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  • Employee Benefits: Getting Health Care under ACA If You Lose Coverage
    Updated On: Apr 15, 2020

    From the Willig, Williams & Davidson Employee Benefits Department

    What Are My Rights To Get Health Care From The Affordable Care Act Marketplace If I Lose My Health Care Coverage From My Job?

    Q: If I lose my employer coverage, will I be able to enroll in a Marketplace health plan?
    A: Yes, you may qualify for a "Special Enrollment Period" for enrolling in a Marketplace health plan if you lose your health coverage through your employer.

    Q: How much time will I have to enroll in a Marketplace health plan after I lose my employer coverage?
    A: You generally have sixty (60) days from the loss of coverage to apply for a Marketplace health plan at www.HealthCare.gov. You will have to provide documents to show when you lost your employer health coverage. For more information, go to: https://www.healthcare.gov/help/prove-coverage-loss/.

    Q: Can I decline COBRA coverage and still be eligible for coverage through the Marketplace?
    A: Yes. When you lose your health coverage from your employer, you generally have two options: you can sign up for COBRA coverage OR you can buy a plan through the Marketplace instead. Losing job-based coverage qualifies you for a Special Enrollment Period. This Special Enrollment Period gives you 60 days to enroll in a Marketplace health plan at www.HealthCare.gov, even if it's outside the annual Open Enrollment Period for Marketplace coverage. For more information, go to: https://www.healthcare.gov/have-job-based-coverage/if-you-lose-job-based-coverage/

    Q: How much does Marketplace coverage cost?
    A: The cost of Marketplace coverage varies depending on the type of coverage you elect. When you go to www.HealthCare.gov, you will be asked questions about the type of coverage you want (HMO, PPO) and the level of deductibles and copayments for medical care and prescriptions.

    Q: Will I be eligible for a tax credit (premium subsidy) or cost-sharing reduction subsidies ("CSR")?
    A: You may be eligible for premium subsidies or CSRs if you meet certain income requirements.

    Q: How does my income affect my eligibility for premium subsidies and CSRs?
    A: There are two kinds of assistance for individuals who purchase Marketplace coverage. You may be eligible for one or both, depending on your household income level and family size:

    Premium subsidies are generally available to people who aren’t eligible for Medicaid and whose household income is not more than 400 percent of the federal poverty level (federal poverty levels are determined by the federal government each year). For example, for Marketplace coverage in 2020, if you are a family of four and your household income is greater than $103,000, you will not be eligible for the premium subsidies. Below is a chart of the income limits for premium subsidies by family size for 2020:

    Family Size

    400% of FPL

    1

    $49,960

    2

    $67,640

    3

    $85,320

    4

    $103,000

    5

    $120,680

    6

    $138,360

    Cost-sharing subsidies, otherwise known as cost-sharing reductions (CSR), reduce the deductibles and copayments under your Marketplace health plan. CSRs are generally available to people who aren’t eligible for Medicaid and whose household income is not more than 250 percent of the federal poverty level. You will have to enroll in a "silver" plan on the Marketplace to get CSRs. For more information on the "metal" categories (bronze, silver, gold and platinum) of plans available in the Marketplace, go to: https://www.healthcare.gov/choose-a-plan/plans-categories/. For example, for Marketplace coverage in 2020, if you are a family of four and your income is greater than $64,375, you will not be eligible for CSRs. Below is the chart for the income limits for CSRs by family size:

    Family Size

    250% of FPL

    1

    $31,255

    2

    $42,275

    3

    $53,325

    4

    $64,375

    5

    $75,425

    6

    $86,475

    To calculate your eligibility for the premium and cost-sharing subsidies based on your family size and your household income, go to: https://www.healthcare.gov/lower-costs/qualifying-for-lower-costs/.

    Q: Can I apply for Medicaid?
    A: Depending on your household income, you may be eligible for Medicaid. Each state’s Medicaid program is different. In order to qualify for Medicaid in Pennsylvania, your household income must not be more than the following amounts:

    Household Size

    Maximum Income Level

    1

    $16,612

    2

    $22,491

    3

    $28,369

    4

    $34,248

    5

    $40,127

    6

    $46,005

    7

    $51,884

    8

    $57,762

    * For households with more than eight people, add $5,878 per additional person.

    For more information on qualifying for Medicaid in Pennsylvania, go to: https://www.benefits.gov/benefit/1148

    Q: How do I know if I should apply for Marketplace coverage or Medicaid?
    A: If you apply for health benefits coverage through the Marketplace and your income level qualifies you for Medicaid, you will be redirected to the Medicaid enrollment site. If you wish to apply for Medicaid or CHIP in Pennsylvania (CHIP is medical coverage for individuals under age 19 whose parents earn too much income to qualify for Medicaid, but not enough to pay for private coverage), you can apply directly at one of these sites: http://www.healthchoices.pa.gov/info/resources/apply/index.htm or https://www.chipcoverspakids.com/AboutCHIP/Pages/ApplyingwithCOMPASS.aspx

    For more information, contact our Employee Benefits Attorneys:

    James S. Beall: jbeall@wwdlaw.com | 215.656.3610
    Susan Bahme Blumenfeld: sblumenfeld@wwdlaw.com | 215.656.3611
    Kelly A. Brogan: kbrogan@wwdlaw.com | 215.656.3631
    Louise "Wendy" F. Pongracz: louisep@wwdlaw.com | 215.656.3621


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