Pre-Medicare Bridge Strategies

For early retirees (under 65), healthcare is the biggest unknown variable. Medicare doesn't start until 65; bridging the gap requires deliberate planning. The wrong approach can cost $30K+/year per couple.

This page covers the options.

The bridge problem

The gap years are typically 50-65 or 55-65 (or 62-65 for "almost there" retirees). During these years:

- No employer coverage (you're retired)

- Not yet Medicare-eligible

- ACA marketplace is the default

- Costs vary dramatically by state, age, income

For couples, costs can range from $500/month to $3,000+/month depending on circumstances.

Option 1: ACA marketplace

Standard for most early retirees.

How it works

Open enrollment late each year for next year's coverage. Plans by tier (Bronze, Silver, Gold, Platinum) and metal levels.

Subsidies

Premium tax credits subsidize coverage based on income relative to federal poverty level (FPL). The subsidy structure changed substantially:

- Pre-2021: hard cap at 400% FPL

- 2021-2025 (American Rescue Plan + Inflation Reduction Act): no upper income cap; premiums capped at 8.5% of income

- Post-2025: depends on legislation

The recent expansion makes ACA more accessible at higher incomes. For retirees with substantial assets but moderate taxable income, this matters.

Strategy: manage MAGI for subsidies

Modified Adjusted Gross Income (MAGI) drives subsidies. For early retirees:

- Roth withdrawals don't count as income

- Long-term capital gains count

- IRA withdrawals count

- Social Security counts (partially)

By drawing primarily from Roth or taxable accounts (with low realized gains), retirees can keep MAGI low and qualify for substantial subsidies.

This single strategy can save $10-20K/year for many couples.

Caveats

- Plans vary dramatically by state and county

- Network restrictions matter (especially specialists)

- Out-of-pocket maximums still apply

- Not all states expanded Medicaid (affecting low-income coverage)

Option 2: COBRA

For retirees leaving employer coverage. Can continue employer plan for up to 18 months (sometimes 36).

Pros

- Same plan; same network

- No transition disruption

- Easy to enroll

Cons

- Pay full premium plus 2% admin fee

- Often $1,500-$2,500/month for family

- Limited to 18 months (or 36 in some cases)

When COBRA fits

- Short bridge (under 18 months)

- Specific health needs requiring continuity

- Money less of a concern

For most: ACA marketplace is cheaper. COBRA is for specific situations.

Option 3: Spousal employer coverage

If spouse is still working with employer coverage, retiree may be covered.

Pros

- Often best plan

- Lowest cost (employer subsidizes)

Cons

- Depends on spouse's employment

- Coverage ends if spouse retires/loses job

For couples where one spouse retires earlier: a strong reason to delay the second spouse's retirement.

Option 4: Continued part-time work

Employer healthcare via part-time job. See [PartTimeWorkInRetirement](PartTimeWorkInRetirement).

Specific opportunities

- **Costco / Starbucks / similar**: known for offering benefits to part-time

- **Educational institutions**: often have generous benefits

- **Government / municipal**: often available

For some early retirees, "Barista FIRE" — work just for healthcare — extends financial independence.

Coverage requirements

Each employer has its own minimum hours. Often 20-30 hours/week. Verify before relying on it.

Option 5: Health Sharing Plans

Religious-based health sharing organizations: Samaritan, Christian Healthcare Ministries, Medi-Share, others.

How they work

Members share medical expenses. Not technically insurance.

Pros

- Lower monthly cost

- For healthy retirees, may be sufficient

Cons

- Not insurance (no consumer protections)

- Pre-existing conditions often excluded

- Not all expenses covered

- May require religious affiliation

For some healthy early retirees, an option. Not for those with significant health needs or risk-averse.

Option 6: Self-insure

Skip insurance; pay out of pocket.

Generally bad idea

Major medical events can be financially ruinous. The whole point of insurance is to absorb the catastrophic case.

For very healthy retirees with substantial assets ($5M+), some self-insure with high-deductible plans. Even then, having something is better than nothing.

State-specific considerations

Medicaid expansion states

Below 138% FPL: Medicaid eligible. Free coverage for low-income retirees.

For retirees with low taxable income but high assets, this is an option in expansion states.

Non-expansion states

Below ~100% FPL: marketplace subsidies don't apply (a "coverage gap" exists). Retirees in this gap have limited options.

State-specific exchanges

Some states run their own exchanges (CA, CO, NY, etc.) with sometimes additional state subsidies.

HSA contributions

If on HDHP (high-deductible health plan) ACA plan: HSA contributions still possible.

For early retirees, contributing to HSA stretches one of the most tax-advantaged accounts.

After Medicare enrollment: HSA contributions stop. Pre-Medicare years are HSA-contribution years.

See [HealthSavingsAccounts](HealthSavingsAccounts).

The income-management strategy

The single biggest pre-Medicare lever:

High-income retiree

Same income through retirement = high marketplace premiums. Subsidy phaseouts hurt.

Income-managed retiree

Draw from Roth (not counted) and small taxable amounts. Stay below subsidy cliff.

For a couple with $1.5M portfolio:

- 50% Roth, 50% traditional

- Live on Roth withdrawals + a bit of taxable

- MAGI: $30-40K

- ACA subsidies: substantial

For a couple with same portfolio but mostly traditional:

- Forced traditional withdrawals

- MAGI: $80-100K

- ACA subsidies: minimal

The Roth allocation in pre-Medicare retirement is much more valuable than the equivalent in post-Medicare retirement.

Worked example

**Couple, both 58, retiring**:

- Portfolio: $2M (60% traditional, 40% Roth)

- Annual spending need: $80K

- Strategy: $30K from traditional + $50K from Roth = $80K spending

Income recognized for ACA: ~$30K (just the traditional portion).

For a couple of 58, ACA premium estimate (Silver plan): ~$1,200/month before subsidies.

With $30K income: subsidy makes premium ~$200/month. Out-of-pocket cost ~$2,400/year.

Without subsidy management (drawing all from traditional): full premium ~$14,400/year.

Difference: $12,000/year × 7 years = $84,000 savings.

Common failure patterns

Not managing income for subsidies

Drawing from traditional when Roth or taxable would maintain subsidies.

Assuming COBRA is the answer

It works but for short bridges only. ACA usually cheaper.

Skipping insurance

Self-insuring is risky even for healthy retirees.

Not coordinating with Medicare timing

Health needs at age 64 trigger Medicare considerations 6 months early.

Forgetting state differences

State of residence matters enormously for ACA cost. Residency planning matters.

A reasonable approach

For early retirees:

1. ACA marketplace as default

2. Manage MAGI to maximize subsidies (Roth-heavy strategy)

3. State residency considerations

4. Compare COBRA cost vs. ACA at retirement

5. Verify spouse's coverage if applicable

6. Plan exit strategies for coverage gaps

7. HSA contributions if on HDHP