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Category: Frequently Asked Questions

I am 66 years old, work for a large employer, and have excellent health insurance coverage through my job. I am planning to keep working for a few more years and would like to keep the coverage that my employer offers. How does the Marketplace affect me?

It doesn’t.  You can keep your employer-sponsored health insurance coverage as long as that is an option for you.  Since you are already eligible for Medicare because you are over age 65, you should sign up for Medicare when you stop working or if you lose your employer coverage before then.  Once you decide when you want to stop working, you should contact the Social Security Administration about how and when to enroll in Medicare to be sure you don’t have a gap in coverage.

My husband and I are retired. He just turned 65 and is now covered by Medicare, but I am 62 and I don’t have health insurance. Can I enroll in Medicare as his spouse?

No.  Although your husband now qualifies for Medicare, you will not qualify for Medicare until you turn 65.  If you do not have health insurance now, you can consider signing up for health insurance coverage through a Marketplace plan.  If your household income is less than 400% of the federal poverty level ($65,840 for a couple in 2019), you may qualify for premium tax credits to reduce your cost of a Marketplace policy.  If your household income is at or below 138% of poverty ($22,715 for a couple in 2019), you might be eligible for Medicaid if you live in a state that has expanded its Medicaid program.

I am 54 and living with a permanent disability, and for the past 12 months I have been receiving Social Security disability insurance (SSDI) payments. But I do not have health insurance. I am required to wait another 12 months before I can go on Medicare due to the two-year waiting period for people receiving SSDI payments. Am I eligible to purchase health insurance coverage from a marketplace plan under the ACA? Am I eligible for a premium tax credit? And what about Medicaid?

Yes, you are eligible to purchase coverage through the Marketplace, and if your income is between 100% and 400% of poverty ($12,140 to $48,560 for an individual in 2019) you will qualify for premium tax credits to help make Marketplace coverage more affordable.  If you live in a state that has expanded its Medicaid program to cover adults under age 65 with incomes up to 138% of poverty (about $16,753 for an individual in 2019), you might also be eligible for this coverage, depending on your income.

If you apply for and receive Marketplace coverage and subsidies, keep in mind that your eligibility for Marketplace subsidies will end when your Medicare Part A and Part B coverage automatically begins after the two-year waiting period.  At that point, you will have to pay the full price for your Marketplace coverage, but you could instead drop your Marketplace coverage and enroll in Medicare Part A, Part B and Part D.  If you keep both Medicare and Marketplace coverage, Medicare will be the primary payer.

Once your Medicare coverage begins, depending on your income, you may qualify for Medicaid in addition to Medicare or for extra help with premiums and cost sharing for your Part D prescription drug benefits.  A good place to turn for information about these programs and whether you might qualify is your local Social Security Administration office or the State Health Insurance Assistance Program in your state.  Medicare provides links and phone numbers for these and other organizations at the following website: http://www.medicare.gov/contacts/.

My mom is an 83-year-old widow with an income of about $12,000 and almost no savings. She is covered by Medicare. Does she qualify for the new Medicaid expansion under the ACA?

No.  The Medicaid expansion provided under the Affordable Care Act is for adults who are under the age of 65 with incomes up to 138% of poverty (about $16,753 for an individual in 2019).  The law explicitly excludes people ages 65 and older from this Medicaid eligibility category.  So even if your mom’s income is low enough to qualify for Medicaid under these rules, she is not eligible for it because she is over age 65.

However, your mom might qualify for Medicaid under the current eligibility rules if her income and assets are low enough.  Under the current rules, Medicaid helps many low income people on Medicare with their Medicare premiums and cost-sharing requirements, and may also cover some benefits that are not covered by Medicare, such as dental services and long-term services and supports.  Also, your mom might qualify for extra financial assistance to help with the cost of Medicare Part D prescription drug coverage.  To find out if she qualifies for these programs, you can contact the State Health Insurance Assistance Program in your state, the State Medical Assistance Office (for Medicaid), or the Social Security Administration (for Part D extra help).  Medicare provides links and phone numbers for these and other organizations at the following website: http://www.medicare.gov/contacts/.

I am about to turn 65 and go on Medicare, and my income is $120,000. I am not married. I know that people with higher incomes are required to pay higher premiums for Medicare Part B and Part D. To avoid paying these higher Medicare premiums, can I sign up for health insurance from a Marketplace plan now instead of enrolling in Medicare when I turn 65?

If you are not yet enrolled in Medicare, you can buy health insurance coverage through the Marketplace before you turn 65, and if you have a Marketplace plan, you can choose to renew it after you turn 65.  But once you turn 65 and become entitled to Medicare coverage, you cannot buy a new Marketplace plan.  This is because insurers are prohibited from selling health insurance coverage that duplicates what you have under Medicare, if they know you are covered by Medicare.

If you are considering renewing a Marketplace policy after you turn 65 and become eligible for Medicare, there may be downsides to this choice.

First, your total costs could be higher with a Marketplace plan than with Medicare, even if your income is high enough that you are required to pay income-related premiums for Medicare coverage.  At your current income level in 2018, you would pay about $4,000 in annual Medicare premiums ($3,215 for Part B and around $823, on average, for Part D.)  You would also likely buy a Medigap supplemental policy to help cover Medicare deductibles and limit annual cost sharing.  The average cost of Medigap is roughly $2,000, though premiums can vary widely depending on the plan you choose, your age, and where you live.

By comparison, premium for a Marketplace policy will vary depending on where you live, your age, and the plan you choose.  In 2018, the national average premium for the lowest cost bronze plan for a 64-year-old was about $9,500 and the average annual deductible under bronze plans was about $6,000.  Most Marketplace participants pick silver plans. On average, the premium for the benchmark silver plan for a 64-year-old was about $13,500 in 2018 – much higher than the total premiums for Medicare – and the average silver plan deductible was about $4,000.  Also keep in mind that the combination of Medicare plus a Medigap policy would offer you more comprehensive coverage with lower overall out-of-pocket costs than a Marketplace plan.

Second, you should also be aware there would likely be differences in access to doctors, hospitals, and prescription drugs between Marketplace plans and Medicare.

Third, keep in mind that if you sign up for a Marketplace plan, rather than enroll in Medicare Part B when you are first eligible to do so, and then later you decide to sign up for Medicare, you may be required to pay a penalty for delaying enrollment in Medicare Part B.  Your monthly Part B premium may go up 10% for each year that you could have had Part B, but didn’t.  You may also owe a late enrollment penalty for Part D drug coverage, which is equal to 1% of the national average premium amount for every month you didn’t have coverage as good as the standard Part D benefit Marketplace.

Finally, if you have Marketplace coverage when you become eligible for Medicare, and decide to drop your Marketplace plan, you need to contact your plan to terminate your Marketplace plan yourself.  It will not happen automatically when your Medicare coverage begins. Your insurer cannot terminate your Marketplace coverage unless you tell them you want this coverage to end.

Is the open enrollment period the same for Medicare and the Marketplaces?

There is some overlap in the enrollment periods for Medicare and the Marketplaces, but this year they are not the same.  The Medicare open enrollment period runs from October 15 through December 7 each year.  For Marketplace coverage in 2019, the open enrollment period will run from November 1, 2018 through December 15, 2018 in states that use the HealthCare.gov website.  Some states that run their own Marketplaces will have a somewhat longer Open Enrollment period for 2019 coverage.  Check with your state Marketplace for more information.

If you are covered by Medicare, and you are interested in reviewing and comparing your Medicare coverage options, make sure the plans you are considering during the open enrollment period are Medicare plans, not Marketplace plans.  Medicare plans are not sold through the federal or state Marketplace websites.  You can review and compare your Medicare options on the Medicare website (www.Medicare.gov) or by calling 1-800-MEDICARE.

Are Medicare Advantage plans, Medicare Part D drug plans, or Medigap policies sold through the Marketplace?

No.  Medicare Advantage plans (such as Medicare HMOs and PPOs), Medicare Part D prescription drug plans, and Medigap policies are not sold through the federal or state Marketplaces.  You can enroll in a Medicare Advantage plan or a Medicare Part D plan on the Medicare website (www.Medicare.gov) or by signing up directly with the company that offers the plan.  To learn more about your coverage options under Medicare, including the Medicare Advantage plans, Part D drug plans, and Medigap supplemental policies available in your area, and how to enroll, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.

I am over age 65 and covered by Medicare, but I’m wondering if I can purchase one of the health plans offered through the Marketplace and drop my Medicare coverage? Is that an option for me or should I keep my Medicare?

If you have Medicare, you should keep it.  In fact, companies that sell Marketplace plans are prohibited from selling these plans to you if they know you are covered by Medicare.  If you do drop Medicare, and choose to re-enroll later, you can only re-enroll during the Medicare general enrollment period (from January 1 to March 31), and your coverage would not begin until July of that year.  You also may face a penalty for late enrollment.  If you don’t sign up for Part B when you’re first eligible or if you drop Part B and then sign up again later, your monthly Part B premium may go up 10% for each year that you could have had Part B, but didn’t.  You may also owe a late enrollment penalty for Part D drug coverage, which is equal to 1% of the national average premium amount for every month you didn’t have coverage as good as the standard Part D benefit.

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