Refusing To Work For Medicaid May Not Translate To Subsidies For ACA Plan


Work requirements for Medicaid coverage. Insurance coverage that don't meet health law standards. Changes to Medicare drug lists. As the ground is constantly on the shift on healthcare coverage, I answer readers' queries this week about these three various kinds of plans.

Q: I’m in a condition that is considering work requirements for Medicaid. At sign-up time, can one simply tell the exchange that I plan to be ineligible for Medicaid by refusing to work and get the premium tax credit to purchase a private plan on the insurance coverage marketplace?

Federal health law regulations don't clearly address the situation you describe, but the short answer is probably not, said policy analysts.

In general, those who are entitled to Medicaid – the federal-state health program for low-income people – or employer coverage can't be eligible for a federal tax credits which help purchase premiums on plans in love with the health insurance exchanges.

This year, Kentucky and Indiana became the first states to get federal approval to require some Medicaid recipients to set up 80 hours every month in a paid job, school or volunteer work, among other activities, to receive benefits. Nearly a dozen other states have made similar requests.

If you won't work, does which make you ineligible for Medicaid? The guidelines aren't clear, said Judith Solomon, vice president for health policy in the center on Budget and Policy Priorities.

States might reason that someone inside your situation is eligible for Medicaid, you just have to fulfill the work requirements, said Timothy Jost, an emeritus professor of law at Washington and Lee University in Virginia who is a specialist on the health law.

There are other actions people might take – or fail to take – where this problem might come up. “You could reason that someone is not eligible simply because they haven't completed the Medicaid application or provided the necessary documentation,” Jost said. “There are a variety of requirements, however i can't imagine someone saying they did not do those things and thus they're not entitled to Medicaid.”

Whatever the guidelines, it's unlikely that many individuals will be in a situation to think about taking this stance. To be eligible for a premium tax credits, your income must be between 100 and 400 percent from the federal poverty level (about $12,000 to $48,500 for just one part of 2021). But you'd also need to qualify for Medicaid, generally with an income limit of 138 percent of poverty (about $16,750) in states that expanded coverage to adults. Additionally, the Medicaid work requirements where you live would have to apply to you.

Q: I lost my job this past year and my employer coverage led to January. I purchased a brand new plan through the marketplace that entered effect recently. I just received policy information, and it states that because the plan doesn't cover major medical services, I may need to pay additional taxes to the government. The trainer told us the program didn’t cover major medical but wasn’t told about any taxes. Am i going to be fined the coming year?

It sounds like you purchased an agenda that does not comply with the Affordable Care Act's requirements, and if this is the case you may indeed need to pay a penalty because of not having comprehensive coverage when you file your taxes next year.

The tax law repealed the person penalty for not having health insurance, but that provision doesn't work until 2021. So, for 2021, you might be charged the higher of $695 or 2.5 percent of the household income.

The federal- and state-run marketplaces established by the ACA sell only comprehensive plans which cover 10 essential health benefits, including “major medical” services like hospitalization and prescription drugs.

But some insurance broker websites call themselves marketplaces too, said Sabrina Corlette, a research professor at Georgetown University's Focus on Health Insurance Reforms. These businesses may sell other insurance items like short-term or accident coverage alongside comprehensive plans that comply with what the law states.

Ever because the health law was passed, “There happen to be opportunistic companies attempting to make the most of consumer confusion to make money,” Corlette said.

If you aren't pleased with your plan, you might still have the ability to switch. Losing your employer coverage qualifies you for any 60-day special enrollment period to choose a new plan. Because it appears you're still in that window, you might be in a position to choose a comprehensive plan.

To ensure you're using your state's official marketplace, go to and then click “see basically can alter.” Which will take you to your state marketplace, even if you reside in one of the dozen or so states that run their own exchanges.

Q: I picked a Medicare Part D drug plan that covered all of the drugs I take. But because soon as I experienced my first Novolin R prescription filled, they notified me they don't cover it anymore. Would they just switch it like that?

Medicare drug plans can alter their list of covered drugs, called formularies. If they're doing so at the start of the new calendar year, as appears to have happened for you personally, the plan may notify you from the change when you fill the prescription the very first time in the new year. At that point, the program would typically give you a 30-day “transition” refill so you can change to another drug that's on the formulary, based on Juliette Cubanski, associate director from the Program On Medicare Policy in the Kaiser Family Foundation. (KHN is definitely an editorially independent program of the foundation.)

If you and your doctor think it's important you have Novolin R and not another drug that's similar, you can ask your intend to make the best to allow you to continue to go ahead and take medication.

To go down that path, you would need to get your doctor to “make the situation why that formulary drug isn't the right drug” for you personally, said Casey Schwarz, senior counsel for education and federal policy in the Medicare Rights Center, an advocacy group.