Is Income-Based Medicaid Right for You?

Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:

• Have low income, no matter how much you have in resources or whether you have a disability. Income-based Medicaid is explained on this page.
• Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
• Have low income, low resources, and a disability. Learn more about SSI-related Medicaid.
• Have a disability and work, even if your income is higher. Learn more about Freedom to Work.

Answer the questions on this page to see if you might qualify for income-based Medicaid. If so, it’s probably your best health coverage option because it doesn’t have a premium, the copayments for services are generally lower than copayments required by private plans, and Medicaid covers more services than most private plans. Also, if you qualify for Medicaid, you cannot get government help paying for an individual plan on HealthCare.gov.

Do You Meet Income-Based Medicaid’s Basic Requirements?

To qualify for income-based Medicaid, you must:

• Be under 65 years old
  • You can be 65 or older if you are the parent or caretaker of a child.
• Not qualify for Medicare
  • You can be on Medicare if you are the parent or caretaker of a child or are pregnant.
• Be a U.S. citizen or meet specific noncitizen requirements

If you are under 65, do not qualify for Medicare, and are either a U.S. citizen or a noncitizen who qualifies, income-based Medicaid might cover you.

Medicaid’s rules for immigrants:

• Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
• Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
• Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for the same programs that U.S. citizens can get.

Is Your Income Low Enough for Income-Based Medicaid?

These are the main income rules for income-based Medicaid:

• If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($21,597 per year for an individual; $44,367 for a family of four), you may qualify.
• If you are 18 or younger and your family’s income is at or under 217% of FPG ($69,766 per year for a family of four), you may qualify.
• If you are pregnant and your family’s income is at or under 200% of FPG ($64,300 per year for a family of four), you may qualify. The unborn baby is counted as a family member.

Income-based Medicaid is based on your Modified Adjusted Gross Income (MAGI), which includes most earned and unearned income. (That's why some people call it "MAGI Medicaid.") However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect income-based Medicaid eligibility.

Note: There are no limits to how much money or other resources you can have for income-based Medicaid.

Health Coverage Income Limits for Your Family

Your family size:	123456789101112
Income limits for your family:
	$15,650
	$5,500
	$15,060
	$5,380
Income-based Medicaid, adults (138% FPG)
Healthy Kids (195% FPG)
MIChild (217% FPG)
Subsidized private plans, reduced fees (250% FPG)
Subsidized private plans (no income limit)	--
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules. Notes: Some types of income do not count against these limits, including SSI benefits. Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG). For private plans with subsidies, your monthly premium amount depends on your income.

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If your income is low enough and you meet all other requirements, you should sign up for Medicaid.

More Ways to Qualify for Medicaid if You Have a Disability

There are other ways to qualify for Medicaid if you have a disability. You might qualify for SSI-related Medicaid if:

• You get Supplemental Security Income (SSI) benefits.
• You make more money at work than income-based Medicaid allows. In that case, you could apply for Freedom to Work.
• You also get Medicare. Usually, Medicaid doesn’t cover people getting Medicare, but SSI-related Medicaid does. It may even help pay your monthly Medicare premiums.
• You are 65 years old or older.

You might qualify for income-based Medicaid, even though you have a disability, if:

• Your disability does not meet Social Security’s definition of disability. SSI-related Medicaid is only for people who have disabilities meeting this standard.
• You have more resources than are allowed by SSI-related Medicaid.
• You make enough money that you would have to pay a monthly premium for Freedom to Work.

Learn more about SSI-related Medicaid and Freedom to Work.

How to Sign Up

You can apply for Medicaid:

• Online using MIBridges or HealthCare.gov, or
• By using form DCH-1426 and giving it to your county human services agency.

Note: With MIBridges, you can apply for the Food Assistance Program (formerly Food Stamps), the Family Independence Program (FIP), and other benefits at the same time as you apply for Medicaid.

For help with your application, visit or call your local county human services agency or call the Medicaid Beneficiary Help Line at 1-800-642-3195 or 1-866-501-5656 (TTY).

Staying on Medicaid

Usually, once approved for Medicaid, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your county human services agency know within 10 days of the change. You can do this in person, by phone, or by email. When you report your changes, the county tells you whether you continue to get Medicaid or if you have new health coverage options, like individual coverage with subsidies or Freedom to Work.

Is SSI-Related Medicaid Right for You?

Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:

• Have low income, no matter how much you have in resources or whether you have a disability. Learn more about income-based Medicaid.
• Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
• Have low income, low resources, and a disability. SSI-related Medicaid is explained on this page.
• Have a disability and work, even if your income is higher. Learn more about Freedom to Work.

Answer the questions on this page to see if you might qualify for SSI-related Medicaid. If so, it’s probably your best health coverage option because it doesn’t usually have a premium, the copayments for services are generally lower than copayments required by private plans, and Medicaid covers more services than most private plans. And, if you also have Medicare coverage, SSI-related Medicaid usually means you can qualify for a Medicare Savings Program that helps pay your Part B premium.

Also, if you qualify for Medicaid, you cannot get government help paying for an individual plan on HealthCare.gov.

Medicaid’s rules for immigrants:

• Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
• Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
• Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for the same programs that U.S. citizens can get.

Do You Have a Disability That Meets Social Security’s Standards?

To qualify for SSI-related Medicaid, you must have a disability that meets Social Security’s definition of disability. For adults, Social Security says you have a disability if:

• You have a physical or mental impairment or combination of impairments
• Your impairments limit your ability to work, preventing you from earning Substantial Gainful Activity ($1,620 per month or $2,700 per month if you’re blind), and
• Your condition has lasted or is expected to last for at least 12 months.

If you currently get disability benefits, like Social Security Disability Insurance (SSDI), you already meet Social Security’s disability standards. If not, Michigan's Disability Determination Service (DDS) checks to see if your disability qualifies for Medicaid.

Note: Learn about Social Security’s definition of disability for children under 18 in DB101’s Benefits for Young People article.

If you already have a disability determination from Social Security or think that your disability meets Social Security’s standards, SSI-related Medicaid might cover you.

Do You Have Very Low Resources?

Resources are money and property you own. For SSI-related Medicaid, you and your family must have very low resources:

• If you are single, the most you can have is $9,660 in resources.
• For couples, the limit is $14,470.

Some resources don’t count towards SSI-related Medicaid’s resource limit, like the home you live in, one car, and any money you have in an ABLE account.

If your family’s resources are below the limit, SSI-related Medicaid might cover you.

Do You Have Very Low Income?

To qualify for SSI-related Medicaid, you must have countable income that is $1,305 per month or less ($1,763 or less for couples).

For SSI-related Medicaid eligibility, not all of your income is counted. The way your income is counted for SSI-related Medicaid is very similar to SSI’s countable income calculation:

• Most of your unearned income is counted.
  • Important: SSI and Food Assistance Program benefits are not counted for SSI-related Medicaid eligibility.
• Less than half of your earned income is counted.

This means that if you have a disability determination, you might be able to get a job and make $2,000 per month or more without losing your SSI-related Medicaid, because more than half of your earned income wouldn’t be counted.

If you live alone, try this tool to see if your countable income is below SSI-related Medicaid’s income limit. If you live with others, some of their income may be counted and you should talk to your local county human services agency about whether you qualify for Medicaid coverage.

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,305
	$20
	$65
	$967
Your Monthly Countable Income
Your Annual Countable Income
	$15,650
Federal Poverty Guideline
Your Countable Income as a Percent of FPG

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If your income is low enough and you meet all other requirements, you should sign up for Medicaid.

More Ways to Qualify for Medicaid if You Have a Disability

There are other ways to qualify for Medicaid if you have a disability. You might qualify for income-based Medicaid if:

• Your disability does not meet Social Security’s definition of disability. SSI-related Medicaid is only for people who have disabilities meeting this standard.
• You have more resources than are allowed by SSI-related Medicaid.
• You make enough money that you would have to pay a monthly premium for Freedom to Work.

You might qualify for SSI-related Medicaid instead of income-based Medicaid if:

• You make more money at work than income-based Medicaid allows. In that case, you could apply for Freedom to Work.
• You also get Medicare. Income-based Medicaid doesn’t cover people getting Medicare, but SSI-related Medicaid does. It may even help pay your monthly Medicare premiums.
• You are 65 years old or older.

Learn more about income-based Medicaid and Freedom to Work.

How to Sign Up

You can apply for Medicaid:

• Online using MIBridges or HealthCare.gov, or
• By using form DCH-1426 and giving it to your county human services agency.

Note: With MIBridges, you can apply for the Food Assistance Program (formerly Food Stamps), the Family Independence Program (FIP), and other benefits at the same time as you apply for Medicaid.

For help with your application, visit or call your local county human services agency or call the Medicaid Beneficiary Help Line at 1-800-642-3195 or 1-866-501-5656 (TTY).

Staying on Medicaid

Usually, once approved for Medicaid, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your county human services agency know within 10 days of the change. You can do this in person, by phone, or by email. When you report your changes, the county tells you whether you continue to get Medicaid or if you have new health coverage options, like individual coverage with subsidies or Freedom to Work.

Is Michigan's Freedom to Work Medicaid Right for You?

Medicaid is government-funded health coverage for people in certain situations. You may qualify if you:

• Have low income, no matter how much you have in resources or whether you have a disability. Learn more about income-based Medicaid.
• Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
• Have low income, low resources, and a disability. Learn more about SSI-related Medicaid.
• Have a disability and work, even if your income is higher. Medicaid's Freedom to Work program is explained on this page.

Answer the questions on this page to see if you might qualify for Freedom to Work. If so, it’s a good option to consider because it lets you earn a lot more money and pay a monthly premium, low copayments and no deductible to get Medicaid’s comprehensive coverage. And, if you also have Medicare coverage, Freedom to Work means you can qualify for a Medicare Savings Program that helps pay your Part B premium.

Do You Meet Freedom to Work’s Basic Requirements?

To qualify for Freedom to Work, you must:

• Live in Michigan
• Be 16 – 64 years old
• Be working, and
• Be a U.S. citizen or meet specific noncitizen requirements.

If you live in Michigan, are 16 – 64 years old, working, and are either a U.S. citizen or a non-citizen who qualifies, Freedom to Work might be an option for you.

Medicaid’s rules for immigrants:

• Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
• Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
• Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for the same programs that U.S. citizens can get.

Do You Have a Disability That Meets Social Security’s Standards?

To qualify for Freedom to Work, you must have a disability that meets Social Security’s definition of disability. For adults, Social Security says you have a disability if:

• You have a physical or mental impairment or combination of impairments, and
• Your condition has lasted or is expected to last for at least 12 months.

Note: For Freedom to Work, Social Security’s disability rules related to earned income do not apply.

If you currently get disability benefits, like Social Security Disability Insurance (SSDI), you already meet Social Security’s disability standards. If not, Michigan's Disability Determination Service (DDS) checks to see if your disability qualifies for Freedom to Work.

If you already have a disability determination from Social Security or think that your disability meets Social Security’s standards, Freedom to Work might be an option for you.

Do You Have Low Resources?

Resources are money and property you own. For Freedom to Work:

• When you apply, you must have less than $9,660 in resources.
• After Freedom to Work coverage starts, you can have up to $75,000 in resources.

Some resources don’t count towards Freedom to Work’s resource limit, like the money you have in an ABLE account, the home you live in, and one car. Additionally, once coverage starts, money you put in a retirement account while you are working does not count towards the $75,000 limit.

If your resources are below the limit, Freedom to Work might be an option for you.

Is Your Income Below Freedom to Work’s Income Limit?

Freedom to Work is designed so that if you have a disability, you can work without worrying that you’ll lose your Medicaid health coverage.

When you apply for Freedom to Work, you must have countable income at or below $3,260 per month. Your countable income includes most of your unearned income and less than half of your earned income. Because of this, you could work and make a lot more than the $3,260 limit and still qualify, depending on your unearned income.

Once you are covered by Freedom to Work, your unearned income must stay at $3,260 per month or less, but it doesn't matter how much you earn, as long as you have some earned income. You can get a great job and still have Freedom to Work coverage.

Note: Only your income is counted, not the income of other household members.

If your income is low enough and you meet all other requirements, you should sign up for Freedom to Work, after making sure it is better than any employer-sponsored coverage you could get.

How to Sign Up

You can apply for Freedom to Work:

• Online using MIBridges or HealthCare.gov, or
• By using form DCH-1426 and giving it to your county human services agency.

Note: With MIBridges, you can apply for the Food Assistance Program (formerly Food Stamps), the Family Independence Program (FIP), and other benefits at the same time as you apply for Medicaid.

For help with your application, visit or call your local county human services agency or call the Medicaid Beneficiary Help Line at 1-800-642-3195 or 1-866-501-5656 (TTY). Tip: If your county human services agency doesn't know about Freedom to Work, mention Section 174 of the BEM manual.

Staying on Freedom to Work

Usually, once approved for Freedom to Work, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your county human services agency know within 10 days of the change. You can do this in person, by phone, or by email. When you report your changes, the county tells you if you continue to get Freedom to Work and if your premium will change.

What Medicare Options Are Right for You?

When you work, some of the money you earn automatically comes out of your paycheck and helps fund Medicare, a national public health insurance program.

If you or your spouse worked enough time while paying Medicare taxes, you qualify for Medicare:

• When you turn 65
• After you get Social Security Disability Insurance (SSDI) benefits for two years, or
• If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).

If you get Disabled Adult Child (DAC) benefits for two years based on a parent’s work record, you also qualify for Medicare.

If you qualify for Medicare, you can choose from two options:

• Original Medicare, including Part A, which helps pay for medical care you get while you’re in a hospital; Part B, which helps pay for medical care you get outside of a hospital, like when you go to the doctor’s office; and Part D, which helps pay for prescription drugs. You also have the option of getting a private Medicare supplement policy, which covers some expenses that Parts A and B do not cover.
  • After you get SSDI or DAC for two years, you automatically get Medicare Parts A and B. Otherwise, you may need to sign up, depending on your situation.
• A Medicare Advantage plan, which combines Parts A, B, and D into a single plan run by a private company. There are many different Medicare Advantage plans to choose from.
  • If you want a Medicare Advantage plan, you need to sign up during your initial Medicare enrollment or during the annual open enrollment period between October 15 and December 7 each year.

Most people don’t have to pay a premium for Part A, but they do have to pay monthly premiums for Parts B and D, or for Medicare Advantage plans. For this reason, nobody is required to get them.

Answer the questions on this page to see if it makes sense for you to get Original Medicare or a Medicare Advantage plan, and also whether you might qualify for programs that can help you pay your monthly premiums, copayments, co-insurance, and deductibles.

Do You Qualify to Get Medicare and Other Coverage at the Same Time?

If you qualify to get Medicare at the same time as you get employer-sponsored coverage, Medicaid, or Freedom to Work, having those other benefits may impact your Medicare decisions:

• If you also qualify for Medicaid or Freedom to Work, they may help pay for some medical expenses that Parts B and D don't pay for. And Medicaid (but not Freedom to Work) may also help pay for the Part B and D premiums, copayments, and deductibles.
• If you also qualify for employer-sponsored coverage, you may wish to decline Part B and Part D coverage, so that you don’t have to pay their premiums. However, your private coverage must meet certain standards, or else you may have to pay monthly penalties if you choose to sign up for Parts B and D later.
  • Important: Before you decline Part B, ask your employer-sponsored coverage to see if you would have to pay monthly penalties if you sign up for Part B in the future. Before you decline Part D, ask if your private insurance is considered creditable coverage by Part D. If it isn't, you would have to pay monthly penalties for Part D if you sign up later. If you have any questions about this, contact MMAP, Inc..

You may have other options as well, such as retirement benefits, Veterans (VA) benefits, or military (TRICARE) benefits. Learn more about how Medicare interacts with other types of coverage.

Can You Get Help Paying for Medicare Parts A and B?

While Medicare offers good coverage, it is not as low-cost as Medicaid. Depending on the care you need, you may have to pay large copayments, co-insurance, or deductibles. And, for Part B, you may have to pay a monthly premium (usually $185.00 per month or a bit less, depending on your situation).

However, if you have low income and low resources, you may qualify for a Medicare Savings Program (MSP). These are Michigan's Medicare Savings Programs:

• The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,305 per month or less if you live alone). QMB helps pay for your Part B premium, copayments, and deductibles. Note: If you have SSI-related Medicaid coverage, you automatically qualify for QMB.
• The Specified Low-Income Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,565 per month or less if you live alone). SLMB helps pay for the Part B premium, but does not help with anything else.
• The Additional Low-Income Medicare Beneficiary (ALMB) program, also called Q1, helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,761 per month or less if you live alone). ALMB helps pay for the Part B premium, but does not help with anything else.
• The Non-Categorically Eligible Michigan Beneficiary (NMB) program helps people who have Medicaid coverage and whose income or resources are too high for other Medicare Savings Programs. People can get NMB if they have Freedom to Work Medicaid, which allows countable income as high as 250% of FPG ($3,260 per month if you live alone) and up to $75,000 in resources. NMB helps pay for the Part B premium (and the Part A premium for people who need to pay it).
• The Qualified Disabled Working Individual (QDWI) program helps people who have lost their SSDI benefits because they earn more than the Substantial Gainful Activity (SGA) level ($1,620 per month), but have countable income that’s 200% of FPG or less ($2,609 per month or less if you live alone). It lets you stay on Medicare Part A even though you don’t get SSDI anymore and it pays for the Part A premium that otherwise applies.

For MSPs, less than half of your earned income is counted. That means you might qualify even if you think your income is over the limits.

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,305
	$20
	$65
	$967
Your Monthly Countable Income
Your Annual Countable Income
	$15,650
Federal Poverty Guideline
Your Countable Income as a Percent of FPG

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The resource limit for QMB, SLMB, and ALMB is $9,660 if you live alone and $14,470 if you live with someone else. For QDWI, it’s $4,000 if you live alone and $6,000 if you live with another person. For NMB, it depends on how you qualify for Medicaid: if you have Freedom to Work coverage, then your resource limit for NMB is $75,000.

You can apply for any of these by using form DCH-1426 and giving it to your county human services agency. For help with your application, visit or call your local county human services agency or call the Medicaid Beneficiary Help Line at 1-800-642-3195 or 1-866-501-5656 (TTY)

Can You Get Help Paying for Medicare Part D?

Part D helps you pay for your medications, but there are some expenses for you, such as the monthly premium, a deductible, copayments, and co-insurance.

If you cannot afford these costs, you may qualify for the Low Income Subsidy (LIS), which is also called “Extra Help.” With it, you don't have to pay a Part D premium or deductible, and there may be lower copayments.

The Low Income Subsidy is for people who also get Medicaid coverage or who are in a Medicare Savings Program. You may also qualify if your countable income is less than $23,475 per year and your resources are less than $16,100 if you are single (the limits are higher for larger households). Not all of your income and resources are counted when you apply for the Low Income Subsidy. You can apply even if you don’t think you qualify.

Apply for the Low Income Subsidy at your local Social Security office.

Note: Before 2024, there used to be a "Partial LIS" that didn't help as much. Now, everybody who qualifies for the LIS gets the full subsidy.

Do You Want a Medicare Supplement Plan That Covers Costs that Original Medicare Doesn't?

If you get Original Medicare with Parts A, B, and D, you can choose to get a private Medicare supplement (sometimes called a Medigap plan) to cover some of the expenses that Medicare Parts A, B, and D don’t cover. For example, a Medicare supplement could cover things like your co-insurance payments for Part B.

You have to pay a monthly premium for a Medicare supplement, in addition to your premiums for Part B and D. The amount you have to pay depends on the plan.

Learn more about Medicare supplements or find one in your area.

Do You Want a Medicare Advantage Plan That Combines Parts A, B, and D?

With Medicare Advantage (sometimes called “Part C”), you can get all of your Medicare benefits combined into a single plan run by a private company. As long as a company follows Medicare’s rules, it can have more flexibility in the benefits it offers, how it organizes payments, and how much the plan costs. Also, Medicare Advantage plans have an out-of-pocket maximum, unlike Original Medicare.

The amount you pay depends on your plan, but most plans make you pay as much as the Part B premium costs, plus an additional amount for extra benefits and prescription drug coverage. A Medicare Savings Program and the Low Income Subsidy may help you pay for your Medicare Advantage plan.

Use the Medicare Plan Finder to see which Medicare Advantage plans might be best for your needs.

Is Employer-Sponsored Coverage Right for You?

To get private health insurance, a premium must be paid every month. Many employers offer to pay part, or all, of this monthly premium as a job benefit for employees, their children until they turn 26 years old, and their spouses. Employer-sponsored health coverage is the most common type of coverage in the U.S.

Answer the questions on this page to see if you can get employer-sponsored coverage. If you can, you probably should because you probably won’t qualify for subsidized individual coverage.

Can You Get Medicaid?

If you qualify for Medicaid, it is usually your best choice, even if you can get health insurance from an employer. That’s because Medicaid usually has no monthly premium and the copayments for services tend to be much lower than private insurance copayments. Also, Medicaid may cover some services that employer-sponsored coverage doesn't pay for.

If you can’t get Medicaid, employer-sponsored coverage might be a good option for you.

You may qualify for Medicaid if you are in one of these situations:

• Your family’s income is at or below 138% of the Federal Poverty Guidelines (FPG) ($21,597 per year for an individual; $44,367 for a family of four). The income limits are higher if you are 18 or younger or are pregnant. There are no limits to how much money or other resources you have. Learn more about income-based Medicaid.
• You have a disability or are elderly:
  • Medicaid for people with disabilities and seniors may offer additional services, but it has more eligibility requirements, such as having a disability, having low resources, and different income rules. (If you get Supplemental Security Income (SSI) benefits, you qualify automatically.) Learn more about SSI-related Medicaid.
  • Freedom to Work lets people with disabilities who make more money than the income limits for other types of Medicaid get Medicaid coverage. However, you may have to pay a monthly premium. Learn more about Freedom to Work.

Does Your Employer, Your Spouse’s Employer, or Your Parent’s Employer Offer Coverage?

Many employers offer health coverage as a job benefit, but they aren't required to. Contact your employer’s Human Resources department to check what benefits are offered.

If an employer offers health coverage as a job benefit for employees, the employer also has to offer the same health coverage to the employees’ children until they turn 26. An employer may also let the employee’s spouse join the plan, but they are not legally required to do so.

If your employer, your parent’s employer, or your spouse’s employer offers health coverage, it might be a good option for you.

Can You Get the Coverage Your Employer Offers?

Employers offer health coverage for employees and their families only if their employees meet certain requirements, such as:

• The employee must work a certain number of hours each week (called the active work requirement).
  • Example: Your wife’s employer only gives health benefits to employees who work 30 or more hours per week.
• The employee must have worked for the employer for a certain amount of time (called the waiting period). A waiting period cannot be longer than 90 days.
  • Example: Your father’s employer offers health coverage to employees who have worked there for at least 90 days.
• You must sign up during open enrollment.
  • Example: After you are hired, you have to sign up for your employer-sponsored coverage during your first month on the job. If you don’t, you have to wait until the next open enrollment period to sign up for coverage.

If your employer, your parent’s employer, or your spouse’s employer offers coverage and you can get that coverage, you probably should.

Getting Medicare and Employer-Sponsored Coverage at the Same Time

If you get Medicare and also have employer-sponsored coverage, you should learn how your benefits work together.

If you get Original Medicare coverage, you can get Medicare Part A, which usually has no monthly premium, and both Parts B and D, which do have monthly premiums.

If you have private coverage that covers the same things Parts B and D cover, you can choose not to get them so that you don't have to pay their premiums. But it's important to make sure you won't have problems later:

• Before you decline Part B, ask your employer-sponsored coverage to see if you would have to pay monthly penalties if you sign up for Part B in the future.
• Before you decline Part D, ask if your private insurance is considered creditable coverage by Part D. If it isn't, you would have to pay monthly penalties for Part D if you sign up later. If you have any questions about this, contact MMAP, Inc..

Learn more about Medicare.

How to Sign Up

Talk to the employer’s Human Resources department to learn how to sign up. An employer may offer more than one plan and usually there are trade offs between them. For example, one plan may require you to pay a higher monthly premium, while another may require you to pay higher copayments when you visit a doctor.

Sign up for coverage when it is first offered; otherwise, you may have to wait until the annual open enrollment period, which is usually near the end of the year. Certain changes in family or coverage status may trigger a special enrollment period. For example, if you get married or have a child, your new spouse or baby will be able to sign up with your employer-sponsored coverage without waiting until open enrollment.

If You Have to Stop Working Temporarily

In certain situations, you may be able to leave your job for a while, but keep getting your employer-sponsored coverage until you return to work.

If you work for any government agency or for a private employer with 50 or more employees, the Family and Medical Leave Act (FMLA) lets you take up to 12 weeks of unpaid leave per year for certain family and medical reasons, such as the birth of a child or to care for a sick family member. During this leave, your employer must continue to offer the same health coverage at the same cost as you would get while working. Learn more about the FMLA.

If you serve in the uniformed services, the Uniformed Services Employment and Reemployment Rights Act (USERRA) protects your job and health coverage for up to 24 months while you are serving. Learn more about USERRA.

COBRA

COBRA lets most employees and family members keep getting the same health plan they got through an employer after losing employer-sponsored coverage.

How long you can get coverage through COBRA depends on your situation. No matter what though, you have to pay the entire premium for COBRA, including any amount that your employer paid in the past. Your plan could be a lot more expensive than you realize.

COBRA used to be important because it was so hard for individuals, especially people with disabilities, to get an individual insurance plan. Now, HealthCare.gov makes that much easier and often much cheaper. That said, there are times when COBRA might make sense, like if you’ve already paid the full deductible or out-of-pocket maximum for the year with your employer-sponsored coverage.

The bottom line: Do not sign up for COBRA without comparing it with your other options.

Learn more about COBRA.

Is Individual Coverage Right for You?

With individual coverage, an individual or family pays a monthly premium and the plan agrees to pay some of the costs of approved medical services when needed, including preventive care, lab tests, surgery, or prescription drugs. If you have low to moderate income, the government may help you pay for your monthly premium and get a plan with lower copayments.

Answer the questions on this page to see if it might make sense for you to get individual health coverage. If it does, sign up using HealthCare.gov, the easiest place to comparison shop for an individual plan and the only place where you might be able to get help from the government to pay for your private insurance.

Do You Have Any Better Options?

If you can get Medicaid, Medicare, or employer-sponsored coverage, you don’t qualify for government help to pay for an individual plan. That means they are usually a better choice than getting an individual plan, because they cost less.

Can You Get Medicaid?

Medicaid is a government health program for people with low income. It’s a great program that usually has no monthly premium and copayments for services that are usually much lower than copayments required by individual plans. Also, Medicaid may cover some services that an individual plan doesn't cover.

If you can’t get Medicaid, individual coverage might be a good option for you.

You may qualify for Medicaid if you are in one of these situations:

• Your family’s income is at or below 138% of the Federal Poverty Guidelines (FPG) ($21,597 per year for an individual; $44,367 for a family of four). The income limits are higher if you are 18 or younger or are pregnant. There are no limits to how much money or other resources you have. Learn more about income-based Medicaid.
• You have a disability or are elderly:
  • Medicaid for people with disabilities and seniors may offer additional services, but has more eligibility requirements, such as having a disability, having low resources, and different income rules. (If you get Supplemental Security Income (SSI) benefits, you qualify automatically.) Learn more about SSI-related Medicaid.
  • Freedom to Work lets people with disabilities who make more money than the income limits for other types of Medicaid get Medicaid coverage. However, you may have to pay a monthly premium. Learn more about Freedom to Work.

Can You Get Medicare?

Medicare is a government health program for seniors (65 years old or older) and people with disabilities. To get Medicare coverage, you or a family member must have worked for a certain number of years and met other eligibility rules.

If you get Medicare, you cannot get government help to pay for an individual health plan. You can still buy an individual plan through HealthCare.gov, but you have to pay the entire premium yourself. Note: If you get Medicare and want more coverage than it offers, look into Medicare Advantage or Medicare supplement policies. HealthCare.gov does not offer these.

If you can’t get Medicare, individual coverage might be a good option for you.

Can You Get Employer-Sponsored Coverage?

Many employers offer private health coverage as a job benefit for employees, their children until they turn 26, and their spouses. If your employer offers you health coverage that would cost you less than 9.02% of your household’s income and that coverage meets a certain benefits level, you won't qualify for government help paying for an individual plan. If you can get employer-sponsored coverage, but sign up for an individual plan anyway, you will have to pay the full premium.

Note: Before 2023, the spouse or children of an employee would not qualify for subsidies on HealthCare.gov if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." This changed starting in 2023. Learn more about affordability rules for family members and how it affects eligibility for tax credits on HealthCare.gov.

If you can’t get employer-sponsored coverage, individual coverage might be a good option for you.

When an Individual Plan Is Your Best Option

You should get an individual plan through HealthCare.gov if you cannot get health coverage from:

• Your job
• Your spouse’s job
• Your parent’s job
• Medicaid, or
• Medicare.

The government may make your individual plan more affordable if you cannot get health coverage from any of the above options:

• You may get a tax subsidy to help pay your monthly premium.
• You may also qualify for a plan with lower expenses, such as smaller copayments, if your family’s income is at or below 250% of the Federal Poverty Guidelines (FPG) ($37,650 for an individual; $78,000 for a family of four).

Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

When HealthCare.gov looks at your income, they count most of your earned and unearned income. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.

Try HealthCare.gov's health plan directory.

Health Coverage Income Limits for Your Family

Your family size:	123456789101112
Income limits for your family:
	$15,650
	$5,500
	$15,060
	$5,380
Income-based Medicaid, adults (138% FPG)
Healthy Kids (195% FPG)
MIChild (217% FPG)
Subsidized private plans, reduced fees (250% FPG)
Subsidized private plans (no income limit)	--
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules. Notes: Some types of income do not count against these limits, including SSI benefits. Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG). For private plans with subsidies, your monthly premium amount depends on your income.

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How to Sign Up

HealthCare.gov is a one-stop shop where you can compare plans and figure out which is right for you. And it is the only place where you can get government help to pay for your individual plan.

Start out by comparing your options so that you can make an informed decision when you are ready. If you find HealthCare.gov confusing or think there is a mistake, get help by calling HealthCare.gov at 1-800-318-2596 or 1-855-889-4325 (TTY) or get local help.

Open Enrollment

Open enrollment for individual plans has ended for this year. People in certain situations can still sign up for a health plan under special enrollment rules.

Usually, you can only sign up for an insurance plan through HealthCare.gov during a specific time called open enrollment:

• To get an individual plan that covers you during 2025, you must sign up between November 1, 2024 and January 15, 2025.
• If you do not sign up during that time, you are not usually allowed to sign up for an individual plan through HealthCare.gov until another year has passed.

Special Enrollment

You can sign up for an individual plan through HealthCare.gov even though it is not the usual open enrollment period if:

• Your household income is at or below 150% of FPG
• You lose other health coverage you had
• Your income changes and you gain or lose eligibility for government help paying for your coverage
• You become a legal resident of the U.S.
• You move
• There was a mistake in your enrollment, or
• In other life-changing circumstances, such as having a child or getting married.

Note: American Indians do not have these restrictions on enrollment.