A retiree carries a bag of educational pamphlets from L.A. Care, the largest public health plan in the United States, at a senior information and resource fair in South Gate, Calif., last month. The event included a discussion of how the Affordable Care Act will affect senior citizens and what insurance plans will be available to them.
The health care law has been a national flashpoint for the past four years, especially in recent days when the government shut down in part because of opposition to the law. But even with all that attention, polls show that most Americans don’t understand what’s in it.
Now that the marketplaces created by the law are open and people can enroll for benefits that start Jan. 1, they are discovering what type of coverage they can get. But there are also many quirks about eligibility that may surprise consumers.
Some of the points were in the original law or decided by the Obama administration in regulations. Some were the consequences of decisions by states with Republican officials to not expand their Medicaid programs for low-income people, as the law encourages.
“What people are going to really start noticing is what this program means for them personally,” said Mark McClellan, who oversaw the creation of the Medicare prescription drug program after it was passed by Congress in 2003.
Below are some of the roadblocks people may encounter as they try to sign up for coverage.
Leeway for Legal Immigrants, But Not for Citizens
If you live in a state that doesn’t expand Medicaid and you are really poor, you can’t get subsidies for coverage in the new marketplaces unless you’re a recent legal immigrant.
This quirk came about after a June 2012 Supreme Court decision gave states more of a choice in deciding whether to broaden their Medicaid programs to add more low-income adults. When the bill was written, lawmakers believed that officials in every state would expand Medicaid, because if they didn’t, they would lose all of their federal matching money. But the high court decision struck that down, and half the states have decided not to expand Medicaid eligibility for now.
The law says that subsidies in the marketplace are only for people with income between the federal poverty level (which is $11,490 for an individual this year) and four times the poverty level ($45,960). Lawmakers envisioned that people with income below the poverty level would get Medicaid. But in states that chose not to cover more adults in Medicaid, such as Texas, citizens with income below the poverty level are left without a chance to buy subsidized coverage.
Thus, a citizen earning up to $45,960 will be entitled to some kind of subsidy, but someone earning $10,000 won’t, if the state did not broaden its Medicaid program to cover people with those incomes.