There are various methods for obtaining health insurance. These include private health insurance, job-based coverage, Medicare and Medicaid.
Your eligibility may qualify you for a subsidy that helps offset the cost of health insurance premiums based on your annual income.
Apply for Medicaid, Children’s Health Plus or NY State of Health any time during the year.
Eligibility for Marketplace Plans
During the annual open enrollment period, you can use the Marketplace to find a plan that meets the criteria established by the Affordable Care Act (ACA), enroll in it, and qualify for assistance paying monthly costs through subsidies or advance premium tax credits – and since 2021 more households who purchase Marketplace plans qualify.
Every Marketplace plan provides the same essential health benefits. You can compare plans by price, services and features before choosing one that best meets your needs and budget. In addition, using this application you can learn whether you qualify for free or low-cost health coverage through Medicaid, Children’s Health Insurance Program (CHIP) savings plans or savings on Marketplace plans; in addition, learn if any documentation or proofs of identity or income will need to be submitted in order to apply.
Apply for a Marketplace plan online, by phone or in person. If you need assistance when enrolling, certified assistors are trained professionals who can help guide your enrollment in a Marketplace plan – certified application counselors and facilitated enrollers are common types. Navigators and other helpers in your community may also be of service.
If you are already covered by Medicare Parts A and B, using the Marketplace won’t allow you to enroll in another private health plan; however, during a Special Enrollment Period (SEP), either continuing your current coverage or switching plans could be possible.
The Affordable Care Act (ACA) mandates that most Americans must have minimum health coverage or face a penalty. Most can obtain coverage either through their employer or marketplace. Others can access Medicaid programs provided by states and territories through state-based marketplaces or the ACA’s state-based marketplaces; regardless of your location you can utilize NY State of Health Marketplace to find coverage that fits both your needs and budget.
Eligibility for Medicaid
Before the Affordable Care Act (ACA) came into force, many states offered Medicaid programs which provided free or low-cost health coverage to people with extremely limited incomes. These programs varied by state, but usually targeted specific populations such as children, pregnant women, or those needing long-term care. The Affordable Care Act has altered how Medicaid eligibility is determined, by mandating that most states use one method – modified adjusted gross income (MAGI) – for counting income. This change was designed to make it easier for individuals and families to qualify for Medicaid, premium tax credits and cost sharing reductions available through the health insurance marketplace, and other forms of financial assistance. Furthermore, it aligns MAGI-based income calculations with other sources of support such as Supplemental Security Income.
The Affordable Care Act provided states with an opportunity to expand Medicaid eligibility to most low-income adults not already covered by it, although not every state took full advantage. Individuals whose incomes do not qualify for Medicaid often find assistance through private health plans available through either health insurance marketplaces or their employers – these plans are known as Qualified Health Plans (QHPs).
Some individuals may qualify for both Medicare and Medicaid at once. To be eligible, they must satisfy both criteria of both programs simultaneously – these usually include being 65+ and meeting SSI eligibility rules for blindness or disability (some 209(b) states may use different eligibility requirements than SSA). People already receiving SSI benefits can apply for Medicaid using the same application they used when filing for their benefits (using Form 3080 for both).
People who do not meet the eligibility requirements for Medicare or SSI may still receive assistance in paying for private health plans through state exchanges or the federal marketplace, NY State of Health. In order to do this, they must fulfill certain criteria of the Affordable Care Act such as having annual income below certain levels and meeting other requirements for financial support.
Eligibility for CHIP
Children’s Health Insurance Program (CHIP) is funded jointly by state and federal governments to serve children whose families earn too much to qualify for Medicaid but too little for private coverage. Most states operate their own CHIP programs while some combine Medicaid and CHIP into one system with one income limit that ranges from 170 percent of FPL in North Dakota up to 400% FPL in New York.
This program provides free or low-cost health coverage to children up to age 19. Depending on state laws, it may also cover pregnant women and young adults under certain conditions.
Eligibility for both CHIP and Medicaid programs is determined using a family’s Modified Adjusted Gross Income (MAGI). This formula takes into account household size, taxable income, tax filing status and other factors; it does not take into account deductions allowed by the Internal Revenue Service nor apply asset or resource tests in determining eligibility; some states utilize different MAGI formulas when administering separate CHIP programs.
Children born to mothers already enrolled in Medicaid or CHIP will automatically qualify (known as “deemed eligibility”) when they reach one year of age, even if the initial determination was after birth. Children who were born after initial determination can still become deemed eligible upon reaching age one.
State agencies must take reasonable measures to identify potentially liable third parties and seek reimbursement from them when applicable for both CHIP and Medicaid programs. States also have an obligation to establish policies and procedures designed to avoid payment for claims they are not liable for, while also identifying any potential liability due to accidents or incidents occurring outside the scope of standard medical practice.
States are required to provide continuous eligibility for both CHIP and Medicaid programs even when families experience a change in financial circumstances that would otherwise cause them to lose eligibility. Any income changes which may cause this outcome must be reported immediately to the agency that made initial determination and annually renewed eligibility must be confirmed.
Eligibility for Special Enrollment Periods
Special Enrollment Periods (SEPs) provide people who experience certain qualifying life events the opportunity to apply for marketplace coverage outside the annual Open Enrollment Period. Such life events could include losing insurance, moving to a different state, getting married, having a baby or any other significant changes that alter circumstances significantly. A SEP could also occur if someone opts to drop COBRA coverage voluntarily or when spouses lose employer-sponsored coverage and enroll instead in the marketplace instead.
SEP eligibility requirements depend on an applicant’s current financial standing and type of plans they qualify for. For instance, applicants must meet cost-sharing reduction or premium tax credit eligibility before being approved for an SEP; typically this is accomplished by providing documents such as bank statements or income records as proof. Depending on state regulations, certain applicants may need to undergo health screening prior to being accepted into an SEP plan.
In addition to an SEP, the Affordable Care Act offers other enrollment exceptions. These may include returning from living abroad, joining a federally recognized tribe or Alaska Native Claims Settlement Act Corporation shareholder, adding or dropping dependents (such as birth of child), returning from imprisonment etc. Some states and exchanges also grant additional SEPs for individuals whose income falls within 150% of poverty line, providing they already possess marketplace coverage.
Rules surrounding Special Enrollment Periods (SEPs) vary year to year. In 2018, for instance, special enrollment provisions were added for people whose circumstances changed such that they no longer qualified to receive cost-sharing reductions from their current insurer. Another special enrollment provision was made available to people moving to an area without marketplace plans available – neither event count as exceptional circumstances and therefore are ineligible for SEP eligibility. Likewise, changes to network access or drug formularies do not qualify as exceptional circumstances and therefore do not qualify as extraordinary circumstances and therefore disqualified them from eligibility for consideration under SEP guidelines.
Some SEPs are only available through exchanges while others can be purchased both on and off exchanges. No matter their source of coverage, even with an SEP consumers must still present proof of qualifying life events to their insurer when applying for plans; critics of this verification process have pointed out that it discourages people from utilizing them; for Black applicants in particular it often proves more challenging to complete necessary documentation than for other groups.
