The Basics
Everybody should have health coverage so that they can visit the doctor or get medications. It used to be that a lot of people, especially people with disabilities, couldn’t afford to get health coverage or couldn’t even qualify to get it. However, that’s changed. Now, there’s a health coverage option for almost everybody, even if you have a disability.
This article will introduce the health coverage options that are most likely for you:
- Medicaid, a government program which is almost free if you have low income, whether or not you have a disability. If you get Supplemental Security Income (SSI) benefits, you qualify for Medicaid automatically.
- Medicaid Buy-In for Workers with Disabilities (MBIWD), which lets you pay a monthly premium to get Medicaid coverage if you have a disability and your income is too high for you to get regular Medicaid.
- Medicare, which you get if you have a disability or are retired, if you or a family member has worked long enough while paying Medicare taxes.
- Employer-sponsored coverage, which your employer or a family member’s employer helps you pay for.
- Individual coverage, which you pay for yourself, possibly with the help of government subsidies.
All of these types of coverage have:
- Clearly defined services they will cover, including most of the physical and mental health needs you may have. For private insurance, all plans must cover Essential Health Benefits. Medicare’s coverage is comparable, while Medicaid offers some additional benefits, like personal assistance services if you need them.
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Payments you must make. Typically, payments for private insurance are highest and the fees for Medicaid are lowest. Your payments may include:
- Premiums, a monthly payment you must make whether or not you use any medical services. (Medicaid usually has no premium.)
- Copayments, a set amount you have to pay for a medical visit or service. The amount of the copayment depends on the service you get.
- Co-insurance, a set percentage of the cost of a visit or service that you must pay.
- A deductible, a set amount of money that you pay out of your own pocket each year before the insurance company will begin to pay for certain services. Once you have paid the deductible, you do not have to pay it again until the next calendar year.
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An out-of-pocket maximum, which is an annual cap on how much you have to spend on copayments, co-insurance, and deductibles. That means you will never have to spend more than $9,100 if you’re single or $18,200 for a family on these expenses.
- Medicare is an exception: It does not always have an out-of-pocket maximum.
None of these types of coverage:
- Have annual or lifetime limits on how much you can get in benefits. No matter how much medical care your insurance has to pay for, they can’t stop paying for care you need.
- Can discriminate against you because you have a disability. They cannot deny you coverage, charge you more, or refuse to pay for certain types of treatment because you have a pre-existing condition.
This article looks at these types of coverage to help you understand which is right for you and how to sign up.
Don’t assume that coverage is too expensive or that you won’t qualify. You probably will qualify for one of these programs and it may be a lot more affordable than you think.
Learn more
Medicaid
You get Medicaid automatically if:
- You get SSI benefits or qualify for 1619(b)
Look at income-based Medicaid if:
- You don't qualify for SSI or 1619(b)
- You are less than 65 years old
- You don’t qualify for Medicare
- You are a U.S. citizen or eligible immigrant, and
- Your household has low income.
Is Medicaid Right for You?
Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:
- Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
- Have low income, no matter how much you have in resources or whether you have a disability. Income-based Medicaid is explained on this page.
- Have a disability and work, even if your income is higher. Learn more about Medicaid Buy-In for Workers with Disabilities (MBIWD).
Answer the questions on this page to see if you might qualify for income-based Medicaid. If so, it’s probably your best health coverage option because it doesn’t usually have a premium, the copayments for services are generally lower than copayments required by private plans, and Medicaid covers more services than most private plans. Also, if you qualify for Medicaid, you cannot get government help paying for an individual plan on Healthcare.gov.
Note: The rules for SSI and Medicaid are different if you are less than 18 years old. Learn about them in DB101’s Benefits for Young People article.
Do You Qualify for SSI or 1619(b)?
If you have a disability, low income, and low resources, you may qualify for SSI. If you already get SSI benefits, you automatically get Medicaid coverage and do not need to apply separately.
If you don’t get SSI benefits yet, you should learn whether you might qualify by reading DB101’s SSI article. At the same time, you should apply for Medicaid separately, because it can take Social Security several months to review your SSI application and it’s important for you to have health coverage until then.
If you used to get SSI benefits, but stopped getting them after you started working, you may qualify automatically for Medicaid through a special rule called 1619(b) as long as your gross income is below $41,830 per year. Learn more about 1619(b) in DB101’s SSI article.
If you do not get SSI benefits and do not qualify for 1619(b), income-based Medicaid might cover you.
Do You Meet Income-Based Medicaid’s Basic Requirements?
To qualify for income-based Medicaid, you must:
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Be under 65 years old
- You can be 65 or older if you are the parent or caretaker of a child
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Not qualify for Medicare
- You can be on Medicare if you are the parent or caretaker of a child or are pregnant
- Be a U.S. citizen or meet specific noncitizen requirements
If you are under 65, do not qualify for Medicare, and are either a U.S. citizen or a noncitizen who qualifies, income-based Medicaid might cover you.
Medicaid’s rules for immigrants:
- 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.
Is Your Income Low Enough for Income-Based Medicaid?
These are the main income rules for income-based Medicaid:
- If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four), you may qualify.
- If you are 18 or younger and your family’s income is at or under 211% of FPG ($63,300 per year for a family of four), you may qualify.
- If you are pregnant and your family’s income is at or under 205% of FPG ($61,500 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.
Note: There are no limits to how much money or other resources you can have for income-based Medicaid.
| Your family size: | |
Income limits for your family: | |
| Income-based Medicaid, adults (138% FPG) | |
| Income-based Medicaid, children (211% FPG) | |
| Subsidized private plans, reduced fees (250% FPG) | |
| Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Notes:
| |
If your income is low enough and you meet all other requirements, you should sign up for Medicaid.
You may see the income limit for income-based Medicaid listed as 133% of FPG in some places. However, when Medicaid counts your income, they’ll knock 5% of FPG off your income if you make more than 133% of FPG. That's why we say that you can make up to 138% of FPG, because it more accurately shows how much income you could have and still get Medicaid. For children, this means we show 211% of FPG as the limit, instead of 206%.
More Ways to Qualify for Medicaid if You Have a Disability
If you have a disability, but don't qualify for SSI, 1619(b), or income-based Medicaid, you might still qualify for Medicaid benefits if:
- You make more money at work than income-based Medicaid allows. In that case, you could apply for Medicaid Buy-In for Workers with Disabilities (MBIWD). Learn more about MBIWD.
- You have mental health needs that private insurance or Medicare won’t pay for. If you are in this situation, talk to a benefits planner about Medicaid for people with severe and persistent mental illness (SPMI).
- You qualify for disability-based Medicaid, but not SSI. Learn more about disability-based Medicaid.
How to Sign Up
You can apply for Medicaid:
- Online, or
- By filling out the combined application form (other languages) and submitting it to your County Department of Job and Family Services (CDJFS) office.
For help with your application, visit or call your local County Department of Job and Family Services (CDJFS) office or call the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or 1-800-292-3572 (TTY).
Staying on Medicaid
Usually, once you are approved for Medicaid, you will continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your County Department of Job and Family Services (CDJFS) office know or report the changes online. When you report your changes, the county will tell you whether you will continue getting Medicaid or if you have new health coverage options, like individual coverage with subsidies or MBIWD.
Learn more
Disability-Based Medicaid
Look at disability-based Medicaid if:
- You don't qualify for Medicaid in any other way
- You don't qualify for SSI
- You are a U.S. citizen or eligible immigrant
- You have a disability
- You have low resources, and
- You have low income.
Disability-Based Medicaid if you don't get SSI
Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:
- Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
- Have low income, no matter how much you have in resources or whether you have a disability. Learn more about income-based Medicaid.
- Have a disability and work, even if your income is higher. Learn more about Medicaid Buy-In for Workers with Disabilities (MBIWD).
If you have a disability and don't get SSI benefits, you may also qualify for disability-based Medicaid if you:
- Have a disability that meets Social Security’s definition of disability. Learn more about the disability determination process in DB101's SSI article.
- Have countable income and resources below the SSI program's limits. Learn more about SSI's income and resources limits in DB101's SSI article.
- Meet all other Medicaid program rules, such as being a citizen or meeting noncitizen requirements.
For disability-based Medicaid, you must meet all of these conditions. If so, you should probably apply for SSI, because that way you'll get monthly SSI payments and get Medicaid coverage. However, if you aren't getting SSI benefits and need medical coverage now, you can apply for disability-based Medicaid:
- Online, or
- By filling out the combined application form (other languages) and submitting it to your County Department of Job and Family Services (CDJFS) office.
For help with your application, visit or call your local County Department of Job and Family Services (CDJFS) office or call the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or 1-800-292-3572 (TTY).
Note: If you have Medicare coverage and don't qualify for Medicaid, you may qualify for a Medicare Premium Assistance Program (MPAP), which would help pay for your Medicare expenses. Learn more about MPAPs.
SSI and disability-based Medicaid have nearly identical eligibility rules, but there are some differences. Here are a few examples of why you might get disability-based Medicaid, but not SSI:
- You don't want to get SSI benefits.
- You have a trust that helps you qualify for Medicaid, but not for SSI.
- You have more than $100,000 in an ABLE account.
- You have severe and persistent mental illness (SPMI).
If you have a disability, don't qualify for SSI, and need help from Medicaid, talk to a benefits planner to see if you might qualify for disability-based Medicaid or MBIWD.
Staying on Medicaid
Usually, once you are approved for Medicaid, you will continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your County Department of Job and Family Services (CDJFS) office know or report the changes online. When you report your changes, the county will tell you whether you will continue getting Medicaid or if you have new health coverage options, like individual coverage with subsidies or MBIWD.
There were major changes to these rules on August 1, 2016. Some of the changes include:
- Anybody who gets SSI now gets Medicaid automatically.
- Disability-based Medicaid now has higher income and resources limits, matching SSI's limits.
- There is only one disability determination for SSI and Medicaid.
- There is no more Medicaid spenddown. If your countable income is over the disability-based Medicaid limit, you may qualify for income-based Medicaid, MBIWD, an MPAP, or individual coverage with a subsidy.
For people who were already getting Medicaid coverage before August 1, 2016, these changes are being phased in over time. Learn more about the changes.
Learn more
MBIWD
Look at MBIWD if:
- You don't qualify for SSI or 1619(b)
- You are 16-64 years old and working
- You are a citizen or eligible immigrant
- You have a disability, and
- You have low resources.
Is the Medicaid Buy-In for Workers with Disabilities (MBIWD) Right for You?
Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:
- Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
- Have low income, no matter how much you have in resources or whether you have a disability. Learn more about income-based Medicaid.
- Have a disability and work, even if your income is higher. MBIWD is explained on this page.
Answer the questions on this page to see if you might qualify for MBIWD. If so, it’s a good option to consider because it lets you earn a lot more money and pay a low monthly premium, low copayments and no deductible to get Medicaid’s comprehensive coverage.
Do You Meet MBIWD’s Basic Requirements?
To qualify for MBIWD, you must:
- Be 16 – 64 years old
- Be working
- Be a U.S. citizen or meet specific noncitizen requirements
If you are 16 – 64 years old, working, and are either a U.S. citizen or a non-citizen who qualifies, MBIWD might be an option for you.
Medicaid’s rules for immigrants:
- 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.
Do You Have a Disability That Meets Social Security’s Standards?
To qualify for MBIWD, you must have a disability that meets Social Security’s definition of disability. For adults, Social Security says you have a disability if:
- You have a physical or mental impairment or combination of impairments
- Your condition has lasted or is expected to last for at least 12 months
Note: For MBIWD, Social Security’s disability rules related to earned income do not apply.
If you currently get a disability benefit like Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), you already meet Social Security’s disability standards.
If not, Ohio’s Division of Disability Determination will check to see if your disability qualifies for MBIWD.
If you already have a disability determination from Social Security or think that your disability will meet Social Security’s standards, MBIWD might be an option for you.
Do You Have Low Resources?
Resources are money and property you own. For MBIWD, you must have less than $13,233 in resources.
Some resources don’t count towards MBIWD’s resource limit, like the home you live in and one car. Additionally, if your disability began before you turned 26, the money you put into an ABLE account won't be counted by the MBIWD program. Learn more about ABLE accounts.
If your resources are below the limit, MBIWD might be an option for you.
Is Your Income Below MBIWD’s Income Limit?
MBIWD is designed so that if you have a disability, you can work without worrying that you’ll lose your Medicaid health coverage. That’s why its income limit is a lot higher.
For MBIWD, you must both:
- Have $36,690 per year or less in total unearned income, such as SSDI, and
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Have countable income that is at or below $56,450 per year. For MBIWD eligibility,
- Almost all of your unearned income is counted, but less than half of your earned income is counted. The way your income is counted for MBIWD is very similar to SSI’s countable income calculation.
- Only your income is counted, not the income of other household members.
Tip: Depending on your unearned income, you could actually earn up to $113,920 per year and still qualify for MBIWD.
| Your Monthly Unearned Income (not including SSI) | $ |
| Your Monthly Earned Income | $ |
| Your Monthly Impairment Related Work Expenses (IRWEs) | $ |
 | |
Unearned Income | |
| Your Annual Unearned Income | |
| Annual Unearned Income Limit | |
| |
Countable Income | |
| Your Annual Countable Income | |
| Annual Countable Income Limit | $56,450 |
| |
If your income is low enough and you meet all other requirements, you should sign up for MBIWD, after making sure it is better than any employer-sponsored coverage you could get.
You have to pay a premium to get MBIWD coverage in any month where your income is over $1,823. The amount you pay depends on your income and your family's income, as well as your family's total medical expenses. To learn how much your premium might be, try DB101's MBIWD Estimator.
Freddy has no unearned income and makes $5,730 per month at his job. He makes way too much money for Medicaid, so his county worker tells him to apply for MBIWD.
When the county reviews his application, it says Freddy only has $2,823 in countable income, so he easily qualifies for MBIWD. He will have to pay a monthly premium, but it’ll be a lot less than he’d have to pay for private insurance.
How to Sign Up
You can apply for MBIWD:
- Online (make sure to specify that you are applying for MBIWD), or
- By filling out the combined application form (available in other languages) and the MBIWD Addendum form and submitting them to your County Department of Job and Family Services (CDJFS) office.
For help with your application, visit or call your local County Department of Job and Family Services (CDJFS) office or call the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or 1-800-292-3572 (TTY).
Staying on MBIWD
Usually, once you are approved for MBIWD, you will continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your County Department of Job and Family Services (CDJFS) office know or report the changes online. When you report your changes, the county will tell you whether you will continue getting MBIWD and if your premium will change.
Learn more
Medicare
If you get Medicare, you may be able to get:
- Employer-sponsored coverage at the same time
- Medicaid or MBIWD at the same time
- Help paying for Parts A, B, and D
- Parts A, B, and D in a combined plan, or
- A supplement plan to cover more medical expenses.
What Medicare Options Are Right for You?
When you work, some of the money you earn automatically comes out of your paycheck and helps fund Medicare, a national public health insurance program.
If you or your spouse worked enough time while paying Medicare taxes, you will qualify for Medicare:
- 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).
If you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record, you will also qualify for Medicare.
If you qualify for Medicare, you can choose to get your coverage through either of these options:
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Original Medicare, including Part A, which helps pay for medical care you get while you’re in a hospital; Part B, which helps pay for medical care you get outside of a hospital, like when you go to the doctor’s office; and Part D, which helps pay for prescription drugs. You also have the option of getting a private Medicare supplement policy, which covers some expenses that Parts A and B do not cover.
- You automatically get Medicare Parts A and B if you’ve been getting SSDI or CDB for two years. Otherwise, you may need to sign up, depending on your situation.
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A Medicare Advantage plan, which combines Parts A, B, and D into a single plan run by a private company. There are many different Medicare Advantage plans to choose from.
- If you want a Medicare Advantage plan, you need to sign up during your initial Medicare enrollment or during the annual open enrollment period between October 15 and December 7 each year.
Most people don’t have to pay a premium for Part A, but they do have to pay monthly premiums for Parts B and D, or for Medicare Advantage plans. For this reason, nobody is required to get them.
Answer the questions on this page to see if it makes sense for you to get Original Medicare or a Medicare Advantage plan, and also whether you might qualify for programs that can help you pay your monthly premiums, copayments, co-insurance, and deductibles.
Do You Qualify to Get Medicare and Other Coverage at the Same Time?
If you qualify to get Medicare at the same time as you get employer-sponsored coverage, Medicaid, or Medicaid Buy-In for Workers with Disabilities (MBIWD), having those other benefits may impact your Medicare decisions:
- If you also qualify for Medicaid or Medicaid Buy-In for Workers with Disabilities, they may help pay for some medical expenses that Parts B and D would not pay for.
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If you also qualify for employer-sponsored coverage, you may wish to decline Part B and Part D coverage, so that you don’t have to pay their premiums. However, your private coverage must meet certain standards, or else you may have to pay monthly penalties if you choose to sign up for Parts B and D later.
- Important: Before you decline Part B, ask your employer-sponsored coverage to see if you would have to pay monthly penalties if you sign up for Part B in the future. Before you decline Part D, ask if your private insurance is considered creditable coverage by Part D. If it isn't, you would have to pay monthly penalties for Part D if you sign up later. If you have any questions about this, contact the Ohio Senior Health Insurance Information Program (OSHIIP).
You may have other options as well, such as retirement benefits, Veterans (VA) benefits, or military (TRICARE) benefits. Learn more about how Medicare interacts with other types of coverage.
Can You Get Help Paying for Medicare Parts A and B?
While Medicare offers good coverage, it is not as low-cost as Medicaid. Depending on the care you need, you may have to pay large copayments, co-insurance, or deductibles. And, for Part B, you may have to pay a monthly premium (usually $164.90 per month or a bit less).
However, if you have low income and low resources, you may qualify for a Medicare Premium Assistance Program (MPAP). There are four Medicare Premium Assistance Programs:
- The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,215 per month or less if you live alone). QMB helps pay for your Part B premium, copayments, and deductibles.
- The Specified Low-Income Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,458 per month or less if you live alone). SLMB helps pay for the Part B premium, but does not help with anything else.
- The Qualified Individual-1 (QI-1) program helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,641 per month or less if you live alone). QI-1 helps pay for the Part B premium, but does not help with anything else.
- The Qualified Disabled Working Individual (QDWI) program helps people who have lost their SSDI benefits because they earn more than the Substantial Gainful Activity (SGA) level ($1,470 per month), but have countable income that’s 200% of FPG or less ($2,430 per month or less if you live alone). It lets you stay on Medicare Part A even though you don’t get SSDI anymore and it will pay for the Part A premium that would otherwise apply.
| Your Monthly Earned Income | $ |
| Your Monthly Unearned Income (not including SSI) | $ |
| Your Monthly Impairment Related Work Expenses (IRWEs) | $ |
| |
| Your Monthly Countable Income | |
| Your Annual Countable Income | |
| |
| Your Countable Income as a Percent of FPG |
The resource limit for QMB, SLMB, and QI-1 is $9,090 if you live alone and $13,630 if you live with someone else. For QDWI, it’s $4,000 if you live alone and $6,000 if you live with another person.
You can apply for any of these:
- Online, or
- By filling out the application form and turning it in at your local County Department of Job and Family Services (CDJFS) office.
If you need help with your application, call the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or 1-800-292-3572 (TTY).
Can You Get Help Paying for Medicare Part D?
Part D helps you pay for your medications, but there are some expenses for you, such as the monthly premium, a deductible, copayments, and co-insurance.
If you cannot afford these costs, you may qualify for the Low Income Subsidy (LIS), which is also called “Extra Help.” The Low Income Subsidy has two levels:
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The full subsidy is for people who also get Medicaid coverage or who are in a Medicare Premium Assistance Program. You may also qualify if your countable income is less than $19,683 per year and your resources are less than $9,090 if you are single (the limits are higher for larger households).
- With the full subsidy, you will not have to pay a Part D premium or deductible, and there may be lower copayments.
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The partial subsidy is for people who can’t get the full subsidy, but have less than $21,870 in annual countable income and less than $15,160 in resources, if you are single (the limits are higher for larger households).
- With the partial subsidy, you will pay 0%, 25%, 50%, or 75% of the Part D premium, depending on your income, and will only have to pay a $104 deductible before you get help paying for drugs. You will have to pay co-insurance and copayments for your medications, but they will be lower than they would be without the partial subsidy.
Note: Not all of your income and resources are counted when you apply for the Low Income Subsidy. You can apply even if you don’t think you will qualify.
Apply for the Low Income Subsidy at your local Social Security office.
You can also save money by finding a better Part D plan for the medications you take. Use the Medicare Plan Finder to find the right Part D plan for you.
Do You Want a Medicare Supplement Plan That Covers Costs that Original Medicare Doesn't?
If you get Original Medicare with Parts A, B, and D, you can choose to get a private Medicare supplement (sometimes called a Medigap plan) to cover some of the expenses that Medicare Parts A, B, and D won’t cover. For example, a Medicare supplement could cover things like your co-insurance payments for Part B.
You will have to pay a monthly premium for a Medicare supplement, in addition to your premiums for Part B and D. The amount you have to pay depends on the plan.
Learn more about Medicare supplements or find one in your area.
Do You Want a Medicare Advantage Plan That Combines Parts A, B, and D?
With Medicare Advantage (sometimes called “Part C”), you can get all of your Medicare benefits combined into a single plan run by a private company. As long as a company follows Medicare’s rules, it can have more flexibility in the benefits it offers, how it organizes payments, and how much the plan costs. Also, Medicare Advantage plans have an out-of-pocket maximum, unlike Original Medicare.
The amount you pay depends on your plan, but most plans make you pay as much as the Part B premium would cost plus an additional amount for extra benefits and prescription drug coverage. A Medicare Premium Assistance Program and the Low Income Subsidy may help you pay for your Medicare Advantage plan.
Use the Medicare Plan Finder to see which Medicare Advantage plans might be best for your needs.
You can only make changes to your Medicare coverage, such as changing your Part D plan, adding a Medicare supplement plan, or switching to Medicare Advantage, during open enrollment, which is from October 15 to December 7 of each year.
If you have any changes you want to make, make sure to do them during this time period, or else you’ll have to wait another year.
Learn more
Employer-Sponsored Coverage
Look at employer-sponsored coverage if:
- Your employer, your parent's employer, or your spouse's employer offers it
- You meet the employer’s requirements, and
- You can't get Medicaid.
Is Employer-Sponsored Coverage Right for You?
To get private health insurance, a premium must be paid every month. Many employers offer to pay part, or all, of this monthly premium as a job benefit for employees, their children until they turn 26 years old, and their spouses. Employer-sponsored health coverage is the most common type of coverage in the U.S.
Answer the questions on this page to see if you might be able to get employer-sponsored coverage. If you can, you probably should because you won’t qualify for subsidized individual coverage.
Can You Get Medicaid?
If you qualify for Medicaid, it will always be your best choice, even if you can get health insurance from an employer. That’s because Medicaid usually has no monthly premium and the copayments for services are usually much lower than copayments required by employer-sponsored plans. Also, Medicaid may cover some services that employer-sponsored coverage does not pay for.
If you can’t get Medicaid, employer-sponsored coverage might be a good option for you.
You may qualify for Medicaid if you are in one of these situations:
- Your family’s income is at or below 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four). The income limits are higher if you are 18 or younger or are pregnant. There are no limits to how much money or other resources you have. Learn more about income-based Medicaid.
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You have a disability or are elderly:
- If you get Supplemental Security Income (SSI) benefits or qualify for SSI 1619(b), you automatically get Medicaid coverage. Learn more about SSI and 1619(b) in DB101’s SSI article.
- Medicaid Buy-In for Workers with Disabilities (MBIWD) lets people with disabilities who make more money than the income limits for other types of Medicaid get Medicaid coverage. However, you may have to pay a monthly premium. Learn more about MBIWD.
Does Your Employer, Your Spouse’s Employer, or Your Parent’s Employer Offer Coverage?
Many employers offer health coverage as a job benefit, but they are not required to. Contact your employer’s Human Resources department to check what benefits are offered.
If an employer offers health coverage as a job benefit for employees, the employer also has to offer the same health coverage to the employees’ children until they turn 26. An employer may also let the employee’s spouse join the plan, but they are not legally required to do so.
If your employer, your parent’s employer, or your spouse’s employer offers health coverage, it might be a good option for you.
Can You Get the Coverage Your Employer Offers?
Employers offer health coverage for employees and their families only if their employees meet certain requirements, such as:
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The employee must work a certain number of hours each week (called the active work requirement).
- Example: Your wife’s employer only gives health benefits to employees who work 30 or more hours per week.
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The employee must have worked for the employer for a certain amount of time (called the waiting period). A waiting period cannot be longer than 90 days.
- Example: Your father’s employer offers health coverage to employees who have worked there for at least 90 days.
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You must sign up during open enrollment.
- Example: After you are hired, you have to sign up for your employer-sponsored coverage during your first month on the job. If you don’t, you have to wait until the next open enrollment period to sign up for coverage.
If your employer, your parent’s employer, or your spouse’s employer offers coverage and you can get that coverage, you probably should.
If you can get employer-sponsored coverage, it may mean you can't get tax credits on Healthcare.gov. It depends on whether the employer-sponsored plan is considered "affordable."
When an employer offers coverage for the employee:
- If it costs less than 9.12% of the employee's household's total income and meets bronze-level standards, it's "affordable." The employee won't qualify for government help through tax subsidies to reduce the premium on an individual plan.
- If it costs more than 9.12% of the household’s total income, it's not affordable and the employee may qualify for tax subsidies to get a plan on Healthcare.gov.
When an employer offers coverage for the employee and the employee's spouse and children:
- If the coverage for the entire family costs less than 9.12% of the employee's household’s total income and meets bronze-level standards, it's "affordable." Nobody in the family will qualify for subsidies on Healthcare.gov.
- If it costs more than 9.12% of the household’s total income, it's not affordable and the spouse and children may qualify for subsidies on Healthcare.gov. However, the employee will not qualify for subsidies unless the cost of insurance for the employee alone is more than 9.12% of the household’s total income.
Note: 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.
Getting Medicare and Employer-Sponsored Coverage at the Same Time
If you get Medicare and also have employer-sponsored coverage, you should learn how your benefits work together.
If you get Original Medicare coverage, you can get Medicare Part A, which usually has no monthly premium, and both Parts B and D, which do have monthly premiums.
If you have private coverage that covers the same things Parts B and D cover, you can choose not to get them so that you don't have to pay their premiums. But it's important to make sure you won't have problems later:
- Before you decline Part B, ask your employer-sponsored coverage to see if you would have to pay monthly penalties if you sign up for Part B in the future.
- Before you decline Part D, ask if your private insurance is considered creditable coverage by Part D. If it isn't, you would have to pay monthly penalties for Part D if you sign up later. If you have any questions about this, contact the Ohio Senior Health Insurance Information Program (OSHIIP).
How to Sign Up
Talk to the employer’s Human Resources department to learn how to sign up. An employer may offer more than one plan. Every option must cover the Essential Health Benefits, but usually there are other trade-offs between plans. For example, one plan may require you to pay a higher monthly premium, while another may require you to pay higher copayments when you visit a doctor.
Sign up for coverage when it is first offered; otherwise, you may have to wait until the annual open enrollment period, which is usually near the end of the year. Certain changes in family or coverage status may trigger a special enrollment period. For example, if you get married or have a child, your new spouse or baby will be able to sign up with your employer-sponsored coverage without waiting until open enrollment.
If You Have to Stop Working Temporarily
In certain situations, you may be able to leave your job for a while, but keep getting your employer-sponsored coverage until you return to work.
If you work for any government agency or for a private employer with 50 or more employees, the Family and Medical Leave Act (FMLA) lets you take up to 12 weeks of unpaid leave per year for certain family and medical reasons, such as the birth of a child or to care for a sick family member. During this leave, your employer must continue to offer the same health coverage at the same cost as you would get while working. Learn more about the FMLA.
If you serve in the uniformed services, the Uniformed Services Employment and Reemployment Rights Act (USERRA) protects your job and health coverage for up to 24 months while you are serving. Learn more about USERRA.
COBRA and Ohio Continuation Coverage
These rules let most employees and family members keep getting the same health plan they got through an employer after losing employer-sponsored coverage.
Which of these rules applies and the amount of time you can keep getting the coverage depends on your situation. Either way, you will have to pay the entire premium for this coverage, including any amount that your employer paid in the past. Your plan could be a lot more expensive than you realize.
These laws used to be really important because it was so hard for individuals, especially people with disabilities, to get an individual insurance plan. Now, Healthcare.gov makes that much easier and often much cheaper. That said, there are times when COBRA might make sense, like if you’ve already paid the full deductible or out-of-pocket maximum for the year with your employer-sponsored coverage.
The bottom line: Do not sign up for COBRA without comparing it with your other options.
Learn more about COBRA and Ohio continuation coverage.
Learn more
Individual Coverage on Healthcare.gov
Look at individual coverage if:
- You can't get Medicaid
- You can’t get Medicare, and
- You can’t get employer-sponsored coverage.
Is Individual Coverage Right for You?
With individual coverage, an individual or family pays a monthly premium and the plan agrees to pay some of the costs of approved medical services when needed, including preventive care, lab tests, surgery, or prescription drugs. If you have low to moderate income, the government may help you pay for your monthly premium and get a plan with lower copayments.
Answer the questions on this page to see if it might make sense for you to get individual health coverage. If it does, sign up using Healthcare.gov, the easiest place to comparison shop for an individual plan and the only place where you might be able to get help from the government to pay for your private insurance.
Do You Have Any Better Options?
If you can get Medicaid, Medicare, or employer-sponsored coverage, you won’t qualify to get government help paying for an individual plan. That means they are usually a better choice than getting an individual plan, because they’ll cost less.
Can You Get Medicaid?
Medicaid is a government health program for people with low income. It’s a great program that usually has no monthly premium and copayments for services that are usually much lower than copayments required by individual plans. Also, Medicaid may cover some services that an individual plan would not.
If you can’t get Medicaid, individual coverage might be a good option for you.
You may qualify for Medicaid if you are in one of these situations:
- Your family’s income is at or below 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four). The income limits are higher if you are 18 or younger or are pregnant. There are no limits to how much money or other resources you have. Learn more about income-based Medicaid.
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You have a disability or are elderly:
- If you get Supplemental Security Income (SSI) benefits or qualify for SSI 1619(b), you automatically get Medicaid coverage. Learn more about SSI and 1619(b) in DB101’s SSI article.
- Medicaid Buy-In for Workers with Disabilities (MBIWD) lets people with disabilities who make more money than the income limits for other types of Medicaid get Medicaid coverage. However, you may have to pay a monthly premium. Learn more about MBIWD.
Can You Get Medicare?
Medicare is a government health program for seniors (65 years old or older) and people with disabilities. To get Medicare coverage, you or a family member must have worked for a certain number of years and met other eligibility rules.
If you get Medicare, you cannot get government help to pay for an individual health plan. You could still buy an individual plan through Healthcare.gov, but you would have to pay the entire premium yourself. Note: If you get Medicare and want more coverage than it offers, look into Medicare Advantage or Medicare supplement policies. Healthcare.gov does not offer these.
If you can’t get Medicare, individual coverage might be a good option for you.
Can You Get Employer-Sponsored Coverage?
Many employers offer private health coverage as a job benefit for employees, their children until they turn 26, and their spouses. If your employer offers you health coverage that would cost you less than 9.12% of your household’s income and that coverage meets bronze-level standards, you won't qualify for government help paying for an individual plan. If you can get employer-sponsored coverage, but sign up for an individual plan anyway, you will have to pay the full premium.
Note: 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.
If you can’t get employer-sponsored coverage, individual coverage might be a good option for you.
When an Individual Plan Is Your Best Option
You should get an individual plan through Healthcare.gov if you cannot get health coverage from:
- Your job
- Your spouse’s job
- Your parent’s job
- Medicaid, or
- Medicare.
The government may make your individual plan more affordable if you cannot get health coverage from any of the above options:
- You may get a tax subsidy to help pay your monthly premium.
- You may also qualify for a plan with lower expenses, such as smaller copayments, if your family’s income is at or below 250% of the Federal Poverty Guidelines (FPG) ($33,975 for an individual; $69,375 for a family of four).
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.
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.
Try Healthcare.gov's health plan directory.
| Your family size: | |
Income limits for your family: | |
| Income-based Medicaid, adults (138% FPG) | |
| Income-based Medicaid, children (211% FPG) | |
| Subsidized private plans, reduced fees (250% FPG) | |
| Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Notes:
| |
Carefully compare your options when you get an individual plan. All plans must cover the Essential Health Benefits. However, the amount you’ll have to pay for your premium and other fees, such as copayments, co-insurance, and deductible depends on your exact plan.
There are four levels of plan:
- Platinum plans have the highest monthly premiums and the lowest fees when you get medical care.
- Gold plans have slightly lower premiums and slightly higher fees when you get medical care.
- Silver plans have lower premiums. The fees for medical services depend on your family’s income; if your income is at or below 250% of FPG, the fees may be as low as a gold or platinum plan.
- Bronze plans have the lowest monthly premiums and the highest fees when you get medical care.
You may see these plans listed with percentage ratings (60%, 70%, 73%, 80%, 87%, or 90%). The higher the percentage rating, the lower the fees you have to pay when you get medical care.
The bottom line: If your income is at or below 250% of FPG, sign up for a silver plan. Otherwise, think about how much you typically spend on medical care to decide which metal plan is best.
How to Sign Up
Healthcare.gov is a one-stop shop where you can compare plans and figure out which is right for you. And it is the only place where you can get government help to pay for your individual plan.
Start out by comparing your options so that you can make an informed decision when you are ready. If you find Healthcare.gov confusing or think there is a mistake, get help by calling Healthcare.gov at 1-800-318-2596 or 1-855-889-4325 (TTY) or get local help.
Open Enrollment
Open enrollment for individual plans has ended for this year. People in certain situations can still sign up for a health plan under special enrollment rules.
Usually, you can only sign up for an insurance plan through Healthcare.gov during a specific time called open enrollment:
- To get an individual plan that will cover you during 2023, you must sign up between November 1, 2022 and January 15, 2023.
- If you do not sign up during that time, you will not usually be allowed to sign up for an individual plan through Healthcare.gov until another year has passed.
Special Enrollment
You can sign up for an individual plan through Healthcare.gov even though it is not the usual open enrollment period if:
- Your household income is at or below 150% of FPG
- You lose other health coverage you had
- Your health coverage is not meeting its obligations
- Your income changes and you gain or lose eligibility for government help paying for your coverage
- You become a legal resident of the U.S.
- You move
- There was a mistake in your enrollment, or
- In other life-changing circumstances, such as having a child or getting married.
Note: American Indians do not have these restrictions on enrollment.
Learn more
Frequently Asked Questions
Where can I sign up for health coverage?
How you sign up depends on the type of coverage you get:
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For Medicaid and MBIWD, you can apply:
- Online (you need to specify if you are applying for MBIWD), or
- By filling out the combined application form (available in other languages) and submitting it to your County Department of Job and Family Services (CDJFS) office (for MBIWD, fill out the Addendum form as well).
- Note: If you get SSI benefits, you automatically get Medicaid coverage and don't need to apply separately.
- For Medicare, you automatically get coverage if you’ve been getting SSDI for two years. Otherwise, you may need to sign up.
- For employer-sponsored coverage, talk to your employer’s Human Resources department.
- For individual coverage, apply at Healthcare.gov. Healthcare.gov will first check whether you qualify for Medicaid and, if not, will let you compare individual plans and see whether the government will help with tax credits.
If my job offers me health coverage, can I still qualify for Medicaid or get subsidies for an individual plan on Healthcare.gov?
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.
Does it matter how I qualify for Medicaid?
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).
What is the most money I can make and still get Medicaid?
For income-based Medicaid, the main income rules are:
- If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four), you may qualify.
- If you are 18 or younger and your family’s income is at or under 211% of FPG ($63,300 per year for a family of four), you may qualify.
- If you are pregnant and your family’s income is at or under 205% of FPG ($61,500 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 $113,920 per year and still qualify, depending on your unearned income.
| Your family size: | |
Income limits for your family: | |
| Income-based Medicaid, adults (138% FPG) | |
| Income-based Medicaid, children (211% FPG) | |
| Subsidized private plans, reduced fees (250% FPG) | |
| Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Notes:
| |
I’m an immigrant. Can I get Medicaid?
- 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.
What happens to my Medicaid coverage if I go back to work?
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 $113,920 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.
Who is eligible for the Medicaid Buy-In for Workers with Disabilities?
To qualify for the Medicaid Buy-In for Workers with Disabilities (MBIWD), you must:
- Be 16 – 64 years old
- Be a U.S. citizen or an eligible immigrant
- Be working
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Have a disability that meets Social Security’s medical standards.
- Social Security’s disability rules related to earned income do not apply.
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Have countable income at or below $56,450 per year.
- MBIWD counts earned income and unearned income differently. You could actually earn up to $113,920 per year and still qualify for MBIWD, depending on your unearned income.
- For eligibility, only your income is counted, not the income of other household members.
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Have resources below $13,233.
- The home you live in and one car are not counted. Additionally, if your disability began before you turned 26, the money you put into an ABLE account won't be counted by the MBIWD program. Learn more about ABLE accounts.
You have to pay a monthly premium to get MBIWD coverage in any month where your countable income is over $1,823. 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.
How many programs does Medicare offer?
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.
How do I become eligible for Medicare?
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.
Will Medicare pay for all of my medical expenses?
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.
Can I be on Medicare and another form of health coverage at the same time?
Yes. Other types of coverage that you can have with Medicare include:
- Medicaid
- Medicaid Buy-In for Workers with Disabilities (MBIWD)
- Coverage from a current employer
- Coverage from a spouse’s employer
- Continued coverage from a former employer through COBRA
- Retirement plans
- Veterans (VA) benefits
- Military (TriCare for Life) benefits, or
- Individual health insurance.
Learn more about how Medicare interacts with other types of coverage.
How much will employer-sponsored health coverage cost and who pays for it?
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 9.12% 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.
Can I get coverage through my parent’s employer-sponsored insurance?
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.
I have a disability. Will I really be able to get insurance that covers my medical problems?
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.
How does the government help people pay for individual coverage?
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:
- 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.
- 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.
- 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.
Do I have to get a silver level plan on Healthcare.gov if I want government help paying for my insurance?
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.
| Your family size: | |
Income limits for your family: | |
| Income-based Medicaid, adults (138% FPG) | |
| Income-based Medicaid, children (211% FPG) | |
| Subsidized private plans, reduced fees (250% FPG) | |
| Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Notes:
| |
What happens if I sign up for an individual plan and then my income changes and I can no longer afford it?
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 2023, then you can’t leave that plan until 2024.
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.
Learn more
Common Pitfalls
Not getting health coverage because you think it will be too expensive
Almost everyone has a health coverage option, even if you have a disability. The exact coverage that’s right for you depends on things like your family’s income, whether you can get employer-sponsored coverage, your age, where you live, and whether you have a disability.
If you can get employer-sponsored coverage or public health coverage, like Medicare or Medicaid, they are probably your best options.
If you can’t, you should look into getting an individual plan through Healthcare.gov, where the government may help you pay a plan's expenses. 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.
Note: It is very important to have health coverage, but starting in 2019 there is no tax penalty if you don't have coverage.
Getting an individual plan without using Healthcare.gov
Healthcare.gov is the best way to get an individual plan. You are still allowed to get insurance through an insurance broker, but there are four big reasons it is better to use Healthcare.gov:
- It’s the only place where you can get government help paying for your premiums and other health expenses.
- It will automatically check if you or your family might qualify for a public health coverage program like Medicaid and will let you know how to apply for it instead of an individual plan.
- Healthcare.gov has customer services representatives available over the phone at 1-800-318-2596 or 1-855-889-4325 (TTY). You can also get local help.
- It’s totally free – there are no commissions and no hidden fees.
Not understanding the expenses involved with private health coverage
When making decisions about health coverage and comparing different plans, make sure you understand all of a plan’s costs, which can include:
- Premiums, a monthly amount that has to be paid whether or not you use medical services. If you have employer-sponsored coverage, your employer pays part or all of the premium and you pay whatever the employer doesn’t pay. If you have individual coverage, you pay the entire premium, though the government may help you pay through tax subsidies if your income is low enough.
- Copayments, a set amount you have to pay for a medical visit or service. The exact amount of the copayment depends on the service you get: Medications, visits to specialists, lab tests, X-rays, emergency room visits, and other services can all have different copayment amounts.
- Co-insurance, a set percentage of the cost of a visit or service that you must pay.
- A deductible, a set amount of money that you pay out of your own pocket each year before the insurance company will begin to pay for certain services, including hospital care, emergency room visits, and brand-name prescription drugs. Once you have paid the deductible, you do not have to pay it again until the next calendar year.
Not looking into Medicaid because you think you won’t qualify
Medicaid used to be mainly for people with disabilities, seniors, children, and pregnant women. Now, it is for anybody with low income (at or below 138% of the Federal Poverty Guidelines (FPG), $20,120 for an individual; $41,400 for a family of four). No matter how much money you have in the bank or what your health situation is, you could qualify.
Not working because you think you’ll lose Medicaid coverage
In the past, people feared that if they got a job while they were on Medicaid, they’d lose their coverage, because they would no longer have low enough income to qualify.
Now, if you lose one health coverage option, there should be another one you can get. If you lose your Medicaid coverage, you will become eligible for Medicaid Buy-In for Workers with Disabilities, employer-sponsored coverage, or private individual coverage. And, if you can’t afford individual coverage, the government may help you pay for it.
The bottom line: There is a coverage option for most people. Do not worry that getting a job will leave you without health coverage.
Learn more
Next Steps
Learn more about Medicaid
- Visit the Medicaid website.
- Visit or call your local County Department of Job and Family Services (CDJFS) office.
- If you have a disability, talk to a benefits planner to learn more about health programs for people with disabilities.
Apply for Medicaid or MBIWD
You can apply for Medicaid and Medicaid Buy-In for Workers with Disabilities (MBIWD):
- Online (you need to specify if you are applying for MBIWD), or
- By filling out the combined application form (available in other languages) and submitting it to your County Department of Job and Family Services (CDJFS) office (for MBIWD, fill out the Addendum form as well).
For help with your application, visit or call your local County Department of Job and Family Services (CDJFS) office or call the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or 1-800-292-3572 (TTY).
Note: If you get Supplemental Security Income (SSI) benefits, you automatically get Medicaid coverage and do not need to apply separately.
Learn more about Medicare
- Visit Medicare.gov.
- Use the Medicare Plan Finder to compare Part D and Medicare Advantage plans.
- See how Medicare interacts with private health coverage in How Medicare works with other insurance.
- Contact the Ohio Senior Health Insurance Information Program (OSHIIP) at 1-800-686-1578.
- Call Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY). The line is open 24 hours a day, 7 days a week.
- Read Medicare & You, Medicare’s official handbook, which explains benefits, costs, services, health plans, and prescription drug plans.
Learn more about employer-sponsored coverage
To learn more about employer-sponsored coverage, talk to your employer’s Human Resources department. It will know about the specifics of the health coverage options it offers.
Learn more about individual coverage
- Visit Healthcare.gov, which has a lot of great information introducing your options.
- Call Healthcare.gov at 1-800-318-2596 or 1-855-889-4325 (TTY).
- Get local help from Healthcare.gov.
- To get an idea of what your premium might be, check out Healthcare.gov's health plan directory.
Benefits Planning Services
If you're currently on SSI, SSDI, or CDB benefits, and you're looking for a job, a trained benefits planner can help you avoid complications when you are working on a job plan for your future. For questions or guidance specific to your situation, you can speak to someone at the Ticket to Work Help Line at 1-866-968-7842 or 1-866-833-2967 (TTY) Monday through Friday from 8:00AM - 8:00PM EST.
View DB101's full list of experts who can help you understand different benefits.