Friday, August 13, 2021

On staying out of the coverage gap: expert advice

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I have a post up on addressing a subject near my heart: how to help more people avoid the "coverage gap" in states that have refused to enact the ACA Medicaid expansion.  That is, how to avoid being denied any help paying by estimating next year's income at a level below 100% of the Federal Poverty Level.

Eligibility for subsidized coverage (now free at incomes in the 100-150% FPL range, e.g., for anyone just over the eligibility threshold) is based on an estimate of next year's income. A lot of variables go into such estimates, especially for people with low incomes, who are often self-employed or work variable and unpredictable hours, or rely on tips, or do seasonal work. In this piece, brokers and enrollment counselors who have been at work since the ACA marketplace launched explain in detail how to maximize a good-faith estimate when necessary.

In many, many cases, failing to qualify for subsidized coverage is a matter of ignorance. The application does not tell you that there's a minimum income threshold you need to cross. Accordingly, the first step in helping low-income people seeking coverage is to spell out the minimum qualifying income:

This point can't be emphasized enough, according to Shelli Quenga Director of Programs at the Palmetto Project, a nonprofit health insurance brokerage in South Carolina.  "You need to know what amount you're shooting for," Quenga says. "You need to know where that line is. does not tell you."

Paradoxically, the application does recognize income uncertainty, and in fact positively invites applicants to take it into account:

But an assumption animating the application is that enrollees will want to minimize their income -- which increases the subsidy if you qualify for a subsidy at all. In the section asking about income deductions, the instructions point out, "telling us about them could make the cost of health coverage a little lower." But low income enrollees do not know that they're at the edge of a subsidy cliff -- and have no way of knowing this unless someone tells them. If you fail to qualify for subsidies and are quoted premiums that are impossibly high at low incomes, does not tell you why.  

The coverage gap is a moral and legal travesty -- a product, very likely, of a Supreme Court compromise that avoided a worse travesty, total negation of the ACA. No one has a moral obligation to acquiesce to being deemed too poor to qualify for coverage. Income estimates at the low end of the spectrum may not be as malleable as at the high end, but there is often a lot of wiggle room for a good-faith estimate. No one with a chance to get over the 100% FPL threshold should fail to do so.

The post on is packed with concrete advice from experienced enrollment assisters who have enrollees' best interests at heart. I hope you'll share it with anyone who needs the info.

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1 comment:

  1. Great article! This is a real public service....and if we only had more navigators, this would have a larger effect.

    In the last seven years, the ACA exchanges have gone from being like the armpit of the healthcare world into a very good destination for millions.