Ask the Medicare Specialist

There is no question today. I want to address small business owners whose revenue has been drastically reduced as well as those who have been laid off and are either losing health insurance or can no longer afford it.

I’ve only written about individual health insurance in one column because the only two companies that offer major medical health insurance in Western PA have made the decision not to pay agents or agencies commissions for applications submitted outside of the 45-day Affordable Care Act (ACA) Annual Election Period (AEP). Other than AEP, only those who lose their health insurance due to circumstances such as retirement, a layoff, resignation, or termination can get a health plan outside of those 45 days. Unfortunately, agents are not compensated to advise people and facilitate enrollments when that doesn’t occur between November 1st and December 15th. Due to this and the fact the ACA enrollment period runs during the same time as Medicare’s, we made the decision to get out of the individual health insurance business with only a few exceptions. I understand there is going to be a large number of people who already are or will find themselves in tough financial situations. Therefore, I’m announcing the Health Insurance Store will immediately help and counsel anyone who has lost their job, had to shut down a business, or had their income drastically reduced.

Let’s discuss small business owners first. Some may already have an ACA (Obamacare) plan. If enrollment was done through the Marketplace, there are a couple of options. Number one; amend your application with a lower estimated income for the year. By doing this, you can not only lower your premiums, but your deductibles and co-pays as well. The other option is to file for Medical Assistance (MA). Many people don’t realize this, but when it comes to those under 65 years old, assets are not considered when determining eligibility. So, if you own a restaurant, a building, and the property it sits on, but your income now falls under the maximum, 138% of the Federal poverty level, you qualify. You could even have a savings account, investments, and an IRA. There is one exception to the asset rule; those collecting Social Security income will have their assets considered and that limit is $2,000, not counting a home, an auto, or personal possessions. Here’s another fact regarding MA. The income you earned last month or last year has no bearing on your qualification. Only what you are making at the time you apply is generally considered. We have made calls to research just how those who are selfemployed and have made a profit in past years can now prove they have little or no revenue stream. Per our conversations, it appears the state is going to be somewhat lenient in this regard. To prove income or lack thereof, those who are self-employed can use their monthly ledgers showing revenues compared to expenditures, and/or a statement that they are no longer working, open, or have been limited (such as take-out only) in their capacity to do business due to COVID-19. We recommend applying for MA online at compass.state.pa.us, at the end of the application there’s a section for additional comments where that statement can be provided. Those in this situation, who aren’t sure if they will qualify, are welcome to call one of the offices or reach out via our website. It’s my opinion anyone in this situation is wise to temporarily go on MA if found eligible. First, MA costs nothing and has no out of pocket costs except for prescription drugs. And, when things get back to normal and you no longer need it, you can again enroll in an ACA plan at that time. Those who have group health plans they can no longer afford can do the same as well.

This won’t be as cut and dry for those who have been laid off. Unless your household income, which includes unemployment, is less than 138% of the Federal Poverty level, you won’t qualify for MA. In this case, ACA plans and COBRA are the safest choices. Our agents can help determine which makes more sense.

There are alternatives to major medical health plans, such as Indemnity or Medi-Share/faith-based plans. They are advertised as lower cost alternatives to the ACA or Obamacare. My agency is not comfortable with, nor sells them because they have no Maximum Out of Pocket (MOOP) limit which caps what one could be billed in a calendar year. As far as I’m concerned, no commission is worth selling a plan that could possibly result in a client being stuck with tens of thousands of dollars in bills due to a cancer diagnosis or other serious injury or illness. Buyer beware.

There are others who may just decide this is an opportune time to retire since they’re already 65 and eligible for Medicare or not that far off. Of course, we can assist those who aren’t yet 65 bridge that gap or explain Medicare options and help choose the right plan to those who are.

Again, if we can help point you in the right direction as far as Medical Assistance, COBRA, or an ACA plan due to the loss of your job or reduced income for those who are self-employed, please don’t hesitate to reach out. It will be our pleasure to assist. Please everyone. Be smart and stay healthy.