Help with ACA / Obamacare and children

[cashistrash]

Since I recently left my job I've been looking at health insurance options.  I have two questions maybe someone here has dealt with.

1. My income will be low enough that my son is eligible for the CHIP program.  If I add him to our marketplace plan, will we lose the tax benefit and cost sharing reduction? 

I'm considering bumping my income up if I need to so that I can avoid having him in CHIP.  I'm concerned about the quality of the program, having to change doctors, and the added complication.  Any thoughts on this?

2.  If my wife and I are on a marketplace plan and we are at an income level where a new child is eligible for medicaid and my wife gives birth what happens?  Do I apply for medicaid?  How can I avoid any coverage gap?

When our son was born I had private insurance and the company payed for the treatment he required immediately after birth once I added him on the policy.

[goatmom]

What  is your current situation? Are you between jobs?  I know where I live it is hard to find doctors that take medicaid because the reimbursement is so bad many doctors have opted out. They get paid less than $50 a visit to see a patient.  Also even getting the medications you need can be a hassle - you need to get prior authorizations for many drugs that other private insurances just pay for.  It makes you wait or just end up paying out of pocket because you don't want to wait. I know it might be state specific.  I wouldn't want my child on medicaid unless I had no other choice. Not so familiar with the ACA plans and how that works.  It might be better. 

[forummm]

CHIP is good insurance. It varies by state (since it's a state-based program), but doctors tend to take CHIP. I would guess that more doctors take CHIP than take a lot of Marketplace plans--but that's just speculation. I would be fine with having my child on CHIP. You can check with your current doctors to see if they take it. In general, CHIP, Medicaid, and Medicare are good coverage options. Studies indicate there is little, if any, difference in outcomes for people on those programs when you adjust for other factors.

You can go through healthcare.gov and apply for coverage. It will tell you what you are eligible for. I'm pretty sure that if your son is eligible for CHIP and you don't enroll him, then you can't get tax credits to enroll him in a private plan. The idea is that if you have affordable coverage somewhere, you have to take it, or pay full price somewhere else.

If your wife gets pregnant, you can go to healthcare.gov and update that information, and see how that affects your coverage. If you're in the CHIP income range, your wife (and child's birth and newborn care for the child) may be eligible to be covered by Medicaid because of the pregnancy. There is no need for there to be an gaps in coverage.

Happy to help you figure out things more as your situation progresses.

[cashistrash]

goatmom, I'm currently taking some time off between jobs.

I've been researching this some more since I posted.  It seems like I can get the subsidies for me and my wife and then get a separate full price plan for my son so he doesn't have to go into CHIP.  Forummm, I'm going to look more into the CHIP program to see if I should do it.  I'm definitely trying to avoid medicaid for the reasons goatmom pointed out.

Say me and my wife have a marketplace plan and my son is on a separate plan.  If a new baby is born can it be added on my son's plan and have it pay from the baby's birth?  Or if I add the baby to me and my wife's plan will I lose the subsidy since the newborn would be eligible for CHIP or medicaid?  Seems like I might have to use CHIP or medicaid for the newborn.

[seattlecyclone]

I'm curious about this same thing. I recently discovered that in Washington, a lot of kids are eligible for Medicaid, and thus not eligible for subsidized coverage through the exchanges. For example, kids in a family of four are eligible for Medicaid if their household income is $75k or below. We don't plan to have income anywhere near this level during FIRE, so we would have to choose between the Medicaid plan or paying full price to cover them on our ACA exchange plan. We will be able to afford either option, but might as well go with the $0-30/month Medicaid option if it offers a decent selection of doctors. Does anyone have experience with this in Washington specifically?

[forummm]

goatmom, I'm currently taking some time off between jobs.

I've been researching this some more since I posted.  It seems like I can get the subsidies for me and my wife and then get a separate full price plan for my son so he doesn't have to go into CHIP.  Forummm, I'm going to look more into the CHIP program to see if I should do it.  I'm definitely trying to avoid medicaid for the reasons goatmom pointed out.

Say me and my wife have a marketplace plan and my son is on a separate plan.  If a new baby is born can it be added on my son's plan and have it pay from the baby's birth?  Or if I add the baby to me and my wife's plan will I lose the subsidy since the newborn would be eligible for CHIP or medicaid?  Seems like I might have to use CHIP or medicaid for the newborn.

There's often a difference between doctors that take Medicaid for adults (less common) and doctors that take CHIP for kids (more common). CHIP is a separate program from Medicaid in most states and may pay differently. Often CHIP is actually administered as a managed care plan (like an HMO) by a private insurance company. The state just pays the private insurer to provide care for anyone enrolled. And doctors are often more friendly to taking kids as patients. As I said above, just check with your doctors to see if they will take CHIP.

When you have a kid, many insurance plans (and all Marketplace plans) immediately cover the kid for a certain amount of time. You'll have to find out from your plan how long that is. But you can also sign up your new baby for insurance even before it's born, or sign up just after it's born (within 30 days) and the coverage will be retroactive.

https://www.healthcare.gov/what-if-im-pregnant-or-plan-to-get-pregnant/

If you buy a private plan for your children, you won't lose subsidies for you and your wife. You will just have to pay full price for your children. The way the subsidies work, it may be that you end up paying full price (or close to it) for you and your wife anyway. They are based on your household size, and premiums are rated for income. You'll have to run the numbers at healthcare.gov to see how it would work out.

[goatmom]

There have been several studies that support the difficulty in access to care for medicaid patients, even children with serious medical conditions due to low reimbursement rates. We see Medicaid patients everyday where I work who just pay cash because they can't get a doctor who will take their insurance.  Not one crappy doctor.  CHIP might be better.  If I had my family on Medicaid it would be just to cover myself and I would make sure I didn't expect it to cover my medical expenses.  Health insurance is not the same as Health care.

[forummm]

There have been several studies that support the difficulty in access to care for medicaid patients, even children with serious medical conditions due to low reimbursement rates. We see Medicaid patients everyday where I work who just pay cash because they can't get a doctor who will take their insurance.  Not one crappy doctor.  CHIP might be better.  If I had my family on Medicaid it would be just to cover myself and I would make sure I didn't expect it to cover my medical expenses.  Health insurance is not the same as Health care.

Agree that health insurance is not the same as health care. And there are issues with low Medicaid reimbursement in certain states. But as I said before, it's a state-based program and the situation varies widely across the country. Your state or county may not be representative of other parts of the country. People need to see if their doctors, or other doctors in the community, take the coverage in order to see what the situation is in their area.

[forummm]

There have been several studies that support the difficulty in access to care for medicaid patients, even children with serious medical conditions due to low reimbursement rates. We see Medicaid patients everyday where I work who just pay cash because they can't get a doctor who will take their insurance.  Not one crappy doctor.  CHIP might be better.  If I had my family on Medicaid it would be just to cover myself and I would make sure I didn't expect it to cover my medical expenses.  Health insurance is not the same as Health care.

Agree that health insurance is not the same as health care. And there are issues with low Medicaid reimbursement in certain states. But as I said before, it's a state-based program and the situation varies widely across the country. Your state or county may not be representative of other parts of the country. People need to see if their doctors, or other doctors in the community, take the coverage in order to see what the situation is in their area.

I remembered this thread that provides some more info on Medicaid programs around the country:

http://forum.mrmoneymustache.com/ask-a-mustachian/obamacare-blues-but-i-don't-want-medicaid/

[Bob W]

In Rural Missouri CHIP is a super program.   For most folks it is very low dough and widely accepted.   

Remember that most all insurance nowadays is either super expensive or doesn't give very good coverage.  Usually both. 

Your best bet is to remain very healthy while buying the lowest cost coverage available.   If that is possible in your situation.  The days of going to a doc for every ache and pain and sniffle are over. 

[Helvegen]

There have been several studies that support the difficulty in access to care for medicaid patients, even children with serious medical conditions due to low reimbursement rates. We see Medicaid patients everyday where I work who just pay cash because they can't get a doctor who will take their insurance.  Not one crappy doctor.  CHIP might be better.  If I had my family on Medicaid it would be just to cover myself and I would make sure I didn't expect it to cover my medical expenses.  Health insurance is not the same as Health care.

A few years ago when I didn't have insurance, I couldn't find a GP doctor that would accept cash period. All of the office staff would get rude or act like you were crazy, as in the most stupid person on Earth, if you offered to pay cash. Maybe that has changed some?

[green daisy]

Not sure what state you're in, but my kids used to have CHIP (not Medicaid) in PA.  It was great.  They were on it for 3 years and we never had any problems with CHIP.  My son has some medical issues.  He had lots of tests and medications, and for the most part, it all went smoothly. 

I had him in the ER once, and the family next to us was there because their child had pink eye.  I remember thinking, "who brings their child to the ER for pink eye?  Why not bring them to their PCP?"  Well, when the ACA first started, Aetna was reorganizing their network, and there was a short length of time where aside from your PCP, Aetna was only allowing CHIP patients to see Medicaid doctors.  My daughter broke her arm during this time.  I took her to the pediatrician who sent us for an X-ray at the hospital and then called to tell us it was fractured and that we would need to take her to an orthopedist.  I called Aetna to get a list of Medicaid orthopedists, and none would see her (not taking new patients, didn't treat children, only did surgical cases, etc).  I kept calling Aetna back for more names and was calling doctors up to 3 hours away who wouldn't see her.  I was sitting in the X-ray waiting room crying with my daughter sitting next to me with her poor broken arm.  The receptionist then got a hospital administrator who called Aetna on my behalf and they still couldn't help me.  There was only one orthopedic group I could find, however, they only saw patients who were referred to them by the ER at another hospital.  I asked Aetna if they would pay for this unnecessary ER visit because she already had the X-ray and diagnosis.  She just needed a cast.  Aetna wouldn't say one way or another if they would pay it.  I took her to this other ER.  They had to take another set of X-rays b/c their computer program couldn't view the CD from the other hospital.  They referred her to the orthopedic group, who couldn't see her for 3 days and then had to take another set of X-rays b/c 3 day old X-rays weren't sufficient.  She got the cast.  Aetna paid everything 100%.  And I finally understood why a family brought their child to the ER for pink eye.  They were probably on Medicaid and couldn't find a doctor who was willing to see their child. 

I wouldn't hesitate to have my child on CHIP, but would do whatever I could to avoid Medicaid. 

Why not try the CHIP?  You could always buy him other coverage if it doesn't work out.

[seattlecyclone]

I wouldn't hesitate to have my child on CHIP, but would do whatever I could to avoid Medicaid. 

Why not try the CHIP?  You could always buy him other coverage if it doesn't work out.

In Washington, Medicaid and CHIP seem to be a single program, branded as Apple Health for Kids. A pretty wide range of incomes qualifies. At the upper end of the range you could owe $20-30/month per kid. This is probably the CHIP zone? I'm not sure. They don't seem to imply that there is any difference in Apple Health coverage between people who owe a premium and people who don't. Again, this seems to be a very state-dependent thing.

[forummm]

I had him in the ER once, and the family next to us was there because their child had pink eye.  I remember thinking, "who brings their child to the ER for pink eye?  Why not bring them to their PCP?"  Well, when the ACA first started, Aetna was reorganizing their network, and there was a short length of time where aside from your PCP, Aetna was only allowing CHIP patients to see Medicaid doctors.  My daughter broke her arm during this time.  I took her to the pediatrician who sent us for an X-ray at the hospital and then called to tell us it was fractured and that we would need to take her to an orthopedist.  I called Aetna to get a list of Medicaid orthopedists, and none would see her (not taking new patients, didn't treat children, only did surgical cases, etc).  I kept calling Aetna back for more names and was calling doctors up to 3 hours away who wouldn't see her.  I was sitting in the X-ray waiting room crying with my daughter sitting next to me with her poor broken arm.  The receptionist then got a hospital administrator who called Aetna on my behalf and they still couldn't help me.  There was only one orthopedic group I could find, however, they only saw patients who were referred to them by the ER at another hospital.  I asked Aetna if they would pay for this unnecessary ER visit because she already had the X-ray and diagnosis.  She just needed a cast.  Aetna wouldn't say one way or another if they would pay it.  I took her to this other ER.  They had to take another set of X-rays b/c their computer program couldn't view the CD from the other hospital.  They referred her to the orthopedic group, who couldn't see her for 3 days and then had to take another set of X-rays b/c 3 day old X-rays weren't sufficient.  She got the cast.  Aetna paid everything 100%.  And I finally understood why a family brought their child to the ER for pink eye.  They were probably on Medicaid and couldn't find a doctor who was willing to see their child. 

I wonder if all the doctors who took Medicaid were just swamped with all the Aetna and new Medicaid enrollees. States had an average of a 30% increase in Medicaid enrollment at the beginning of 2014--that's a lot of extra demand to deal with. And then if private insurers were only letting people go to doctors that took Medicaid, the backup must have been crazy! No wonder you couldn't find anything.

[cashistrash]

I have an update to my questions. 

I now realize that question #1 isn't even possible, since if my son is eligible for CHIP or medicaid I wouldn't be able to add him to a marketplace plan.  I would need to get a separate plan for him off the marketplace or a plan for all three of us off the marketplace.

For question #2 I am still unsure what happens if my wife gives birth and the baby is eligible for medicaid.  I am thinking that we would be unable to add the baby to our plan, and we would have to apply for medicaid for the baby but I am not sure. Can I buy a private plan for the baby that would be retroactive to birth?

There was also a question #3 I didn't originally ask.  Here is what I found in case it helps someone.  My concern was that if my wife is pregnant she would not be able to switch marketplace plans since she would be eligible for medicaid coverage for pregnant women.  I did some research and this was apparently a problem in the past but it sounds like from IRS ruling 2014 71 this is no longer the case:

An individual enrolled in a qualified health plan who becomes eligible for Medicaid coverage for pregnancy-related services that is minimum essential coverage, or for CHIP coverage based on pregnancy, is treated as eligible for minimum essential coverage under the Medicaid or CHIP coverage for purposes of the premium tax credit only if the individual enrolls in the coverage.

[forummm]

I have an update to my questions. 

I now realize that question #1 isn't even possible, since if my son is eligible for CHIP or medicaid I wouldn't be able to add him to a marketplace plan.  I would need to get a separate plan for him off the marketplace or a plan for all three of us off the marketplace.

For question #2 I am still unsure what happens if my wife gives birth and the baby is eligible for medicaid.  I am thinking that we would be unable to add the baby to our plan, and we would have to apply for medicaid for the baby but I am not sure. Can I buy a private plan for the baby that would be retroactive to birth?

There was also a question #3 I didn't originally ask.  Here is what I found in case it helps someone.  My concern was that if my wife is pregnant she would not be able to switch marketplace plans since she would be eligible for medicaid coverage for pregnant women.  I did some research and this was apparently a problem in the past but it sounds like from IRS ruling 2014 71 this is no longer the case:

An individual enrolled in a qualified health plan who becomes eligible for Medicaid coverage for pregnancy-related services that is minimum essential coverage, or for CHIP coverage based on pregnancy, is treated as eligible for minimum essential coverage under the Medicaid or CHIP coverage for purposes of the premium tax credit only if the individual enrolls in the coverage.

For #1, it is possible to purchase a private plan for your kid. You'll just have to pay the full cost out of pocket since you are declining the free coverage. You can purchase something separate for a child in the Marketplace.

For #2, again, it is possible to purchase a private plan for your newborn. You'll just have to pay the full cost out of pocket since you are declining the free coverage. You can purchase something separate for a child in the Marketplace. The links I provided previously in this thread show that you can buy a private plan for the baby that would be retroactive to birth.

When you have a kid, many insurance plans (and all Marketplace plans) immediately cover the kid for a certain amount of time. You'll have to find out from your plan how long that is. But you can also sign up your new baby for insurance even before it's born, or sign up just after it's born (within 30 days) and the coverage will be retroactive.

https://www.healthcare.gov/what-if-im-pregnant-or-plan-to-get-pregnant/

If you buy a private plan for your children, you won't lose subsidies for you and your wife. You will just have to pay full price for your children. The way the subsidies work, it may be that you end up paying full price (or close to it) for you and your wife anyway. They are based on your household size, and premiums are rated for income. You'll have to run the numbers at healthcare.gov to see how it would work out.

[des999]

sorry if I missed it some where, but what income levels are we talking about where you would be forced to get Medicaid for your child? 

I just keep seeing if you are on the cusp of the levels, but what are the specific details/incomes where Medicaid is forced on you, or else you have to purchase a high dollar plan.

[des999]

ok, I guess we are only talking about below 138% FPL. 

[cashistrash]

ok, I guess we are only talking about below 138% FPL.

It depends on the state.  For many states, including mine, the % FPL for medicaid coverage for ages 0-1 is higher than coverage for other ages.  CHIP coverage goes higher than all of the medicaid percentages.

http://www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/medicaid-and-chip-eligibility-levels-table.pdf

[forummm]

sorry if I missed it some where, but what income levels are we talking about where you would be forced to get Medicaid for your child? 

I just keep seeing if you are on the cusp of the levels, but what are the specific details/incomes where Medicaid is forced on you, or else you have to purchase a high dollar plan.

For non-pregnant, non-disabled (etc) adults, Medicaid is available in expansion states up to 138% of FPL. However, for pregnant women, children, disabled (etc), eligibility for Medicaid and CHIP varies (significantly) by state. Some states provide CHIP to kids or Medicaid to pregnant women at 300% of FPL.

[forummm]

OP, this just repeats what I said earlier. But in case you want to see an official source:

What if my children are eligible for CHIP, but I would rather buy a Marketplace plan?
If your children are eligible for CHIP, they won't be eligible for any savings on Marketplace insurance. CHIP coverage will probably be more affordable. Remember, you and other family members may be eligible for savings on Marketplace coverage.

https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/

[cashistrash]

OP, this just repeats what I said earlier. But in case you want to see an official source:

What if my children are eligible for CHIP, but I would rather buy a Marketplace plan?
If your children are eligible for CHIP, they won't be eligible for any savings on Marketplace insurance. CHIP coverage will probably be more affordable. Remember, you and other family members may be eligible for savings on Marketplace coverage.

https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/

Ok, so my misunderstanding was that I couldn't buy a marketplace plan for my son (even without subsidies/APTCs) through healthcare.gov if he is eligible for CHIPS or medicaid.  This is what someone on their help line told me, but apparently that is incorrect.

[forummm]

OP, this just repeats what I said earlier. But in case you want to see an official source:

What if my children are eligible for CHIP, but I would rather buy a Marketplace plan?
If your children are eligible for CHIP, they won't be eligible for any savings on Marketplace insurance. CHIP coverage will probably be more affordable. Remember, you and other family members may be eligible for savings on Marketplace coverage.

https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/

Ok, so my misunderstanding was that I couldn't buy a marketplace plan for my son (even without subsidies/APTCs) through healthcare.gov if he is eligible for CHIPS or medicaid.  This is what someone on their help line told me, but apparently that is incorrect.

Unfortunately, the people on the help line are not experts. They are just regular call center people that read from scripts (other companies use them to read from scripts for their businesses too). Unfortunately, the ACA is new and complicated and unable to be streamlined and made less complicated due to Congress only wanting to repeal and not fix the quirks. So there are these policies to navigate that are much more complicated than if we had single payer.

[Blonde Lawyer]

If you have medicaid the key to finding good care is to look up your local FQHC.  That is a federally qualified health care center.  Usually they are called the local community health clinic.  Regular providers lose money on medicaid patients.  FQHCs get a higher reimbursement rate on Medicaid patients to help them deal with the number of uninsured patients that they treat.  While other providers try to avoid Medicaid patients, FQHCs welcome them.  FQHCs also tend to provide comprehensive care.  Your primary is likely also and OB/gyn and can (and will) deliver a baby.  They have referral partnerships as part of the FQHC program.  While you likely couldn't get into a specialist calling around on your own, your FQHC primary can refer you to the same person and they will accept you because the FQHC will be funding part of your care.  I'm on the board of one and they provide amazing services.

The other thing is to look into your state's requirements.  For awhile, Mass was requiring all providers, as a condition of being licensed to practice in Mass, to accept a minimum number of Medicaid patients.  States that don't have this requirement can be more difficult to deal with.

Lastly, your coverage might only apply in your state.  Not everyone knows that Medicare (not caid, care) does not cover you when you are outside the country.  I do not know if this applies to Medicaid but I have heard of patients having to return to their home state to get needed treatment covered.

[des999]

ok, I guess we are only talking about below 138% FPL.

It depends on the state.  For many states, including mine, the % FPL for medicaid coverage for ages 0-1 is higher than coverage for other ages.  CHIP coverage goes higher than all of the medicaid percentages.

http://www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/medicaid-and-chip-eligibility-levels-table.pdf

wow, thanks for that link, apparently where I live (Ohio) it goes all the way up to 206%, and CHIP is not available.  I guess I need to think a bit more about my part time/pre retirement plan of making 40k   :)

[forummm]

ok, I guess we are only talking about below 138% FPL.

It depends on the state.  For many states, including mine, the % FPL for medicaid coverage for ages 0-1 is higher than coverage for other ages.  CHIP coverage goes higher than all of the medicaid percentages.

http://www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/medicaid-and-chip-eligibility-levels-table.pdf

wow, thanks for that link, apparently where I live (Ohio) it goes all the way up to 206%, and CHIP is not available.  I guess I need to think a bit more about my part time/pre retirement plan of making 40k   :)

FYI: There's a significant chance that CHIP is allowed to sunset before 2020. People feel it's not necessary now that the ACA exists. There's still a good case for keeping it, but we'll see what happens.