Annual premium and out of pocket expenses on ACA plan

My Dad, aged 80, is currently on CAPD (Continuous Ambulatory Peritoneal Dialysis) at home (manual dialysis using bags, 3-4 times a day.) Currently he doesn’t have insurance. He is a new immigrant and not eligible for Medicare (has never worked in the US) and possibly not Medicaid as well (he is retired and doesn’t have any income, but he has some assets overseas, though I’m not sure of the requirements and whether he is eligible for some share of cost programs through Medicaid - we are in California, so Medi-Cal.)

His Nephrologist has recommended considering moving to the cycler machine. I’m not sure what it will cost and if we can buy one on cash payment since he doesn’t have insurance currently. Trust it would be covered if we get him on an ACA plan.

What premiums and annual out of pocket expenses can we expect if we can find him an ACA plan? If you have any other suggestions for programs/coverage to look for him, please let me know as well.

Those who are not legally present in the U.S. are not eligible for a health plan on the health insurance marketplace. In California, this is called “Covered California.” However, California Medi-Cal provides limited coverage for emergency care (dialysis is considered emergency care). You might want to that agency to find out if he’s eligible. This page includes information for people who are undocumented.

If he’s not eligible for Medi-Cal, you might want to check with an insurance broker to see if he can buy an individual health plan.

If you have health insurance through your job, you could find out if you can add him as a dependent.

You might want to speak with an immigration attorney to see if there is any way to get him legal status.

If he had Medicare, dialysis clinics are not allowed to charge more for CCPD than CAPD. Without insurance, CCPD might be more costly because it uses a machine. Home dialysis machines and supplies are provided by the dialysis clinic and billed on a per treatment basis once a month. Dialysis clinics generally bill at a commercial rate. Medicare and Medi-Cal require clinics to accept a reduced amount. If he can’t get insurance coverage, you could ask the dialysis clinic if they’d be willing to accept amount that Medicare or Medi-Cal allow them to charge and use his overseas assets to pay for that as long as possible. Maybe before he runs out of money, he’ll be eligible for coverage one way or another. BTW, the dialysis clinic social worker or insurance counselor should be able to advise about coverage options and how to apply.

Thanks for your response.
I should have added that he recently got his green card and SSN. Does that change the response below? Pls let me know. Thanks.

Also he has been in the US since March 2020, and got his green card and SSN in November 2020.

Yes, it does make a difference. I thought you had said he was undocumented. It he now has a green card, he’s considered a “lawful permanent resident.” That makes him eligible to buy a health insurance from Covered California, the state-run Marketplace. He only has until December 15 to enroll so you I suggest you call them ASAP or compare plans and sign up on their website.

Be sure you know what the costs are. The cheapest premiums (Bronze) have the highest out-of-pocket costs. The plans with lower out-of-pocket costs typically have higher premiums. When income is within a certain percentage of the federal poverty level, there can be savings in premiums and out-of-pocket costs. Here’s the page that shows the poverty level for 2020. The 2021 poverty level won’t be published on this website until January or February.

If his income is between 100% and 400% of the federal poverty level, he could pay a lower premium through the “premium tax credit.” The American Kidney Fund has the Health Insurance Premium Program that can help. Talk with the dialysis clinic social worker or call AKF at 1-800-638-8299 to ask about that.

If his income is between 100% and 138% of the federal poverty level and he chooses a Silver plan, he could save money on out-of-pocket costs. You should be able to read about this on the Covered California website.

Coverage through the Marketplace would be better than emergency Medi-Cal which

Under federal law, he will not be eligible for Medicare or full Medicaid (Medi-Cal in California) until he has lived in the U.S. as a lawful permanent resident 5 years. At that time, since he has no work credits, he’d have to pay a premium for Part A and Part B. However, if he’s eligible for the Medicare Savings Program called Qualified Medicare Beneficiary, the state would pay those premiums as well as the Medicare deductibles and coinsurance and copays.

His dialysis social worker or the insurance counselor for the dialysis clinic should know all this.

His household income is less than FPL. Can he still enroll for an ACA plan?

Looks like your comment below did not show up completely in the response, can you pls clarify it? Thanks.

Coverage through the Marketplace would be better than emergency Medi-Cal which

There is no income limit (high or low) so he can apply for an ACA plan through Covered California. It’s just that he’ll pay full price without the premium tax credit or cost saving subsidies for out-of-pocket costs.

Sorry…What I meant to say is that emergency Medi-Cal is not full Medi-Cal and may have limits to what it will cover. ACA plans are required to have a set of basic benefits that include many things that I don’t think emergency Medi-Cal will cover. However, the social worker at your father’s California dialysis clinic should be knowledgeable about California emergency Medi-Cal and what it does and doesn’t cover compared with the ACA plan you think would offer the best coverage for what he can afford with the funds he has.

Thanks for the quick response.
I found a quite well written article focused on new immigrants such as my father which describes this issue in more detail. Takeaway for me is that most likely he should qualify for premium subsidy on an ACA plan.

Here is the relevant quote from the above article:

Low-income, lawfully present immigrants – who would be eligible for Medicaid based on income, but are barred from Medicaid because of their immigration status – are eligible to enroll in plans through the exchange with full subsidies during the five years when Medicaid is not available. Their premiums for the second-lowest-cost Silver plan are capped at 2.07 percent of income in 2021 (this number changes slightly each year).

In early 2015, Andrew Sprung explained that this provision of the ACA wasn’t well understood during the first open enrollment period, even by call center staff. So there may well have been low-income immigrants who didn’t end up enrolling due to miscommunication. But this issue is now likely to be much better understood by exchange staff, brokers, and enrollment assisters. If you’re in this situation and are told that you can’t get subsidies, don’t give up — ask to speak with a supervisor who can help you (for reference, this issue is detailed in ACA Section 1401©(1)(B), and it appears on page 113 of the text of the ACA).

Thanks for sharing this information. I wasn’t aware of it before. I did find the information on the federal government’s website about the Health Insurance Marketplace.

I read about the premium tax credit on the IRS site. There are some criteria he’ll have to meet and he’ll have to file a tax return with the Form 8962 for the tax credit. You can read that here:

I saw on a non-government website that the premium tax credit in 2021 for someone with income below 133% of federal poverty will be 2.07%.

I hope this works out for him. You might ask about cost saving subsidies because out-of-pocket costs in these plans can be high.

Thanks Beth for digging up the details. They are indeed helpful.

Good information thanks for sharing
Fieldengineer