Many people who have health insurance obtain it through an employer, however, there may be times in your life when you are without coverage, facing coverage choices, or grappling with retirement health issues. This guide addresses some of the main health care coverage options and issues. (Note: This guide is intended to provide general information and is not intended as legal advice.)
Without Workplace Coverage
- If you, your spouse, or both, are working, but your employers do not offer health care coverage, are there affordable coverage options?
Health Insurance Marketplace
- The federal Affordable Care Act (ACA) requires employers 50 or more employees to offer group health insurance to their employees. If your workplace does not offer group health insurance, or if you cannot afford your employer’s plan, the ACA established state insurance marketplaces for consumers to purchase insurance individually (also called the Health Insurance Marketplace). If your state does not have a marketplace, you can purchase a plan from the federal marketplace. Depending on your income, you might also be eligible for subsidies to help cover costs and make the plan more affordable. Open Enrollment for the marketplace runs from November 1 of each year to January 30 of the following year. Under certain circumstances, such as divorce or birth of a child, you may be eligible to enroll outside of the open enrollment period. The ACA also prohibits insurers from denying coverage due to a pre-existing condition. If you’ve been turned down for insurance in the past, you should try again and see what options are available to you now.
- To learn more about Health Insurance Marketplace plans, visit healthcare.gov. This website can help you navigate to your state insurance marketplace and answers many of the commonly asked questions. You can enroll in coverage online, by phone or in-person with the help of a trained “navigator.”
- If your current healthcare needs are minimal, you may want to consider plans with a high deductible. Even though these plans generally have higher out-of-pocket costs, they have much lower monthly premiums. You will be responsible for all of your health care costs until the deductible of that particular plan is met, but you would be protected from major expenses thereafter.
- If you enroll in an eligible high deductible plan, you might also consider opening a tax-advantaged Health Savings Account (HSA). An HSA allows you to deposit pre-tax money to use for health, dental and vision expenses. (Generally, you may not use funds in an HSA to pay the premiums for your health plan, but there are limited exceptions to this rule.) This option may be right for you if you have the money to set aside in an HSA, if you can use additional tax deductions, and if you have trouble finding health care coverage that you can afford. You may only have an HSA if you also have a high deductible health plan deemed “HSA eligible” under federal standards. Be sure to ask before enrolling in a high deductible health plan if it is “HSA eligible.” Unlike flexible spending accounts, funds in an HSA roll over from year-to-year and are portable from job-to-job. A word of caution: for some people, the tax savings of an HSA will be lower than the out-of-pocket costs of a higher deductible health insurance plan. Talk to a bank or credit union that offers HSA accounts for more information.
- If you work part-time, can you qualify for health care coverage from your employer if you increase your hours?
Most companies that offer health benefits require that you work a certain number of hours per year to qualify for health benefits, so it is worth finding out if changing your work schedule would make you eligible for benefits.
- If you are not working, or have a low annual income, are there other options besides the Health Insurance Marketplace?
- Medicaid provides health coverage for lower-income individuals and families. Children can also be covered through the Children’s Health Insurance program (CHIP), and some state programs are now covering parents and childless adults as well. Call your state Medicaid office or go to healthcare.gov for more information and to see if you qualify. For more information on covering children, go to insurekids.gov. Learn more about Medicaid at Medicaid.gov.
- If you have lost your insurance due to loss of a job or spousal coverage, look into COBRA coverage. COBRA is a law that gives you the right to buy coverage in a workplace plan if you are no longer eligible to be covered under the plan as an employee or a dependent of one. You have 60 days to sign up for it through your previous employer or your spouse’s previous employer. Once you sign up for COBRA coverage, you will be allowed to stay in the plan for a specified time period, although you will be required to pay the full premium for coverage and a small administrative fee. Ask the former employer for more details. Don’t rush into this decision without comparing the COBRA coverage to individual insurance available to you through your state insurance exchange. The health insurance exchange might have a more affordable option for you.
- If you don’t have health care coverage, can you negotiate fees with providers or do you have to pay whatever the doctor or hospital charges?
If you don’t have coverage, always try to negotiate a price and/or a payment schedule. Providers have no obligation to accept your offer but many are willing to try and work with you if you are having trouble paying costs. You might offer to pay the provider whatever an insurance plan would have paid for your treatment, which would generally be lower than the provider’s “sticker price.”
On the Job
If both you and your spouse are offered health care coverage through your employers, should you each enroll in your own plan, both enroll in one plan, or both enroll in both plans?
The answer to this question depends on what each of your plans offer. Ask for the Summary Plan Descriptions for each plan (the documents should have this title) and read about family coverage and coordination of benefits. Your plans may require that each of you be enrolled in your own employer’s plan as your primary plan. In that case, you could still enroll in your spouse’s plan, but your spouse’s plan would only cover expenses your own plan does not. You may also have a choice of choosing one plan and enrolling in family coverage. Many times, it is more cost effective for an entire family to be enrolled in one plan.
You and Your Family
- What are your rights to health care coverage through your spouse’s job if you and your spouse separate or divorce? If your spouse dies? What are your children’s or stepchildren’s rights in these cases?
In general, a divorce or the death of the spouse with the coverage qualifies you under COBRA to remain covered under the plan for up to 36 months, but your own circumstances could lengthen or shorten this period. Children covered under the plan may be able to retain coverage even longer in the event of a divorce. If you are getting a divorce or need to enforce child support, you should also ask your attorney about filing a qualified medical support order (QMSO). A QMSO can be used to require employer-sponsored group health plans to extend health care coverage to the children of a parent/employee who is divorced, separated, or never married when ordered to do so by state authorities.
- Can you or your family qualify for health care coverage through the military if one of you served and was honorably discharged even though s/he did not serve a full 20-year career?
Depending on your family’s income, you and your family may be eligible for health care coverage through the military, even if the one who served did not serve a full career. You should contact your local Veteran’s Affairs office if you think you might qualify. To find your local office, go to: www1.va.gov/directory/guide/map.asp
If you are enrolled in Medicare and cannot afford to pay the out-of-pocket costs Medicare does not cover, there are several types of assistance that may fit your circumstances:
- There are several different “Medicare Savings Programs” administered by the states that provide assistance in paying Medicare’s costs, including the QMB or Qualified Medicare Beneficiary and SLMB or Specified Low-Income Beneficiary Program. Visit Medicare.gov for a complete list of Medicare Savings Programs and information on qualifying for help.
- Look into Medicare Advantage Plans (like HMOs, PPOs, or Private Fee-for-Service Plans). Some of these plans offer more comprehensive coverage than traditional Medicare.
- Look into Part D prescription drug coverage if you don’t have it already. There is also “extra help” available from Medicare if you meet income requirements and some states have programs to help with prescription drug costs.
- You might also benefit from a Medigap insurance policy, which is a private insurance policy that pays out-of-pocket medical costs not covered by Medicare. Contact Medicare for more information or use their online interactive tool at Medicare.gov that helps consumers find prescription drug and Medigap plans sold in their area.
For additional help:
State’s State Health Insurance Assistance Program (SHIP)
SHIP is a free health benefits counseling service for Medicare beneficiaries and their families or caregivers. A SHIP program is available in every state. SHIPs mission is to educate, advocate, counsel and empower people to make informed healthcare benefit decisions. SHIP is an independent program funded by Federal agencies and is not affiliated with the insurance industry.
Make an appointment to with a trained counselor to find out all of your options for getting help with your medical expenses. Find your state SHIP program at shiptacenter.org.
Benefits Check Up
Benefits Check Up is a free service of the National Council on Aging (NCOA), a nonprofit organization. This online tool asks a series of questions to help identify benefits that you or someone you are caring for may be eligible. Types of expenses you may find help with include Medications, Food, Utilities, Health care, Housing, In-home services, and Transportation. Try it out at benefitscheckup.org.
A free nationwide service offered by the Department of Health and Human Services that connects older adults and their caregivers with a variety of local, trusted services and resources in their communities. Call 1-800-677-1116 or visit eldercare.acl.gov.