My father is turning 65 in a few months and lives in New York State, USA.
Right now, he's self-employed and enrolled in Essential Plan (through HealthFirst) through NYS Health Exchange. He has $0 premiums and reasonable co-pays and deductibles, etc. He lives around NYC and doesn't usually have trouble finding a doctor in-network.
He doesn't qualify for Medicaid because he was doing ok pre-COVID but has not been so lucky financially since the pandemic.
I've been looking to educate myself on Medicare parts, Advantage Care plans, etc. And he would have to pay more for the premium (anything is more than $0), as well as more for anything else.
My first question is: Is there a way for him to stay on the Essential plan?
My other question is about the Medicare Advantage plan. It's been all over the news how terrible these plans are for patients and how people get denied care, have to stay in strict in-network rules, etc. But is it significantly different than his current plan in terms of needing prior auths and staying in-network?
Lastly, if he were to choose the Advantage Care plan, and later qualify for Medicaid, would that replace his insurance?
US NYS Essential plan vs. Traditional Medicare vs. Medicare Advantage Plan
byu/ikael90 inInsurance
Posted by ikael90
1 Comment
* My first question is: Is there a way for him to stay on the Essential plan?
No, when Medicaid was expanded under the ACA the government offered states an experimental program called a Basic Health Plan to tweak the coverage NOT the demographics. As people over 65 already had different rules for Medicaid, including asset caps and home recovery rules, dating back to the 1990s they were not included.
E.g. the payment structures can be different, states can add more funds to raise the income limit, as NY did, but NOT add people outside the limits of Federal Medicaid.
NY actually opted to suspend their Federally-designed BHP but keep the funds under an expanded waiver, which the feds only agreed to with this clause.
>The 1332 Waiver will allow New York to expand the Essential Plan beyond the statutory population, reaching New Yorkers with incomes up to 250% of the FPL who would otherwise be eligible for subsidized coverage on the marketplace.
[NY BHP Suspension Application_11.13.2023 (medicaid.gov)](https://www.medicaid.gov/basic-health-program/downloads/ny-bhp-suspension-app-mar-2024.pdf)
I.e. you have to otherwise be eligible for subsidies on New York State of Health, which those eligible for Medicare part A are NOT to stay on the Essential Plan.
HOWEVER:
NY has some state-run Medicaid programs, such as those that cover DACA and recent immigrants, which might work for the over 65s.