What to do if you fall into the Medicaid Gap

By healthsherpa

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One of the cornerstones of the Affordable Care Act (ACA) was financial support from the federal government for states to expand their Medicaid programs. But as of January 2020, there are 14 states in the U.S. that have not expanded their Medicaid programs. And in these states, Medicaid eligibility is very limited for adults. According to the Kaiser Family Foundation, the median income limit for parents in these states is just 40% of the federal poverty level. This translates an annual income of $8,532 for a family of three in 2019. And childless adults remain ineligible in nearly all states that did not participate in the expansion of Medicaid, even if they are low-income individuals. You can grab our free guide to Medicaid here to learn more. 

Right now in the United States, Medicaid covers one in every four children, 21% of low-income adults, and 60% of all nursing home residents. Without Medicaid, 50 million Americans would be without any form of health coverage.

Those who make too much to qualify for Medicaid where they live but don’t make enough to be able to afford Marketplace insurance are in what’s known as the Medicaid coverage gap. And if this is you, you still have options for accessing health insurance coverage. 

Here’s what to do. First, you should make absolutely sure you don’t qualify for Medicaid or a subsidized Marketplace plan (aka Obamacare or Affordable Care Act insurance). Enter your zip code below to see.

If you don’t qualify, you can check out free or low-cost clinics, GoodRx for prescription discounts, fee-based providers, and low-cost specialty care. Read on for more information.

Free or Low-Cost Health Clinics

In the Medicaid gap, uninsured, and worried you can’t afford health care? You do still have choices. And one great choice is a free or low-cost community clinic. Here’s more information on how to find one near you.

A Federally Qualified Health Center (FQHC) is a government-funded community clinic where care is available on a sliding-scale of costs. This means that depending on your income level, care at a FQHC might even be free. Migrant health centers, county health department clinics, and homeless shelter health centers are just some of the kinds of FQHCs available. You can find an FQHC in your area here. 

These kinds of clinics exist specifically for those who fall in the Medicaid gap — those who are uninsured, do not qualify for Medicaid, and cannot afford to buy health insurance. There are no specific requirements that need to be met to be seen at an FQHC, though, meaning anyone who wants to get care there can.

There are also non-government-funded community health centers that are funded by charitable organizations and often staffed by volunteer providers. These kinds of clinics are also typically sliding scale, and potentially even no-cost. You can find a free community health clinic in your area here. 

Free and low-cost clinics typically provide a range of primary care services for adults and children, and many often provide some forms of prenatal care, too. Prescriptions and vaccinations are also available. 

If you have prescriptions and don’t have insurance, you can use GoodRx to see if there are any discounts available for you.

Fee-based Providers

If you are uninsured and in need of medical care, there are also options for care outside of community health clinics, though the fees will be higher. Urgent care centers are located in cities large and small, and have things like X-ray machines on site. This means they provide an option for healthcare for some less critical emergency situations — like sinus infections that need antibiotics or a broken arm needing evaluating — and saving patients a trip to the emergency room. Without health insurance, you may pay up to $150, or more, for seeing a provider at an urgent care clinic. But this will likely still be less than you may pay out-of-pocket in an ER and allow for quick and easy access to healthcare for situations that cannot wait. 

Many pharmacies and drug stores also have retail clinics located within their facilities. At these mid-level providers like a nurse practitioner or a physician’s assistant  are on-hand to see and treat basic illnesses, and even provide some vaccines. They are also typically less expensive than an urgent care clinic, and much less expensive than an emergency room. Emergency rooms are located within hospitals and, without insurance, the most expensive way to access walk-in care. Without insurance, a trip to the ER could end up costing thousands of dollars. 

Low-Cost Specialty Care

Family planning, contraceptive counseling and dispensing, and other preventative care services related to reproductive health like Pap smears and breast cancer screenings can also be accessed at special low- or no-cost clinics. 

In terms of government-funded options, Title X clinics make these kinds of services available at no-cost or for a nominal fee to anyone who needs them. Title X is the federal family planning program, which ensures access to these services to anyone, regardless of income or insurance coverage. You can find a Title X provider here.

There are also non-Title X women’s health and reproductive health clinics that also provide these services, typically at a sliding scale, such as Planned Parenthood and independent abortion providers. Many of these clinics also provide basic primary care as well. You can find a Planned Parenthood here and an independent women’s clinic here.  

What Else You Can Do

Medicaid expansion varies by state, so you do have the option of moving to a state that has expanded Medicaid. Non-expansion states include Alabama, Florida, Georgia, Mississippi, South Carolina, Texas, Oklahoma, Kansas, Missouri, Tennessee, North Carolina, Wyoming, South Dakota, and Wisconsin. 

First and foremost, you should see if you qualify for Medicaid or a subsidized Marketplace plan (aka Obamacare or Affordable Care Act insurance). You can put in your zip code, household income, and other information on HealthSherpa to see the health plans and prices available to you. And if you’re 65 or over, you should apply for Medicare.

Secondly, even if you are not eligible for Medicaid, your children could be eligible for the Children’s Health Insurance Program (CHIP). Learn more and apply here.

HealthSherpa’s Consumer Advocate team can also help you with your application to ensure you’re calculating your income correctly. Give them a call at (872) 228-2549. They can also guide you through an application for Marketplace insurance during the annual Open Enrollment Period to ensure you’re getting every possible tax credit and subsidy to make coverage affordable. 

Marketplace insurance can very well be affordable—in 2019, 51% of all of those who enrolled through HealthSherpa had monthly premiums of less than $50/mo after subsidies. By plan-comparing and shopping the Marketplace, you can get covered and learn how the Affordable Care Act’s (ACA) financial assistance and cost-sharing reductions might help get you the coverage you need at a minimal cost.