It's not too late to apply for Medicaid

Consumer Reports

Open enrollment for private health insurance has come and gone for 2014, but you can apply for Medicaid at any time. And you may be more likely to qualify than you realize.

If your household income is less than 138 percent of the Federal Poverty Level, go onto your state’s health insurance marketplace and fill out an application. (Yes, you can do that even though it’s not open enrollment, since Medicaid eligibility and enrollment happen year-round.) Use this list to see if you are below that cut-off:

  • Single person: $15,586
  • Couple: $21,404
  • Family of three: $26,951
  • Family of four: $32,499
  • Family of Five: $38,047

If you’re not sure what counts as income, here’s a handy visual aid that will tell you.

You should definitely apply even if you live in one of the states, such as Florida and Texas, that have declined the opportunity to enlarge their Medicaid programs (with the federal government picking up the entire tab) to cover all low-income residents.

That is because you may be eligible for some other kind of Medicaid that already exists in those states without realizing it. As of the end of February, the most recent date for which we have government figures, 908,000 people who had applied for insurance coverage in states not expanding Medicaid had found out they were entitled to it anyway.

Here’s an up-to-date list of which states have expanded Medicaid and which have decided to express their opposition to Obamacare by leaving millions of working poor people in the notorious "coverage gap." (This decision is already having consequences, such as the much-publicized death of this 32-year-old working single mother from Florida. But I digress.)

Furthermore, just the fact that you applied, even if you're not eligible for Medicaid right now, will protect you if your income goes up during the year to above 100 percent of the Federal Poverty Level, which, in states that aren't expanding Medicaid, entitles you to premium subsidies to buy private insurance.

Because you're "in the system" of your state's marketplace, if that happens you can go back in and report your new, higher income. That will trigger a Special Enrollment Period during which you can sign up for a private plan, with financial help, even though it's not Open Enrollment. But if you never applied in the first place, you can't get this Special Enrollment Period even if your income goes up. (Right, it doesn't make sense, but that's how the law works.)

Here are three common questions I’ve received from readers concerning Medicaid.

1. I applied for health insurance several months ago on HealthCare.gov and was told I was eligible for Medicaid and would get more information from my state. But I haven’t heard anything yet and the Open Enrollment period has ended. What should I do?

That automatic transfer from HealthCare.gov to Medicaid was supposed to happen, but it didn’t always, especially in the first months when HealthCare.gov wasn’t working, says Matt Salo, executive director of the National Association of Medicaid Directors. “A lot of the applications came through with missing data like your birth date or your Social Security number, even though you supplied it when you applied on HealthCare.gov,” he explains. “These applications are having to be processed by hand, so it’s quite possible your application is still in a stack of paper on somebody’s desk.”

In that case, apply again, directly to your state’s Medicaid agency this time (here’s a page with a drop-down menu of agency websites). Unlike private health insurance, Medicaid coverage is retroactive, typically for up to three months. Moreover, hospitals and community health centers have the authority to declare you “presumptively eligible” for Medicaid right on the spot if you show up and need immediate care. If you submit a full application for Medicaid by the end of the following month, your expenses will be covered as long as it takes for your application to be processed, even if you are ultimately turned down.

If it turns out that you weren’t eligible for Medicaid after all, for instance because your income was too high, or because you haven't been a permanent resident of the U.S. for five years or more, you’ll be given a Special Enrollment Period to sign up for private coverage through your state’s marketplace even though open enrollment is over. I strongly recommend enlisting the help of a Navigator or In-Person Assister to help with this project. Here’s where to find such people near you.

2. Our family’s income qualified us to enroll in Medicaid, but what happens if my income goes up above the threshold. Do I have to pay Medicaid back?

No. Medicaid eligibility is determined month-to-month. But if during 2014 you can see that you’re going to earn enough to raise your income above the Medicaid eligibility threshold, you can go back to your state marketplace, report the income change, and qualify for a Special Enrollment Period to switch to a private insurance plan with a premium subsidy.

3. I live in a state that’s not expanding Medicaid. When I applied for coverage on my state marketplace, I projected my 2014 income to be just barely above the poverty line, so I was able to get a subsidy to buy a private plan. What happens if at the end of the year it turns out I didn’t make that much?

If you gave your 2014 income projection in good faith, with no intention to deceive the government, and at the end of the year your income hasn’t topped that amount, you won’t have to pay back the subsidy.

Got a question for our health insurance expert? Ask it here; be sure to include the state you live in. And if you can't get enough health insurance news here, follow me on Twitter @NancyMetcalf.

— Nancy Metcalf

We're providing regular coverage of the new health care law. To get health insurance advice tailored to your situation, use our Health Law Helper, below.



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