A collection of frequently asked questions about Medicare – answered by the editors of healthinsurance.org and guest experts on Medicare issues.
By Jan Greene, Contributor
Medicare Resource Center
Health writer and Medicare Resource Center contributor Jan Greene responds to a question submitted by one of our readers.
When it comes to folks like your grandmother, one patient advocate, Katalin Goencz, puts it this way: “They (immigrants over 65) have no options. Insurance companies don’t sell policies to them. They can work for a large corporation or enroll in Medicaid.”
And it’s true: The individual insurance market isn’t promising. But there actually are options, and they depend on factors such as your grandmother’s income and – to a large degree – the state where you live:
An obvious question is whether your grandmother would be covered since she’s over 65. If your grandmother was a U.S. citizen – and if she had been paying payroll taxes for 10 years – she could expect coverage from Medicare, as most Americans do at age 65. (Folks who have paid into the system don’t have to pay a premium for Part A.)
But your grandmother obviously hasn’t been paying into the system. What’s more, Medicare regulations stipulate that she needs to have been lawfully admitted for permanent residence and have resided continually in the country for five years before she’s eligible to enroll.
Then, upon becoming eligible after five years, she’d still have pay for the Part A and Part B premium since she wouldn’t have the Social Security work credits. Part A and Part B premiums added up to $557.50 per month in 2010.
A 1996 welfare reform law stipulates that immigrants must have five years of legal U.S. residency to become eligible for federal benefits such as Medicaid. The good news is that some states decided to not adhere strictly to that rule, and they provide coverage through state dollars for those who meet specified income standards.
In 2004, 23 states used state funds to cover immigrants who had been ineligible because their immigration status – including the fact that they had resided in the United States for less than five years. Some states have made decreases in that coverage because of budget pressures, but it’s still worth checking with your state Medicaid office.
It’s possible you can find individual health insurance for your grandmother on the private market, though the number of companies willing to sell coverage to an elderly person may be limited. Patient advocates say few major insurers are interested in selling coverage to people over 65 because of their high health risks.
“There are so few people who are ineligible for Medicare that I can not think of any insurance carriers that offer coverage to individuals over age 65 without Medicare,”says Mary Kesel, president of Benefit Advocates, a firm that provides health and benefits advocacy services to individuals and businesses.
In some states, companies simply won’t sell policies to anyone over age 65. If companies do sell to seniors, it’s likely that the monthly premium would be high, in the range of $800 to $1,200 per month.
Immigrants will find no shortage of links to special “inbound-immigrant” policies by doing a simple Web search such as “immigrant health insurance” or “health insurance options for immigrants.”
These policies provide health insurance for recent immigrants for a limited period of time – usually five years or less. The policies may focus on emergency benefits and may have a maximum benefit of $50,000 or $100,000 or daily limits on expenses like hospital stays.
Buyers should definitely be on the lookout for exclusions, including not only pre-existing conditions, but a long list of exams and treatments one might otherwise expect under individual coverage.
Even if you have health insurance coverage through your employer, you can’t add your grandmother as a dependent. However, some families that own and operate a small business actually hire their older family members as employees so they can offer them health benefits.
Bear in mind that premiums would still likely be expensive, and a major health expense for Grandma could drive up premiums for the entire group.
More than 30 states currently operate high-risk insurance pools for individuals who have been denied health coverage by insurance carriers due to a pre-existing condition. In addition, the federal government launched a temporary high-risk insurance pool program – the Affordable Care Act’s Pre-Existing Condition Insurance Plan (PCIP) – in 2010.
Both risk pool programs offer coverage options for individuals with pre-existing conditions. And at 80, it’s likely your grandmother would have at least one existing health condition.
Eligibility requirements – including citizenship and age requirements – for the state-sponsored risk pools vary by state, so first check whether your state operates a risk pool. The good news is that state pools have no requirement that an individual be uninsured for six months. However, an individual may have a waiting period to enroll due to a pre-existing condition.
To enroll in the PCIP, you need to either be a U.S. citizen or residing in the U.S. legally. (The plan does not require a period of legal residency.) In addition, you must have been uninsured in the United States or abroad for six months and have a pre-existing condition or have been denied coverage because of a health condition.
The PCIP will continue until 2014, when the state health insurance exchanges created by health reform are scheduled to be in place.
Premiums in both programs are likely to be more expensive than the private market, but federal government continues to tweak the PCIP to keep premiums as affordable as possible, so check frequently on rates in your state.
Jan Greene has been reporting about the health care system for nearly 20 years. Her work has appeared in the Los Angeles Times, Health magazine, OnHealth.com and a variety of trade publications for doctors and health care organizations. Jan’s articles for the Medicare Resource Center include “Medicare out-of-pocket costs: Ten Medicare bills you can expect to pay” and “What free preventive services does Medicare offer?”