Public medical insurance plans provided by the government for low-income individuals or families are accessible via programs like Medicaid, Child Health Plus and Essential Plan. Qualification for these plans varies based on income level; before applying you should estimate household income to determine eligibility.
1. Age
The age limit for being eligible for public medical insurance under Obamacare (the Affordable Care Act) is 26. This rule was implemented so young adults could opt between remaining covered under their parents’ policies or purchasing individual plans through either marketplaces or directly from insurers; alternatively they may also purchase low-cost “catastrophic” plans through New York State of Health marketplaces and receive premium subsidies based on household incomes.
Other young adults may qualify for children’s Medicaid and Child Health Plus programs in their states depending on the gross income of their family. Income limits differ for these programs but tend to be higher than subsidized marketplace plans.
Young adults may qualify for Medicaid in their states or Medicare Savings Programs that reimburse part of a participant’s premiums, coinsurance costs and deductibles. Eligibility requirements differ by state; eligibility determination typically follows similar income methodologies to SSI administered by Social Security Administration.
If you have queries regarding eligibility rules in your state, reach out to either your local Medicaid/CHIP agency or health plan’s member services department (phone numbers can often be found on eligibility letters and enrollment cards), visit their websites for more information, or speak to an independent agent who can help find an ideal plan that matches up with your needs.
2. Pre-existing conditions
Before the Affordable Care Act (commonly referred to as Obamacare), insurance companies could deny coverage for people with preexisting conditions, or charge higher premiums. Pre-existing conditions refer to any illness or health issue that existed prior to an individual purchasing or enrolling in a healthcare plan. They range from chronic issues such as asthma and diabetes to acute problems like an injury sustained in an accident or surgery. Based on the nature and severity of a condition, some plans may provide different definitions for pre-existing conditions. Insurance companies typically define pre-existing conditions as anything that required medical treatment in the last six months, while others use a more inclusive definition that encompasses any illness or injury with symptoms that prompted a prudent person to seek advice or treatment from healthcare providers.
Pre-existing condition issues have become less relevant in today’s larger employer-based insurance market. Most employers offer their employees access to group health plans that cover everyone in the company’s workforce; premiums are calculated based on an overall risk pool rather than individual risks. Furthermore, this type of group insurance allows portability allowing workers to move jobs without losing health coverage; something especially helpful for workers with chronic illnesses as they tend to change jobs less often than healthy workers.
Individual market consumers, however, remain constrained by preexisting condition barriers that prevent many Americans from buying health insurance. Obamacare mandated all states create temporary high-risk pools to assist individuals when the private market fails them in getting coverage at an affordable price. To address this ongoing concern, advocates of pro-market health reform should advocate for an efficient state-based high-risk pool system with strong oversight and funding mechanisms.
3. Income
The Affordable Care Act (ACA) created a standardized method of determining financial eligibility for Medicaid and Children’s Health Insurance Program (CHIP), using Modified Adjusted Gross Income, or MAGI. MAGI includes income earned both directly by an individual as well as indirectly through spouse income or tax-exempt children living within their household. Furthermore, regulations specify which forms of income must be included when calculating an individual’s MAGI; furthermore it sets rules regarding how household members must be counted when calculating MAGIs.
Some states employ other measures of income in determining eligibility for public medical insurance programs beyond MAGI, such as standard poverty measures or average cost of living formulas to identify low-income levels. States may also establish “medically needy” categories to define individuals whose income exceeds other qualifying thresholds – individuals can become eligible for Medicaid by spending down any surplus funds they earn above this standard through purchasing qualified health coverage or other means to achieve adequate care levels.
Some individuals lose access to Medicare and CHIP when their status in the workforce changes, such as when taking on jobs requiring private health coverage or losing employer-sponsored coverage. Under the Affordable Care Act’s Special Enrollment Period (SEP), these individuals can regain eligibility by submitting form CMS-L564 with all prior premium payments in full.
Marketplace shoppers typically receive financial help in the form of lower up-front monthly premiums and reduced deductibles, copayments and coinsurance when using their plan. Subsidies for these subsidies depend on estimated household income; it is therefore crucial that an accurate estimation is made.
4. Disability
Numerous factors could impede an individual’s eligibility for disability benefits. One common cause is physical or mental impairments which significantly limit an individual’s ability to engage in substantial gainful activity for at least 12 months or can be expected to cause death.
The Social Security Act and SSA’s Implementing Regulations contain rules for determining whether an individual has severe impairment. It should be remembered that their definition may differ from other government or private disability evaluation criteria.
Additionally, financial eligibility for Medicaid and CHIP programs is typically determined using an income measurement called modified adjusted gross income or MAGI. This calculation includes specific rules as to what income counts towards MAGI calculation as well as who must be included when counting it.
Persons who did not enroll in Medicare Part B or premium Part A when first eligible can sign up during the General Enrollment Period (GEP), which runs annually from January through March. The GEP allows people who were incarcerated or had other qualifying circumstances delay enrollment to sign up at any time during that period.
For more information about the GEP and how to qualify, individuals should reach out to their state Medicare/CHIP agency or health plan’s member services department – usually listed on eligibility letters or back of enrollment cards. Alternatively, they can sign up for a Medicare Application Review Center presentation offered by CMS that can assist professionals or staff assisting clients in filing Medicaid applications.
5. Exclusions
Prior to the Affordable Care Act (ACA), pre-existing condition exclusion periods were a standard feature of individual and family plan coverage in the US. These dates prevented insurance providers from covering health issues related to pre-existing conditions until some time had passed since an applicant first applied for their plan.
This often meant waiting to receive medical help for their health-related problems despite paying monthly premiums, or incurring out-of-pocket costs related to health care services.
Social exclusion raises equity issues that are essential to UHC, including risks to healthcare systems that serve socially excluded populations – for instance, this may result in their being underfunded, mismanaged and experiencing abusive staff behaviour; or their system becoming susceptible to powerful ideologies that deny people from socially excluded groups access to healthcare and other services.
Example: Being denied public health insurance due to sexual transmitted disease diagnosis violates their right to health and wellbeing as articulated in both the Universal Declaration of Human Rights and UN Convention on Elimination of All Forms of Discrimination against Women.
Individuals denied public health insurance often must seek private healthcare solutions on their own, which may be costly and complex – creating gaps in coverage if regular care needs exist. But there are ways to mitigate this risk, including applying for public health plans through NY State of Health’s website which will let individuals discover what plans they qualify for.