Figuring out health care options is probably one of hardest things for newbies hitting the road, especially those who are younger (pre-Medicare) and self-employed. When you’re an RVer it’s not just the traveling part that makes it hard (the fact that you’re always in a different city, with different doctors), but rather the insurance options too. There are so many choices, and the details are complicated and over-whelming. Is it best to buy insurance on the Marketplace? Off-Market? Somewhere else? What options do I really have, and how will they cover me if I get ill or injured?
Well, I’m not going to tell you that health insurance is easy, and I’m certainly not going to be able to cover every plan out there in one post, but hopefully I can help you narrow down the options. In this article my goal is to cover the basics, the top-level stuff on what insurance options are available for the self-employed today, and how to decide which one makes the most sense for you.
So, make yourself a beverage of choice, get settled into your most comfortable RV chair and let’s dig right in.
Official Disclaimer: I am not a qualified health insurance broker, nor am I in the medical field. This is simply a layman’s view of health insurance options, as I see them. Please consult an expert before you buy.
Self-Employed RVer Health Insurance Needs
Before we enter the nitty gritty of what kinds of insurance plans you can buy (and where) I think it’s important to look at needs. Personally, I think there are several basic things that all self-employed RVers should consider when they shop for an insurance plan, no matter what or from whom they buy:
- Solid Nationwide Provider Network – RVers are travelers, so having access to a network of doctors throughout the country is essential. The wider your insurance provider network, the more likely you are to find an “in-network” doctor (or hospital) wherever you go, which is critical for keeping your costs down. Out-of-network care is expensive and can expose you to hidden costs (including a wicked gotcha known as “balance billing”), so staying in-network is something you always want to try to do. In insurance terms, PPO (Preferred Provider Organizations) plans generally provide the largest accessible network with the least restrictions, but even these can vary a ton by size. Always check network details for any plan before you buy!
- RV (Travel) Friendly – Certain insurances 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 (we ran into this problem in SD, back in the day). This is obviously a no-go for fulltime travelers, so it’s important to choose an insurance that does not have these restrictions in place.
- Out-Of-Network Caps – Our goal is always to try and stay in-network, but sometimes it can’t be helped. If it’s offered, choose plans that limit out-of-network costs, just in case. This isn’t something that is regulated, so it’s you’ll need to check for it specifically.
- Overall Costs, Including Deductibles and Co-Insurance – It’s always essential to compare overall costs for whatever plan you decide on, including deductibles and co-insurance before you buy. For example, a lower-cost plan will usually have higher deductibles, which is a non-issue if you are healthy but can add significant costs if you have on-going issues or incur new health issues during the year. So, make sure to look at the total (combined) numbers, before you make the assessment on what’s right for you.
- Support For Pre–Existing Conditions (If Needed) – If you have a pre-existing health condition, you must choose a plan that covers your needs. In today’s landscape “ACA-compliant” plans are all required to cover pre-existing conditions, whereas “non-ACA-compliant” plans are not (see below for more on these). This may all change in the future however, so it’s important to keep this in mind whenever you shop around.
- Support For Maternity (If Needed) – If you’re a younger RVer, planning or thinking about getting pregnant on the road, it’s important to make sure your insurance plan covers maternity care. Once again, in today’s landscape “ACA-compliant” plans are all required to cover maternity care, whereas “non-ACA-compliant” plans are not (see below for more).
- Support for an HSA Account (If Wanted) – This is not an essential item, but something to consider. A Health Savings Account is a nice benefit and something I’d recommend for all self-employed RVers. 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. Not all insurance plans support this, so if you want it, you have to look specifically for it. We’ve always bought plans that support an HSA.
A Full-Time RV “Benefit” - Domicile!
When you’re shopping around for health insurance, you’ll very quickly discover that plan offerings and costs vary tremendously not just by state, but even by county!
As a full-time RVer, your domicile determines where you buy, and one of the “benefits” you can exercise (as long as you do not have legal ties to a specific state) is to switch your domicile to a less expensive location.
Now, domicile choice is a rather complex topic and should never be undertaken on just one thing (Escapees has great articles on this), but health insurance is definitely one of the considerations to take into account.
Traditional Insurance (Marketplace, Off-Exchange & Non-ACA)
So now that we’ve covered basic needs, what kind of health insurance can a self-employed RVer actually buy? As it turns out, this landscape has changed a TON over the last 10 years.
Around 10 years ago, self-employed RVers could only buy insurance by shopping for private plans in their state of domicile. Then in 2010, the ACA (Affordable Care Act) was passed which standardized coverage requirements for major medical and created a centralized “marketplace” where you could buy subsidized insurance plans, depending on your income level. This was a massive change.
Fast forward 8 more years, and things are changing again! New legislation enacted this year will eliminate the “individual mandate” penalty (the tax penalty you paid if you chose not to get insured or bought a non-ACA-compliant plan) and allow certain formerly-limited plans (like short-term insurance) to be bought over the longer term. The net result of all this is that in 2019, self-employed RVers will now have THREE options to buy insurance!
- They can buy plans through the “Marketplace/Exchange”
- They can buy plans “Off-Market/Off-Exchange”
- They can buy “Non-ACA-Compliant” plans
I’m not here to say that one is better than the other, nor am I here to comment on the politics of the situation, but I can certainly lay out the pros and cons of each, so you can make the best decision on which one might be right for you.
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Marketplace (Exchange) Insurance
The “Marketplace” or “Exchange” is a centralized location (healthcare.gov in most cases, although some states run their own exchange) where you can shop & enroll in plans that meet the requirements enacted by the ACA in 2010. Enrollment happens once per year (typically Nov 1 – Dec 15th), plans are presented in 5 categories (the 4 “Metal” tiers = Bronze, Silver, Gold, Platinum, plus “Catastrophic*”) and all must meet a set of 10 “Essential Health Benefits (EHBs)” covering various things from emergency services to maternity & preventative care. Note that certain details such as network provider size & out-of-network care (except emergency) are not regulated by the ACA, so make sure you shop accordingly.
- Coverage For Pre-Existing Conditions: All marketplace plans are required by ACA law to cover pre-existing health conditions and cannot charge extra for them.
- Coverage For Maternity: This is one of the 10 EHBs and all ACA-compliant plans must cover it. For younger RVers who might want to start a family on the road, this is a definite advantage.
- Subsidies (If You Qualify): If your MAGI (Modified Adjusted Gross Income) falls between 100-400% of the federal poverty level (which translates to between $12,140-$48,560 for a single person in 2018) you will receive a monthly credit on your healthcare costs for any “Metal” plan (Bronze to Platinum) bought through the exchange. The lower your income the higher the subsidy, and the $ involved can be substantial (for low-earners, insurance might even be free). If you qualify, you should definitely take advantage of this!
- Subsidies (If You DO NOT Qualify): If you do not qualify for subsidies, either you earn too little (less than 100% FPL) or too much (even $1 over the 400% FPL number disqualifies you) then you pay full price on all “Metal” plans (Bronze to Platinum), and that can be $! If this is the case, you might want to consider a “Catastrophic*” plan, and/or shop around outside the marketplace.
*What Are “Catastrophic” Plans? These are higher deductible, lower premium, non-subsidy plans. In previous years, only folks under 30 or those who qualified for a “hardship exemption” were eligible to buy them without having to pay the tax penalty. As of Jan 1st, 2019 this tax penalty is going away, so these plans may become an option for more folks.
Who Should Buy Here?
Marketplace Plans are the best way to go if you qualify for subsidies. They are also worth looking at for anyone with a pre-existing condition, and/or younger RVers looking to start a family on the road. Just make sure the plan you buy is RV (travel) friendly and offers a solid nationwide provider network.
Off-Market (Off-Exchange) Insurance
“Off-Market” or “Off-Exchange” insurance plans are basically just major medical plans bought outside of the official ACA-created health insurance exchange. They are identical to “Marketplace” plans in that they have to meet ACA regulations. So, they’re presented in the same 5 tiers (Bronze, Silver, Gold, Platinum, plus Catastrophic) and must cover pre-existing conditions and the same 10 “Essential Health Benefits”. The biggest difference however, is that off-exchange plans are NOT eligible for subsidies. Also, they may work with different networks, have different prescription drug coverage and/or vary somewhat in structure.
- Coverage For Pre-Existing Conditions: All “off-exchange” major medical plans are required by ACA law to cover pre-existing health conditions.
- Coverage For Maternity: This is one of the 10 EHBs and all ACA-compliant plans, including off-exchange plans, must cover it.
- More Options: In certain states, carriers might have pulled out of the ACA exchange, but still offer off-exchange options. Also network offerings from off-exchange plans can be different and might (sometimes) be better. For folks who don’t qualify for subsidies, this can give a wider range of plans to choose from.
- Expensive: Since “off-exchange” plans are still regulated by ACA, and do not qualify for subsidies, the “Metal” plans tend to be on the expensive side. Price depends a lot on age, so younger folk will find much more affordable solutions than folks nearing Medicare age. Also, if a “Catastrophic” plan works for you, this can be a less expensive offering to look at.
Who Should Buy Here?
Off-Market plans are worth looking at for anyone who does NOT quality for subsidies, but still needs the protections offered by ACA (e.g. coverage for pre-existing conditions, maternity care etc.). Once again, make sure the plan you buy is RV (travel) friendly and offers a good nationwide provider network.
“Non-ACA-compliant” insurance basically covers any private plan that does not meet ACA requirements. The most important thing to understand about these kinds of plans is that they do not have any regulation on pre-existing conditions, coverage levels, or lifetime caps. In recent years, buying this kind of plan would force you to pay a tax penalty, but as of Jan 1st, 2019 this will no longer be the case. This opens up a lot of new possibilities, especially for younger RVers, but also means you really need to scrutinize the fine print to make sure the plan you buy actually covers what you need.
Examples of non ACA-Compliant plans include:
- Short-Term Insurance – These are high-deductible plans that were originally designed to cover temporary (less than 3 months) insurance gaps, for example when moving states, or jobs. Just this year, new rules were enacted which will allow these plans to be sold up to 364 days at a time, with renewals for up to 36 months. They typically have lifetime caps between $250,000 to $2 million, but can provide pretty decent coverage, and often have good nationwide provider networks too. They typically exclude pre-existing conditions though, so they’re not an option if you already have a health condition. We’ve bought short-term insurance in the past and would do so again.
- Indemnity Plans – These are plans that provide limited, fixed-sum benefits for expenses related to accidents and certain illnesses. They are not comprehensive insurance and are not designed to replace major medical but can be a useful supplement. For those interested, Escapees offers a very reasonable indemnity plan called “Axis Healthcare Assist”.
- Minimum Essential Coverage (MEC) Plans – these are plans that only cover the “minimum essentials” of ACA, such as preventative care and wellness benefits. Once again, these are not comprehensive insurance and will not cover you for major medical but can be a useful supplement for preventative care. Escapees offers a plan here called WellMEC.
- Association Health Plans (AHPs) – these are plansoffered by certain associations (e.g. trade groups, business associations etc.) for the benefit of small businesses or self-employed individuals who join them. AHPs have actually existed for years but have traditionally been rather restrictive to join. However new legislation (enacted this year) has relaxed how they work, so I think many more offerings will pop up here in the future. This will be a space to watch for self-employed RVers!
- Lots More Options: Since these plans are not regulated by the ACA, there are a ton more options available to consumers from extremely minimal to fuller coverage.
- Much Cheaper Plans: The same lack of regulation also means providers can offer much cheaper plans such as high-deductible plans with restrictions in place (e.g. no coverage for pre-existing conditions). As long as these restrictions are acceptable to you, prices can be very affordable indeed.
- Lots More Options (Beware The Fine Print!): Lack of regulation also means you need to read the fine print on these plans much, much more closely. Details such as lifetime caps, maternity coverage, pre-existing condition coverage (all of which are regulated by ACA-law) no longer apply. Also plans are not regulated on exactly what they must cover, so they may just cover a teeny portion of medical care (say, preventative care in the case of MEC plans) and not protect you at all in the event of an accident or major illness. There are some very interesting (and viable) options for RVers in this space, but you do need to be vigilant when you buy.
Who Should Buy Here?
Non-ACA-Compliant plans are worth a look for anyone who does not have a pre-existing condition and is seeking more affordable or alternative choices outside of the ACA.
Cost-Sharing & Ministry Options
A complete alternative to traditional insurance is to join what is known as a cost-sharing or ministry plan. This idea has blossomed in popularity over the last 8 years, in large part because of massive cost increases on ACA plans (especially for folks who do not qualify for subsidies), with Ministries offering comparable-looking options at a fraction of the price. Before you jump on this bandwagon however, it’s important to understand the following:
Ministry plans are NOT insurance
These are faith-based cost-shares where individuals pool their money together to pay medical costs for other individuals in the same faith group. There is no regulation, no financial oversight, no guarantee that your medical expenses will be paid, and no legal recourse if they do not get paid.
With that said, many are strongly attracted to the idea of a faith-based share for religious or personal reasons, and the costs to join are inexpensive compared to traditional insurance. If you want to research this more, the most popular ministries to look into are Samaritan Ministries, Christian Healthcare Ministries, Medi-Share, and Liberty Healthshare.
I do want to quickly mention this, because it does come up often in RV health care discussions. Some people chose to “self-insure” by simply putting money aside into a health care fund each month.
This kind of approach can work for many things in life (e.g. RV repair fund), but in my opinion it does not work for health care. Health care is so expensive in the USA that unless you happen to have millions of extra cash on-hand, a single, major health incident (e.g. accident, illness) could potentially ruin you financially for life.
I don’t think anyone should ever put themselves in that situation, so I would always recommend getting yourself insured, no matter which route you choose.
Tele-Medicine & Online Docs
A final note on Tele-Medicine & Online Docs.
As you’re shopping around for health insurance, you may hear rumblings about tele-medicine and online docs. This is a fairly new development in the US healthcare industry (we didn’t discover it ourselves until our last few years on the road), but we think it’s an AWESOME resource for RVers, and something every traveler should consider as they’re putting together their health care plan for the road.
There are several ways to access tele-medicine. Some insurance plans include it as part of their services (e.g. our old Avera plan in SD had it), but you can also buy separate plans that cover it, or you can sign-up for monthly or one-time service directly with a provider (e.g. Escapees MyHealthPass) Costs are typically inexpensive, running anywhere from free (if it’s part of your insurance or a monthly service) to $45-$75 for a single visit (if you’re just using it one time).
Once you’ve decided on a service, they all work pretty much the same way.
When you have something you want to speak to a doc about, you sign-in (either from your computer, or through an app on your phone or pad), chose an available doctor (from a list, which may also list their qualifications, history, and reviews), and then you have a 1-1 video call, typically lasting around 15 mins, about your problem. It’s a quick, relaxed, and frankly really pleasant way to see a doc, all done from the comfort of your RV!
Online docs obviously can’t handle everything. They can’t handle emergencies or anything requiring an in-person diagnostic (for those things, go immediately to an Urgent Care or Emergency Room), but they can handle a surprising number of basic problems, and can help you sort out whether your symptoms require an in-person visit to a doc or not. Plus, they can prescribe basic meds (to be picked up at the nearest pharmacy), and some can even order blood tests too (to be fulfilled at the nearest lab). These days Telehealth is expanding, and starting to offer extra services like concierge care, mental health care and even preventative care. We think it’s the trend of the future.
That’s All She Wrote
Phew! If you made it through all that I congratulate you! Hopefully I managed to give you a few useful pointers on what insurance to choose for your life on the road. Healthy traveling to you all!
Nina Fussing (SKP#106238) is a blogger, photographer and all-around nature-lover who spent 8 years fulltime RVing with her hubby & 12 paws around USA. They are now in Europe continuing the adventure there.
Follow their story at: wheelingit.us