Speak with a Covered California certified agent! Call (888) 413-3164 or Shop Online Now

Shop and Compare

California Health Insurance Plans and Rates

It's easy. Just enter your zip code.

Covered California Q&A

Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.


APTC over 65?

By on | 11 Comments

Question: Can a person over 65 receive APTC?

Answer: Usually not, because most Californians over age 65 are covered by Medicare wich is considered Minimum Essential Coverage (MEC). Applicants who are eligible for MEC are not eligible for financial assistance unless they fall in this exception: If an applicant is eligible for Medicare part A coverage requiring payment of premiums, but is NOT enrolled in the program at the same time he or she enrolls in a Covered California plan (i.e., no dual coverage) will be eligible for financial assistance.

11 Comments

You’re welcome, Phil.

Let me clarify a couple of points. When the ACA regulations first came out in 2012, the discussion on the issue of eligibility for Minimum Essential Coverage (MEC) was incomplete. The 2013 IRS ruling (despite its awkward presentation) clarified how MEC eligibility would be defined in certain situations (including those who have to pay for Medicare Part A).

Covered CA and other marketplaces used this 2013 ruling to issue clarifications. The document that I linked from lisibroker.com was not a Covered CA document per se but rather a private broker’s consolidation of information that it received from Covered CA. I used it because of its clear layout, but if anyone wants to cite a reference on the Covered CA website itself, go to the answers on this FAQ:

http://www.coveredca.com/FAQs/Tax-Credits/

Covered CA also provides more detail on its pages for people under “special circumstances” including Medicare, students and so on at this page (click on the links on the right):

http://www.coveredca.com/individuals-and-families/special-circumstances/

Fred, Thanks for your comment. Our discussions on the APTC over 65 issue have until now been anecdotal. We have been looking for an authoritative source on this issue. I did not find the IRS.gov link you supplied helpful, but the link to the lisi.com FAQ, (that you attribute to Covered California) nails it. Here is the section that applies.

“MEC - Minimum Essential Coverage: Applicants who are eligible for MEC are not eligible for financial assistance unless they fall in the exception described below. MEC includes, but is not limited to, government-sponsored coverage, such as Medicare or Medi-Cal, and employer-sponsored coverage that is both affordable and covers at least 60% of the costs of the benefits provided to the employee. However, there is an exception to this general rule. If an applicant is eligible for any of the following MECs but is NOT enrolled in the program at the same time he or she enrolls in a Covered California plan (i.e., no dual coverage), the applicant will be eligible for financial assistance, if otherwise eligible. The MECs that fall under this exception include: 1. Medicare part A coverage requiring payment of premiums. Coverage offered under Medicare for which the individual must pay a premium for Medicare part A coverage. 2. State high risk pools. Health coverage offered by the State under a qualified high risk pool, such as MRMIP (Major Risk Medical Insurance Program). 3. Student health plans. Self-funded health coverage offered by a college or university to its students. 4. Certain TRICARE programs. Coverage under the following TRICARE programs: (a) The Continued Health Care Benefit Program; (b) Retired Reserve; (c) Young Adult; and (d) Reserve Select. 5. Coverage for Veterans (VA plans). 6. COBRA coverage. “

The answer is yes, people over age 65 who do not have minimum essential coverage (MEC) can still receive both advanced premium tax credits (APTC) and cost-sharing reduction (CSR) if they meet the income requirements.

Most people age 65 and older are eligible for premium-free Medicare Part A (as part of their social security benefits) or Medi-Cal, both of which constitute MEC. But some people are not eligible for either (I know people who will be in this position and I myself could have fallen in this category had I taken my early retirement a few years earlier). Persons not eligible for premium-free Medicare Part A can BUY premium Part-A (subject to citizenship and residency requirements), but if they choose not to do so they will NOT be considered to be eligible for MEC. As long as they do NOT buy premium Part-A Medicare, they can simply keep their Covered CA policy after they turn 65 and keep any APTC and CSR they are currently receiving.

The policy stating that a person is NOT considered eligible for MEC unless they apply in certain circumstances (including those who choose not to buy premium Part-A) was spelled out in this publication:

http://www.irs.gov/pub/irs-drop/n-13-41.pdf

The policy was also included in the last page of this Covered CA document:

http://blog.lisibroker.com/wp-content/uploads/2013/12/Covered-CA-Individual-Lead-Program-FAQ.pdf

The policy is also explicitly addressed in the FAQ Download on this page for prospective Medicare enrollees (this FAQ also addresses the very complicated matter of delaying social security benefits and Medicare in order to continue on a marketplace such as Covered CA past age 65):

http://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Overview1.html

I have an immigrant client over the age of 65, also eligible for Medi-Cal based upon household MAGI, where Medi-Cal denied coverage, and where Covered California insisted this client was/is eligible for, and was provided, a health plan WITH tax credit subsidy.

Steve, I would prefer an authoritative source like healthcare.gov, Covered California, or the IRS.

How’s Kaiser Foundation? http://kff.org/health-reform/faq/health-reform-frequently-asked-questions/#question-i-entered-the-u-s-lawfully-and-im-over-65-but-i-dont-qualify-for-medicare-can-i-apply-for-coverage-and-subsidies-in-the-marketplace-i-hear-premiums-can-be-higher-based-on-age-ho

Craig, you can get your Covered California questions answered here and sometimes (depending on the question) only here. But you should also call Covered California. They’re in the book.

David, if a person is currently ineligible for Medicare because they are still within the 5 year waiting period for eligibility, they may purchase coverage through CC at the age 65 rate but they are not eligible for APTC.

Steve, a link to your own website does not constitute a “citation”.

If I have any questions regarding CC, do I submit them here.

Thanks,

Craig

I believe there is a narrow exception to this rule if they person is currently ineligible for Medicare. Usually a recent immigrant still within the 5 year waiting period for eligibility.

Leave a comment

Do You Have California Health Insurance Questions?

Ask An Expert

View Previous Questions
Call Us at (888) 413-3164


© 2019 California Health Benefit Advisers, LLC
Home / About / Start Shopping / Ask a Question

“Covered California,” “California Health Benefit Exchange”, and the Covered California Logo are registered trademarks or service marks of Covered California, in the United States. This web site is owned and maintained by California Health Benefit Advisers, LLC, which is solely responsible for its content.