SOAR and the Affordable Care Act

Medicaid Expansion

The Affordable Care Act, signed into law on March 23, 2010, brought expanded access to Medicaid in 34 states and Washington, DC, which means that people living in poverty in these states can access Medicaid much more quickly and easily than before. In Medicaid expansion states, adults with incomes at or below 138% of the federal poverty level (FPL) are now eligible to receive coverage.

• The FPL is a measure of income determined each year by the Department of Health and Human Services (HHS)
• The FPL for an individual in 2022 is $13,590 and $27,750 for a family four. Additional information is available on HealthCare.gov.

What services does Medicaid cover?

States have flexibility in what services they choose to cover under Medicaid expansion, but their plans must include ten sets of services, known as “essential health benefits”:

1. Mental health and substance use disorder services, including behavioral health treatment
2. Prescription drugs
3. Trips to the emergency room
4. Preventive and wellness services and chronic disease management, including counseling, physicals, immunizations, and care for long-term illnesses such as diabetes or asthma
5. Outpatient care
6. Hospitalization
7. Maternity and newborn care
8. Rehabilitative and habilitative services, such as speech or occupational therapy, and devices
9. Laboratory tests
10. Pediatric services, including oral and vision care

Some states may also choose to cover services supporting stability in permanent housing, such as case management or care coordination.

How do I know if my state expanded Medicaid?

A Supreme Court ruling in 2012 allowed states to choose if they want to expand Medicaid. The Henry J. Kaiser Family Foundation maintains an updated list of states that have expanded Medicaid.

If my state expanded Medicaid, does that mean individuals do not need SSI?

• While increased access to Medicaid is incredibly beneficial, income benefits such as SSI remain critical to accessing safe and stable housing
• Additionally, people in housing who engage in treatment have better health outcomes and use treatment services more effectively
• SOAR trained case managers are especially poised to help individuals who are experiencing homelessness enroll in Medicaid and continue to help consumers access disability benefits

If my state didn’t expand Medicaid, what does this mean for me?

• If your state did not expand Medicaid, then the health insurance and income benefits from SSI are especially critical for individuals experiencing homelessness
• Be aware that states may choose to expand Medicaid at any time, so even if your state has not expanded yet, they have the right to do so in the future

Dependent Coverage

For children, a key provision of the Affordable Care Act is the extension of dependent coverage, allowing them to remain on their parents’ insurance through age 26. It also provides coverage up to age 26 for children who are aging out of the foster care system.

• The ACA also prevents health insurance plans from denying coverage for children aged 19 years and younger with preexisting medical conditions.

The ACA includes coverage for preventive health services for children, without family co-pays.

• For example, preventive services for infants include screening for hearing, development, sickle cell disease, phenylketonuria, and several other health conditions.
• These services are particularly important, as early detection of medical conditions during infancy can help prevent long-term disability and improve children’s health and well-being.

For many low-income families, the ACA enabled them to access low-cost health care coverage.

Health Insurance Marketplace

Individuals experiencing homelessness may qualify for private health insurance through the Health Insurance Marketplace, (also known as “Exchanges” or “Marketplace”), which helps people compare coverage plans, find out if they qualify for lower costs based on their income level, and enroll in a plan.

Each of the Qualified Health Plans (QHPs) offered through the Marketplace must provide the essential health benefits, listed above. Also:

• Some plans may cover additional benefits
• You may have to see certain providers or use certain hospitals (networks)
• The premiums, copayments, and coinsurance vary across plans
• Some plans are structured differently, like high-deductible (catastrophic) plans

Ways to reduce costs when using the Marketplace

Families whose total household income is between 100% and 400% of the FPL may be eligible for lower monthly premiums and out-of-pocket costs.

• The premium tax credit may be taken as advance payments to lower monthly premium costs, or as a refundable credit on a tax return
• Cost-sharing reductions are available to help reduce out-of-pocket expenses, including deductibles, copayments, and coinsurance
  • Cost sharing does not apply to premiums and families must have a household income of 250% or less of the FPL to qualify
• Members of federally recognized tribes, shareholders of Alaska Native regional and village corporations, California Indians, and persons of Indian descent who are eligible for services from the Indian Health Service, tribal programs, or urban Indian health programs, who purchase health insurance through the Marketplace don’t pay premiums and cost-sharing if their income is under 300% of the FPL