FEBRUARY 27, 2018
KHN
contributing columnist Michelle Andrews writes the series Insuring Your
Health, which explores health care coverage and costs.
To
contact Michelle with a question or comment, click here.
This
story also ran on NPR. This story can be republished for free (details).
Work
requirements for Medicaid coverage. Insurance plans that don’t meet health law
standards. Changes to Medicare drug lists. As the ground continues to shift on
health care coverage, I answer readers’ queries this week about these three
different types of plans.
Q: I’m
in a state that is looking into work requirements for Medicaid. At sign-up
time, can I simply tell the exchange that I intend to be ineligible for
Medicaid by refusing to work and get the premium tax credit to buy a private
plan on the insurance 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, people who are eligible for Medicaid — the federal-state health
program for low-income people — or employer coverage can’t qualify for federal
tax credits that help pay for premiums on plans sold on the health insurance
exchanges.
This
year, Kentucky and Indiana became the first states to receive federal approval
to require some Medicaid recipients to put in 80 hours each month at a paid
job, school or volunteer work, among other activities, to receive benefits.
Nearly a dozen other states have made similar requests.
If you
refuse to work, does that make you ineligible for Medicaid? The rules aren’t
clear, said Judith Solomon, vice president for health policy at the Center on
Budget and Policy Priorities.
States
might argue that someone in 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
an expert on the health law.
There
are other actions people could take — or fail to take — where this issue might
come up. “You could argue that someone is not eligible because they haven’t
completed the Medicaid application or provided the required documentation,”
Jost said. “There are any number of requirements, but I can’t imagine someone
saying they didn’t do those things and so they’re not eligible for Medicaid.”
Whatever
the rules, it’s unlikely that many people will be in a position to consider
taking this stance. To qualify for premium tax credits, your income must be
between 100 and 400 percent of the federal poverty level (about $12,000 to
$48,500 for one person in 2018). But you’d also have to be eligible for
Medicaid, generally with an income limit of 138 percent of poverty (about
$16,750) in states that expanded coverage to adults. In addition, the Medicaid
work requirements in your state would have to apply to you.
Q: I
lost my job last year and my employer coverage ended in January. I bought a new
plan through the marketplace that went into effect last month. I just received
policy information, and it states that because the plan does not cover major
medical services, I may have to pay additional taxes to the government. I was
told that the plan didn’t cover major medical but wasn’t told about any taxes.
Will I be fined next year?
It
sounds like you bought a plan that doesn’t comply with the Affordable Care
Act’s requirements, and if that’s the case you may indeed have to pay a penalty
for not having comprehensive coverage when you file your taxes next year.
The tax
law repealed the individual penalty for
not having health insurance, but that provision doesn’t take effect until
2019. So, for 2018, you may be charged the greater of $695 or 2.5 percent
of your household income.
The
federal- and state-run marketplaces established by the ACA sell only
comprehensive plans that 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 Center on Health
Insurance Reforms. These companies may sell other insurance products like
short-term or accident coverage alongside comprehensive plans that comply with
the law.
Ever
since the health law was passed, “There have been opportunistic companies
trying to take advantage of consumer confusion to make money,” Corlette said.
If you
aren’t happy with your plan, you may still be able to switch. Losing your
employer coverage qualifies you for a 60-day special enrollment period to pick
a new plan. Since it appears you’re still in that window, you may be able to
choose a comprehensive plan.
To
ensure you’re using your state’s official marketplace, go to healthcare.govand
click on “see if I can change.” That will take you to your state marketplace,
even if you live 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 the drugs I take. But as
soon as I got my first Novolin R prescription filled, they notified me that
they don’t cover it anymore. Can they just switch it like that?
Medicare
drug plans can change 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 in your case, the plan may notify you of the change when you fill the prescription for
the first time in the new year. At that time, the plan would
typically give you a 30-day “transition” refill so you can switch to another
drug that’s on the formulary, according to Juliette Cubanski, associate
director of the Program On Medicare Policy at the Kaiser Family Foundation.
(KHN is an editorially independent program of the foundation.)
To go
that route, you would need to get your doctor to “make the case for why that
formulary drug is not the right drug” for you, said Casey Schwarz, senior
counsel for education and federal policy at the Medicare Rights Center, an
advocacy group.
