If I Have Medicaid or CHIP, am I Considered “Covered” by the Health Care Law?

Calendar Icon Updated January 15, 2019

The short answer is yes. However, there are some exceptions to be aware of. The Affordable Care Act set out 10 areas of coverage that must be provided. Although there are exceptions to that rule, CHIP and Medicaid do not fall under the exceptions.

CHIP plans fit all the minimum requirements for the Affordable Care Act. If your children are enrolled in this program, you will not have to worry about possible penalties. This is true regardless of the state you reside in. CHIP actually goes beyond the minimum requirements in many areas including dental coverage. While all pediatric coverage plans are required to provide dental coverage, CHIP offers the best possible dental coverage for children.

Most Medicaid plans also meet the minimum requirements for the Affordable Care Act. However, there are some limited coverage Medicaid plans that do not. Limited plans vary by state, but they are plans that only cover specific services. When you are accepted into a limited coverage plan, you will be aware that it is limited coverage.

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For example, some limited plans are set up solely to cover the costs of family planning, emergency Medicaid, tuberculosis services, or outpatient hospital services. While these plans are essential for those that need the services and don’t qualify for comprehensive plans, they do not meet the minimum requirements for coverage. For some, like non-qualifying immigrants due to their immigration status, limited coverage plans are their only option.

Under the Affordable Care Act, there are 10 coverage areas that must be met in order for a plan to meet the essential health benefits. Those 10 areas are:

  • Emergency room visits
  • Prescription drugs
  • Outpatient treatment
  • Inpatient hospital treatment
  • Lab tests
  • Prenatal and postpartum care
  • Pediatric care including dental and vision
  • Preventative services
  • Mental health and substance abuse treatment
  • Recovery services. These may include physical therapy, speech/language pathology, psychiatric care or other services that help you recover following a medical issue, disease, or trauma.

The health coverage you have does not have to cover all the costs of these 10 services or provide a full range of options. For example, your health coverage does not have to cover all prescription drugs. Insurance providers are allowed to offer lists of specific drugs that they are willing to cover and not cover. As long as each of these 10 service areas is met at a minimum level, the plan is acceptable.

The plan may require co-pays or shared costs and also still be acceptable. The amount of the co-pays or shared costs will vary and those expenses are based on income eligibility. For example, depending on your income, your Marketplace plan may include lower shared costs or simply just lower monthly premiums.

Eligibility Team

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