurboTax on-line; no proof was required, just an assertion that we met the exemption. So I suppose if audited we would show up with passports that would provide the necessary proof. There aren't exit stamps in the US, but there are entrance stamps in other countries, plus exit stamps from them and entrance stamps to the US. So anybody with good eyesight could figure out the in-US periods given photocopies of all passport pages for a person claiming this exemption. And who gets audited anyway these days? A recent newspaper article said that one IRS office, don't remember which part of the US, has so few agents that they only chase down taxpayers owing more than $1million. I don't have that problem!
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Old 13-04-2015, 13:06   #11
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Re: Maximizing the ACA

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And who gets audited anyway these days? A recent newspaper article said that one IRS office, don't remember which part of the US, has so few agents that they only chase down taxpayers owing more than $1million. I don't have that problem!
I have a buddy in MA who would argue that. He was hounded for $16.50 for a tax mistake, and called into an IRS office to be grilled.

Meanwhile, Al Sharpton, who owes something like $4.5 million in taxes, waltzes around the country unfettered.

I wonder how the IRS handles the obamacare penalty if you are out of country? A different buddy opted to not sign up and when he did his taxes was informed of a $1500 penalty. He had to pay in taxes due but omitted $1500. Hmmmmm
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Old 13-04-2015, 13:22   #12
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Re: Maximizing the ACA

lets not start ranting etc., there's always a minor chance that we can hear from cruiser about their experience with ACA or Medicaid
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Old 13-04-2015, 15:51   #13
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Re: Maximizing the ACA

In Rhode Island, you don't get Medicaid just because you have no income. If you are an able bodied person and don't work, you will be turned down. I have a step daughter in this situation. Her mother, who is an expert in this area, kept herself and the kids on Medicaid as long as she had two minor children. They age out at 19 and she doesn't qualify, either, now that the kids are grown. She tried very hard to get around this, but was not able to. The daughter is on our insurance now. We have warned her not to expect his to last until age 26, but so far she is not listening.

You will need income of a certain amount to qualify for a subsidy with ACA. If you have a job but it pays less than this, you should qualify for Medicaid (depends on the state). The subsidy varies with your income. You can still buy through the exchanges with a high income or zero income, but you won't qualify for a subsidy. You estimate what your income will be for the year and the subsidy is based on that. Estimate too low and you will have a tax bill when you file. Estimate too high and you get a refund when you file. You can have a recalculation done (monthly, I think) so you don't get too far away from the actual subsidy you should be getting.

There is a radio show every Thursday from 12 pm to 2 pm Eastern time on Doctor Radio on SiriusXM, called Healthcare Connect, that deals with these issues. It's an excellent resource if you are interested in this subject. The host also has a website, Rubinhealth.com, and you can ask questions there, as well.

I am often in my car on Thursday afternoons and have been listening for a couple of years now. They also help with Medicare questions and other health insurance questions.


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