Work requirements for Medicaid coverage. Insurance plans that don鈥檛 meet health law standards. Changes to Medicare drug lists. As the ground continues to shift on health care coverage, I answer readers鈥 queries this week about these three different types of plans.
Q: I’m in a state that is looking into work requirements for Medicaid. At sign-up time, can I simply tell the exchange that I intend to be ineligible for Medicaid by refusing to work and get the premium tax credit to buy a private plan on the insurance marketplace?
Federal health law regulations don鈥檛 clearly address the situation you describe, but the short answer is probably not, said policy analysts.
In general, people who are eligible for Medicaid 鈥 the federal-state health program for low-income people 鈥 or employer coverage can鈥檛 qualify for federal tax credits that help pay for premiums on plans sold on the health insurance exchanges.
This year, Kentucky and Indiana became the first states to receive federal approval to require some Medicaid recipients to put in 80 hours each month at a paid job, school or volunteer work, among other activities, to receive benefits. Nearly a dozen other states have made similar requests.
If you refuse to work, does that make you ineligible for Medicaid? The rules aren鈥檛 clear, said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.
States might argue that someone in your situation is eligible for Medicaid, you just have to fulfill the work requirements, said Timothy Jost, an emeritus professor of law at Washington and Lee University in Virginia who is an expert on the health law.
There are other actions people could take 鈥 or fail to take 鈥 where this issue might come up. 鈥淵ou could argue that someone is not eligible because they haven鈥檛 completed the Medicaid application or provided the required documentation,鈥 Jost said. 鈥淭here are any number of requirements, but I can鈥檛 imagine someone saying they didn鈥檛 do those things and so they鈥檙e not eligible for Medicaid.鈥
Whatever the rules, it鈥檚 unlikely that many people will be in a position to consider taking this stance. To qualify for premium tax credits, your income must be between 100 and 400 percent of the (about $12,000 to $48,500 for one person in 2018). But you鈥檇 also have to be eligible for Medicaid, generally with an income limit of 138 percent of poverty (about $16,750) in states that expanded coverage to adults. In addition, the Medicaid work requirements in your state would have to apply to you.
Q: I lost my job last year and my employer coverage ended in January. I bought a new plan through the marketplace that went into effect last month. I just received policy information, and it states that because the plan does not cover major medical services, I may have to pay additional taxes to the government. I was told that the plan didn’t cover major medical but wasn’t told about any taxes. Will I be fined next year?
It sounds like you bought a plan that doesn鈥檛 comply with the Affordable Care Act鈥檚 requirements, and if that鈥檚 the case you may indeed have to pay a penalty for not having comprehensive coverage when you file your taxes next year.
The tax law for not having health insurance, but that provision doesn鈥檛 take effect until 2019.聽So, for 2018, you may be charged the greater of $695 or 2.5 percent of your household income.
The federal- and state-run marketplaces established by the ACA sell only comprehensive plans that cover 10 essential health benefits, including 鈥渕ajor medical鈥 services like hospitalization and prescription drugs.
But some insurance broker websites call themselves marketplaces too, said Sabrina Corlette, a research professor at Georgetown University鈥檚 Center on Health Insurance Reforms. These companies may sell other insurance products like short-term or accident coverage alongside comprehensive plans that comply with the law.
Ever since the health law was passed, 鈥淭here have been opportunistic companies trying to take advantage of consumer confusion to make money,鈥 Corlette said.
If you aren鈥檛 happy with your plan, you may still be able to switch. Losing your employer coverage qualifies you for a 60-day special enrollment period to pick a new plan. Since it appears you鈥檙e still in that window, you may be able to choose a comprehensive plan.
To ensure you鈥檙e using your state鈥檚 official marketplace, go to and click on 鈥渟ee if I can change.鈥 That will take you to your state marketplace, even if you live in one of the dozen or so states that run their own exchanges.
Q: I picked a Medicare Part D drug plan that covered all the drugs I take. But as soon as I got my first Novolin R prescription filled, they notified me that they don鈥檛 cover it anymore. Can they just switch it like that?
Medicare drug plans can change their list of covered drugs, called formularies. If they鈥檙e doing so at the start of the new calendar year, as appears to have happened in your case, the plan may notify you of the change when you 聽for the first time in the new year.聽聽At that time, the plan would typically give you a 30-day 鈥渢ransition鈥 refill so you can switch to another drug that鈥檚 on the formulary, according to Juliette Cubanski, associate director of the Program On Medicare Policy at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
If you and your doctor think it鈥檚 important that you have聽聽and not another drug that is similar, you can to allow you to continue to take the medication.
To go that route, you would need to get your doctor to 鈥渕ake the case for why that formulary drug is not the right drug鈥 for you, said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.
