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What Caregivers Need to Know About The Affordable Care Act

You might agree that Medicare is difficult to understand with all the parts A, B, C, & D. Besides the rest of the alphabet, caregivers need to understand other issues regarding when to apply or their coverage eligibility. Then there is this thing about a donut hole. If your loved one is not the eligible age or meets specific income limits, then we also need to wrap our minds around what the Affordable Care Act (ACA) is and how it can affect enrolling into a Medicare plan.

ACA is a health care law that offers rights and protections to make coverage more fair and easy to understand. Some rights and protections apply to plans in the Health Insurance Marketplace® or other individual insurance, some apply to job-based plans, and some apply to all health coverage. Although the ACA became law in 2010, many of its key features are coming into effect now. The open enrollment period for ACA begins on November 1, 2022, and ends on December 15, 2022, for coverage to start on January 1, 2023.

The ACA established the Individual Shared Responsibility provision that requires individuals to have qualifying health care coverage (QHC), also referred to as minimum essential coverage, qualify for an exemption, or make a payment when filing their tax return. When discussing healthcare needs for our loved ones, many caregivers need the minimum essential care, which translates to the minimum out-of-pocket expense. As their loved ones' needs progress, they need the maximum amount of care their insurance will provide by the time they are on a fixed income.

Each year during the Medicare open enrollment, I stress knowing this is one more layer of complexity to meeting Mom's care needs. Thankfully, after speaking with licensed agents, Joe & Monique Barajas, owners of Barajas Insurance Group, LLC, I did not worry for long. They listened to my concerns and Mom's current conditions with potential scenarios to ensure I knew what was necessary to make the best decision.

Here are a few questions I asked Joe Barajas to help me understand ACA and how it affects Mom's Medicare choices:

  1. Can a person purchase a Marketplace plan in addition to Medicare?

No. It's against the law for someone who knows you have Medicare to sell you a Marketplace plan. They cannot sell a Marketplace plan even if you have only Medicare Part A (Hospital Insurance) or only Part B (Medical Insurance).

If you want coverage to add to Original Medicare (Part A and Part B), you can buy a Medicare Supplement Insurance (Medigap) policy. Instead of Original Medicare, you can also join a Medicare Advantage Plan that may offer some extra benefits. Medicare Advantage plans are increasingly popular because Original Medicare has been falling behind.

  1. Is there a penalty for ending a marketplace insurance plan to begin a Medicare policy?

Even if you have coverage through the Marketplace, you should generally sign up for Medicare when you're first eligible (usually when you turn 65) to avoid a delay in Medicare coverage and the possibility of a Medicare late enrollment penalty.

Don't end your Marketplace plan until you know when your new coverage starts. Once you terminate Marketplace coverage, you can't re-enroll until the next annual Open Enrollment Period. Unless you qualify for a Special Enrollment Period, such as losing health coverage, moving, getting married, having a baby, adopting a child, or having a household income below a certain amount, you may be without insurance for a long time.

  1. If people have a marketplace insurance plan through work, can they keep it in addition to Medicare coverage starts?

If you like, you can keep your Marketplace plan too. But once your Medicare Part A coverage starts, you'll no longer be eligible for any premium tax credits or other cost savings you may be getting for your Marketplace plan. So you'd have to pay full price for the Marketplace plan.

It certainly helped me to have insurance agents that listened and stayed up to date on any changes that may save Mom money in the next year. Understanding the insurance coverage better also helped me know what questions to ask at doctor's appointments.

For example, if the doctor explains a care need I know her insurance does not cover, I can ask for an alternative procedure or treatment rather than receive an expensive out-of-pocket bill after the fact. If this happens during one coverage year that does not have a life-threatening immediate need then I know to expect to change plans in the next open enrollment period while making the most of the services her plan does cover.

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