Enrolling in health insurance: Medicaid and the ACA marketplace

Seeing a doctor in the US without insurance is expensive. A single emergency room visit can run to tens of thousands of dollars. What many people do not realise is that a great many people who qualify for help never apply, either because they assume they will not qualify or because they are afraid of the effect on an immigration case.

The two main routes#

Medicaid: for lower incomes#

Medicaid is free or near-free coverage, funded jointly by the federal government and the states. Each state sets its own income limits, so whether you qualify genuinely depends on where you live.

Children usually qualify at much higher incomes than adults, through Medicaid or the CHIP program. Even when you do not qualify, your children may.

Medicaid takes applications all year round. There is no enrolment season to wait for.

The ACA marketplace: for everyone else#

If you have no coverage through an employer and your income is above the Medicaid limit, you buy a plan through the marketplace at HealthCare.gov. Some states run their own site, and HealthCare.gov redirects you to the right one.

The key point: most people who buy through the marketplace have part of their monthly premium paid by the government. The amount depends on your income and household size. Many people see the full sticker price, give up, and never find out they would only have paid a fraction of it.

Enrolment periods#

The ACA marketplace opens for enrolment during a set window each year, usually starting 1 November. Outside that window you can only enrol if you have a qualifying life event:

• Losing your existing coverage, for example by leaving a job
• Moving to another state
• Getting married or divorced
• Having or adopting a child
• Becoming a citizen, or newly gaining a qualifying immigration status

After one of these you normally have 60 days to enrol. Do not let it lapse.

Can immigrants enrol#

This is the question that stops most people.

• Lawful permanent residents (green card holders), refugees, people granted asylum, and many other qualifying statuses can buy through the ACA marketplace and can receive premium help.
• Full Medicaid applies a waiting period to some statuses, but many groups are exempt from it, including refugees and people granted asylum.
• Children and pregnant women are covered more broadly in many states, sometimes where an adult in the same status would not be.
• People without lawful status cannot buy through the ACA marketplace, but emergency care is still available, and some states run their own programs for children or adults. Community health centres see everyone and charge on a sliding scale based on income.

What to have ready when you apply#

• Date of birth and Social Security number for each household member, where they have one
• Immigration documents for anyone applying for coverage
• An estimate of your household income for the year. Recent pay stubs or last year's tax return make this easy
• Details of any coverage you already have through an employer

The application asks about the income of your whole tax household, not only yours.

Choosing a plan#

Marketplace plans come in tiers: Bronze, Silver, Gold, Platinum. Higher tiers cost more each month but leave you paying less when you actually receive care.

One thing that is easy to miss: if your income is low, Silver plans carry extra cost-sharing reductions that the other tiers do not. That often makes Silver the best value for a lower-income household, even though Bronze looks cheaper.

Before you commit, check two things: that the doctor you want is in the plan's network, and that any medication you take is on its covered list.

If you have no coverage right now#

• Community health centres see uninsured patients and charge on a sliding scale. Find one at findahealthcenter.hrsa.gov
• Call 211 to ask about local assistance programs
• Many hospitals run a financial assistance program that reduces or cancels bills for lower-income patients. You have to ask; hospitals rarely offer it

What to do next#

• Go to HealthCare.gov and run the eligibility check; it takes a few minutes
• If your household income is low, apply for Medicaid today rather than waiting for an enrolment season
• Save the number of a nearby community health centre in your phone, for when you need it quickly