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Elder law: What you need to know about the Health Insurance Marketplace and Medicaid expansion

Enrollment is open in the Health Insurance Marketplace for health insurance, and Pennsylvania has embraced expanded Medicaid to provide coverage for people whose income is too low to qualify for private health insurance.

In 2010, President Barack Obama signed the Patient Protection and Affordable Care Act. Just before it became effective, almost 50 million individuals in the United States had no health insurance. These folks would go to already over-burdened hospital emergency rooms for care, or put off getting help until their conditions became too bad to ignore, which hurt all taxpayers. The same Act contemplated that states would expand their traditional Medicaid programs for people whose income was too low to purchase private health insurance. This past February, Gov. Tom Wolf announced that Pennsylvania would participate.

According to the Social Security Administration, almost one-third of those people have now gained coverage. The Department of Health and Human services says that “providing affordable health care and preventative health care services decreases the likelihood of long-term disability and the need for Social Security Disability payments or Supplementary Security Income.” Reducing illness also reduces human suffering. In Pennsylvania, 472,697 consumers selected or were automatically re-enrolled in quality, affordable health insurance coverage through the Marketplace as of Feb. 22.

For coverage in the Marketplace effective Jan. 1, 2016, people must sign up before Dec. 15 for new or changing plans. Between Dec. 15 and Jan. 15, people may sign up for coverage effective Feb. 1, and enrollments or changes between Jan. 16-31 take effect March 1.

After Jan. 31, unless an applicant meets special enrollment rules, coverage will no longer be available until 2017. There are no deadlines for enrollment for Medicaid or the Children’s Health Insurance Program; eligible people may sign up for these plans anytime.

Medicaid coverage — which was traditionally limited to those with disabilities (including age-related) — has been expanded to individuals with family incomes at or below a percentage of the federal poverty level (generally $33,465 for a family of four and $16,243 for a single person in 2015), irrespective of disability. This expansion includes non-elderly adults without dependent children, who have not previously been eligible for Medicaid. Historically, Pennsylvania provided health services through Medical Assistance and several other state programs with strict asset and income guidelines for people with disabling conditions (and people with extremely low incomes may still be limited to these services).

However, historically, Medicaid was limited to those people. A poor but non-disabled person would not be covered. Now, Pennsylvania has expanded the Medicaid program to people simply meeting income guidelines. However, participants with an annual income greater than 100 percent of the Federal Poverty level (currently $11,670 for an individual and $23,850 for a family of four) will have to pay monthly premiums of up to 2 percent of household income.

In addition, the Health Insurance Marketplace compiles private health insurance available to people whose income exceeds Medicaid guidelines. A family of six whose annual income is less than $130,000 can get at least some help with premiums for policies purchased through the Marketplace. A single person — even without a disability — whose income is between $16,243 and 29,425 can purchase a Marketplace health plan with lower monthly premiums plus savings on out-of-pocket costs, like deductibles and copays. Moreover, depending on age and income, an applicant may be entitled to help in paying the premium through tax credits.

Fully 51 percent of Pennsylvania Marketplace enrollees obtained coverage for $100 or less after any applicable tax credits in 2015, and 81 percent had the option of doing so.

There are four levels of plans available through the Marketplace: bronze, silver, gold and platinum. Although the basic coverage is the same for all plans in the same categories, there are copays, deductibles and other provisions that vary among plans in each category. These categories are based on how a consumer and the insurance company split the costs of health care. They have nothing to do with quality of care. There are more than 40 such plans available in Centre County.

Amos Goodall is a certified elder law attorney practicing in State College with Steinbacher, Stahl, Goodall & Yurchak. He is also a fellow of the American College of Trust and Estate Counsel and was recently listed by Best Lawyers as the 2015 Best Elder Lawyer in the Harrisburg area, which includes central Pennsylvania.

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