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How Health Benefits Work

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    How Health Benefits Work

    Frequently Asked Questions

    How you sign up depends on the type of coverage you get:

    You can qualify for Medicaid if your family’s income qualifies, even if your job offers insurance.

    You cannot get subsidies for purchasing an individual health plan through HealthCare.gov if your job offers you affordable insurance.

    In most cases, no. The actual medical coverage you get from Medicaid will be the same, no matter how you qualified. Generally speaking, the big difference is that people with disabilities get extra ways to qualify and if you have a disability and start working, you can earn a lot more while still getting Medicaid coverage through Medicaid Buy-In for Workers with Disabilities (MBIWD).

    For income-based Medicaid, the main income rules are:

    1. If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,783 per year for an individual; $43,056 for a family of four), you may qualify.
    2. If you are 18 or younger and your family’s income is at or under 211% of FPG ($65,832 per year for a family of four), you may qualify.
    3. If you are pregnant and your family’s income is at or under 205% of FPG ($63,960 per year for a family of four), you may qualify. The unborn baby is counted as a family member.

    Income-based Medicaid counts most types of earned and unearned income you have. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect income-based Medicaid eligibility.

    If you have a disability and get Supplemental Security Income (SSI) benefits or used to get SSI benefits and now qualify for SSI 1619(b), you automatically are covered by Medicaid. If your income is higher, you can get Medicaid Buy-In for Workers with Disabilities (MBIWD) coverage. With MBIWD, you could make as much as $116,320 per year and still qualify, depending on your unearned income.

    Health Coverage Income Limits for Your Family
    • Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
    • Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
    • Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for all of the same programs that U.S. citizens can get.

    There are different health coverage options as your income goes up:

    • Depending on how much your income goes up, your Medicaid may continue, unchanged.
    • If you got Supplemental Security Income (SSI) before you started earning more, you can usually keep Medicaid thanks to SSI’s 1619(b) rule.
    • If you have a disability and work, you can also consider Medicaid Buy-In for Workers with Disabilities (MBIWD). With MBIWD, you can work, earn up to $116,320 per year, and pay a monthly premium to get Medicaid coverage.
    • If your employer offers it, you may be able to get employer-sponsored coverage.
    • If your employer does not offer coverage, you should consider private individual coverage. You may get government help to pay for an individual plan on HealthCare.gov. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

    The bottom line: There is a coverage option for almost everybody. Do not worry that getting a job will leave you without health coverage.

    To qualify for the Medicaid Buy-In for Workers with Disabilities (MBIWD), you must:

    You have to pay a monthly premium to get MBIWD coverage in any month where your countable income is over $1,883. The amount of your premium depends on your income and your family's income, as well as your family's medical expenses. To learn how much your premium might be, try DB101's MBIWD Estimator.

    Medicare has three main parts:

    • Medicare Part A helps pay for medical care you get while you’re in a hospital.
    • Medicare Part B helps pay for medical care you get outside of a hospital.
    • Medicare Part D helps pay for prescription drugs.

    Medicare Advantage (also called Medicare Part C) is a way to get a single combined plan including Parts A, B, and D through a private company. With Medicare Advantage plans, you may have less flexibility, but your costs could be lower.

    If you or your spouse worked enough time while paying Medicare taxes, you will qualify for Medicare Parts A and B:

    • When you turn 65
    • When you’ve been getting Social Security Disability Insurance (SSDI) benefits for two years, or
    • If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).

    Note: If you have had a disability since before you were 22 years old, you will start getting Medicare if you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record.

    No. Medicare will only help pay for care that it considers reasonable and necessary. If you need a service that Medicare doesn’t cover, you’ll have to pay for it yourself, unless you have other coverage, such as Medicaid, employer-sponsored coverage, or a Medicare supplement (Medigap) policy.

    For certain services, you’ll pay a deductible, copayment, or co-insurance before Medicare will begin to help pay for that service. For Medicare Part B or Part D, or for Medicare Advantage, you may have to pay a monthly premium.

    You may qualify to get help paying for your Medicare premiums, copayments, and deductibles if you have low income. Medicare Premium Assistance Programs help pay for Part B coverage and the Low Income Subsidy (LIS) helps pay for Part D coverage.

    Yes. Other types of coverage that you can have with Medicare include:

    Learn more about how Medicare interacts with other types of coverage.

    You may pay nothing, a percentage of the cost, or whatever amount your employer doesn't pay.

    Employers are supposed to offer plans that cost the employee, for the employee’s policy alone, less than 8.39% of the employee’s household income for the monthly premium. Also, that coverage must meet bronze-level standards for copayment, co-insurance, and deductible expenses.

    If your employer offers a plan that does not meet these standards, you may qualify for government help through tax subsidies to reduce the premium on an individual plan.

    Note: The coverage your employer offers must meet affordability standards for the employee, but not for the family. It may be very expensive for family members to join an employer-sponsored health plan. Before 2023, the spouse or children of an employee would not qualify for subsidies on HealthCare.gov if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." This changed starting in 2023. Learn more about affordability rules for family members and how it affects eligibility for tax credits on HealthCare.gov.

    Yes, if you are under 26 and cannot get health coverage through your own employer. Employers who offer coverage to their employees must also offer it to their children under the age of 26.

    Employers do not have to offer coverage to the spouses of employees, but many do.

    Note: While employers must offer this coverage to children, the employee may be required to pay for all of it.

    Yes. Plans cannot deny people coverage. When you apply for insurance, they cannot reject your application and they cannot say that they won’t cover medical needs related to your disability. They also cannot charge you more because you have a disability.

    Additionally, all plans must cover the Essential Health Benefits (EHBs), which means that they offer comprehensive coverage, including chronic disease management, rehabilitative and habilitative services and devices, and mental health and substance abuse coverage, just to name a few.

    Depending on your situation, you may qualify to have the government help pay for your individual health plan through tax credits. Here's how it works:

    1. When you sign up at HealthCare.gov, you give details about your family's situation. HealthCare.gov reviews that information instantly. If your family qualifies for government help to pay for individual coverage, HealthCare.gov tells you and lists insurance options for you.
    2. Your insurance options list the full cost of the monthly premium, how much of that premium the government will pay each month, and how much you will pay each month. The way the government helps pay for the premium is by giving you a tax credit every month, so you don't have to think about it during the year. All you have to do is make sure you keep paying your part of the premium.
    3. In January or February, the government will send you a form listing how much your total health coverage tax credits were for the previous year. You will need this form at tax time, because it is possible the government paid more or less than it should have for your health coverage. If so, this will be sorted out when you file your taxes.

    No, but depending on your income, you may get more help from the government if you get a silver-level plan:

    • The government may help pay for your premium through tax credits. That means you would pay less each month. You might get this help no matter what metal your plan is.
    • If you make 250% of the Federal Poverty Guidelines (FPG) or less and get a silver plan, the government also pays to reduce your copayments, co-insurance, deductible, and out-of-pocket maximum. That means you pay less each time you need medical services. If you get this help, your silver plan might actually be as good or better than many platinum or gold plans. If you do not get a silver plan, the government does not help you with these expenses.

    When HealthCare.gov looks at your income, they will count most types of earned and unearned income you have. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.

    Health Coverage Income Limits for Your Family

    Usually, when you sign up for a plan through HealthCare.gov, you need to stay on the plan for the entire calendar year. So, if you are signed up for 2024, then you can’t leave that plan until 2025.

    However, there are certain situations when you may be able to change plans mid-year:

    • If your income changes and you gain or lose eligibility for government help paying for your coverage
    • If your health provider is not meeting its obligations
    • If you move, or
    • In other life-changing circumstances, such as having a child or getting married.

    The first one is the key. If your income goes down and you can’t afford your plan anymore, report your change in income to HealthCare.gov. You may qualify to get Medicaid or to have the government increase how much it pays for your current insurance (meaning that you have to pay less).

    Note: American Indians do not have these restrictions and can change up to once a month.

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