Q. I know that whether I qualify for expanded Medicaid depends on whether my income is less than 138 percent of the Federal Poverty Level (FPL). I also understand if I earn too much to qualify for Medicaid, I can buy insurance in the exchange, where I may be eligible for subsidies, again depending on how my income compares to the FPL. Can you spell out what that means in dollars?
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A. First, in states that have expanded Medicaid you will qualify for Medicaid if you earn less than 138 percent of the FPL. For a single individual in 2016, the upper income limit for Medicaid eligibility is $16,394, and for a family of four, the upper income limit is $33,534.
In states that have not expanded Medicaid, eligibility for Medicaid has remained unchanged as a result of the ACA, and in most cases, able-bodied adults without dependent children are not eligible for Medicaid regardless of how low their income is.
Families USA has a useful page that includes both 2015 and 2016 FPL numbers, including dollar amounts up to 400% of FPL for households with up to eight members.
It’s important to note that Medicaid and CHIP eligibility are now calculated based on the 2016 FPL guidelines, which were released in January 2016. But eligibility for premium subsidies in the exchange will still be based on the 2015 FPL guidelines until open enrollment for 2017 begins in the fall of 2016. In all cases, the exchange first checks to see if applicants are eligible for Medicaid. Subsidy eligibility is only determined if and when the exchange has determined that the applicant is not eligible for Medicaid.
- you’re not eligible for Medicaid
- your income is at least 100 percent of the poverty level but not more than 400 percent of FPL (if the unsubsidized premiums are low enough, subsidy eligibility will end below 400 percent of FPL)
- you don’t have access to affordable employer-sponsored health insurance that provides minimum value (it’s important to understand the family glitch in this scenario).
So in states that have expanded Medicaid, subsidy eligibility starts at 138 percent of the poverty level, while in states that haven’t expanded Medicaid, subsidy eligibility starts at 100 percent of the poverty level.
For plans effective in 2016, 100 percent of the poverty level (for subsidy eligibility) is $11,770, and $24,250 for a family of four.
400 percent of the poverty level is $47,080 for a single individual and $113,640 for a family of five.
In addition, if your income is at least 138 percent of poverty (or 100 percent in states that haven’t expanded Medicaid) and also doesn’t exceed 250 percent of the FPL, you will be eligible for a cost-sharing subsidies if you buy a Silver Plan. Cost-sharing subsidies reduce the maximum out-of-pocket costs for the health plan, and also lower the deductibles and copays that you’ll have to pay if you need care. For a description of how this subsidy works, see this FAQ on cost-sharing subsidies.
For coverage effective in 2016, 250 percent of FPL is $29,425 for a single individual, $50,225 for a family of three, and $81,425 for a family of six.