Jane Dotson
If your wages don't cover your medical insurance, you have several options. You can look into Marketplace plans, which may offer savings based on your income and household information. You can also apply for an affordability hardship exemption if your health insurance costs are more than a certain percentage of your projected annual household income. Additionally, it's important to understand your rights and protections under the No Surprises Act, which protects you from unexpected out-of-network bills. Review your health insurance plan to understand what is covered and if there are any options to reduce costs.
| Characteristics | Values |
|---|---|
| Affordability | If your health insurance costs are more than 8.17% of your projected annual household income in 2023, 7.97% for 2024, and 7.28% for 2025, it is considered unaffordable. |
| Affordability Hardship Exemption | If your health insurance is unaffordable, you can apply for an exemption, and you may claim it on your state income tax return. |
| Job-Based Insurance | If your job-based insurance isn't affordable, you may qualify for savings on a Marketplace plan. |
| Marketplace Plan | You may be able to lower your costs with a premium tax credit. |
| No Surprises Act | You are protected from unexpected out-of-network bills. However, ground ambulance services are not covered by billing protections. |
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What You'll Learn
Affordability hardship exemption
If your wages don't cover your medical insurance, you may be able to apply for an affordability hardship exemption. This type of exemption is available for individuals who cannot afford health insurance due to personal and/or financial circumstances.
To be eligible for an affordability hardship exemption, your health insurance costs must be considered unaffordable. This typically means that the lowest-cost coverage available to you, either through an employer or a government-provided service, would cost more than a certain percentage of your projected annual household income. For example, in 2023, health insurance is considered unaffordable if it costs more than 8.17% of your projected annual household income. This threshold will decrease slightly in 2024 and 2025, to 7.97% and 7.28% respectively.
In addition to affordability, there are other criteria that may qualify you for a general hardship exemption. These include experiencing homelessness, eviction, domestic violence, the death of a close family member, natural disasters, unexpected medical expenses, and more.
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Marketplace insurance plans
If your wages don't cover your medical insurance, there are a few options to consider. Firstly, it's important to understand the type of health insurance coverage you have and what it includes. You can contact your insurance company or health plan provider to clarify this. Some plans may not cover certain services, such as emergency care or ground ambulance services, so it's crucial to know what you are and aren't covered for.
If you are unable to afford your health insurance, you may be eligible for an affordability hardship exemption. This exemption applies if your health insurance costs more than a certain percentage of your projected annual household income. For example, in 2023, the plan is considered unaffordable if the costs exceed 8.17% of your projected annual household income. To apply for this exemption, you will need to provide specific information, including your date of birth, Social Security number, and details of your health coverage and income.
Additionally, it's worth noting that maintaining continuous coverage is essential. If you have health insurance through an employer's group health plan and take a leave of absence, you generally have the right to continue that coverage during your leave. This ensures that you maintain access to medical care, surgical care, hospital care, and other benefits on the same terms as if you were still working.
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Cost-sharing
If your wages don't cover your medical insurance, you may be able to apply for an affordability hardship exemption. Affordability is calculated based on the lowest-cost coverage available to you in relation to your projected annual household income. For example, in 2023, your health insurance is considered unaffordable if your costs are more than 8.17% of your projected annual household income.
Copayments are a fixed dollar amount that you must pay towards the cost of a medical item or service covered by your insurance plan. Copayments are common for prescription drugs and physician visits. For example, you may pay $10 for a prescription drug, and your insurance plan will cover the rest of the cost.
A deductible is an amount you must pay annually before your insurance plan will pay for most of your medical bills, supplies, or other services covered by your plan. For example, if your deductible is $500, your insurance plan won't pay anything until you've paid $500 out-of-pocket. Some plans have multiple deductibles, such as separate deductibles for in-network and out-of-network care.
Coinsurance is the percentage of the medical cost you pay after you have met your deductible. For example, if your doctor bills $300 and you have a $500 deductible that you haven't met, you will pay the entire $300 yourself. However, if you've already met your deductible, you may only pay a portion, such as 20% or 40%, with your insurance plan covering the rest.
It's important to note that health insurance plans have limits. Once you reach your out-of-pocket maximum, your insurance plan will typically begin paying 100% of your in-network medical costs. Additionally, certain preventive care services, such as emergency care, radiology, and laboratory services, may be covered by your insurance plan without requiring you to meet your deductible.
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Out-of-network care
If your wages don't cover your medical insurance, you may find yourself in a situation where you need to seek out-of-network care. Out-of-network care refers to seeking medical treatment from a doctor or facility that does not have a contract with your health insurance plan. This can result in significantly higher out-of-pocket expenses for you as the patient.
When you receive care out-of-network, your insurer might set a different deductible and may not count these costs towards your annual out-of-pocket limit. Out-of-network providers can charge full price for their services, which is often much higher than the discounted rates negotiated by in-network providers. Additionally, out-of-network providers are not bound by the same restrictions on charges as in-network providers, and you may be subject to "balance billing", where you are charged the difference between what your insurance covers and the provider's actual bill.
To avoid unexpected medical bills, it is essential to understand your health insurance plan and the potential costs associated with out-of-network care. Before receiving treatment, you can request that your insurer cover you at the in-network rate, providing supporting documentation from your doctor and possibly a patient advocacy group. If your request is approved, a case manager can handle your out-of-network claims. If your request is denied, you may have the option to appeal the decision through an internal or external review process, especially if your need for care is urgent.
It is worth noting that emergency services are typically covered by insurance plans, even when received out-of-network. Additionally, there are federal and state protections in place to prevent balance billing in certain situations, such as receiving emergency care or unintentionally receiving care from an out-of-network provider while at an in-network hospital. Understanding your insurance plan and knowing your options can help you navigate unexpected medical expenses when your wages don't cover your medical insurance needs.
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Balance billing protections
If your wages don't cover your medical insurance, you may be able to apply for an affordability hardship exemption. To be eligible for this, your health insurance must be considered unaffordable. Affordability is calculated based on the lowest-cost coverage available to you through an employer or Covered California. This coverage is deemed unaffordable if your costs are more than a certain percentage of your projected annual household income.
In addition, there are balance billing protections in place to shield consumers from surprise medical bills. The No Surprises Act, a federal law enacted in December 2020, protects all consumers with private health insurance from out-of-network surprise bills in certain situations. This law came into effect for health plans that started on or after January 1, 2022.
Balance billing occurs when an enrollee receives emergency care at an out-of-network facility or from an out-of-network provider, or when an enrollee receives elective non-emergency care at an in-network facility but is inadvertently treated by an out-of-network healthcare provider. In these cases, the insurer may decide not to pay the entire bill, leaving the enrollee with a balance bill.
The No Surprises Act bans surprise bills for most emergency services, even if they are received out-of-network and without prior authorization. It also bans out-of-network cost-sharing for most emergency and some non-emergency services, ensuring that consumers are not charged more than in-network cost-sharing rates. Additionally, it bans out-of-network charges and balance bills for certain additional services, such as anesthesiology or radiology, provided by out-of-network providers as part of a patient's visit to an in-network facility.
It's important to note that ground ambulance services are generally not covered by billing protections in the No Surprises Act, and they are allowed to charge out-of-network rates. However, if you receive emergency room care, you are protected from unexpected out-of-network bills for post-stabilization services in most cases.
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Frequently asked questions
If your wages do not cover your medical insurance, you may be able to apply for an affordability hardship exemption. To be eligible, your health insurance costs must be more than a certain percentage of your projected annual household income. This percentage varies by year, and you will need to provide supporting documentation.
In 2025, a job-based health plan is considered "unaffordable" if your share of the monthly premium in the lowest-cost plan offered by your employer is more than 9.02% of your household income.
If you cannot afford your job-based health insurance, you may be able to switch to a Marketplace plan. You can apply to see if you qualify for savings based on your income and household information. However, keep in mind that if you already have a Marketplace plan and receive an offer for job-based insurance, you may no longer qualify for savings on your Marketplace plan.
If you believe you are being charged unfairly, you can submit a complaint. For example, if you receive an out-of-network ground ambulance bill, you can learn about your options by answering a few questions. Additionally, if you use most types of health insurance, you may be eligible for 90 days of in-network coverage if your provider leaves the plan's network.
