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Who is not eligible for the Affordable Care Act?

The U.S. government insists that everyone is entitled to health insurance. However, there are some exceptions to the rule. People who fit into one of the following categories are usually ineligible for federal health insurance subsidies and cannot buy insurance policies on the Affordable Care Act (ACA) marketplaces:

 

The Poor

The very definition of the “poor” differs from county to county and state to state, but generally speaking, it means people making less than $40,000 a year (or $50,000 for individuals and couples in some counties). These people are often times eligible for Medicaid or a low-cost CHIP (Children's Health Insurance Plan) program. In most cases, they are also ineligible for federal subsidies to purchase insurance plans on the exchanges.

It is important to note here that if you make too much money, you can also become ineligible for Medicaid. There is a minimum income level ($16,000 a year for an individual or $24,000 a year for a couple) that determines whether or not you will qualify for Medicaid in your state. In addition to income restrictions, most Medicaid programs have “assets” or “resources” restrictions as well. This means that if you have a certain amount of money in the bank, you are usually ineligible for Medicaid. Similarly, your house can also be considered an “asset” and prevent you from getting government insurance benefits. In some cases, people with unhealthful lifestyles or poor lifestyle choices may be disqualified from Medicaid as well.

 

The Young

In some states, the young are also considered “uninsurable” and cannot get health insurance coverage through their employers. In others, they have to wait till they are 26 years old to be eligible for government health insurance. In the federal healthcare law, people who are under 30 years old are considered part of the “younger” crowd and are oftentimes ineligible for ACA subsidies. However, people ages 30-39 are categorized as “older” under the law and can qualify for premium subsidies.

Even though you may be eligible for Medicaid or a low-cost CHIP program, if you are under 30 years old, you will also be unable to get coverage on the individual marketplaces due to your age. This has more to do with the rule that prohibits people under 30 from being on the individual marketplaces than it does with your health status.

 

The Self-Employed

In some cases, the self-employed are ineligible for government health insurance benefits as well. To be considered part of the “job-related” labor force, you must have an “employer” and be “actively” seeking employment. Unfortunately, many self-employed people struggle to meet this requirement and can be denied government insurance benefits in most cases.

If you are rejected from an employer-sponsored insurance plan due to pre-existing conditions (that is, you have an illness or injury before the policy year), you will not be able to purchase coverage through an insurance marketplace. This is because your pre-existing condition will be considered “experienced” or “historic” and you will be denied insurance coverage. As a result, you will have to pay the full cost of your health policies yourself unless you meet the criteria for a tax credit or subsidy.

 

The Retired

People who are retired are also usually considered “uninsurable” and cannot get healthcare insurance coverage through their employers. However, this is not always the case. Many Medicare recipients obtain supplemental policies to cover the cost of healthcare-related services not covered by traditional Medicare policies. In many cases, these insurance policies are purchased through private insurance carriers that contract with the government to provide services.

If you are unable to work and meet the criteria for Social Security Insurance (SSI) or Medicare benefits, you can apply for Medicaid or a low-cost CHIP plan. To be considered a Medicaid “qualifier,” you must meet the income restrictions for your state and have no resources or assets. You also need to be between the ages of 18 and 64 and have a household composition that meets the legal definition of “indigency” (that is, you have no one else to rely on for support if you were to become sick or injured). In some cases, people who are retired may be barred from purchasing insurance coverage due to their age or the income of their spouse.

 

The Illegal

Undocumented immigrants and their illegal relatives are also usually ineligible for Medicaid or a low-cost CHIP plan. This is because federal law bars individuals from receiving benefits if they are aware that they are living in the country illegally. If you are in one of these groups, you have several remedies including applying for citizenship, applying for an asylum case, or applying for a work permit. You may also be able to get insurance coverage through an employer, but it will not be government-sponsored and may not be as affordable as your usual care. In addition, if you do have insurance coverage, it is likely to be expensive and may cover only a fraction of your costs.

As you can see, there are several categories of individuals who are not eligible for the Affordable Care Act. This does not mean that they should not have access to healthcare coverage. In many cases, they will have options including applying for Medicaid, a low-cost CHIP plan, or getting insurance coverage through an employer. However, the lack of available healthcare insurance may leave them with fewer choices and potentially higher costs in the long run.