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 $46,314 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:

• Be under 65 years old
  • You can be 65 or older if you are the parent or caretaker of a child
• 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) ($21,597 per year for an individual; $44,367 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 ($67,837 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 ($65,908 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.

Health Coverage Income Limits for Your Family

Your family size:	123456789101112
Income limits for your family:
	$15,650
	$5,500
	$15,060
	$5,380
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: Some types of income do not count against these limits, including SSI benefits. Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG). For private plans with subsidies, your monthly premium amount depends on your income.

Add to favorites

Add to favoritesAdd to favoritesOne of my favorites

If your income is low enough and you meet all other requirements, you should sign up for Medicaid.

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.

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.

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.

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.

PLeHgx8W9UqgZ1r2AOePkQwDgp46DCK-_I

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 $15,210 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 $39,365 per year or less in total unearned income, such as SSDI, and
• Have countable income that is at or below $59,125 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 $119,270 per year and still qualify for MBIWD.

MBIWD: Income Limits

Your Monthly Unearned Income (not including SSI)	$
Your Monthly Earned Income	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,305
	$20
	$65
	$967
	$15,650
Your Monthly Countable Income
Your Annual Countable Income
Your Annual Countable Unearned Income
Unearned Income
Your Annual Unearned Income
Annual Unearned Income Limit
Your unearned income is under the limit	0.00
Your unearned income is over the limit	0.00
Countable Income
Your Annual Countable Income
Annual Countable Income Limit	$59,125
Your countable income is under the limit	0.00
Your countable income is over the limit	0.00
» You may qualify for MBIWD.	0.00
» You don't appear to qualify for MBIWD.	0.00

Add to favorites

Add to favoritesAdd to favoritesOne of my favorites

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.

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.

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:

• 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.
• 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.
• 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 $185.00 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 ($1,305 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 ($1,565 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 ($1,761 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 ($1,620 per month), but have countable income that’s 200% of FPG or less ($2,609 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 Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,305
	$20
	$65
	$967
Your Monthly Countable Income
Your Annual Countable Income
	$15,650
Federal Poverty Guideline
Your Countable Income as a Percent of FPG

Add to favorites

Add to favoritesAdd to favoritesOne of my favorites

The resource limit for QMB, SLMB, and QI-1 is $9,660 if you live alone and $14,470 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.” With it, you don't have to pay a Part D premium or deductible, and there may be lower copayments.

The Low Income 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 $23,475 per year and your resources are less than $16,100 if you are single (the limits are higher for larger households). 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 qualify.

Apply for the Low Income Subsidy at your local Social Security office.

Note: Before 2024, there used to be a "Partial LIS" that didn't help as much. Now, everybody who qualifies for the LIS gets the full subsidy.

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.

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 probably 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) ($21,597 per year for an individual; $44,367 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.
• 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:

• 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.
• 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.
• 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.

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).

Learn more about Medicare.

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 and usually there are trade offs between them. 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.

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) ($21,597 per year for an individual; $44,367 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.
• 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 9.02% of your household’s income and that coverage meets a certain benefits level, 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) ($37,650 for an individual; $78,000 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.

Health Coverage Income Limits for Your Family

Your family size:	123456789101112
Income limits for your family:
	$15,650
	$5,500
	$15,060
	$5,380
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: Some types of income do not count against these limits, including SSI benefits. Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG). For private plans with subsidies, your monthly premium amount depends on your income.

Add to favorites

Add to favoritesAdd to favoritesOne of my favorites

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 2025, you must sign up between November 1, 2024 and January 15, 2025.
• 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 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.