Many couples find health insurance a complicated topic to discuss. Securing coverage can feel overwhelming, but understanding your options is the first step toward ensuring your family's health and financial stability.
As it pertains to non-retired folks, employment-based insurance covers 54.5 percent of the population, Medicaid 18.8 percent, and direct-purchase coverage through HealthCare.gov, 9.9 percent, according to the US Census Bureau.
We wrote this post for couples who do not have access to health insurance through their employers.
As the illustration below shows, health insurance options for people who lack access to employer-based health care have increased significantly since 2010.
As you can see below, there is a significant discrepancy between uninsured rates from one state to the next. As you will learn later in this post, much of this stems from states who did and did not accept Medicaid expansion.
This post will guide you through the two primary reasons why, which are also your two primary options: Healthcare.gov and Medicaid. We will also share detailed insights into their income limitations, average costs, and specific recommendations for different family situations.
Subscribe to our newsletter receive ideas to manage money and the home as a team delivered to your inbox every couple of weeks.
Understanding Healthcare.gov
Healthcare.gov, also known as the Health Insurance Marketplace, is a robust resource for individuals and families seeking health insurance. It was established under the Affordable Care Act (ACA) and provides a platform where you can compare different health plans and find one that suits your needs and budget.
Eligibility and Enrollment
Open Enrollment Period
Generally runs from November 1 to December 15 each year. However, you may qualify for a Special Enrollment Period (SEP) if you experience certain life events, such as getting married, having a baby, or losing other health coverage.
Income Requirements
Subsidies reduce your cost to purchase health insurance on the marketplace. To qualify for subsidies that lower your premium costs, your household income must be between 100% and 400% of the federal poverty level (FPL). For 2023, this range is approximately $27,750 to $111,000 for a family of four and $18,310 to $73,240 for a family of two.
Healthcare.gov Plan Types
Healthcare.gov offers a variety of health insurance plans categorized by their coverage levels and costs. These plans are divided into four metal tiers: Bronze, Silver, Gold, and Platinum. Each tier represents a different balance of premium costs and out-of-pocket expenses, allowing you to choose a plan that best suits your financial and healthcare needs.
Bronze Plans
Bronze plans typically have the lowest monthly premiums of all the metal tiers and come with the highest deductibles and out-of-pocket costs. Bronze plans are often suitable for individuals who don’t expect to need frequent medical care.
Bronze plans cover approximately 60% of healthcare costs, with the enrollee responsible for the remaining 40%.
Silver Plans
Silver plans have higher premiums than Bronze plans but lower than Gold and Platinum plans. They offer a balance between premiums and out-of-pocket costs.
Silver plans cover about 70% of healthcare costs, with the enrollee responsible for the remaining 30%.
If your income is below 250% of the federal poverty level, you might qualify for cost-sharing reductions (CSRs), which lower your out-of-pocket costs when you use healthcare services. These reductions are only available with Silver plans.
Gold Plans
Gold plans have higher premiums compared to Bronze and Silver plans. They offer lower deductibles and out-of-pocket costs, making them ideal for individuals or families who expect to use more healthcare services.
Gold plans cover about 80% of healthcare costs, with the enrollee responsible for the remaining 20%.
Platinum Plans
Platinum plans have the highest premiums of all the metal tiers. They come with the lowest deductibles and out-of-pocket expenses, providing the most comprehensive coverage.
Platinum plans cover approximately 90% of healthcare costs, with the enrollee responsible for the remaining 10%.
Catastrophic Plans
Catastrophic plans have the lowest premiums but are designed to cover worst-case scenarios. They come with very high deductibles, meaning most routine medical expenses are paid out-of-pocket until the deductible is met.
Catastrophic plans are only available only to individuals under 30 years old or those who qualify for a hardship or affordability exemption.
Catastrophic plans cover essential health benefits and provide coverage after you have paid your deductible and cover three primary care visits per year before the deductible is met.
Choosing the Right Plan
When choosing a plan, consider the following factors:
Healthcare Needs: If you expect frequent medical care, a Gold or Platinum plan might be more cost-effective despite higher premiums.
Budget: If you need to keep monthly expenses low, a Bronze or Silver plan might be a better fit.
Income: If your income qualifies you for subsidies or cost-sharing reductions, a Silver plan may provide the best value.
Steps to Apply
Visit Healthcare.gov: Create an account and complete an application.
Compare Plans: Review available plans and choose the one that best meets your needs.
Submit Documentation: Provide any required documentation, such as proof of income.
Enroll: Enroll in the plan during the open enrollment period or a special enrollment period if you qualify.
Click here for a free preview of our Marriage Toolkit and join other couples using it to start, strengthen, or rebuild their marriages using our ideas to manage money and the home as a team.
Exploring Medicaid
Medicaid is a joint federal and state program that provides health coverage to low-income individuals and families. It offers comprehensive coverage, often with no or minimal costs to enrollees.
Medicaid Expansion
Medicaid Expansion is a critical component of the Affordable Care Act (ACA) designed to extend healthcare coverage to more low-income individuals and families. Under this provision, states that choose to expand Medicaid eligibility provide coverage to all adults with incomes up to 138% of the federal poverty level (FPL).
For married couples without children, or those with low incomes, this expansion provides a crucial pathway to obtaining affordable health insurance.
As illustrated below, 39 states (including Washington D.C.) have adopted Medicaid Expansion, offering comprehensive healthcare benefits, often at no or minimal cost to enrollees.
Eligibility and Enrollment
Income Requirements
Medicaid eligibility varies by state, but it generally covers individuals and families with incomes up to 138% of the FPL. For a family of four, this is about $38,295 annually, and for a family of two, it is about $25,760 annually.
Medicaid Expansion
States that have expanded Medicaid under the ACA provide coverage to all adults with incomes up to 138% of the FPL. If your state has not expanded Medicaid, eligibility may be more restrictive, often limited to specific groups such as pregnant women, children, elderly adults, and individuals with disabilities.
Average Costs
Most Medicaid enrollees pay no monthly premiums and the out-of-pocket costs are generally very low and may include nominal copayments for certain services, depending on the state.
Considerations for Married Couples with Children
Children's Health Insurance Program (CHIP)
If your income is too high for Medicaid but too low to afford private insurance, your children might qualify for CHIP, which provides low-cost coverage for children in families with incomes too high for Medicaid but below 200% of the FPL.
Comprehensive Coverage
Medicaid often covers a wide range of services, including dental and vision care for children. Take full advantage of these benefits.
Considerations for Married Couples Without Children
State-Specific Programs
Check if your state has additional health programs for low-income adults that could supplement Medicaid.
Medicaid Expansion
If your state has expanded Medicaid, you are likely eligible if your income is below 138% of the FPL. Apply through your state's Medicaid website or through Healthcare.gov.
Steps to Apply
Visit Your State's Medicaid Website: Find your state's Medicaid program through Healthcare.gov or directly on your state's health department website.
Complete an Application: Fill out the application form with necessary details about your household and income.
Submit Documentation: Provide required documentation to verify your eligibility.
Receive Coverage: Once approved, you will receive information about your coverage and how to use it.
Wrapping it Up
The world of health insurance is full of myths and lies. It's complicated, and highly politicized. The bottom line is that many folks lack access to employer based health care and need access to honest information to make informed decisions.
For further assistance and detailed information, visit Healthcare.gov and your state’s Medicaid website.
Follow Modern Husbands
Start, Strengthen, or Rebuild Marriages. For couples who want to manage money and the home as a team.
Winning ideas from experts to manage money and the home as a team. 2023 Plutus Award Finalist: Best Couples or Family Content
Winning ideas to manage money and the home as a team delivered to your inbox every two weeks. You'll even receive a few free gifts!