If someone took a worker’s compensation settlement several years ago, will an Obamacare health plan take over coverage for that injury under the pre-existing clause?


Answer

Worker's comp doesn't counts toward ObamaCare subsidy eligibility, as it's not taxable. You can switch to an ObamaCare plan when worker's comp ends.

Worker's compensation is not taxable by the state or federal government, however there is one lone exception: individuals who also receive disability benefits through Social Security disability insurance (SSDI) or Supplemental Security Income (SSI) may have their benefits reduced so that the combined amount of the workers' comp benefits and the disability payments remains below a certain threshold. This is called the workers' compensation offset.

No matter what time of year it is, if a health plan provided by worker's comp ends you can switch to a Marketplace plan with cost assistance via special enrollment (you have a 60 day window once the plan ends).

If worker's compensation is not providing health coverage, and is just reimbursing you for medical costs you may have to wait until next open enrollment to get covered unless you qualify for another special enrollment opportunity. You can always contact HealthCare.Gov for help.

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Cathy on

If an individual was on workers compensation income is non taxable. How does that effect obama care? The only thing workers compensation paid for medically is the involved injury but was not allowed to return to work. Therefore income was not taxable but they continued to pay premium for Obama Care.

ObamaCareFacts.com on

Thank you so much for the feedback.

This answer has been updated to clarify: Worker’s compensation is non-taxable and thus does not affect ObamaCare’s tax credits or out-of-pocket cost assistance. Even someone who got this wrong during the year can adjust it on their taxes using the correct forms and claim the credits in retrospect.

Tonia on

What forms due to acceptance for Obama Care during Workers Comp.assistance can you fill out, please id like to know?Or are you just responsible for the premium tax credit?

ObamaCareFacts.com on

If you want to enroll in a ACA plan and have access to workers comp the best thing to do is call the Marketplace. They will direct you to any information you need to have to be approved.

Martha LaCombe on

I have workers’ compensation for a back injury. I did have COBRA until August because failure to keep up premium payments and have been dropped by COBRA, will I be penalized under the affordable healthcare act?

ObamaCareFacts.com on

So typically when you lose COBRA you can use “special enrollment” to switch to marketplace coverage. However, not paying a premium is generally going to be the only type of coverage loss that doesn’t qualify you for special enrollment. Luckily, if this happens during open enrollment you can simply enroll in a new plan.

Open enrollment for 2016 coverage ends January 31st, 2016.

Lola Bare on

My husband worked 28 years in upper management & as a long haul trucker. In those 28 years, he was absent 3 times. He had always made sure our entire family had the best medical coverage available. Then in 2013, he suffered a severe traumatic back injury losing his income & all his insurance. He now receives Worker’s Comp.payments & he can’t get regular medical insurance due to his injury. My husband saw Obama Care as his last best chance at good medical coverage. At long last… Obama Care became available & he was the first in line to sign up. Obama Care’s answer to my husband was, no insurance was available to him because he didn’t work & NC Medicaid is not available to him because he made too much money through Workman’s Comp. If he gets sick or breaks a bone, on top of his permanent injury, he will lose everything. If he pays the prices that Obama Care or any other insurance company charges to get basic insurance just for himself, he loses everything! What can he do? Please help us with any answer you or anyone else might have available. Is there something we are missing? Wasn’t Obama Care suppose to consider & help everyone?

ObamaCareFacts.com on

This is due to your state rejecting Medicaid. ObamaCare expanded Medicaid, state rejected because Democrats and Obama are bad (something like that, I forget the logic). We get to hear stories every day about people suffering because of this. Make sure to write your governor and let them know they have jeopardized the livelihood of a hard working family with their political games.

You should check the federal poverty level and see if you can aim to get a plan on healthcare.gov with tax credits.

https://www.medicaid.gov/medicaid-chip-program-information/by-state/north-carolina.html
https://obamacarefacts.com/federal-poverty-level/

Dunked disabled on

Fact, POLITICIANS ARE BAD!
The Retardicans screw us in one position and then the democrats come along and “save” us with another 10 yards of BS! Obamacare oshamacare… All it cared about was how much the big pharmaceutical companies and insurance companies would make on the back end and how much those proposing and pushing it would get in “campaign contributions”.
Another political heave ho, bait and switch!

Ted on

This is a flat out ducking lie..i am on workers comp in nevada and DO NOT qualify for obama care because of it as a fact i do not qualify for any assistance because workers comp pays a measly 66 1/3 of my former income i have lost my house and i am now 45000 in debt. And i get treated like I’m working the system this s^it has taken two years of my life And the only way i can get insurance is to pay full price at 900 a month. .so kiss my ass Obama kiss my ass workers comp all of you are nothing more than clucking profiteers milking the lower middle class for what you can get before we disappear we are this one’s that truly struggle….So get your DUCKING FACTS STRAIGHT and stop screwing real Americans

Ted on

Really you meen my answer is waiting to be edited to make you look better

Dunked disabled on

Ted,
EXACTLY! Political speek for “no one ever suspects us of dirty dealing…
Retardicans and DemoNcrats… Two sides of the same dirty quarter!
One cuts your benefits and starves you out and the other raises false hopes then pulls the rug out from under you! BS…

ObamaCareFacts.com on

That must be really frustrating. No real way to say that so you understand I mean it. However, I think you are misdirecting your anger.

1) Medicaid is expanded in Nevada so if you make less than 100% FPL you should be getting free coverage.
2) Cost assistance covers people from 100% – 400% FPL.

You would have to be making over 400% FPL and that would have to be 66 1/3rd the cost of your previous wages. This is not adding up!!! You should seek help from HealthCare.Gov immediately.

John on

Kudos to you Ted, I feel your pain and frustration, I am in a similar situation and this s*hit
As you say has got to come to an end.

Nicole on

I’m really confused. I have worked for the same company for 10 plus years….I have recently been out on a workman’s comp claim. I have a doctor’s note that says that I’m unable to work and even have a case manager that helps me with appointments. I tried to go back to work, however, it is creating even more pain and do not have another Doctor’s appointment until the end of the month. So now with this pain I’m out for another couple weeks. When I notified my employer, they said that I can only miss 12 weeks in two years or they will have to cut me off of my medical, or they will be sued by Obamacare. Is this true?

ObamaCareFacts.com on

Doesn’t seem true to me. However this is more an issue for the Department of Labor than anything. ObamaCare is a law, it can’t sue anyone. The IRS can penalize you for non-compliance (the mandates), so perhaps that is what they mean. Essentially if you aren’t a full-time employee then they don’t need to offer you coverage (although they still may need to offer you COBRA / Workers comp stuff, that isn’t related to the ACA). Also, an employer CAN offer coverage to part-time employees, they just don’t have to. The fee is for not offering coverage, not for offering coverage to a worker on workman’s comp. So now that makes two of us who are confused. Why not get advice from HealthCare.Gov or even the Department of Labor on this one.

Paula Brady on

In October of 2014 my insurance agent signed me up for Obamacare….she added in my husband’s worker’s comp and social security disability as our only income. I got a note back from my Obama care insurance and they approved of the income. Now I just did my 2015 taxes and have NO income to report and will be receiving back $2124.00 which is a years worth of my paying in to Obama care. I am now in panic mode….I’ve been reading up on worker’s comp, and it’s NOT income…… I got back on Obama care using just Social Security income and qualified for nothing!! insurance premiums through the roof….and told to try Mainecare. Well…Mainecare requires ALL incomes so I don’t qualify for that either……

Now I am at a total loss at what to do….. 🙁

ObamaCareFacts.com on

This is a sticky situation, first check out this page on MAGI to make sure you are counting income right for the Marketplace and Medicaid (you are right there are a few differences). Generally it’s set up so you will qualify for either Medicaid or the Marketplace, but Maine didn’t expand Medicaid so you could be falling in the Medicaid gap.

https://obamacarefacts.com/medicaid-gap/

Paula Brady on

Instead of using my worker’s comp income…..I did try my total benefit of Disability and that worked…..instead of just our monthly direct deposit I used the total from our SSA-1099 which included ALL benefits paid including medicare, pres. drug premiums and worker’s comp offsets. I wonder if that is acceptable income? At least I qualify for tax credits using this figure…..hhhmmm this figure makes more sense as I use it on my 1040A tax form!

Paula Brady on

found this: Does MAGI count any income sources that are not taxed?

Yes. Some forms of income that are non-taxable or only partially taxable are included in MAGI and thus affect financial eligibility for premium tax credits and Medicaid, specifically:
•Tax-exempt interest. Interest on certain types of investments is not subject to federal income tax but is included in MAGI. These investments include many state and municipal bonds as well as exempt-interest dividends from mutual fund distributions. However, some other forms of tax-exempt interest, such as interest earned on an IRA, HSA, Archer or Medicare Advantage MSA, or Coverdell education savings account, is not included in MAGI.
•Non-taxable Social Security benefits. For many people, particularly those with no other source of income, Social Security benefits are not taxable. However, the full amount of a person’s Social Security benefits as indicated on Form SSA-1099 (the Social Security Benefit Statement) — whether or not those benefits are taxable — is included in MAGI.

So I believe I can now get a tax credit for my insurance….seems as though I can claim the total benefits from my 1099…..I need coffee…

ObamaCareFacts.com on

Good finds. It’s not easy compiling all the income and tax related information on the ACA, but we do our best here: https://obamacarefacts.com/modified-adjusted-gross-income-magi/

sheri on

I dont think the representatives for Marketplace health know that, as many are applying and they are accepting applications on Workers Comp. Then what?

ObamaCareFacts.com on

You can see what is and isn’t counted on this page (used the IRS as a source to verify) : https://obamacarefacts.com/modified-adjusted-gross-income-magi/

If you get advanced premium tax credits you shouldn’t have, you owe it back based on your MAGI at the end of the year. You should obviously notify the marketplace in general if you know you are getting too much to save the headache down the road. https://obamacarefacts.com/advanced-tax-credit-repayment-limits/

LogicLone on

I don’t believe that the answer addresses the heart of the question. The question is asking if the ACA allows a health insurance company to deny treatment for work-related injuries after settlement. The question is not asking whether settlement of a workers’ compensation case effects access to Marketplace plans.

There are typically three different exclusions in a health insurance contract 1) exclusions for pre-existing conditions; and 2) exclusions for work related injuries; 3) exclusions when other insurance is primary.

Work related injuries covered by workers’ compensation clearly can be denied while someone has workers’ compensation that is responsible for the treatment, under the 3rd exclusion which would not violate the ACA… However, the question asks about after settlement when the carrier closes your access to the primary medical coverage, can the insurance company still deny your treatment under exclusions against “work related injuries.”

These work related injuries ARE pre-existing conditions; however, in some cases the insurance companies pay large settlements to claimants in order to provide incentive for the closure of their medical benefits.

To restate the question more clearly: “Can a health insurance carrier, regardless of whether the patient qualified for a Marketplace plan, deny payment for treatment that was related to compensable work injury, after the patient accepts a cash payout for closure of future medical coverage under the Affordable Care Act?”

ObamaCareFacts.com on

That was really well stated, thank you. From this frame I realize that I don’t know the answer to this question. If someone does it would be awesome if they answered. I’ll try to research it and update the page in the meantime.

Tina on

Here is the answer that I found… this page, from Healthcare.gov tells what can and cannot be counted. Scroll down and it specifically states that Worker’s compensation is NOT counted in the income:

https://www.healthcare.gov/income-and-household-information/income/

Tinca on

And I am just on the monthly benefits from Workers Comp, but never had Healthcare through my employer… and pay full price for Healthcare.gov plan (NO SUBSIDIES). But, not eligible for Medicaid because GA declined to expand Medicaid as Obama had intended (Georgia’s fault, not Obamacare, because we were intended to be covered).
Worker’s compensation is NOT included…

https://www.healthcare.gov/income-and-household-information/income/

Tina on

Sorry this is in 3 comments…

However, I do qualify for a “hardship exemption” and will not be penalized for not having Healthcare due to the fact that GA declined to expand Medicaid to cover individuals in my situation. BUT… if I want healthcare, I have to pay full price with NO subsidies to help.

ObamaCareFacts.com on

Still 100% right, you should be able to get an exemption with the rejection letter, but that doesn’t help you to afford coverage.

ObamaCareFacts.com on

Right agree. Workers comp not included, so below the subsidy level, state didn’t expand, and thus have to pay full price for coverage. Georgia’s fault. Very frustrating.

ObamaCareFacts.com on

I agree 100%, did I say different? I will double check. Our site shows workers comp isn’t counted for Medicaid or the marketplace? So I confirm this. Thanks for posting.

Paul nelson on

the question is whether a policy issued under the affordable care act covers an injury that was treated under workers comp.

ObamaCareFacts.com on

I would assume yes because there are no more pre-existing conditions. But I don’t like to assume when it intersects with another law (like with VA or workers comp). So you would want to verify this sort of thing.

Jane on

I am a union stagehand and have many employers that pay into my insurance. I must meet a certain amount before I am eligible for medical coverage.
In November of 2014 I broke 7 bones in my ankle and shattered the ankle socket while at work. Workmans comp kicked in and paid for treatment and therapy for my injury. However due to the fact that I could not walk or work (there is no light duty work in my field) I did not receive any contributions to my health plan.
I now have filed my tax return and am being penalized for not having medical coverage.
How is this even fair? The amount that I received from workmans comp was just barely enough to pay rent and utilities .
What can I do so I’m not fined? I live in Arizona.

ObamaCareFacts.com on

That is a confusing situation. You shouldn’t be punished for not having coverage, but this is the problem with basing the fee on income (where you work part of the year and can’t the rest, but lose coverage). The thing to do would likely have been to apply for medicaid when you lost your income source and insurance, if you were rejected then that could have helped trigger an exemption. You can try looking closer at form 8965 to see if you have other exemption options (remember your workers comp counted as coverage for months you had it.)

adrienne hansen on

This answer does not tell me if my Obamacare plan will cover the cost of medical care for treatment for an injury that was work related but settled such that the workers’ compensation carrier’s liability for payment of medical has ended.

ObamaCareFacts.com on

ObamaCare is essentially a program that regulates and offers cost assistance on insurance, so this question is best posed to your health plan. I’m not sure on the specifics.

Timothy Kear on

Does a plan purchased through the standards of the ACA act cover work related injuries for a self employed individual while on the job? Two scenarios may happen:
1)
I work as a carpenter and purchase a ACA qualified plan, I get hurt while working and because of my small business status I do not have work mans com in place because I can’t purchase it on myself. Will my ACA Health Care Plan cover me?
2) I am covered under my spouses ACA plan supplied to our family through my spouses job. I am a self employed Lawn care specialist. Because I work alone I can not put workman compensation in place. Am I covered under my spouses Job Provided ACA qualified plan if I am to be hurt while working?

Dunked disabled on

Fact?
Obamacare was not designed to help those needing help the most.
Period.
When the majority of states provide no help or mandate that an injured, recooperating or disabled worker be provided access to affordable healthcare and don’t provide Medicaid then common sense would expect that Obamacare would step in for those people.
No, no it didn’t.
In fact, as we’ve seen over the last 6 years since Obamacare was thrust upon us, it has only worsened the healthcare dilemma.
The price of prescription medications has risen dramatically as have insurance premiums.
Funny how those needing help the most were left out of the entire process while big pharma and the insurance giants all seem to have had adequate representation and benefitted quite handsomely.
Endgame, American people screwed again!

karen on

What if you are on obamacare and then have to be off work because of workers comp injury, how does that affect you premium. Do you have to notify covered ca or is it just figured out at year end and I just have to keep paying the premium even though not making as much money???

ObamaCareFacts.com on

You should notify the marketplace, subsidies are based on annual income vs. family size, so a month of missed income means more cost assistance (just like more income means less assistance).

In some instances you can end up qualifying for Medicaid and no longer qualifying for subsidies based on lost income. So all things to keep in mind.

The above said, this is why updating them is good. It gives you help in figuring out what to adjust.

Corina Velasco on

If i get a settlement from Workers comp, can i still apply for medicaid and add it as income,

Lottie Mihail on

How does the marketplace do you workman’s compensation is non-taxable income and Medicaid counted as income I’m clueless people in this situation need help hurt can’t work what is one to do I’m not looking for free health care just a break my workman’s comp income does meat the criteria for a subsidy

steve on

“Worker’s comp doesn’t counts toward ObamaCare subsidy ” That pretty much set the tone on what a quality answer it is. Wow

John Covici on

does workmans comp checks and ssi considered as income if one applys for medicaid in the state of new jersey

Sheri on

I’m on Medicaid (expanded in Michigan), unemployed and am currently working on a workers comp case. When I get my settlement, will my Medicaid be affected?

B. on

HI I made $29,932 in 2015 tax return and for 2016 I made $20,162since I’m on workers comp. My question is what Income do I put down since I’m not sure what my income is going to be since I been pulled off work. next year I might not beable to work.

Erin on

You are going to project your income to the best of your ability. If your income projection appears to be off substantially as the year progresses you will want to update the Marketplace to ensure that you are not getting more Premium Tax Credits than you are eligible for. If your income ends up being lower than expected you may be eligible for additional Premium Tax Credits at the end of the year. This is true even if you end up falling below the 100% Federal Poverty Level though falling below 100% FPL may effect your ability to use the Marketplace in the following year. Some state will require you to verify that your income has increased or that it was just a temporary loss of income in order for you to be eligible for the Marketplace in a following year if you fall below 100% FPL. If your state has expanded Medicaid and you fall below the 138% threshold during the year, you can apply at anytime during the year that it becomes clear that you are going to fall under the line.

Larry on

I’m receiving workers comp pay at this time. There will bemail mediation in February to settle on work injury case. After that I will be applying for social security disability. Do I have to sign up for health care? I was denied assistance for affordable care act. What do I do now?

Chris on

My company dropped my Healthcare while I was on workers comp. I won’t be able to afford it until my settlement comes which is after the deadline. Do I qualify for an exemption which will allow me to enroll after the deadline? Will I be exempt from the penalty?

Lina Perez on

I have a client that was on a workers comp claim in 2016, is there an exemption for him not to pay the ACA penalty for no health insurance. Or does he mark that he had health insurance because most medical expenses in 2016 were covered under the workers comp claim.

ObamaCareFacts.com on

So:

According to https://www.irs.gov/instructions/i8965/ch01.html

Minimum essential coverage means health care coverage under any of the following programs. It does not, however, include coverage consisting solely of excepted benefits. Excepted benefits include stand-alone vision and dental plans, workers’ compensation coverage, and coverage limited to a specified disease or illness.

So, oddly enough, it seems like you would not check the box and pay the fee in this case. I feel like there must be an exemption on form 8965, but more than one source is saying no and the 8965 and 8962 instructions seem to confirm they are right (see also: http://www.healthreformbeyondthebasics.org/wp-content/uploads/2014/11/Tax-Webinar-11.04.14-Part-2_Exemptions.pdf)

And it is confirmed again here: https://www.healthcare.gov/fees/plans-that-count-as-coverage/

Jim fair on

I’m on workers comp right now. Can I get Obama care

ObamaCareFacts.com on

You would switch from workers comp to an ObamaCare marketplace plan. You wouldn’t have both at the same time. Workers compensation essentially works as a form of health insurance just like COBRA does. In both cases when your benefit ends you can switch onto a marketplace plan. As for switching early, I’m not sure of the exact mechanics, but you could call healthcare.gov and find out.

Ann on

I have been on Obamacare since 2015
And on silver plan.

I just found out yesterday 9/21/17 that I have been awarded workers comp going back to sept 2015.
What happens to my health insurance for 2016 and 2017?

ObamaCareFacts.com on

Great question, I would have to research the answer to this.

You might want to call HealthCare.Gov or the DOL (Department of Labor) and ask for advice.

The DOL helpline is: 866-OWCP-IVR (866-692-7487), see also https://www.dol.gov/owcp/dfec/fec-faq.htm