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I am age 60 and have been receiving Social Security disability insurance (SSDI) payments for two years. I recently received my Medicare card, and I would like to get coverage to supplement my Medicare Part A and Part B coverage. I live in a state that does not require insurance companies to sell Medigap supplemental policies to people under age 65. Can I purchase a Marketplace plan to supplement Medicare?

No, companies that sell Marketplace plans are prohibited from selling these plans to you if they know you are covered by Medicare.  If you do not live in a state that requires insurance companies to sell Medigap policies to people under age 65, some insurance companies still may voluntarily sell Medigap policies to people under 65, although they will probably cost you more than Medigap policies sold to people age 65 and older.  If you want prescription drug coverage to supplement your Medicare Part A and Part B benefits, you can purchase a Part D prescription drug plan.  You can also look into receiving your Medicare-covered benefits through a Medicare Advantage private plan, such as an HMO or PPO.  Medicare Advantage plans are not allowed to turn down people with Medicare based on your health status or having a pre-existing condition, but access to providers is generally more limited than in traditional Medicare.
Keep in mind that when you turn 65 and are enrolled in Part B, you will get a six-month opportunity to enroll in any Medigap policy you want.

Did the ACA change how much my doctor is paid by Medicare?

The ACA temporarily increased Medicare payments by 10% for certain services provided by primary care practitioners (including doctors, nurse practitioners, and physician assistants) as well as general surgeons practicing in underserved areas.  These increases were in place from 2011 through the end of 2015.

Until April 2015, Medicare was required to pay doctors based on a certain formula.  The ACA did not make any changes to that formula, but Congress repealed it in the Medicare Access and CHIP Reauthorization Act (MACRA).   Among other things, this law created a new method for determining how Medicare pays physicians. Specifically, Medicare payments to physicians will be based on either their participation in an alternative payment model that assumes financial risk, or their performance on quality and spending measures. Medicare is currently working on implementing this new system, which will begin to affect physician payments in 2019.

I am enrolled in a Medicare Advantage plan. Did the ACA make changes to this program?

Yes, the law did make some changes to the Medicare Advantage program.  This program is an alternative to traditional Medicare, where people on Medicare can choose a private plan, such as an HMO or PPO, to receive Medicare-covered benefits.  The law reduced federal payments to these plans to bring them closer to the average costs of traditional Medicare.  The law also provided additional payments to plans that earn high quality ratings.

In addition, the law limited how much cost sharing plans can charge enrollees for certain services, and limited how much plans can spend on administrative expenses and profits (referred to as “medical loss ratio” requirements.)

To learn more about how your coverage options under Medicare, including all of the Medicare Advantage plans, Part D drug plans, and Medigap supplemental policies available in your area, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.

I am enrolled in a Medicare Part D drug plan. Did the ACA make changes to my Medicare drug coverage?

Yes, the law included changes that could save you money if you have very high prescription drug costs.  If you are enrolled in a Medicare Part D plan and you have very high drug costs, the law is helping to reduce the costs you pay when you reach a gap in coverage that is sometimes referred to as the “doughnut hole.”  This gap in coverage is being phased out between now and 2019 for brand-name drugs.  If your total drug costs are more than $3,820 in 2019, after that point you will pay 25% of the cost of your brand-name drugs and 37% of the cost of your generic drugs.  In 2020, you will pay 25% for both brand-name and generic drugs.

The law also included a new requirement that people on Medicare with higher incomes pay a higher premium for Part D coverage.  These higher premiums are paid by single beneficiaries enrolled in Part D plans with incomes greater than $85,000 and married couples with incomes greater than $170,000.

I am in my early 60s and have signed up for a Marketplace plan so that I have health insurance coverage until I qualify for Medicare at age 65. What happens when I go on Medicare?

When you turn 65, you should sign up for Medicare and notify your Marketplace plan that you now qualify for Medicare coverage.  Your Marketplace coverage will not be cancelled automatically by your plan when you turn 65 and sign up for Medicare, but if you receive premium tax credits to help you pay for your Marketplace plan premium, your eligibility for these tax credits will end when your Medicare Part A coverage starts (people with Medicare are not eligible for these tax credits, and the premium tax credit can only be used for the purchase of Marketplace coverage, not Medicare).

If you choose to enroll in Medicare Part A and keep your Marketplace coverage, you will have to pay the full price for your Marketplace plan, and Medicare will be the primary payer.  If you were receiving financial assistance for your Marketplace coverage prior to signing up for Medicare, you will receive a letter in the mail from the Marketplace informing you that you are no longer eligible to receive this financial assistance since you are enrolled in Medicare Part A. You should contact your Marketplace plan to make sure that your financial assistance is stopped when your Medicare coverage begins. If you do not stop receiving the premium tax credit and other financial assistance for your Marketplace plan when your Medicare coverage begins, you may have to repay some or all of the amount of financial assistance you received for the months you had both types of coverage.

If you decide to drop your Marketplace coverage when you become eligible for Medicare, make sure your Medicare coverage has started before you cancel your Marketplace plan so that you avoid any gaps in coverage.  You can start signing up for Medicare three months before your 65th birthday.

I am turning 65 years old next month, but I am not entitled to Medicare without having to pay a premium for Part A because I have not worked long enough to qualify. Can I sign up for a Marketplace plan?

Yes, in general, people age 65 or older who are not entitled to premium-free Medicare can purchase health insurance coverage in the Marketplace (except undocumented immigrants).  If you sign up for a Marketplace plan, you will be eligible for premium tax credits to make the coverage in the Marketplace more affordable if your income is between 100% and 400% of the federal poverty level ($12,140 to $48,560 for an individual in 2019).

Keep in mind that if you are able to continue working, you may be able to earn enough work history to qualify for premium-free Medicare in the future.  So another option for you to consider would be to sign up for Part A and Part B coverage when you turn 65 (you will have to pay a premium for both Part A and for Part B), and when you become eligible for premium-free Part A through your work history, you will then only have to pay a premium for Part B.

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/.