The Medicaid Gap explained


The Medicaid Gap refers to a situation that came in some states as the Affordable Care Act went into effect in 2013.  Folks who earn between 138 – 400% of the Federal Poverty Level in affected states are not covered by Medicaid. Additionally, they are not eligible for Marketplace subsidies.  This means it’s more challenging to find quality, affordable healthcare options.  If you happen to fall into the Medicaid Gap, our team at HealthSherpa is here to help. Here are a few questions to help you better understand The Medicaid Gap:

Does your state offer expanded Medicaid coverage?

As of January, 2016, 31 states and Washington DC had laws in place or laws awaiting approval to support folks who fall into the Medicaid Gap.  You can look up your state’s law here to check out their current status.

Is your household income below these limits?

For all states, with the exception of Alaska and Hawaii, here are the 2016 income guidelines that allow you to receive expanded Medicaid (if your state offers it):

  • For a household of one person, the income limit is $16,242.
  • For two people: $21,983.
  • For three people: $27,724.
  • For four people: $33,465.
  • For five people: $39,205.

Options if you fall into the Medicaid Gap

If your state does not offer expanded Medicaid and your income is below the levels listed above, you may want to consider other options that give you access to health care coverage. The Federal or State Marketplace is always an option, but coverage can be more expensive as you may not qualify for a government subsidy.  Here are a few options you could consider:

  • Community Clinics: Since people everywhere need health care, regardless of whether they have access to insurance, some cities have sliding-scale community health clinics. You can go to these clinics regardless of your insurance situation and pay only what you can afford.
  • Medicaid: In some states that don’t have expanded Medicaid, there is still some regular Medicaid coverage for children, disabled adults and expecting mothers. Your state or county public assistance department will be able to tell you if you qualify for this coverage.
  • Charity Care: Many state hospital associations require hospitals to discount or write-off charges for low-income patients, if the patient requests this assistance. If you have hospital bills you can’t pay, you should ask the hospital billing office if you can fill out an application for charity care.
  • Emergency Rooms: Hospitals can’t refuse to treat people who have medical emergencies. You should never think twice before going to an emergency room if you have an acute or dangerous medical situation.

It’s likely, within the next few years, that a solution will be developed for the millions of Americans who fall into this unfortunate health care coverage gap. If you have questions about your coverage eligibility, know that our Consumer Advocates are here to answer any questions year-round.

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