Losing one’s health insurance is a “life qualifying event” for special enrollment. However, losing one’s job is not. Given that most of workers’ compensation clients are required to resign as a condition of settlement, they would then be eligible to purchase insurance through the Marketplace if they had health insurance with their prior employer. Since most of our clients have already lost their health insurance coverage during the pendency of their claim, they would have to wait until open enrollment to purchase health insurance through the Marketplace.
The most an individual can be charged for health care in 2014 for a marketplace plan is $6,350, and the most a family plan can cost is $12,700, exclusive of the premiums. We can consider these caps when advising our clients what their yearly maximum health care cost would be. Even though they may not be eligible for a subsidy, they are eligible to purchase insurance through the exchange, which is subject to the out-of-pocket cap. If the settlement is high enough, the client can set aside sufficient funds for payment of future medical expenses.
Another thought is to have the client estimate how much money he or she will earn following a workers’ compensation settlement. If the client estimates being able to get a $10/ hr job, then he or she can estimate 2014 income at $20,800 and receive the cost sharing reduction subsidy. Because these subsidies are not reconciled on the following year’s tax return and do not need to be repaid, this may be a way of securing affordable health care while trying to secure post-settlement work. (Remember cost sharing reduction subsidies are only available to those who earn between 100 to 250 percent of FPL.)