Interaction between health exchange and under-65 Medicare coverage
First off, you should contact your health plan administrator as soon as possible.  Different plans may interact differently with Medicare; any advice we could provide here would be tentative at best.  Some of the issues you may face: A person with both Medicare and a QHP would potentially have primary coverage from 2 sources: Medicare and the QHP. No federal law addresses this situation. Under state insurance law an individual generally cannot collect full benefits from each of 2 policies that together pay more than an insured event costs. State law usually specifies how insurance companies will coordinate health benefits when a person has primary coverage from more than one source. In that situation, insurance companies determine which coverage is primary and which is secondary. It’s important to understand that a QHP is not structured to pay secondary benefits, nor are the premiums calculated or adjusted for secondary payment. In addition, a person with Medicare would no longer receive any premium assistance or subsidies under the federal law. While previous federal law makes it illegal for insurance companies to knowingly sell coverage that duplicates Medicare’s coverage when someone is entitled to or enrolled in Medicare Part A or Part B, there has been no guidance on the issue of someone who already has individual health insurance and then also enrolls in Medicare. We and other consumer organizations have asked state and federal officials for clarification on this complicated situation. As such, it likely is up to the plan how they choose to pay - and I wouldn't expect them to pay much if they think they can avoid it.  You may also want to talk to someone at your local Medicare branch office - they may know more about your state specifically; or someone in your state's department of health/human services, or whomever administers the Exchanges (if it's not federal) in your state. Secondly, as far as enrolling for Part B, you should be aware that if she opts not to enroll in Part B at this time, if your wife later chooses to enroll before she turns 65 she will be required to pay a penalty of 10% per 12 month period she was not enrolled.  This will revert to 0 when she turns 65 and is then eligible under normal rules, but it will apply every year until then.  If she's enrolling during the normal General Enrollment period (Jan-March) then if she fails to enroll then she'll be required to pay that penalty if she later enrolls; if this is a Special Enrollment Period and extends beyond March, she may have the choice of enrolling next year without penalty.
I was in your situation a few years ago and I discovered something that worked perfectly for me - a local health insurance broker. I met with her, discussed my needs, reviewed the options with her, then acted. She received a commission from the insurer, so it cost me nothing. I would certainly follow a similar approach again. "HSAs as they exist today allow a person to contribute tax deductible money (like a traditional IRA) to a savings account.  The funds in the savings account can be spent tax free for qualified expenses.  If the money is invested it also grows tax free.  This means a discount on your cash health expenses of the amount you would have paid in taxes, which given your relative's income isn't likely to be very much. As HSAs exist today they must be paired to a qualified High Deductible Health Plan (HDHP).  Many plans have a deductible that meets or exceeds the level set by the regulations but many plans waive the deductible for things like X-Rays; waiving the deductible causes most ""high deductible"" plans to not qualify for HSA accounts. There are other qualified HSA expenses like Long Term Care (LTC) insurance premiums that can also be spent tax and penalty free from HSA funds. At age 60 with low income an HSA serves little purpose because the tax savings is so marginal and an HDHP is required.  That does not however mean that the scope of HSA availability should not be expanded.  Just because this is not a silver bullet for everyone does not mean it is of no use to anyone." Here's the issue with LTC and, really, underwritten insurance in general; no one has a crystal ball.   Based on today's available rates where's the sweet spot to buy LTC? Probably right around the mid-60s, because you probably won't pay much in before you start gutting the carrier (assuming you can make it through underwriting in your mid-60s). The issue is, what happens when some life event changes your underwriting status?  Would you rather buy prematurely or be excluded entirely?  Those are generally your two options when it comes to individual LTC.  The underwriting eligibility window on LTC is very  narrow.  There's a very very small space between the best possible underwriting and being flatly declined.   Look for an LTC agent in your area.  Likely someone in your circle of friends and family will know a reputable/knowledgeable insurance agent who can run up some quotes at various underwriting classes.  Try to avoid looking at quotes for your age + 10 years to see what the quote will look like 10 years from now.  10 years from now the rate tables will be significantly different. Whether or not you should buy LTC now rather than waiting will depend on a whole host of other criteria.  Personally, if I was 50 and my biggest health concern was improving my run time and LTC is on my mind, I'd just pick up a policy now while I will likely be in a preferred underwriting class rather than waiting and hoping my health doesn't betray me. Obviously I'm a stranger on the internet and none of this is actual advice.  You should find an agent local to you and talk about your options and situation. While the OP disses the health insurance coverage offered through his wife's employer as a complete rip-off, one advantage of such coverage is that, if set up right (by the employer), the premiums can be paid for through pre-tax dollars instead of post-tax dollars. On the other hand,  Health insurance premiums cannot be deducted on Schedule C by self-employed persons. So the self-employed person has to pay both the employer's share as well as the employee's share of Social Security and Medicare taxes on that money. Health insurance premiums can be deducted on Line 29 of Form 1040 but only for those months during which the Schedule C filer is neither  covered nor eligible to be covered by a subsidized health insurance plan maintained by an employer of the self-employed person (whose self-employment might be a sideline) or the self-employed person's spouse. In other words, just having the plan coverage available through the wife's employment, even though one disdains taking it, is sufficient to make a Line 29 deduction impermissible.  So, AGI is increased. Health insurance premiums can be deducted on Schedule A but only to the extent that they (together with other medical costs) exceed 10% of AGI. For many people in good health, this means no deduction there either. Thus, when comparing the premiums of health insurance policies, one should pay some attention to the tax issues too. Health insurance  through a spouse's employment might not be that bad a deal after all. Nothing has changed. I work with many 20 somethings and over the past five years none of them opted into the company health care and when I have talked with 30 somethings they stated that they took the same approach 10 years ago.  It wasn't until they started to experience physical issues (due to growing older) and starting a family did they buy into health care.  This is just another PR in the never ending pieces floating around the media these days.  No fact checking. "For the person being hired this is a tricky situation. Specially with the new laws. There is no real magic number that can be applied as a lot will depend on what benefits you want, and what is actually available. This will really shift the spectrum quite a bit.  Under the affordibal care act, everyone has to have insurance or pay a ?fine? (were really not sure what to call this yet) but there are two provisions that really mess with the numbers you look at as an employee.  First, the cost of heath care has skyrocketed. So the same benefits that you had 5 years ago now cost maybe 10-15 times as much as they used to. This gets swept under the rug a bit because the ""main costs"" of insurance has only increased a tiny amount. What this actually comes down to is does your new ACA approved heath plan cover exactly the benefits you need, or does it cut corners.  Sorry this is complicated, and I don't mean it to come off as a speech against the ACA so I will give an example. My wife has RA, she really has it under control with the help of her RA doctor. This is not something she ever wants to change. Because she has had RA from the age of 15, and because it's degenerative, she doesn't want to spend 5 years working with a new doctor to get to the same place she is with her current doctor.  In addition, the main drugs she takes for RA are not covered under any ACA plan, nor are the ""substitutions"" that her doctor makes (we are trying to have kids so she has to be off the main meds, and a couple of the things this doctor has tried has been meds that reduce inflammation, are pregnancy safe, but are not for the treatment of RA) You now have to take into effect rather the cost of health insurance + the cost of the things now not covered by the heath insurance + the out of pocket expenses is worth the insurance.  Second the ACA has set up provisions to straight up trick those people that have lower income and are not paying close attention. When shopping for insurance, they get quotes like ""$50 a month"" or ""$100 a month"". The truth is that the remainder of the actual cost is deducted from their tax returns. This takes consideration, because if you thing your paying $50 a month for insurance but your really paying $650 then you need to make sure your doing your math right. Finally, you need to understand how messed up things are right now in the US with heath care. Largely this goes unreported. I'm not really sure why. But in order to do this I will have to give examples.  For my wife to see a specialist (her RA doctor) the co-pay is $75. So she goes to the doctor, he charges her $75 and bills the insurance $200. The insurance pays the doctor $50. With out insurance, the visit costs $50.  At first you want to blame the doctor for cheating the system, but the doctor has to pay for hours of labor to get the $50 back from the insurance company. From the doctors perspective it's cheaper to take the $50 then it is to charge the insurance company. And by charging the insurance company he has no control over the cost of the co pay. He essentially has to charge more to make the same money and the patient gets the shaft in the process. Another example, I got strep throat last year. I went to the walk in clinic, paid $75, saw the doctor got my Z-Pack for $15, went home crawled in bed and got better. My wife (who still had separate insurance from before the marriage) got strep throat (imagen that) went to the same clinic, they charged her $200 for the visit ($50 co-pay) and $250 for the z-pack ($3 co-pay). The insurance paid the clinic $90 for the visit and $3 for the drugs. Again the patient is left out in this scenario. In this case it worked better for my wife, unless you account for the fact that to get that coverage she had to pay $650/month.  My point is that when comparing costs of heathcare with insurance, and without out insurance, its often times much cheaper for the practices to have you self pay then it is for them to go through the loops of trying to insurance to make them whole. This creates two rates. Self pay rates and Insured rates. When your trying to figure out the cost of not having insurance then you need to use the self pay rates. These can be vastly different.  So as an employee you need to figure out your cost of heath care with insurance, and your cost of heath care without insurance. Then user those numbers when your trying to negotiate a salary. The problem is that there is no magic number to use for this because the cost will very a lot. For us, it was cheaper to not have insurance. Even with a pre-existing condition that takes constant attention, it's just better if we set aside $500 a month then it is to try to pay $750 a month. That might not hold true for everyone. For some people or conditions it may be better to pay the $750 then to try to handle it themselves.  So for my negotiations I would go with x+$6,000 without insurance or x+$4,500 with insurance.  Now as an employer it's a lot simpler. Usually you have a ""group plan"" that offers you a pretty straight $x per year per person or $y per year per family. So you can offer exactly that. Salary - $x or Salary - $y. AS a starting point. However this is where negotiations start.  If your offering me $50,500 and insurance, I would rather just have $57,000 and no insurance. Of course your real cost is only $55,000 cause you don't care about my heath care costs only about insurance costs. So you try to negotiate down towards $55,000 and no insurance. But that's not good enough for me. So I either go else where and you loose talent, or I accept $50,500 and insurance (or somewhere in between)." No, I'd prefer a healthcare environment where prices are so reasonable you don't need outlandish insurance and trillion dollar government programs.  But no, the government refuses to negotiate. Why? Because the almost all healthcare legislation is created to enrich the industry itself. Obamacare is nice in theory, but what it really does is give the insurance industry 30 million new customers without so much as a token discount. Medicare has a provision that specifically prohibits negotiation of prices on drugs.   So you tell me, should the role of the government be to enrich the companies by feeding them more customers, err.... I mean enrolling more citizens. Or should the role of government be to keep regulation in check to where it doesn't cost $80 for a single pair of latex gloves. The payer system doesn't matter when the health care industry is being massively demand side subsidized year after year primarily by Medicaid and Medicare. It's econ 101 that massively demand side subsidizing an industry drives up prices, but too many pockets are being filled by the subsidization, so this point is not emphasized. Edit: Let's forget about Wikipedia.  From the horse's mouth: The cafeteria plan rules require that a health FSA provide uniform coverage throughout the    coverage period (which is the period when the employee is covered by the plan).  See Proposed    Treasury Regulations Section 1.125-5(d).  Under the uniform coverage rules, the maximum amount    of reimbursement from a health FSA must be available at all times during the coverage period.  This    means that the employee’s entire health FSA election is available from the first day of the plan year    to reimburse qualified medical expenses incurred during the coverage period.  The cafeteria plan    may not, therefore, base its reimbursements to an employee on what that employee may have    contributed up to any particular date, such as the date the employee is laid-off or terminated.  Thus,    if an employee’s reimbursements from the health FSA exceed his contributions to the health FSA at    the time of lay-off or termination, the employer cannot recoup the difference from the employee. (emphasis added)  http://www.irs.gov/pub/irs-wd/1012060.pdf Uniform Coverage Rule The IRS has required that “health FSAS must qualify as accident or health plans. This means    that, in general, while the health coverage under the FSA need not be provided through a    commercial insurance contract, health FSAS must exhibit the risk-shifting and risk-distribution    characteristics of insurance.” This concept has led to the “uniform coverage” rule.  The uniform­coverage rule requires that the maximum amount of an employee’s projected    elective contributions to a health FSA must be available from the first day of the plan year to    reimburse the employee’s qualified medical expenses, regardless of the amount actually    contributed to the plan at the time that reimbursement is sought.  Citing proposed Treasury Regulations Section  the IRS General Counsel has    determined that:  “Under the uniform coverage rules, the maximum amount of reimbursement from    a health FSA must be available at all times during the coverage period. The    cafeteria plan may not, therefore, base its reimbursements to an employee on what    that employee may have contributed up to any particular date, such as the date the    employee is laid-off or terminated. Thus, if an employee’s reimbursements from    the health FSA exceed his contributions to the health FSA at the time of  or    termination, the employer cannot recoup the difference from the employee.”  This rule is unfair and also constitutes a disincentive to establishing FSAS because of the    exposure to out-of pocket expenditures arising from employees who leave the company.  NSBA believes that the uniform coverage rule should also be revised if the  or lose-   it rule is changed. Revising the use-it or lose-it rule while leaving the uniform coverage rule unchanged will introduce an inappropriate asymmetry to FSAS. An employer should    be allowed to deduct any negative amount arising from insuftîcient employee    contributions from a terminating partieipant’s last paycheck. http://www.ecfc.org/files/legislative-news/NSBA_(David_Burton).pdf (emphasis added)  Now, that's some fresh bitterness for you right there.  (Dated August 17, 2012) Many big companies self insure. They pay the insurance company to manage the claims, and to have access to their network of doctors, hospitals, specialists, and pharmacies; but cover the costs on a shared basis with the employees. Medium sized companies use one of the standard group policies. Small companies either have expensive policies because they are a small group, or they have to join with other small companies through an association to create a larger group. The bigger the group the less impact each individual person has on the group cost. The insurance companies reprice their policies each year based on the expected demographics of the groups, the negotiated rates with the network of providers, the required level of coverage, and the actual usage of the group from the previo year.. If the insurance company does a poor job of estimating the performance of the group, it hits their profits; which will cause them to raise their rates the next year which can impact the number of companies that use them. Some provisions of the new health care laws in the US govern portability of insurance regarding preexisting conditions, minimum coverage levels, and the elimination of many lifetime cap. Prior to these changes the switching of employers while very sick could have a devastating impact on the finances of the family. The lifetime cap could make it hard to cover the person if they had very expensive illnesses.  If the illness doesn't impact your ability to work, there is no need to discuss it during the interview process. It won't need to be discussed except while coordinating care during the transition. There is one big issue though. If the old company uses Aetna, and the new company doesn't then you might have to switch doctors, or hospitals; or go out-of-network at a potentially even bigger cost to you. "J Gruber's consulting reports for the various states (Minnesota, Wisconsin, etc).  * http://www.washingtonpost.com/blogs/ezra-klein/post/jon-gruber-on-the-premiums-in-health-care-reform/2011/08/25/gIQAN0TUWS_blog.html  ...and the article it addresses (which included some numbers from the reports):  * http://dailycaller.com/2012/02/11/obamacare-architect-expect-steep-increase-in-health-care-premiums/  Note that Gruber has made a whole spectrum of claims (from initially claiming that premiums would go DOWN for a consulting agreement with the Obama administration, to later ""revisions"" showing significant increases {to varying degrees depending on the individuals specific demographic}), to wit:  &gt;Gruber’s new reports are in direct contrast Obama’s words — and with claims Gruber himself made in 2009. Then, the economics professor said that based on figures provided by the independent Congressional Budget Office, “[health care] reform will significantly reduce, not increase, non-group premiums.”  &gt;During his presentation to Wisconsin officials in August 2011, Gruber revealed that while about 57 percent of those who get their insurance through the individual market will benefit in one way or another from the law’s subsides, an even larger majority of the individual market will end up paying drastically more overall.  &gt;“After the application of tax subsidies, **59 percent of the individual market will experience an average premium increase of 31 percent,”** Gruber reported.  &gt;The reason for this is that an estimated 40 percent of Wisconsin residents who are covered by individual market insurance don’t meet the Affordable Care Act’s minimum coverage requirements. Under the Affordable Care Act, they will be required to purchase more expensive plans.  &gt;Asked for his own explanation for the expected health-insurance rate hikes, Gruber told TheDC that his reports “reflect the high cost of folding state high risk pools into the [federal government's] exchange — without using the money the state was already spending to subsidize those high risk pools.”  Note: Emphasis added.    Note 2: To begin with, an ""average"" increase of 31% qualifies as ""significant"" (hell, it's a lot more than merely ""significant"", that's a HUGE increase); and secondly, that is an AVERAGE, meaning that while some of the people in that ""59%"" will probably not see such a high increase, a fairly large segment {and per the provisions of the Act versus current premium calculation methods, we KNOW these will be ""young healthy singles"", and especially males} will face increases that are substantially HIGHER than 31%, and in fact will probably be in the nature of double or triple previous premiums {as would be required in order to meet another provision of the act, that highest premiums for older/sicker pool members cannot be higher than 3x that of the youngest/lowest tier premiums -- and if the company is to balance the books, it can only ""bring down"" the one end if it makes a compensating increase at the other end.})  None of that is ""rocket science"" and it is entirely predictable. (The only things that would be ""odd"" would be that anyone should expect anything different, and that Gruber's initial claims of across the board lower costs were ever accepted in the first place.)" A free market requires consumer feedback in the market as a check to the actions of the producer/seller.  Because of the nature of health care, the consumer doesn't have the power to check the price setting power of the producer/seller by going to another seller with a better price.  Market competition in the health care market is illusory. It will not do anything except make insurance companies really happy and create a [race to the bottom, where we get the worst policies offered by encouragin insurers to go to the states with the least restrictions.](http://www.kaiserhealthnews.org/stories/2010/september/30/selling-insurance-across-state-lines.aspx)  In fact, there is no evidence [insurers even want to do this.](http://thehill.com/blogs/healthwatch/health-insurance/260049-study-little-practical-interest-in-selling-insurance-across-state-lines-) "Putting middlemen into the equation is never going to reduce costs, but this is what the U.S. did in the 1970s when they made it much easier for new HMOs to be established and grow. Now the middlemen (HMOs, insurance companies, and their paid political toadies) have almost choked the market to death and they have no incentive to release their death grip because the status quo is profitable for them. The only way out is the single-payer solution and *everyone* -- business, government, individuals -- benefits from this *except* the middlemen and their bought-and-paid-for ""representative"" politicians.  This situation of barely functional health care in the U.S. is the perfect example of what happens when politicians are manipulated to make policy based on who gives them the most money and until the money/profit element is removed from governance it is only going to get worse.  Wealth as free speech? Yelling ""Fire"" in a packed theater is free speech too, but we don't allow it and for good reason." Are corporations not already passing along the cost of healthcare to the consumer?  When the employer pays, directly, for the employees health insurance, it goes directly into overhead costs.  Goods and service costs have to rise to meet that.  It's already happened.    Ideally, the healthcare savings would just offset the VAT.  Employee salaries probably wouldn't increase any, even ideally.