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Qualified Health Plans and Medicare


Qualified Health Plans (QHP) are health insurance plans distributed through the Marketplace that meet eligibility requirements set by the Affordable Care Act. Below, we discuss how QHPs work, as well as the dos and don’ts of QHP’s when you have Medicare.

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How Does a Qualified Health Plan Work?

Qualified Health Plans extend affordable healthcare to eligible Americans through tax credits and subsidies. All QHPs follow cost-sharing guidelines and cover general health benefits to be considered credible coverage.

On the Marketplace, plans rank by metal levels based on actuarial value. The lowest plans (bronze) offer essential benefits and higher deductibles, whereas the highest-ranked pans (platinum) offer extended benefits and lower deductibles.

Qualified Health Plan Eligibility

To be eligible for a Qualified Health Plan, you must be a U.S. citizen or national living in the country and not currently incarcerated.

To be eligible for tax credit or subsidies, you have to meet specific income requirements and not be offered credible coverage through a spouse or employer.

Do I Need a Qualified Health Plan When on Medicare?

The short answer is no. If you are on Medicare, you will not need to enroll in a Qualified Health Plan. QHPs are for individuals who do not have employer coverage and are not eligible for Medicare or Medicaid.

Enrolling in Medicare on a QHP

When you become eligible for Medicare and are on a Qualified Health Plan, it is essential to be proactive. Once you qualify for Medicare, you will no longer be able to utilize your QHP tax credit or subsidy. This means that you will be responsible for paying the entire premium cost of your health plan, which could be more than the Medicare monthly premium.

You will not receive notice from your QHP that you are eligible for Medicare. So, it is important to cancel the policy as soon as you enroll in Part A and Part B to avoid unnecessary premium costs.

Keeping a QHP When Eligible for Medicare

There are a few instances when you are eligible for Medicare and can still maintain your QHP benefits. Deciding which health coverage to utilize will depend on your circumstances.

  • You are ineligible for premium-free Part A
    If eligible to enroll in Medicare but not entitled to premium-free Part A, you may keep your QHP. If you do not enroll in any part of Medicare, you will be able to maintain your QHP premium assistance.
  • You have End-Stage Renal Disease (ESRD)
    When diagnosed with ESRD and eligible for Medicare, you can opt to keep or enroll in a QHP and still qualify for tax credits. Be sure to consider the coverage of the QHP and how it compares to Medicare before deciding which plan you keep

Keep in mind, if you decide to keep your Marketplace plan and after you are eligible for Medicare and do not meet the above criteria, you could potentially lose your Initial Enrollment Period or owe a late enrollment penalty.

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Small Business Health Options Program (SHOP)

If you work for a small business with fewer than 50 employees, you are eligible for a SHOP plan through the Marketplace.

Once eligible for Medicare, you can choose to continue your SHOP plan benefits alongside Medicare. If your employer has more than 20 employees, your SHOP plan pays primary. On the contrary, if your employer has less than 20 employees or if you are eligible for Medicare based on disability, your SHOP plan will be the secondary payer.

If you would like to keep your SHOP plan as the primary payer and do not meet the requirements, you can opt to defer your Medicare enrollment. Be sure your SHOP plan includes credible drug coverage to avoid a Part D penalty in the future.

FAQs

Should Medicare Beneficiaries enroll in a QHP?
No. You should not enroll in a Qualified Health Plan if you are on Medicare. If they know you have Medicare, it is illegal for an agent to enroll you into a QHP or a Marketplace plan.
Can I purchase dental, vision, and hearing coverage through the Marketplace if on Medicare?
No. The Marketplace does offer stand-alone plans, however, they are only available to those also purchasing a QHP.
Can I leave Medicare for a QHP?
Although it is possible to disenroll from Medicare and enroll in a QHP, it is not recommended. When disenrolling from Part A, you must repay all medical costs paid by Part A during your enrollment with Medicare. This can become costly. Also, you would be ineligible for tax credits and subsidies, making you responsible for the full premium amount for the QHP.

How Do I Find a Qualified Health Plan?

If you meet the eligibility requirements and would like to enroll in a Qualified Health Plan, you can review plans and enroll on the Marketplace at Healthcare.gov.

If you meet Medicare eligibility requirements and have questions about your QHP eligibility, complete our online rate form or call the number above to work with a licensed agent to review all of your health care options.

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Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

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