What State Do You Buy Health Insurance In When You're Never Home?

Drivers ask me this constantly, usually phrased as “which state is best.” That is the wrong question, and the right answer is written into a regulation almost nobody reads — one that anticipated your situation specifically, in plain language, decades after most people assumed the rules had no room for someone who lives in a sleeper cab.

The Rule Is Presence Plus Intent, Not Paperwork

Most drivers assume the marketplace wants proof of a fixed home, and that having no such home puts them outside the system. It does not. Here is what the regulation actually says.

45 CFR § 155.305(a)(3) sets the residency standard for marketplace eligibility. For an adult 21 or older who is not institutionalized, the applicable exchange is the one covering the service area where the person is living and either:

• intends to reside, including without a fixed address; or
• has entered the state with a job commitment, or is seeking employment.

That phrase — including without a fixed address — is in the regulation itself. It was written for people experiencing homelessness, but it is not limited to them, and it means the absence of a permanent residence does not disqualify you.

Two things the rule does not require, both of which drivers routinely assume it does:

• No minimum length of residence. There is no 30-day rule, no six-month rule, no rule at all on duration.
• No intent to remain permanently. The test is intent to reside, not intent to stay forever.

The same section carries a protection built for exactly your job. An exchange may not deny or terminate your eligibility if you meet the standard but for a temporary absence from the service area, so long as you intend to return when the purpose of that absence is done. Six weeks running the West Coast out of a home base in Florida is a temporary absence. You are still a Florida resident on day forty.

What Actually Goes in the Address Box

The regulation is permissive. The application form is more literal, and this is where drivers get stuck.

Healthcare.gov instructs you to give the permanent home address where everyone on the application lives, and states that this cannot be a P.O. box. It also confirms that someone living out of state temporarily can still be considered a resident of their home state.

CMS publishes separate guidance for applicants experiencing homelessness, and it is the closest official analog to a driver with no fixed residence. That guidance says an address is required to complete an application, and that acceptable options include the address of a shelter, a friend, or a relative within the state in which they are applying — or a P.O. box.

In practice, a driver whose family home is in Georgia, who returns there between runs and considers it home, is a Georgia resident with a Georgia address. That is not a workaround. That is the rule working normally.

The Question I Have to Say No To

Sooner or later a driver asks some version of this: my brother lives in a state with better plans, can I just use his address?

No. Not because it is hard, but because of what you sign.

The marketplace application carries this attestation: “I'm signing this application under penalty of perjury, which means I've provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.” The home address field is the address where the people on the application live. Listing one where you do not live and have no intent to live is not a gray area in the way people hope it is.

Here is the part worth sitting with: you do not need the workaround. The regulation already solved your problem with the words “including without a fixed address.” The honest path is to identify the state you genuinely consider your base — where you return, where your family is, where your license and your truck are registered — and use a real address there that you are entitled to use. A relative's home, a shelter, a P.O. box where the state permits it for a mailing address.

One more distinction, because it trips people up. “Domicile” is not the marketplace's word. Domicile is a common-law concept that matters for taxes, voting and licensing. The regulation uses “living,” “residing” and “intends to reside.” A driver can have a tax domicile in one state and still fail the marketplace test somewhere else, or the reverse. Do not assume your accountant's answer is the exchange's answer.

Crossing a State Line Is Not Moving

Your plan does not know where the truck is. It knows where you enrolled.

Nothing about your coverage changes when you cross into another state on a run. You do not need to notify anyone, you do not get a new plan, and you cannot switch plans just because you are somewhere else. CMS states it directly in its consumer guidance on special enrollment periods: “Moving only for medical treatment or staying somewhere for vacation doesn't qualify for a Special Enrollment Period.” Travel is not a triggering event.

What does change is which providers are in network around you, which is a completely different problem and the reason plan type matters more for drivers than for almost anyone else. We cover that in the nationwide PPO guide, and what happens when you need care on the road in using your plan out of state.

When You Actually Do Move

A permanent move is different, and it opens a door.

Under 45 CFR § 155.420(d)(7), gaining access to new qualified health plans as the result of a permanent move triggers a special enrollment period. The window is 60 days, and depending on how the exchange operates it may run 60 days before or after the move.

There is a condition most people miss. Under (d)(7)(i), you generally must have had minimum essential coverage for one or more days during the 60 days preceding the move. Move while uninsured and you may not get the SEP at all. The exceptions, at (a)(5), cover people who were living in a foreign country or a U.S. territory, members of a federally recognized Tribe or ANCSA Corporation shareholders, and people who lived in a service area where no qualifying marketplace coverage was available.

The practical lesson for a driver relocating a home base: do not drop coverage before the move. Keep it through the move, then use the SEP.

Why the State You Pick Decides Your Network

Individual-market plans are not national products. Under 45 CFR § 155.1055, a qualified health plan's service area must cover at least an entire county, and plans are certified and sold against those service areas. The network is built around that geography.

This is why the state where you legitimately reside carries real consequences for a driver. Some states have generous PPO availability on the exchange; others have effectively none, which shapes what “coverage that works in all 48” can realistically mean for you. Research from the Robert Wood Johnson Foundation on 2025 plan-year data found PPOs made up only about 14% of marketplace plans nationally, and that roughly 37% of Americans live in a state with no marketplace PPOs at all — New York and Texas among them. That analysis is from January 2025 and we have not found a 2026 update, so treat the direction as reliable and the exact figures as a snapshot.

None of that is a reason to shop for a state. It is a reason to know what your actual state offers before you assume a PPO is on the table, and to plan around it if one is not.

Medicaid follows a parallel structure, for what it is worth: 42 CFR § 435.403 uses nearly identical residency language, including the same “without a fixed address” protection and the same bar on minimum-duration requirements. Medicaid is administered state by state, so coverage does not follow you automatically across a permanent move — you apply in the new state.

Health Insurance Residency for Drivers: FAQs