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.)
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.
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.
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.
rvSeniorMoments 
It gets more confusing as the day is long. I wonder if you are thinking of moving and you already have a Medicare Plan in place thru your employer do you or are you able to retain that healthcare plan. Say you want to move to Arizona and you have a BCBS plan are you better off just keeping the domicle you already have?
Though I have Medicare, my wife still has 1 more year before she turns 65. But, no, we’re not considering moving.
However, if we had to pay for individual health insurance for more than a year, then, yes, we’d consider moving. For example, on her last year of ACA, my wife will pay $1134/month. In Pima county, she would pay $578 for the same plan — that’s a $6,672 yearly difference!
I guess I should consider myself lucky, that my Medicare and my secondary health insurance plan covers everything we get. I applied for a Part D plan and was told by Medicare that the plan that is included in my employer provided plan i do not need a Part D supplement. I was wondering if they have that plan in in Arizona. I will need to call them. Might be better off just staying in the domicile we have now. (Taxifornia aka California)
Wow.. valuable information.. literally! I’m sure many would find this a useful tool Tom.. way to go!
Mary
How did you decide to add Arizona and Nevada to the standard 3 states for RVers. North Dakota and Wyoming also appear to have Blue Card programs with out of state networks.
I am researching to change domicile myself but physical address is often an issue.
Nevada is a state with no state income tax so I added it to my list. I added Arizona because that’s our domicile.
We’ve been using our mail forwarding address for almost everything — so far, no problems. Also, we’ve been using ordinary mail forwarding businesses, nothing fancy.
In your article you say, “None of the 67 Florida counties offer PPO ACA plans.” That’s not true!!!!! People are already confused enough on this topic without confusing them more with inaccurate info. For FL your info is definitely incorrect!!!
FL BCBS Blue Options and Blue Select plans are a combination EPO/PPO (PPO/EPO) and not just an EPO. They are EPO in-state and PPO out-of state and do cover both in-network and out-of-network providers. Blue Select plans are not available in all Fl counties.
I have PPO coverage with the 1419 FL BCBS Blue Options ACA plan for when I’m out of state and it covers both in-network and out-of-network providers. It’s available both on-exchange and off-exchange. The healthcare.gov site just says the FL BCBS 1419 plan is an EPO plan, but it’s actually both and if you click on ‘Learn More About This Plan’ and scroll down, you’ll see where it say ‘Yes’ to National Provider Network. Here’s a link to the 2016 1419 plan PDF from FL Blue’s (BCBS) website and it clearly shows on the PDF that it’s a PPO/EPO plan. It also shows the PPO logo on my insurance card.
Click to access 1419.pdf
Sue
I’m glad your happy with your FL EPO plan from BCBS — but I stand by my statement:
There are no ACA exchange PPO plans in Florida.
I agree with Sue. I have a lot of professional experience in the healthcare industry and I just switched my domicile from Illinois to Florida precisely to get the Florida Blue’s EPO/PPO plan, as it is the only one I found to offer a broad nationwide network of “in-network” providers, as well as continuing to offer a cap on out-of-network out of pocket costs). Many 2016 ACA plans might be calling themselves “PPO” but are anything but! You now really need to read each plan’s detail page on the ACA site, examine their Summary of Benefits and Provider Directory links, before being able to tell just how much of a traditional PPO they are. Some PPO’s (such as those in South Dakota) are calling themselves PPO’s but are only offering SD providers as in-network. Other plans, such as those being offered in IL, AZ, and many other states next year on the ACA, are still calling themselves PPOs and offering “nationwide networks” but they’ve now stopped capping out of pocket costs for out of network providers. This can expose you to huge financial risks (as it almost did to me this year if I’d not called proactively to check before having surgery).
Here’s an excellent article on this new “gotcha” to many of the 2016 PPO plans – http://khn.org/news/2016-ppo-plans-remove-out-of-network-cost-limits-a-costly-trap-for-consumers/
You are absolutely correct that we full-timers have wheels and should be looking at various states, counties, and zip codes for the coverage that works best. But be sure to look beyond the health plan’s name (EPO, PPO, etc) to determine how comprehensive it really is, and how protected both of your in- and out-of-network out-of-pocket costs might be.
How do you establish residence in another state?