Moving from Medicaid to Employer-Provided Coverage

Things may have changed for you since the start of the COVID-19 pandemic – including where you live, where you work, and how much you earn. As a result, it’s possible you are no longer eligible for Medicaid. But you may be able to get health insurance through your job. This type of health insurance is called “employer provided coverage.” While up to 18 million people are expected to no longer be eligible for Medicaid, more than half of them (9.5 million) will be able to get coverage through their employer.

Medicaid is health coverage provided by states to people with very low or no income. Employer-provided coverage is offered by an employer to their employees, as well as to employees’ spouses or partners and dependents. Employer-provided coverage can go a long way to protecting your financial stability and peace of mind.

If you are no longer eligible for Medicaid, you should reach out to your employer immediately. You are eligible for a special enrollment period (SEP) to enroll in coverage through your employer. Employees typically only have 60 days from the date they lose Medicaid coverage to request an SEP - but if you lose Medicaid eligibility on or before July 10, 2023, you can request an SEP until September 8, 2023.

Employers also offer an annual open enrollment period at another time during the year, when all employees can re-examine their coverage choices and make changes that are right for them.

Ask yourself a few questions about what kind of health care you want to be covered, and what costs you are most comfortable paying. Typically, plans cover similar services but will have different costs and cost structures. For example, if you are willing to pay more toward your premium – or the amount you contribute to your health insurance every month, after your employer contributions are deducted – you are likely to pay less out of pocket for health care services, and vice versa. Your employer may have other resources – like an expert in HR, or an insurance broker – to help you through this process.

Health insurance providers negotiate lower prices for you with hospitals, health systems, doctors, and other providers. These providers are considered “in network.” Going to in-network providers helps you save money with your health plan. If a doctor or facility does not contract with your health plan, they’re considered out-of-network and can charge you full price. If you see an out-of-network provider, you will likely pay significantly more than you would pay in-network. In cases of emergency services, you will owe only the in-network cost sharing amount regardless of who you see.

Each employer-provided plan has its own “formulary,” which is a list of prescription drugs that it covers. Some drugs may be 100% covered, while others may require some payment from you. Before enrolling, check the plan’s formulary to see if your medications are covered and what your costs would be.

If you have a chronic condition – such as a heart condition, or diabetes - make sure services, treatments, or benefits you expect to use are covered by the health plan.

A premium is the amount you pay monthly to keep your coverage. Employers pay the majority of monthly premiums, and employees pay the rest.

A deductible is the amount you pay for most eligible medical services or medications before your health plan begins to share the cost of covered services.

A copay (or copayment) is a flat fee that you pay on the spot each time you go to your doctor or fill a prescription. Copays cover your portion of the cost of a doctor’s visit or medication.

Coinsurance is a portion of the medical cost you pay after your deductible has been met. Coinsurance is a way of saying that you and your insurance carrier each pay a share of eligible costs that add up to 100 percent.

Employer-provided coverage is the right choice for millions of Americans and their families. But some employees choose to enroll themselves in employer-provided coverage, and their families in coverage through the health insurance marketplaces. As you make your decision, you may want to determine whether your spouse (or partner) and dependents are eligible for financial assistance from the federal government to enroll in coverage through the health insurance marketplaces.

Once you have enrolled in employer-provided coverage, be sure you understand your benefits and the costs for various procedures and services. Here are a few important things to remember when using your new employer-provided coverage:

• Contact your providers and pharmacy to make sure they have your updated insurance information.
• If you don’t already have a primary care provider, find a doctor that is in your network. If you do have a primary care provider, be sure to make sure your doctor is in network before seeking care.
• Be sure to get regular check-ups, ask your doctor about preventive screenings, and consider enrolling in a workplace wellness program to help you stay healthy.
• Keep track of your health care spending so you can use that information during the next open enrollment period to ensure you have a plan that best fits your needs.