By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
August 15, 2024
Watch the video: https://youtu.be/rOeHiS_TaiE
Turning 26? Happy Birthday and Congrats!
But do you know how this impacts your health insurance coverage? Do you know what to do about it? Here are some answers, and tips.
A. Up to age 26
1. A dependent child can stay on a parent’s plan until they turn 26, and even if:
· That child gets married
· Or has a child themselves
· Is a student
· Lives with the parent, or not
· Are or are not claimed as a dependent on the parent’s tax return
· Has a job but did not accept the company’s plan
2. Notice of loss of coverage
An employer and its insurance will notify the parent/subscriber that the dependent’s 26th birthday is about to cause them to drop off. Some policies will cancel coverage on the last day of the month of the dependent’s birthday. Other plans, including those through the ACA Marketplace, will cancel coverage on December 31 of that birthday year.
B. What to do?
The one solution is to get a separate policy for that dependent.
1. Dependent is eligible for a “Qualifying Event” to buy a plan
· Turning 26 and losing coverage is a personal and financial circumstance that makes the dependent eligible to enroll in a policy outside of the yearly Open Enrollment Period
· The Open Enrollment Period covers the time period, usually at the end of the year, when people can renew, enroll into or change plans for the following year
· The dependent can therefore enroll in a policy on the open market (i.e through an insurance agent), buy an ACA Marketplace plan, or purchase a catastrophic policy at any time of the year when their birthday is. A catastrophic plan with low monthly premiums and a very high deductible, is for those under 30 who would primarily use medical services in case of emergency.
· This dependent can also claim COBRA coverage for continued coverage of the current plan for 18 months (sometimes 36).
2. Other group coverage
· If employed, the dependent can also join their own company’s health plan if offered
· The dependent can join a spouse’s company health plan, if available
3. Student insurance
· A number of private insurance companies – such as United HealthCare or Aetna – offer student insurance coverage.
· Each school has a specific plan, which the dependent should be able to enroll in, due to the Qualifying Event
· The school administration will provide details and application
4. COBRA
· This is the program which might unable the dependent to apply for continuation of the parent’s current coverage – though under their own name – for 18 (sometimes 36) months
· The dependent would need to apply, and pay the full monthly premiums plus a small administrative fee
· The parent’s employer will stop any financial contribution toward premiums, and adjust the parent's policy accordingly.
· This is a federal and state joint program that covers individuals with limited income or medical needs such as pregnancy or disability
· Medicaid coverage can also help a dependent with medical needs causing high medical expenses but whose income might be too high to qualify for Medicaid
· Every State sets their own criteria for eligibility
C. What to know
1. Know your plan options:
· HMO : plan with a limited list of local providers, with services subject to PCP approval
· PPO: plan with larger network, easy free access to providers, but usually more expensive
· EPO: same as PPO, except with a very limited network of contracted providers, and often without benefits or coverage when outside the network
· Catastrophic: plan with a very high deductible and low premiums, best used for emergency only
2. Consider all factors:
· Budget: A high deductible plan should be considered if one prefers low monthly premiums, but best if medical care is no often sought. The deductible is the amount the plan member must pay before the insurance
· HSA/HRA option: some plans with high deductibles could allow for the dependent to start a HSA or HRA account to help pay the high share of cost and medical expenses. While a HSA account belongs to the individual, and carries over from job to year, the HRA reverts to the employer if unused at the end of December. Contributions are pre-tax and would be made either by the dependent (HSA) or the employer (HRA) or both.
· Health status: the healthier you and your lifestyle are, with the lowest risk factors, the more interesting should a high deductible plan be. If you are currently under treatment, anticipate medical services in the near future, or have an unhealthier lifestyle, low deductible/high premiums plans might be more interesting.
· COBRA premiums are likely to be higher than for a similar plan. But if you already met your share of cost this year, it might make sense to use COBRA to reduce your costs until the end of the year, as a new plan would mean new deductible and share of cost to meet.
· ACA Marketplace: plans offer subsidies and savings to help reduce costs, especially if low income.
D. Pay attention!
1. Stay timely!
· The dependent has 30 days form the day of losing coverage to sign up for a plan through an employer, theirs or a spouse’s
· The deadline to sign up for COBRA is 60 days
· The deadline to enroll in a Marketplace plan is also 60 days
2. Tax consequences
· If the dependent is claimed as a legal dependent on someone’s tax return, they are not eligible for subsidies on a Marketplace plan
· HSA contributions are limited by the IRS, which release a list of medical expenses that can be paid using HSA or HRA funds
3. Reach out!
· Your parent’s HR dept should help you determine COBRA benefits and pricing
· Your HR dept – and/or your spouse’s – can help explain what insurance plans may be available, and at what cost
· Your school student admin can help you enroll in the school’s student plan
· Insurance agents can help determine what plans are available on the open market, and at what price
· Navigators at Healthcare.gov and in your State’s ACA Exchange – if your State has one – are vetted and trained to help you find the best plan at the best price. Their services are free of charge
· Your State’s Medicaid agency can provide details on eligibility, and help you apply for coverage.
While this matter may not have been a concern until now, with your parent or their employer likely paying for premiums, and claims being handled outside of your direct attention, turning 26 is a big step in the world of health insurance coverage.
As for everything in this landscape, some preparation, reaching out for answers and some advance detective efforts should make the process easier, and the results bring about better health, clinical and financial.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024
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