Published: October 29, 2025

Healthcare Planning: The FI Wildcard

Healthcare can be the single biggest swing factor in your FI plan. Here’s the standard playbook—plus creative options many people overlook.

The “standard” paths (pre-65)

ACA Marketplace: Control MAGI to qualify for premium credits; choose high-value Silver plans with CSR if eligible.
COBRA / Retiree coverage: Useful as a bridge year (e.g., between jobs and ACA open enrollment).
HSA strategy: Pair HDHP + invest HSA; pay expenses out of pocket now, reimburse later tax-free.

Post-65 (Medicare)

Understand A/B/D basics and timing to avoid penalties.
Medigap vs Advantage: Medigap = broader access/predictability; Advantage = network-managed tradeoffs.

Hidden costs to budget explicitly

Dental, vision, audiology.
Fertility, maternity, mental health.
Long-term care risk; consider partial self-funding or hybrid policies.

Out-of-the-box options (pro/cons)

Direct Primary Care (DPC): Monthly membership for unlimited primary care; pair with a wraparound catastrophic plan.
Part-time employment for benefits: Some employers offer health insurance at 20–30 hrs/week—acts like a subsidy while preserving lifestyle.
Medical tourism: Elective procedures abroad with accredited hospitals; plan for follow-up care at home.
Expat/Global insurance: If living abroad part/all year, international policies can be cheaper with quality networks.
Healthsharing ministries/ALOs: Not insurance; lower costs but real coverage gaps and contract risks.
Self-insuring deductibles: Maintain a dedicated “medical reserve” to raise deductibles and cut premiums.

MAGI management (the lever you control)

Prioritize taxable withdrawals/dividend control, Roth conversions, and capital gains timing.
Use charitable tools (QCDs post-70½, donor-advised funds) to hit bracket targets while meeting giving goals.

Case study: retiring at 50

Target spend $70k; by blending taxable withdrawals + small Roth conversions and limiting ordinary income, a couple can retain ACA support and lower lifetime tax—while keeping a DPC membership for primary care access.

Your annual healthcare checklist

Estimate next year’s healthcare line item (premiums + OOP max + routine care).
Choose a plan during open enrollment that fits your providers and expected usage.
Set a medical reserve equal to your plan’s OOP max.
Map MAGI targets for subsidies/IRMAA and plan conversions/withdrawals accordingly.

Bottom line: Treat healthcare like a project: define requirements, pick a strategy, and review annually. Creativity can save thousands without sacrificing care.