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Navigating the Evolving Health Insurance Landscape

Podcast

Ep. 588 Navigating the Evolving Health Insurance Landscape

ACA premium tax credits hit a 400% federal poverty cliff — and your zip code determines more than you think

Brad Barrett · · Guests: Cody Garrett, CFP® · 43,161 plays
59m 57s
  1. Introduction
  2. Discussion on ACA Changes
  3. Zip Code Impacts on Healthcare Costs
  4. Health Insurance Options
  5. Navigating the ACA Marketplace
  6. Potential Pitfalls and Tax Credit Cliffs
  7. Wrapping Up and Key Takeaways

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Episode Summary

In this episode of ChooseFI, Cody Garrett provides an in-depth analysis of the changing landscape of health insurance in the U.S., focusing on the Affordable Care Act (ACA) and adjustments to premium tax credits. He emphasizes the critical role that zip codes play in determining healthcare costs and highlights the importance of understanding the 400% federal poverty level cliff, which poses financial risks for many families. Various health insurance options are discussed, including COBRA, retiree coverage, health sharing ministries, and private insurance, equipping listeners with vital insights for making informed healthcare decisions.

Listeners will learn actionable strategies for tax planning related to health insurance, including how to maximize benefits and minimize costs while navigating available healthcare options effectively.

Key Tactical Takeaways

  • Understand Income Levels: Monitor your income to avoid going over the 400% federal poverty level, which can eliminate premium tax credit eligibility.
  • Evaluate COBRA Costs: Review code DD on your W-2 to understand total health insurance premiums and assess whether continuing with COBRA is financially wise.
  • Explore Health Sharing Ministries: These may have lower premiums but lack the legal protections of traditional insurance; evaluate carefully.
  • Use HSA Contributions: Contribute to Health Savings Accounts to lower taxable income and potentially maintain premium tax credits; you can contribute even without earned income.
  • Utilize Marketplace Resources: Access healthcare.gov to determine premium tax credits based on your specific circumstances, including zip code and household income.
  • Be Cautious with Tax Planning: Adjust advanced premium tax credits based on estimated income cautiously to avoid unexpected tax liabilities.

Core Rules & Formulas

Rule/Formula Description
400% Poverty Level Threshold Know the household income limits that could affect premium tax credits.
COBRA Cost Calculation Employee + Employer Premium (W-2 code DD x 102%) = COBRA Costs.
HSA Contribution Can lower modified adjusted gross income; contribute by April 15 without earned income requirements.
Premium Tax Credit Calculation Estimated Credit = Based on adjusted gross income, household size, and the second lowest-cost silver plan.
Adjust Premium Tax Credits You can change the advanced credit amount month-to-month via healthcare.gov.

Tools, Accounts, or Strategies Mentioned

Tool/Strategy Description
healthcare.gov Website for ACA marketplace and health insurance options.
Health Savings Account (HSA) Account for saving for healthcare costs that reduces taxable income.
COBRA Coverage Allows continuation of employer health insurance post-employment.
Health Sharing Ministries Group healthcare cost-sharing options that offer lower premiums but higher risk.
Private Insurance Individual insurance plans that require medical underwriting.

Resources & References

Clear Calls to Action

  • Review your income and health insurance options during open enrollment.
  • Assess your COBRA costs by checking your W-2 for current premium data.
  • Explore HSA contributions to manage your taxable income prudently.
  • Adjust advanced premium tax credits through healthcare.gov based on changes in your financial situation.
  • For further clarity on health insurance strategies, consider consulting a financial planner to avoid potential costly mistakes.
Read Transcript

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Comments (26)

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David Robinson 2 months ago

I'm retired and in my first year made exactly the type of mistake discussed here where you end up owing a large bill on taxes later. The root of the problem is that the ACA asks you to "predict" your income at the beginning of the year and if you end up making more than your prediction, you end up paying massive "tuition" for the learning experience.

Learn from my mistake. The root of the problem is predicting and then locking in taxable income at the beginning of the year for living expenses.

The solution? By ACA rule, you've got to predict your income at the start of the year. However, there is no rule that says you need to make your taxable distributions for that year at the beginning also… it's just a practical reaction. Now I do all my taxable distributions in December after I know what income has transpired throughout the year. This creates a conundrum – how did I cover living expenses? In my case, I pre-funded that first year with tax-free Roth assets (which do not count towards AGI). Then December rolled around and after accounting for small income opportunities I received that year (dividends, side-hustles, whatever) I topped off my predicted income with taxable assets. Now, this distribution done in December funds my expenses for the FOLLOWING year. Repeat. It was painful to take a whole year of expenses from my Roth that first year – but the flexibility it creates to generate income through the year is enormous.

2
David Robinson 2 months ago

I'm retired and in my first year made exactly the type of mistake discussed here where you end up owing a large bill on taxes later. The root of the problem is that the ACA asks you to "predict" your income at the beginning of the year and if you end up making more than your prediction, you end up paying massive "tuition" for the learning experience.

Learn from my mistake. The root of the problem is predicting and then locking in taxable income at the beginning of the year for living expenses.

The solution? By ACA rule, you've got to predict your income at the start of the year. However, there is no rule that says you need to make your taxable distributions for that year at the beginning also… it's just a practical reaction. Now I do all my taxable distributions in December after I know what income has transpired throughout the year. This creates a conundrum – how did I cover living expenses? In my case, I pre-funded that first year with tax-free Roth assets (which do not count towards AGI). Then December rolled around and after accounting for small income opportunities I received that year (dividends, side-hustles, whatever) I topped off my predicted income with taxable assets. Now, this distribution done in December funds my expenses for the FOLLOWING year. Repeat. It was painful to take a whole year of expenses from my Roth that first year – but the flexibility it creates to generate income through the year is enormous.

2
Shanda Finnigan 2 months ago

GREAT episode as always! I'm a current Federal employee and still 5.5 years from minimum retirement age (which would allow me to retire with gov health care). But… I'm already FI and really just done with working. This episode scared me back into thinking I need to stay working - the ACA sounds so complicated and expensive! 😞

Shanda Finnigan 2 months ago

GREAT episode as always! I'm a current Federal employee and still 5.5 years from minimum retirement age (which would allow me to retire with gov health care). But… I'm already FI and really just done with working. This episode scared me back into thinking I need to stay working - the ACA sounds so complicated and expensive! 😞

adamlee 2 months ago

Question: if I have a spouse who is still working and is eligible for health insurance through her employer, how does that affect the eligibility for health insurance subsidies?

Thanks for the wonderful episode, very informative!

David Robinson 2 months ago

If you choose to NOT be on your wife's insurance, then you can sign up for an ACA plan. However, her income counts towards household income when applying for healthcare insurance through the ACA. So, you may not be able to stay below the current 400% FPL required to get ACA subsidies. 🤷🏻‍♂️

1
adamlee 2 months ago

Question: if I have a spouse who is still working and is eligible for health insurance through her employer, how does that affect the eligibility for health insurance subsidies?

Thanks for the wonderful episode, very informative!

David Robinson 2 months ago

If you choose to NOT be on your wife's insurance, then you can sign up for an ACA plan. However, her income counts towards household income when applying for healthcare insurance through the ACA. So, you may not be able to stay below the current 400% FPL required to get ACA subsidies. 🤷🏻‍♂️

1
Mrs_Green 2 months ago (edited)

Question: If still working, can your 401(k) be used to lower taxable income and potentially maintain premium tax credits in addition to the HSA?

1
Cody Garrett, CFP® 2 months ago

Yes, traditional 401(k) contributions reduce MAGI for all purposes, including for Premium Tax Credit (PTC) eligibility.

2
Mrs_Green 2 months ago (edited)

Question: If still working, can your 401(k) be used to lower taxable income and potentially maintain premium tax credits in addition to the HSA?

1
Cody Garrett, CFP® 2 months ago

Yes, traditional 401(k) contributions reduce MAGI for all purposes, including for Premium Tax Credit (PTC) eligibility.

2
ATreth 2 months ago (edited)

This will be our lowest income year, probably ever, as we both have recently retired. Husband will sign up for social security in June. So all we have coming in until then is interest income, dividends, rental income, and a small annuity. We have lots of money in our "bridge" bucket to get us to IRA withdrawals, social security, medicare, etc. House is paid off, and our living expenses are reasonable..

We WERE going to sell the rental but it won't happen this year – we're having a hard/impossible time getting our tenant out, and I LOVE LIVING IN CALIFORNIA, but GOT DAMN they make it hard to evict.

So I just updated our ACA income info based on not receiving capital gains from the rental sale this year, and our monthly premium for the Bronze HDHP is now $0! If we did sell the rental, the capital gains from the sale would increase our monthly premiums to $2,200. We might just hang on to the rental for a few more years…

Not gonna lie, I feel a slight pang of guilt for getting healthcare for free when other people have it so crazy hard. But as Brad often mentions, in FI, we learn the rules and we play by them.

ATreth 2 months ago (edited)

This will be our lowest income year, probably ever, as we both have recently retired. Husband will sign up for social security in June. So all we have coming in until then is interest income, dividends, rental income, and a small annuity. We have lots of money in our "bridge" bucket to get us to IRA withdrawals, social security, medicare, etc. House is paid off, and our living expenses are reasonable..

We WERE going to sell the rental but it won't happen this year – we're having a hard/impossible time getting our tenant out, and I LOVE LIVING IN CALIFORNIA, but GOT DAMN they make it hard to evict.

So I just updated our ACA income info based on not receiving capital gains from the rental sale this year, and our monthly premium for the Bronze HDHP is now $0! If we did sell the rental, the capital gains from the sale would increase our monthly premiums to $2,200. We might just hang on to the rental for a few more years…

Not gonna lie, I feel a slight pang of guilt for getting healthcare for free when other people have it so crazy hard. But as Brad often mentions, in FI, we learn the rules and we play by them.

rcost300 2 months ago (edited)

This was a fantastic listen, thank you Cody and Brad! It's hyper-relevant to me given that I'm approaching 2 years in FIRE, using an ACA plan. Because I've been in this headspace for so long, a few things jumped out at me that might benefit the larger community (or maybe the larger community can point out errors in my reasoning which would benefit me 😂)

Firstly: there was some discussion of the pros and cons of just not getting insurance and just going with the "cash pay rate". This is risky! Recently a family member had to have a procedure that was quoted by the hospital at the idiotic, insane, totally fictitious price of $43,000. There was a delay in the pre-approval and I asked what would the cash pay rate be. They told me $10,000. Seemed like a "discount", but when all was said and done (the pre-auth came through), the insurance negotiated rate ended up being $2,000. What it made me realize is the value of insurance is not just that it pays some expenses but that it negotiates for non-ridiculous rates in the first place!

Secondly: for those of us (1/16th of Americans) who live in the state of New York, please know that some of the general information online DOES NOT APPLY in this very unique state of ours. Premiums don't increase with age as they do everywhere else except Vermont and DC. Private off-exchange insurance is, as far as I could tell, illegal here and does not exist. The income range to qualify for PTC isn't 100%-400% of FPL, and it isn't 138%-400% of FPL like in the "expansion states", it's actually 250%-400% of FPL since they have this thing called the Essential Plan which is a bit like Medicaid-lite. And if you want to take advance PTC here, you have to report your income monthly which is dangerous because for those of us in FI, we may not have any income for a month and they may resultingly take us off the ACA plan and put us on Medicaid! (I am not sure this is a NY-specific thing actually, but when I called the state insurance office to ask, they told me that's how it works!)

As a result I do use the strategy talked about in the episode of taking no APTC and just getting everything back at year end. A bit of a white knuckler (especially since as you mentioned, many tax accountants don't know what to do with the 1095-A and Form 8962, I actually had to switch accountants because my existing one was totally unaware of this and would have entirely failed to get me any PTC refund!)

1
SoccerCoach518 2 months ago

A fellow New York'er here to share my personal experience with our New York State of Health (NYSOH) plans which is our state's version of the ACA. We've been using it for several years now.

From 2022-2024 we had either a silver level plan, paying a portion of the premiums each month based on what the APTC didn't cover, then reconciling everything when filing taxes each year. We never had to report income monthly so not sure if that is a new rule or for specific plans?

For 2025 thru now (March 2026) we have been on the Essential Plan (we're about @280% of FPL). We got a notice just prior to open enrollment last November that due to current federal legislation, New York will only be able to offer the Essential Plan through June 2026. The notice said we would be notified of alternatives before our current plan expires on 6/30. We have yet to receive any other updates (I keep checking!).

rcost300 2 months ago (edited)

This was a fantastic listen, thank you Cody and Brad! It's hyper-relevant to me given that I'm approaching 2 years in FIRE, using an ACA plan. Because I've been in this headspace for so long, a few things jumped out at me that might benefit the larger community (or maybe the larger community can point out errors in my reasoning which would benefit me 😂)

Firstly: there was some discussion of the pros and cons of just not getting insurance and just going with the "cash pay rate". This is risky! Recently a family member had to have a procedure that was quoted by the hospital at the idiotic, insane, totally fictitious price of $43,000. There was a delay in the pre-approval and I asked what would the cash pay rate be. They told me $10,000. Seemed like a "discount", but when all was said and done (the pre-auth came through), the insurance negotiated rate ended up being $2,000. What it made me realize is the value of insurance is not just that it pays some expenses but that it negotiates for non-ridiculous rates in the first place!

Secondly: for those of us (1/16th of Americans) who live in the state of New York, please know that some of the general information online DOES NOT APPLY in this very unique state of ours. Premiums don't increase with age as they do everywhere else except Vermont and DC. Private off-exchange insurance is, as far as I could tell, illegal here and does not exist. The income range to qualify for PTC isn't 100%-400% of FPL, and it isn't 138%-400% of FPL like in the "expansion states", it's actually 250%-400% of FPL since they have this thing called the Essential Plan which is a bit like Medicaid-lite. And if you want to take advance PTC here, you have to report your income monthly which is dangerous because for those of us in FI, we may not have any income for a month and they may resultingly take us off the ACA plan and put us on Medicaid! (I am not sure this is a NY-specific thing actually, but when I called the state insurance office to ask, they told me that's how it works!)

As a result I do use the strategy talked about in the episode of taking no APTC and just getting everything back at year end. A bit of a white knuckler (especially since as you mentioned, many tax accountants don't know what to do with the 1095-A and Form 8962, I actually had to switch accountants because my existing one was totally unaware of this and would have entirely failed to get me any PTC refund!)

1
SoccerCoach518 2 months ago

A fellow New York'er here to share my personal experience with our New York State of Health (NYSOH) plans which is our state's version of the ACA. We've been using it for several years now.

From 2022-2024 we had either a silver level plan, paying a portion of the premiums each month based on what the APTC didn't cover, then reconciling everything when filing taxes each year. We never had to report income monthly so not sure if that is a new rule or for specific plans?

For 2025 thru now (March 2026) we have been on the Essential Plan (we're about @280% of FPL). We got a notice just prior to open enrollment last November that due to current federal legislation, New York will only be able to offer the Essential Plan through June 2026. The notice said we would be notified of alternatives before our current plan expires on 6/30. We have yet to receive any other updates (I keep checking!).

christyr1q 2 months ago

This was a great listen. We keep debating if my husband can / should continue to work for the government as rules change.

1
christyr1q 2 months ago

This was a great listen. We keep debating if my husband can / should continue to work for the government as rules change.

1
aub_engineer 2 months ago

The episode didn’t discuss the use of low interest loans (heloc, security backed LOC, etc.) to help manage and smooth out income.

Paying a little interest seems like a no brainer if you are approaching the 400% cliff.

1
Westie 2 months ago

As a matter of fact, in terms of adjusting your taxable income, I think there's a bigger conversation about the role loans (and credit in general) could play. For example a loan could help bridge the gap between early retirement and withdrawing from your IRA conversion ladder.

2
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