‘Medicaid gap’ leaves some Pennslyvanians frustrated amid final push for ACA signups

The last minute push to get people signed up for health coverage through the Affordable Care Act has generated excitement among those who are now able to purchase affordable insurance for the very first time.

It has also created a cloud of confusion for some low-income residents in Pennsylvania.

That’s because tens of thousands of people fall into a so-called “Medicaid gap” in Pennsylvania. They don’t qualify for Medicaid or for discounts on insurance offered through the federal marketplace.

Nicole Wimbush, a 39-year-old resident of Philadelphia falls into the gap. She initially sought coverage through the Affordable Care Act after hearing that options might be available for people like herself.

“And I have quite a few health issues going on, and it’s getting very costly,” she says.

Wimbush then learned she is not eligible for low-cost coverage in Pennsylvania. She didn’t earn enough to qualify for financial help through the federal marketplace. Nationwide, subsidies are only available for people with incomes between 100 and 400 percent of the federal poverty level, but not below.

Under the Affordable Care Act, states also have the option to draw down generous federal funding to expand Medicaid, to include childless adults and those with incomes up to about 133 percent of the federal poverty level, like Wimbush.

New Jersey and Delaware have enacted an expansion, effective last January. But Pennsylvania’s governor is seeking federal approval for an alternative plan.

Adding to Wimbush’s confusion, she had applied for medicaid, was denied and then received a state notice that she was being referred to the federal marketplace, where she may qualify for affordable coverage. A spokesperson with the state’s Department of Public Welfare says states are required, under the ACA, to refer people who may be eligible for coverage to the marketplace.  

Area groups tasked with helping people through the ACA application process one-on-one have reported regular encounters with those who fall in this Medicaid gap and who may leave their appointments frustrated.