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Health Care Reform – SSDI and Medically Needy

Authored By: Northwest Justice Project LSC Funded
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5184EN - If you do not have health insurance or your health insurance does not cover the care you need, you may have new options under the Affordable Care Act, the federal health reform law.

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Introduction

If you do not have health insurance or your health insurance does not cover the care you need, you may have new options under the Affordable Care Act, the federal health reform law. Our publication called Health Care Reform – General Information has more information.

I get Social Security Disability Insurance (SSDI), I do not get Supplemental Security Income (SSI) and/or I have Medicaid with a Spenddown (Medically Needy Program). What will health care reform mean for me?

Currently, if you have gross income above $710 per month, you can only get Medicaid after you have enough health care bills to meet a "spenddown" amount. The publication called The Medically Needy "Spenddown" Program has more information on spenddowns.

Health care reform may change your options.

If your income is at or below 138% of the Federal Poverty Level, you are under age 65, and you do NOT qualify for Medicare, you may be able to get health care coverage through Medicaid Expansion. Our publication called Health Care Reform – Medicaid Expansion has more information on Medicaid Expansion.

You may want to keep getting coverage through the spenddown program. You should compare the costs (Medicaid Expansion is free) and the benefits available under both programs. (Medicaid Expansion does not include certain services for persons with disabilities.)

If your income is above 138% of the Federal Poverty Level and you do NOT qualify for Medicare, you may be able to get health care coverage through a Qualified Health Plan. Our publication called Health Care Reform – Qualified Health Plans has more information. If you prefer, you can keep getting coverage through the spenddown program. Qualified Health

Plans may cost less, but they may have different benefits than your current spenddown coverage.

If you qualify for Medicare, you do not qualify for Medicaid Expansion or for a Qualified Health Plan.[1]  You can keep getting coverage through the Medically Needy spenddown program and Medicare Savings Programs.

Examples:

Sally is 33 years old. Her income is $800 SSDI per month. She has been on SSDI for six months. She is not yet eligible for Medicare. Here are her options: 

  • Sally can apply for Medicaid through Healthplanfinder. She should qualify for Medicaid Expansion coverage at no cost.

  • If Sally receives medical services that Medicaid Expansion does not cover, she can apply for the Medically Needy spenddown program and find out whether the cost of the services would be greater than her spenddown. If so, she may choose to switch.

Tim receives $1700 per month from a pension. He is 62. He is not yet eligible for Medicare. Here are his options: 

  • Tim can apply for a Qualified Health Plan through the Health Plan Finder.

  • If Tim has out-of-pocket medical expenses even though he has a Qualified Health Plan, he can apply for extra coverage through the spenddown program.

Ethel and Sam are married. They are both 70 years old. They get Social Security Retirement. They have Medicare coverage. Here are their options: 

  • Since Ethel and Sam are over age 64 and on Medicare, they do not qualify for Medicaid Expansion or for a Qualified Health Plan.

  • If they have out-of-pocket medical expenses that Medicare does not cover, they can apply for extra coverage through the spenddown program.

  • They may also qualify for a Medicare Savings Program.

How can I apply for coverage?

You can apply for coverage through Healthplanfinder online at www.wahealthplanfinder.org, by phone at 1-855-923-4633 (1-855-WAFINDER), or by requesting a paper application from Healthplanfinder or from your local DSHS office. If you go online, be sure to go the correct website (www.wahealthplanfinder.org).

What if I need help applying or understanding my options?

If you need help applying for coverage, call an In-Person Assister for free help. You can find a list of In-Person Assisters at WashingtonLawHelp.org.

What if I need legal help?

CLEAR is Washington's toll-free, centralized intake, advice and referral service for low-income people seeking free legal assistance with civil legal problems. 

  • Outside King County: Call 1-888-201-1014 weekdays from 9:10 a.m. until 12:25 p.m. CLEAR works with a language line to provide free interpreters as needed to callers. If you are deaf or hard of hearing, call 1-888-201-1014 using your preferred TTY or Video relay service.

  • King County: Call 211 for information and referral to an appropriate legal services provider Monday through Friday from 8:00 am – 6:00 pm. You may also call (206) 461-3200, or the toll-free number, 1-877-211-WASH (9274). 211 works with a language line to provide free interpreters as needed to callers. Deaf and hearing-impaired callers can call 1-800-833-6384 or 711 to get a free relay operator. They will then connect you with 211. You can also get information on legal service providers in King County through 211's website at www.resourcehouse.com/win211/.

  • Persons 60 and Over: Persons 60 or over may call CLEAR*Sr at 1-888-387-7111, regardless of income.

 

Footnote:


1. If you get Medicare, but you have to pay more for your Part A coverage because of your immigration status or because you have few work quarters, you can buy a Qualified Health Plan through Healthplanfinder. You probably cannot qualify for subsidies or cost-sharing reductions.

 

5184EN

This publication provides general information concerning your rights and responsibilities. It is not intended as a substitute for specific legal advice.
This information is current as of October 2013.

© 2013 Northwest Justice Project — 1-888-201-1014
(Permission for copying and distribution granted to the Alliance for Equal Justice and to individuals for non-commercial use only.)

Last Review and Update: Oct 24, 2013
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