Common Pitfalls

In the past, some people found it impossible to find health coverage that was affordable and met their needs. Now, there are more options, and you may qualify for more affordable coverage than you realize.

The exact health coverage that will be right for you will depend on things like your family’s income, whether you have access to employer-sponsored coverage, your age, where you live, and whether you have a disability.

If you have the option of employer-sponsored coverage or public health programs like Medicare or Medicaid, they are probably your best bet.

If you don’t have either of those options, you can get an individual plan through Georgia Access and the government may help you pay for that plan. Note: There is no maximum income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

Note: It is very important to have health coverage, but since 2019 there is no tax penalty if you don't have coverage.

When making decisions about health care coverage and comparing different types of plans, make sure you understand all of the costs of a plan. These costs include:

• Premiums, a monthly amount that has to be paid whether or not you use medical services. If you have employer-sponsored coverage, the employer pays part or all of the premium and you pay whatever the employer doesn’t pay. If you have individual coverage, you pay the entire premium, though the government may help you pay it through tax credits if your income is low enough.
• Copayments, a set amount you have to pay for a covered medical visit or service. The exact amount of the copayment depends on the service you get: medications, visits to specialists, lab tests, X-rays, emergency room visits, and other services can all have different copayment amounts.
• Co-insurance, a set percentage of the cost of a covered visit or service that you must pay.
• A deductible, a set amount of money that you pay out of your own pocket each year before the insurance company will begin to pay for certain covered services, including hospital care, emergency room visits, and brand-name prescription drugs. Once you have paid the deductible, you do not have to pay it again until the next calendar or plan year.

If your employer offers you health insurance, or if you can get health insurance through your parent's or spouse's employer, in most cases it will be less expensive than if you were to buy an individual plan on Georgia Access.

If your employer-sponsored health coverage is affordable, you won't qualify for government help through tax subsidies to pay for an individual plan on Georgia Access. That means if you decide to purchase an individual health plan, you will have to pay the full price of the premium, which will likely be more expensive than the coverage provided by the employer.

In some cases, a plan will be affordable for the employee, but it will not be affordable to cover the rest of their family. In this situation, it may be cheaper for those family members to buy individual plans through Georgia Access (and they may qualify for government subsidies). Learn more about affordability rules for family members and how it affects eligibility for tax credits on Georgia Access.

Note: Before 2023, the spouse or children of an employee would not qualify for government subsidies if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch."

There may be situations where it makes more sense for different members of your family to get health coverage in different ways. Do not feel that just because one member of your family gets a certain plan, the entire family needs to get that plan.

For example, let’s say you work for a company that only offers health coverage for you and your children but not your spouse. You could take the coverage for yourself and your spouse could get coverage on Georgia Access. Since your employer doesn’t offer coverage for your spouse, your spouse might even qualify to get government help paying for an individual plan through tax subsidies. Or, if your income is low enough, your children could sign up for Medicaid, even if you and your spouse don’t qualify for it.

As you can see, in some situations it can make sense for a single family to get totally different types of coverage for different family members.

Even if you have private health coverage through your employer (or your spouse's or parent's employer), you may still be able to get public coverage through the Georgia Pathways to Coverage Medicaid program if your income is at or below 100% of the Federal Poverty Guidelines (FPG) ($15,650 for an individual; $32,150 for a family of four).

If you are in this situation, Medicaid will either pay your employer-sponsored coverage costs, like your premiums and copayments, or give you Medicaid coverage through a managed care plan. Medicaid will determine which coverage option to offer you after you apply, based on which option is more cost-effective; you do not get to choose.

If you have public health coverage, it may make sense to also sign up for your employer's plan (or your spouse's or parent's employer's plan). With private coverage, you may have a wider pool of doctors and other medical service providers to choose from than with public coverage. Meanwhile, public coverage might pay for some services that many private plans don’t cover, like transportation, private-duty nursing, and Personal Care Assistant (PCA) services.

If you have Medicaid and an offer of employer-sponsored coverage, Medicaid may want to see if the employer's plan is "cost-effective." If so, Medicaid may pay your expenses for the employer-sponsored plan, like what you'd have to pay for the premium and copayments.