On the cusp of Medicaid vs Healthcare.gov

[SomedayStache]

TLDR
What happens if someone signs up via healthcare.gov for a Silver Plan w/a tax credit and at the end of the year should have qualified for Medicaid?
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Trying to help my family member figure out health insurance.

• His employer dropped him from coverage because he doesn't regularly work full-time hours.
• He tried to get on our states Medicaid (Soonercare here in Oklahoma) and they told him his income is a bit too high based on a current bi-weekly paycheck.
• If he makes that income all-year long it is too much for Medicaid/Soonercare, BUT he will not actually make that over the entire year because he works at a public school cafeteria and is unpaid during all school breaks and summer.

Using the calculators at https://www.healthcare.gov/see-plans/#/ and the bi-weekly income that disqualifies him from Medicaid it looks like he is eligible for a premium tax credit of over $476/month.
But if I enter a slightly lower income then he is no longer eligible for the tax credits (I presume because he should at the point be eligible for Medicaid?) and instead of a $0.21/month premium he has a $476/month premium.

I do not want to advise him to enroll in a healthcare.gov plan if he's going to be hit with a big tax penalty because he ultimately made too little to qualify for the tax credits. Is that a possibility?

[SomedayStache]

(Posting a response here for my benefit mostly)

This website is the clearest table I have found of income limits https://obamacarefacts.com/2024-obamacare-eligibility-chart-and-subsidy-calculator/

For a single person making 138% of the federal poverty level ($20,120) is the cutoff. If he makes $20,219 he does not qualify for tax credits. If he makes $20,121 he does qualify for tax credits.

[seattlecyclone]

A few things:

1) People under 100% of the poverty level are generally ineligible for premium tax credits but there is an exception for people who submit an estimate above that amount to the Exchange, they get advance tax credits, and their year-end income nevertheless ends up below the poverty level. Your relative could submit their current monthly income to the Exchange, get their advance tax credits based on that, and there would be no claw-back at tax time.
2) People who experience a decrease in income are eligible to switch to Medicaid mid-year, and similarly people on Medicaid who are kicked off due to having an income too high are eligible for a special enrollment period in a Marketplace plan. Switching health insurance a few times a year based on how many weeks kids are in school that month seems like a royal pain, but it may be the most "correct" thing to do given the poorly thought-out integration at the borders between these two programs.
3) Recommend looking for a local healthcare navigator who can advise on the state procedures for Medicaid income verification and change reporting; it's possible they have a procedure for taking monthly averages for people like your relative who have irregular income that nevertheless averages less than the Medicaid threshold.

[SomedayStache]

Thank you seattlecyclone! That is a big relief to learn about the exception and no danger of claw-back.

My parents have always handled these things for my brother, but we're now in that terribly sad transition period where I am slowly realizing they can no longer handle his finances and I need to figure this shit out. (My mom didn't even know what healthcare.gov was when I asked her if they had checked that out as an option)

I truly don't want to add more to my plate but am grateful to be semi-capable person who can at least type questions on a forum and get an understandable answer. Google was not helpful in this case, probably because I didn't know the right search terms.

[jim555]

ACA is calendar year while Medicaid is current month based.  You can always make a new estimate and drop into Medicaid mid-year, be under $1,677 a month income.  Medicaid does not involve subsidies, it is possible to have some months on ACA with subsidies and some in Medicaid.  The ACA months subsidies are reconciled based on actual calendar year income at tax time.

[SomedayStache]

ACA is calendar year while Medicaid is current month based.

This sentence helped clarify a large part of my confusion.

~It's so great how we have this complicated, moving-pieces puzzle, and if you fail to properly solve it you will lose healthcare coverage and/or pay a lot of money~

I think my brother is set for now with coverage to start Jan 1. He was officially denied Medicaid/Soonercare and I've given him firm instructions to get a copy of his denial letter and save it with his tax stuff. Of course, he can't access his Soonercare portal because it's tied to an old email address he also can't access so he's going to have to make a phone call and try to sort that out *sigh*
My brother has some disabilities that make this sort of thing pretty much impossible for him to do on his own. Even simply getting him to give me a list of all his medications ended up turning into a pseudo comedy skit as my mom reminded him of medications he had forgotten and then he struggled through the house trying to find them. (And he apparently didn't know insulin should be stored in the fridge! He knows that now)

[eostache]

ACA is calendar year while Medicaid is current month based. 

I'm trying to figure this out right now.
Colorado.
I'm on ACA Medicaid.
I recently got a part time job. The hours are variable, 0 to 15 hours a week, occasionally more than 15 hours, depending on what projects come up. Most months I will be well under the monthly limit, occasionally I may go over the monthly limit. I did update the CO Medicaid website with my information from my first paycheck which their system calculated my projected yearly income as under the limit. Not sure if they will get some notice from DOL if I get monthly income above what I reported.

I can keep my yearly MAGI income under the Medicaid limit. I can contribute to IRA to lower MAGI if I need to.

I have been searching the web for Colorado specific information but I cannot find helpful specific information. I get info like update the system if your income changes. Every week my hours are different, so yeah, my income changes every two weeks. Many websites just give a chart of the yearly income limits. I suppose I could call someone and ask but I expect even a customer service agent won't really know what to tell me.

I found this on Colorado income verification. It's from 2018 so I'm not sure if there is an updated document.
chrome-extension://oemmndcbldboiebfnladdacbdfmadadm/https://hcpf.colorado.gov/sites/hcpf/files/IEVS%20and%20RC%20FAQ%20Final.pdf

[seattlecyclone]

ACA is calendar year while Medicaid is current month based. 

I'm trying to figure this out right now.
Colorado.
I'm on ACA Medicaid.
I recently got a part time job. The hours are variable, 0 to 15 hours a week, occasionally more than 15 hours, depending on what projects come up. Most months I will be well under the monthly limit, occasionally I may go over the monthly limit. I did update the CO Medicaid website with my information from my first paycheck which their system calculated my projected yearly income as under the limit. Not sure if they will get some notice from DOL if I get monthly income above what I reported.

I can keep my yearly MAGI income under the Medicaid limit. I can contribute to IRA to lower MAGI if I need to.

I have been searching the web for Colorado specific information but I cannot find helpful specific information. I get info like update the system if your income changes. Every week my hours are different, so yeah, my income changes every two weeks. Many websites just give a chart of the yearly income limits. I suppose I could call someone and ask but I expect even a customer service agent won't really know what to tell me.

I found this on Colorado income verification. It's from 2018 so I'm not sure if there is an updated document.
chrome-extension://oemmndcbldboiebfnladdacbdfmadadm/https://hcpf.colorado.gov/sites/hcpf/files/IEVS%20and%20RC%20FAQ%20Final.pdf

Two options I can think of:
1) Report your new income each and every month because you haven't been given any guidance to the contrary, or
2) Make that customer service phone call and hope for the best. "So if my income changes by $1 from one month to the next, do you really want me to report that? How about $10? $100?"

[eostache]

Two options I can think of:
1) Report your new income each and every month because you haven't been given any guidance to the contrary, or
2) Make that customer service phone call and hope for the best. "So if my income changes by $1 from one month to the next, do you really want me to report that? How about $10? $100?"

I may need to call and see what customer service suggests.

I found this documents, not sure if they still use this system:

From 2018, income verification
https://hcpf.colorado.gov/sites/hcpf/files/IEVS%20and%20RC%20FAQ%20Final.pdf

From 2016, better explanation if still valid
https://coloradohealth.org/sites/default/files/documents/2017-01/Client_correspondance_handouts_combined.pdf


I think I will update my income in the system in January so they will have a projected income from me for 2024, then just wing it and see if they someday send me a notice about my irregular income.

[jim555]

If you are on Medicaid now, legally you have reporting requirements.  In my state reporting any change that would make you ineligible within 30 days.

[SomedayStache]

Coordination betweenMedicaid and Premium Tax Credits Discussion:
https://www.healthreformbeyondthebasics.org/wp-content/uploads/2013/12/Coordination-Between-Medicaid-and-Premium-Tax-Credits-FAQ.pdf

What happens when someone who lives in a state that has expanded Medicaidreceives advance payments of premium tax credits, but her actual income ends upbeing 125 percent of the poverty line, which would have made her eligible forMedicaid? Does she have to pay the advance payments back when she files hertaxes?
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No. She would still be considered eligible for premium tax credits because the Marketplace found shewas not eligible for Medicaid based on her estimated income, and her final income is between 100 and400 percent of the poverty line, which is within the eligibility range for premium tax credits.

This exact question answered on healthinsurance.org: https://www.healthinsurance.org/faqs/if-my-income-is-less-than-expected-this-year-i-might-be-eligible-for-medicaid-what-can-i-do-during-open-enrollment-to-cover-my-bases/

Bogleheads forum discussion on this topic: https://www.bogleheads.org/forum/viewtopic.php?t=414817
Another current discussion on this forum: https://forum.mrmoneymustache.com/post-fire/finding-the-right-magi-for-aca-subsidies/