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Selecting a Domicile — It’s All about Counties

FOR PRE-MEDICARE RVers ONLY

If you’re a full-time RVer under 65, selecting a domicile state became more complicated with the passage of the Affordable Care Act (ACA) or “Obamacare”.

Traditionally, popular domicile states like South Dakota, Texas, and Florida were chosen primarily because these states have no state income taxes. Other factors, like mail forwarding services, vehicle registration, vehicle insurance, and so on also played a part in the decision.

However, the health care plans available or not available in a state may now be the most important factor in choosing a domicile.

For health care plans offered on the ACA exchange, an RVer’s domicile county, not the state, determines the number, type (NOTE 1), and cost of health plans.

Choosing the “wrong” domicile county could result in inferior coverage or increased cost — or both (NOTE 2).

– In Florida, Seminole county offers 96 ACA plans — 24 POS, 18 EPO, and 54 HMO plans. By contrast, Florida’s Jefferson county (and a number of others) only offers 15 plans — 9 EPOs and 6 HMOs.

— In Texas, Polk county just offers HMO plans on the ACA exchange. On the other hand, Robertson county (and 57 other Texas counties) offers 9 PPO plans. (For a larger image of “Texas PPO Health Plans”, click here.)

Texas PPO Counties - 2016

PPO Plans — the Heart of Texas

– In Arizona, the most basic PPO plan costs almost twice as much in Mohave county than it does in Pima county.

HOW DO YOU PICK THE “RIGHT” COUNTY FOR A DOMICILE?

In short, select the “healthiest” county.

The County Health Rankings & Roadmaps (NOTE 3) ranks the health of each state county. A number of factors are used in the ranking, but the end result is a listing of each state’s counties from the most to the least healthy.

TX Health Rating

I’m not privy to the criteria used by health insurance companies to set their rates and plans. However, I think it’s reasonable to assume that in general the healthier a county, the better the insurance plans and rates.

This appears to be true for the 2016 ACA health plans offered in Texas, South Dakota, Florida, Nevada, and Arizona . . .

The Top 25% healthiest counties in these states offer ACA health plans that are less expensive and that have more options than those counties in the Bottom 25% of each of these five states.

Though there is no guarantee, I think it’s reasonable to assume that the same will be true next year.

STATE-BY-STATE ACA HEALTH PLAN SUMMARIES

TEXAS
— 58 of 254 Texas counties offer PPO ACA plans from Scott & White Health Plans and Allegiant Health Plans.
— Most Texas PPO plans are in the “healthiest” counties: The Top 25% healthiest counties have 41% of PPO plans. The Bottom 25% counties only offer 9% of the total PPO plans.
— 55 of 58 Texas counties offer PPO plans by Scott & White Health Plans.
— 3 of the 58 Texas counties offer PPO plans by Allegian Health Plans (El Paso, Nacogdoches, and Bexar counties).
— Scott & White Health Plans has a 2015 NCQA (NOTE 4) overall rating of 3.5 (Good).
— Allegiant Health Plans has a 2015 NCQA overall rating of 1.0 (Poor).

SOUTH DAKOTA
— All 60 South Dakota counties offer PPO ACA plans by Avera Health Plans.
— Almost half of the most expensive PPO plans are in the “least healthy” (Bottom 25%) counties.
— Avera Health Plans is unrated by the NCQA.

FLORIDA
— None of the 67 Florida counties offer PPO ACA plans.
— The “most healthy” Florida counties (Top 25%) have the most number of health plan options (total HMOs + POSs + EPOs).
— On average, the healthiest Florida counties (Top 25%) pay less for a plan than the unhealthiest counties (Bottom 25%).
— BCBS of Florida (Florida Blue) has an NCQA average rating of 3.0 (Good).
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NEVADA
— All 17 Nevada counties offer PPO ACA plans by Anthem BCBS.
— The Top 25% healthiest Nevada counties offer more plans than the Bottom 25%.
— The Top 25% healthiest Nevada counties offer less exensive plans than the Bottom 25%.
— Anthem BCBS in Nevada is unrated by the NCQA.

ARIZONA
— All 15 Arizona counties offer PPO ACA plans by United Healthcare.
— The Top 25% healthiest Arizona counties offer more plans than the Bottom 25%.
— The Top 25% healthiest Arizona counties offer less exensive plans than the Bottom 25%.
— United Healthcare has a 2015 NCQA rating of 3.0 (Good).

WE’RE MOBILE 

Full-time RVers greatest strength is the ability to move much easier than people who live in houses.

But moving to a different county — even in the same state — may be problematic because it involves a new mail forwarding address, possible tax and vehicle insurance issues, and so on.

Keep in mind that while PPO plans are the Holy Grail of RVer health plans because of out-of-network coverage, it looks like most of the current non-BCBS PPO plans do not have much, if any, nationwide doctors, hospitals, and clinics.

Only Nevada has nationwide 2016 ACA PPO plans offered by Anthem BCBS.

Nevertheless, if changing a domicile county could save you a lot of money or get you a quality health plan . . . move!

 

NOTES:

(1) Types of health plans:

PPO – You can choose your own specialists. Covers out-of-network providers, though less that in-network.

EPO – You can choose your own specialists, but does not cover out-of-network providers.

HMO – You are required to see a primary-care doctor and get referrels to see specialists. Does not cover out-of-network providers.

POS – You are required to see a primary-care doctor and get referrals to see specialists. There is limited coverage for out-of-network providers.

(2) Methodology: I used HealthSherpa to determine the health plans and plan cost for each county in Texas (254 counties), South Dakota (66 counties), Florida (67 counties), Nevada (17 counties), and Arizona (15 counties). A 63-year-old female with a $75,000 income was used for each HealthSherpa query. A single Zip code was used for each county’s data. A health ranking was assigned to each county using County Health Rankings & Roadmaps.

Sample Excel Data

Data Collection Sample

(3) Healthiest counties — The County Health Rankings & Roadmaps program is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. See www.countyhealthrankings.org. I used their “Health Factors Overall Rank”.

(4) NCQA Rating — the National Committee for Quality Assurance rates health care plans for each state.