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How Health Benefits Work

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    How Health Benefits Work

    Frequently Asked Questions

    How you sign up depends on the type of coverage you get:

    • For Medicare, you automatically get coverage if you’ve been getting SSDI for two years. Otherwise, you may need to sign up.
    • For employer-sponsored coverage, talk to your employer’s Human Resources department.
    • For individual coverage, apply at HealthCare.gov. HealthCare.gov will first check whether you qualify for Medicaid and, if not, will let you compare individual plans and see whether the government will help with tax credits.

    For Medicaid or the Working Disabled Medicaid Buy-In, you can apply:

    If you use an application form, you can also apply for other benefits at the same time, such as Adult Public Assistance (APA), SNAP (formerly Food Stamps), and Alaska Temporary Assistance Program (ATAP). If you apply online, you have to apply for other benefits separately.

    You can qualify for Medicaid if your family’s income qualifies, even if your job offers insurance.

    You cannot get subsidies for purchasing an individual health plan through HealthCare.gov if your job offers you affordable insurance.

    In most cases, no. The actual medical coverage you get from Medicaid will be the same, no matter how you qualified. Generally speaking, the big difference is that people with disabilities get extra ways to qualify and if you have a disability and start working, you can earn a lot more while still getting Medicaid coverage through the Working Disabled Medicaid Buy-In.

    Note: If you qualify for APA-related Medicaid, you may also get a monthly payment from the APA program. Learn more in DB101's SSI and APA article.

    For income-based Medicaid, the main income rules are:

    • If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($2,164 per month for an individual; $4,486 for a family of four), you may qualify.
    • If you are 18 or younger and your family’s income is at or under 208% of FPG ($6,761 per month for a family of four), you may qualify. Income-based Medicaid for children is also called Denali KidCare (DKC).
    • If you are pregnant or gave birth within the last 12 months and your family’s income is at or under 230% of FPG ($7,476 per month for a family of four), you may qualify. The unborn baby is counted as a family member.

    Income-based Medicaid counts most types of earned and unearned income you have. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect income-based Medicaid eligibility.

    If you have a disability, you may be able to get Medicaid coverage if your income is a lot higher than this, thanks to the Working Disabled Medicaid Buy-In program. With the Working Disabled Medicaid Buy-In, the exact income limit depends on your living situation. If you live alone and don't have any unearned income, you could make as much as $7,923 per month and still qualify. (That's as much as $95,070 per year!) Learn more about the Working Disabled Medicaid Buy-In program.

    Health Coverage Income Limits for Your Family
    • Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
    • Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
    • Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for all of the same programs that U.S. citizens can get.

    Note: You can get Medicaid coverage if you are a Native American born in Canada or Mexico who has rights to cross the border.

    There are different health coverage options as your income goes up:

    • Depending on how much your income goes up, your Medicaid may continue, unchanged.
    • If you got Supplemental Security Income (SSI) before you started earning more, you can usually keep Medicaid thanks to SSI’s 1619(b) rule.
    • If you have a disability and work, you can also consider the Working Disabled Medicaid Buy-In. With the Working Disabled Medicaid Buy-In, if you live alone, you can work, earn up to $7,923 per month, and pay a monthly premium to get Medicaid coverage. The income limit is higher if you live with others. Note: The amount of earned income you can have for the Working Disabled Medicaid Buy-In depends on how much unearned income you have.
    • If your employer offers it, you may be able to get employer-sponsored coverage.
    • If your employer does not offer coverage, you should consider private individual coverage. You may get government help to pay for an individual plan on HealthCare.gov. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

    The bottom line: There is a coverage option for almost everybody. Do not worry that getting a job will leave you without health coverage.

    To qualify for the Working Disabled Medicaid Buy-In, you must:

    • Be 18 or older
    • Be a U.S. citizen or a qualified immigrant
    • Be working or have a spouse who is working
    • Have a disability that meets Social Security’s medical standards.
      • Note: For the Working Disabled Medicaid Buy-In, SSA’s disability rules related to income do not apply.
    • Have unearned income at or below the APA RC limit ($1,751 per month). If you are married, the limit is $2,593 and your spouse's deemed unearned income is also counted.
      • Note: The APA RC limit is also called the "Expanded Refused Cash Income Limit." What it means is that you may qualify for APA-related Medicaid even if you don't qualify for APA cash benefits.
    • Have household countable income at or below 250% of the Federal Poverty Guidelines (FPG), including other members of your family you live with. That’s $3,919 per month if you live alone.
      • Not all of your earned income is counted. If you live alone and have no unearned income, you could actually earn up to $7,923 per month and still qualify for the Working Disabled Medicaid Buy-In. (That's as much as $95,070 per year!)
    • Have less than $10,000 in resources ($15,000 for couples). The house you live in and one car are not counted.

    If you get Working Disabled Medicaid Buy-In coverage, you may need to pay a monthly premium. The amount you pay is based on your income and your family’s income. To learn how much your premium might be, try DB101's Benefits and Work Estimator.

    Medicare has three main parts:

    • Medicare Part A helps pay for medical care you get while you’re in a hospital.
    • Medicare Part B helps pay for medical care you get outside of a hospital.
    • Medicare Part D helps pay for prescription drugs.

    If you or your spouse worked enough time while paying Medicare taxes, you will qualify for Medicare Parts A and B:

    • When you turn 65
    • When you’ve been getting Social Security Disability Insurance (SSDI) benefits for two years, or
    • If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).

    Note: If you have had a disability since before you were 22 years old, you will start getting Medicare if you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record.

    No. Medicare will only help pay for care that it considers reasonable and necessary. If you need a service that Medicare doesn’t cover, you’ll have to pay for it yourself, unless you have other coverage, such as Medicaid or employer-sponsored coverage.

    For certain services, you’ll pay a deductible, copayment, or co-insurance before Medicare will begin to help pay for that service. For Medicare Part B and Part D, you may have to pay a monthly premium.

    You may qualify to get help paying for your Medicare premiums, copayments, and deductibles if you have low income. Medicare Savings Programs help pay for Part B coverage and the Low Income Subsidy (LIS) helps pay for Part D coverage.

    Learn more about MSPs and the LIS.

    Yes. Other types of coverage that you can have with Medicare include:

    Learn more about how Medicare interacts with other types of coverage.

    You may be responsible for no cost, a percentage of the cost, or the amount of the cost of the coverage that is above what the employer agrees to pay.

    Employers are supposed to offer plans that cost the employee, for the employee’s policy alone, less than 8.39% of the employee’s family income for the monthly premium. Also, that coverage must meet a certain benefits level for copayment, co-insurance, and deductible expenses.

    If your employer offers a plan that does not meet these standards, you may qualify for government help through tax subsidies to reduce the premium on an individual plan.

    Note: The coverage your employer offers must meet affordability standards for the employee, but not for the family. It may be very expensive for family members to join an employer-sponsored health plan. Before 2023, the spouse or children of an employee would not qualify for subsidies on HealthCare.gov if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." This changed starting in 2023. Learn more about affordability rules for family members and how it affects eligibility for tax credits on HealthCare.gov.

    Yes, if you are under 26, you can be covered by your parent's insurance plan. Employers who offer coverage to their employees must also offer it to their children under the age of 26.

    Employers do not have to offer coverage to the spouses of employees, but many do.

    Note: While employers must offer this coverage to children, the employee may be required to pay for all of it.

    Yes. Plans cannot deny people coverage. When you apply for insurance, they cannot reject your application and they cannot say that they won’t cover medical needs related to your disability. They also cannot charge you more because you have a disability.

    Depending on your situation, you may qualify to have the government help pay for your individual health plan through tax credits. Here's how it works:

    1. When you sign up at HealthCare.gov, you give details about your family's situation. HealthCare.gov reviews that information instantly. If your family qualifies for government help to pay for individual coverage, HealthCare.gov tells you and lists insurance options for you.
    2. Your insurance options list the full cost of the monthly premium, how much of that premium the government will pay each month, and how much you will pay each month. The way the government helps pay for the premium is by giving you a tax credit every month, so you don't have to think about it during the year. All you have to do is make sure you keep paying your part of the premium.
    3. In January or February, the government will send you a form listing how much your total health coverage tax credits were for the previous year. You will need this form at tax time, because it is possible the government paid more or less than it should have for your health coverage. If so, this will be sorted out when you file your taxes.

    No, but depending on your income, you may get more help from the government if you get a silver-level plan:

    • The government may help pay for your premium through tax credits. That means you would pay less each month. You might get this help no matter what metal your plan is.
    • If you make 250% of the Federal Poverty Guidelines (FPG) or less and get a silver plan, the government also pays to reduce your copayments, co-insurance, deductible, and out-of-pocket maximum. That means you’ll pay less each time you need medical services. If you get this help, your silver plan might actually be as good or better than many platinum or gold plans. If you do not get a silver plan, the government will not help you with these expenses.

    When HealthCare.gov looks at your income, they will count most types of earned and unearned income you have. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.

    Health Coverage Income Limits for Your Family

    Usually, when you sign up for a plan through HealthCare.gov, you need to stay on the plan for the entire calendar year. So, if you are signed up for 2024, then you can’t leave that plan until 2025.

    However, there are certain situations when you may be able to change plans mid-year:

    • If your income changes and you gain or lose eligibility for government help paying for your coverage
    • If you move, or
    • In other life-changing circumstances, such as having a child or getting married.

    The first one is the key. If your income goes down and you can’t afford your plan anymore, report your change in income to HealthCare.gov. You may qualify to get Medicaid or to have the government increase how much it pays for your current insurance (meaning that you have to pay less).

    Note: American Indians and Alaska Natives do not have these restrictions and can change up to once a month.

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