How to Help Residents in States That Are Not Expanding Medicaid

Enrollment assisters and stakeholder organizations are working tirelessly to help consumers enroll in health coverage that meets their needs and budgets. But for enrollment assisters working in states that have not yet expanded Medicaid, it isn’t always possible to find an affordable health coverage option. Some people will not be able to get financial help to purchase health insurance through the marketplaces or access low- or no-cost coverage through Medicaid.

Specifically, adults with incomes below 100 percent of the federal poverty level for 2013($11,490 for an individual and $23,550 for a family of four) who don’t currently qualify for Medicaid in their state will not be able to get financial assistance to purchase health insurance through the marketplace. And if their state has not opted to expand Medicaid, they will remain unable to afford health insurance.

Fortunately, there are important steps enrollment assisters can take— beyond making referrals to local organizations or programs that may be able to help with the cost of coverage—to help these individuals and their families get covered. Here’s how:

Step 1: Help individuals seeking health insurance complete their application for marketplace coverage—even if they can’t get financial help now.

Consumers who apply for coverage, even if they can’t get financial help now, will receive important protections:

• They will receive a certificate of exemption from the marketplace. Individuals who can get an exemption will not pay a fine at the end of the tax year if they do not have health insurance (and otherwise have to file taxes). The certificate of exemption will also allow these individuals to enroll in a marketplace plan with financial help later in the year if their income increases above 138 percent of the federal poverty level for 2014 ($16,105 for an individual and $32,913 for a family of four).
• They may be able to enroll in a catastrophic plan, which will provide limited, low-cost health coverage. This will allow them to switch to another marketplace plan if their income increases above 100 percent of poverty later in the year.
• Their children may be eligible for low- or no-cost coverage through Medicaid or CHIP (Children’s Health Insurance Program), even if the adults are not able to get covered.

Step 2: After helping consumers fill out the application for marketplace coverage, provide consumers with information about next steps.

Between March 31 and November 15, 2014—when the next open enrollment period begins— people will only be able to enroll in a health plan through the marketplace if they are eligible for a “special enrollment period.” Individuals will qualify for a special enrollment period if they experience certain life events and report these to their state’s marketplace.

Individuals who don’t have access to affordable coverage before March 31, 2014 will be eligible for one of these special enrollment periods if they experience a life event (like getting married or having a baby). Solely having an increase in income will not qualify a person for a special enrollment period; after March 31, 2014, people without coverage must already have an exemption from the Marketplace in order to qualify for a special enrollment period when their income increases.

It’s crucial for navigators and assisters to share this information with low-income consumers who can’t get health coverage before March 31. These consumers need to understand the importance of reporting life events to the marketplace once they have received an exemption, including changes that result in an increase in income, such as getting a new job or a promotion.  Consumers must report new information to the marketplace within 60 days of the change to qualify for a special enrollment period. Reporting changes as soon as possible can help connect these consumers to the financial help they need to buy health insurance.

During the next few weeks, organizations across America are going to be pushing for individuals to get covered before the March 31 deadline for marketplace coverage. It’s crucial that during this time, states that have not yet expanded Medicaid help inform their residents about the important protections they’ll get when they complete the application for health insurance. Furthermore, these protections will serve to help them get covered later this year.