Navigating Coverage During the COVID-19 Pandemic: Frequently Asked Questions

The novel coronavirus (COVID-19) has been the cause of confusion and anxiety for individuals and families across the country, especially when it comes to health care. We’ve pulled together some frequently asked questions (FAQs), and added new COVID-19-specific inquiries, from our Navigator Resource Guide to help guide Navigators, brokers, assisters, and consumers through this complex and trying time.

We go over the basics of what happens if you’ve experienced a sudden drop or loss of income, what counts as income to determine eligibility for financial help, and what to do if you’ve lost your job-based health insurance coverage. We will also go over ways to estimate your income, and how to respond to a data matching issue in your Marketplace application.

Please keep in mind that as state and federal policy changes during this unprecedented moment, the answers to your questions may change. It is always best to check with your state Marketplace to confirm your options.

If you’ve experienced a sudden drop in income due to loss of work hours or loss of employment and want to know if you can apply for premium tax credits on the Marketplace:

There are a few scenarios with varying outcomes.

If you are already enrolled in a health insurance plan through your state’s marketplace, you can report a change in income. If you previously qualified for premium tax credits, and your income loss qualifies you for additional tax credits, you will be able to adjust how much of your tax credit you apply towards each month’s premium. If you are newly eligible for premium tax credits, you should qualify for a special enrollment period and will be able to switch your health plan within the same metal level of your current health plan. If your income has fallen to between 100 and 250 percent of the federal poverty level, you can switch to a silver-level plan in order to benefit from cost-sharing reduction subsidies that lower your copayments and deductibles.

If you are enrolled in an off-Marketplace, individual health plan considered Minimum Essential Coverage, then your ability to qualify for a special enrollment period will depend on your circumstances and the state in which you live. Check with your state Marketplace to go over your options.

If you are currently enrolled in job-based insurance and you were laid off or you lost hours, making you ineligible for your employer’s plan, you will qualify for a special enrollment period for 60 days from the day you lost eligibility for your job-based insurance. You can go onto your state’s health insurance marketplace website and file for a special enrollment period. Some important income information applies:

  • If your projected income for 2020 is below 100 percent of the federal poverty level, in some states that have chosen not to expand Medicaid, while you may be eligible to buy a Marketplace plan, you may be ineligible for premium tax credits. Check with your state’s marketplace or Medicaid agency to determine if you are eligible for Medicaid.
  • If your projected income for 2020 is within 100 and 400 percent of the federal poverty level, you will either be eligible for premium tax credits or expanded Medicaid depending on your income and the state in which you live.
  • If your projected income is over 400 percent of the federal poverty level, you will be eligible to buy Marketplace coverage, but ineligible for premium tax credits.
  • You may also be eligible for your job’s COBRA benefits to extend your job-based benefits (See our FAQ on pros and cons of COBRA).

If you are currently uninsured, your ability to qualify for a special enrollment period and/or premium tax credits will depend on the state in which you live. As of March 26, 2020, 11 states and the District of Columbia have opened special enrollment periods for those who are currently uninsured amid the COVID-19 pandemic. To see if your state has opened a special enrollment period and for how long it will last, see this state-by-state map. Note that you may also be eligible for another special enrollment period depending on your circumstances.

Note that for your state health insurance marketplace, your income is a projection of what you expect to make over the entire year. If your projected income is lower than the actual income you report on your 2020 tax return, you may owe back a portion or all of the premium tax credits received. You will not have to pay back cost-sharing reduction subsidies. If your current income is at or below 138 percent of the federal poverty level, you may be eligible for Medicaid, depending on the state in which you live.

What income is counted in determining my eligibility for premium tax credits and Medicaid?

Eligibility for premium tax credits is based on your expected household income for the year in which you are applying for coverage. For example, if you are applying for coverage in March of 2020, you should provide an estimate your total income from January 1 through December 31, 2020. You can always report a change if your income changes during the year.

The Marketplace assesses your Modified Adjusted Gross Income, or MAGI, to determine your eligibility for premium tax credits. When you file a federal income tax return, you must report your adjusted gross income (which includes wages and salaries, interest and dividends, unemployment benefits, and several other sources of income). MAGI modifies your adjusted gross income by adding to it any non-taxable Social Security benefits you receive, any tax-exempt interest you earn, and any foreign income you earned that was excluded from your income for tax purposes.

To learn more about what details to include in your household income estimate, see HealthCare.gov’s table on what to include in your income estimate.

Eligibility for Medicaid and CHIP is also based on MAGI, although some additional modifications may be made in determining eligibility for these programs. Contact your Marketplace or your state Medicaid program for more information.

How do I estimate my income amid job uncertainty?

It’s common for income to fluctuate, especially if you are self-employed, work a seasonal job, or are faced with a sudden unemployment due to an emergency like COVID-19. You will want to make your best guess as to what you think you will make, and be sure to adjust your income within 30 days of an income change.

For example, if you made $2,000 in January and February, and $500 in March, then you know you’ve made $4,500 so far in 2020. If you don’t believe you will make an income for the rest of the year, you can adjust your income so that the months following March have $0 for income. If you live in a state with expanded Medicaid, this level of income would likely make you eligible for that program. However, if you live in a state that has not expanded Medicaid, this may leave you ineligible for premium tax credits.

If you project that you will again return to work, you can account for estimated loss in months of work, and project what you think your income over the whole year will be. So, if you typically make $1,500 per month, and you expect to be out of work until June, then you can estimate your income by adding the income earned from January, February, and March ($4,500) to what you expect to make by returning to work in June at $2,000 per month until January 2021 ($14,000 for seven months). In this example, your estimated yearly income would be $18,500, within the range of eligibility for marketplace premium tax credits and cost-sharing subsidies

I received a notice saying there is a data matching issue on my application and the marketplace needs to verify my income. How should I verify my income when I just lost my job?

A data matching issue means the marketplace is not able to verify the information on your application based on the data the marketplace already has for you (generally pulled from your previous tax returns). If you have unexpectedly lost income or employment due to the COVID-19 pandemic, your Marketplace might require you to verify your income or other information. To resolve the data matching issue with your application, you can verify your income by uploading documents to the marketplace online or by sending photocopies in the mail. Verifying documents might include a federal or state tax return, a letter of termination, proof of unemployment benefits, pay stubs, or a written letter attesting to your change in income. To determine which documents you need to submit, please consult this guide here.

I think Marketplace plans are too expensive. Do I have any other options?

There may be other coverage options available outside of the marketplace that do not provide the Affordable Care Act’s protections. These include plans that are not traditional health insurance products, including short-term, limited duration insurance, health care sharing ministries, fixed indemnity products, and Farm Bureau plans. If an insurer or entity does not provide a Summary of Benefits and Coverage that indicates coverage is Minimum Essential Coverage, be aware that the plan may have coverage limitations, particularly for pre-existing health conditions or for basic medical care, like treatment and testing for the COVID-19 virus. Always insist on getting plan documents to review prior to buying a plan.

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