What if I Have Medicaid Now, But I Have Only Limited Benefits?

Eligibility Team
Researcher & Writer
February 04, 2016

If you have limited benefits through Medicaid, you are not filling your need for coverage under the Affordable Care Act, which may result in you being charged a penalty for failing to have adequate coverage. Limited benefits plans often include coverage for a particular illness or disorder, family planning services, or emergency services.

For example, common limited benefits Medicaid plans are for emergency services, family planning services, or health coverage for the treatment of specific diseases such as tuberculosis. These limited benefits plans also tend to be for a limited time. For example, you may take advantage of Medicaid-funded family planning services, but once the services are provided, you no longer need it. Limited plans vary from state to state.

To avoid being fined, you need to get a health care insurance plan that covers the 10 essential health benefits; emergency care, prenatal and postpartum care, outpatient care, prescription drugs, inpatient care, lab tests, preventative services, pediatric care, recovery services, and mental health and substance abuse treatment services. These are the healthcare benefits deemed as essential under the Affordable Care Act.

You can go to the Marketplace website heathcare.gov and check your eligibility for a savings plan through the Marketplace. You will need to provide your household size and your estimated income for the following year. Depending on your income, you may be eligible for one of two savings options.

The first option, if you make too much for a full Medicaid plan, is a Marketplace plan that provides lower monthly premiums and lower out-of-pocket expenses. The out-of-pocket expenses include things like deductibles and copayments. This option offers the greatest savings.

The second option is a Marketplace plan that offers lower monthly premiums, opposed to simply buying health insurance. There are no savings on deductibles or co-payments, and the actual cost of the plan will vary based on a broad range of factors.

Although Marketplace health plans will cost you money, they will provide sufficient health insurance, and they will prevent you from being fined for inadequate coverage. Another option is to look at why you are not eligible for a full Medicaid plan.

Depending on your eligibility, you may be able to get a comprehensive plan under Medicaid, opposed to a limited benefits plan. For example, if you are only eligible for emergency services due to your immigration status, you can see what you need to do to change your status, which would change your eligibility. If your eligibility for full coverage is blocked due to your income being too high, then you will be eligible under the Marketplace and should explore that option.

Eligibility Team
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