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The Basics
Everybody should have health coverage so that they can visit the doctor or get medications. It used to be that a lot of people, especially people with disabilities, couldn’t afford health coverage or even qualify for it. Now, that’s changed: there’s a health coverage option for almost everybody, even if you have a disability.
This article introduces your most likely health coverage options:
- Income-based Medicaid (sometimes called NJ FamilyCare), a government program which is almost free if you have low income, whether or not you have a disability.
- Disability-based Medicaid, which is almost free if you have a disability and low income. (If you get Supplemental Security Income (SSI) benefits, you qualify automatically.)
- Medicaid's NJ WorkAbility program, which lets you get Medicaid coverage if you have a disability, you work, and your income is too high for you to get regular Medicaid. You may need to pay a monthly premium.
- Medicare, which you get if you have a disability or are retired, if you or a family member has worked long enough while paying Medicare taxes.
- Employer-sponsored coverage, which your employer or a family member’s employer helps you pay for.
- Individual coverage, which you pay for yourself, possibly with the help of government subsidies.
All of these coverage options have:
- Clearly defined services they cover, including most of the physical and mental health needs you may have. For private insurance, all plans must cover Essential Health Benefits. Medicare’s coverage is comparable, while Medicaid offers some additional benefits, like personal assistance services, if you need them.
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Payments you must make. Typically, payments for private insurance are highest and the fees for Medicaid are lowest. Your payments may include:
- Premiums, a monthly payment you must make whether or not you use any medical services. (Medicaid usually has no premium.)
- Copayments, a set amount you have to pay for a medical visit or service. The amount of the copayment depends on the service you get.
- Co-insurance, a set percentage of the cost of a 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 begins to pay for certain services. Once you have paid the deductible, you do not have to pay it again until the next calendar year.
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An out-of-pocket maximum, which is an annual cap on how much you have to spend on copayments, co-insurance, and deductibles. That means you never have to spend more than $9,100 if you’re single or $18,200 for a family on these expenses.
- Medicare is an exception: It does not always have an out-of-pocket maximum.
None of these coverage options:
- Have annual or lifetime limits on how much you can get in benefits. No matter how much medical care your insurance has to pay for, they can’t stop paying for care you need.
- Can discriminate against you because you have a disability. They cannot deny you coverage, charge you more, or refuse to pay for certain types of treatment because you have a pre-existing condition.
Read the rest of this article to discover which coverage is right for you and how to sign up.
Don’t assume that coverage is too expensive or that you don’t qualify. You probably qualify for one of these programs and it may be more affordable than you think.
You can use DB101's Finding the Right Coverage for You interactive guide to get an idea of which program might work best in your situation.
Note: DB101 keeps track of changes to health coverage and related laws. DB101 has been and will continue to be updated to reflect any changes. For news related to health coverage, visit the Kaiser Family Foundation.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
How Health Benefits Work
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Income-Based Medicaid
Look at income-based Medicaid if:
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You are less than 65 years old
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You don’t qualify for SSI or Medicare
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You are a U.S. citizen or eligible immigrant, and
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Your household has low income.
Is It Right for You?
Medicaid, also called NJ FamilyCare, is government-funded health coverage for people in certain situations. You may qualify if you:
- Have low income, no matter how much you have in resources or whether you have a disability. Income-based Medicaid is explained on this page.
- Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
- Have low income, low resources, and a disability. Learn more about disability-based Medicaid.
- Have a disability and work, even if your income is higher. Learn more about Medicaid's NJ WorkAbility program.
Answer the questions on this page to see if you might qualify for income-based Medicaid. If so, it’s probably your best health coverage option because it doesn’t usually have a premium, the copayments for services are generally lower than copayments required by private plans, and Medicaid covers more services than most private plans. Also, if you qualify for Medicaid, you cannot get government help paying for an individual plan on GetCoveredNJ.
Do You Meet Income-Based Medicaid’s Basic Requirements?
To qualify for income-based Medicaid, you must:
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Be under 65 years old
- You can be 65 or older if you are the parent or caretaker of a child.
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Not qualify for Medicare
- You can be on Medicare if you are the parent or caretaker of a child or are pregnant.
- Be a U.S. citizen or meet specific noncitizen requirements
If you are under 65, do not qualify for Medicare, and are either a U.S. citizen or a noncitizen who qualifies, income-based Medicaid might cover you.
Medicaid’s rules for immigrants:
- Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
- Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
- Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for the same programs that U.S. citizens can get.
Is Your Income Low Enough for Income-Based Medicaid?
These are the main income rules for income-based Medicaid:
- If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four), you may qualify.
- If you are 18 or younger and your family’s income is at or under 200% of FPG ($60,000 per year for a family of four), you may qualify and won't have to pay a monthly premium.
- If you are 18 or younger and your family’s income is between 200% and 355% of FPG ($106,500 per year for a family of four), you may qualify if you pay a monthly premium.
- If you are pregnant and your family’s income is at or under 205% of FPG ($61,500 per year for a family of four), you may qualify. The unborn baby is counted as a family member.
Income-based Medicaid, sometimes called "Medicaid expansion," is based on your Modified Adjusted Gross Income (MAGI), which includes most earned and unearned income. However, some income is not counted, including Supplemental Security Income (SSI) benefits, growth of the investments in an ABLE account, and some contributions to retirement accounts. Learn more about what types of income affect income-based Medicaid eligibility.
Note: There are no limits to how much money or other resources you can have for income-based Medicaid.

Your family size: | |
Income limits for your family: | |
$14,580 | |
$5,140 | |
$13,590 | |
$4,720 | |
Income-based Medicaid, adults (138% FPG) | |
NJ FamilyCare, children, free (200% FPG) | |
NJ FamilyCare, children, premium (355% FPG) | |
Subsidized private plans, reduced fees (250% FPG) | |
Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Note: Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG).
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If your income is low enough and you meet all other requirements, you should sign up for Medicaid.
More Ways to Qualify for Medicaid if You Have a Disability
There are other ways to qualify for Medicaid if you have a disability. You might qualify for disability-based Medicaid if:
- You get Supplemental Security Income (SSI) benefits.
- You make more money at work than income-based Medicaid allows. In that case, you could apply for Medicaid's New Jersey WorkAbility program.
- You also get Medicare. Usually, Medicaid doesn’t cover people getting Medicare, but disability-based Medicaid does. It may even help pay your monthly Medicare premiums.
- You are 65 years old or older.
You might qualify for income-based Medicaid, even though you have a disability, if:
- Your disability does not meet Social Security’s definition of disability. Disability-based Medicaid is only for people who have disabilities meeting this standard.
- You have more resources than are allowed by disability-based Medicaid.
- You make enough money that you would have to pay a monthly premium for NJ WorkAbility.
Learn more about disability-based Medicaid and NJ WorkAbility.
How to Sign Up
Before you apply, NJHelps lets you get an anonymous estimate of whether you qualify for Medicaid or other state and federal programs.
You can apply for Medicaid:
- Online using NJ FamilyCare Quickstart, or
- At an outreach and enrollment site in your county.
NJ FamilyCare lists the information and documents you may need when you apply. For help with your application, talk with a Health Benefits Coordinator at 1-800-701-0710 or 1-800-701-0720 (TTY).
Staying on Medicaid
Usually, once approved for Medicaid, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your county Board of Social Services know within 10 days of the change. You can do this in person, by phone, or by email. When you report your changes, the county tells you whether you continue to get Medicaid or if you have new health coverage options, like individual coverage with subsidies or NJ WorkAbility.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
How Health Benefits Work
Try It
Disability-Based Medicaid
Look at disability-based Medicaid if you get SSI or if:
- You are a U.S. citizen or eligible immigrant
- You have a disability
- You have low resources, and
- You have low income.
Is It Right for You?
Medicaid, also called NJ FamilyCare, is government-funded health coverage for people in certain situations. You may qualify if you:
- Have low income, no matter how much you have in resources or whether you have a disability. Learn more about income-based Medicaid.
- Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
- Have low income, low resources, and a disability. Disability-based Medicaid is explained on this page.
- Have a disability and work, even if your income is higher. Learn more about Medicaid's NJ WorkAbility program.
Answer the questions on this page to see if you might qualify for disability-based Medicaid. If so, it’s probably your best health coverage option because it doesn’t usually have a premium, the copayments for services are generally lower than copayments required by private plans, and Medicaid covers more services than most private plans. Also, if you qualify for Medicaid, you cannot get government help paying for an individual plan on GetCoveredNJ.
Medicaid’s rules for immigrants:
- Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
- Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
- Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for the same programs that U.S. citizens can get.
Do You Have a Disability That Meets Social Security’s Standards?
To qualify for disability-based Medicaid, you must have a disability that meets Social Security’s definition of disability. For adults, Social Security says you have a disability if:
- You have a physical or mental impairment or combination of impairments
- Your impairments limit your ability to work, preventing you from earning Substantial Gainful Activity ($1,470 per month or $2,460 per month if you’re blind), and
- Your condition has lasted or is expected to last for at least 12 months.
If you currently get disability benefits, like Social Security Disability Insurance (SSDI), you already meet Social Security’s disability standards. If not, New Jersey's Disability Determination Service (DDS) checks to see if your disability qualifies for Medicaid.
Note: Learn about Social Security’s definition of disability for children under 18 in DB101’s Benefits for Young People article.
If you already have a disability determination from Social Security or think that your disability meets Social Security’s standards, disability-based Medicaid might cover you.
Do You Have Very Low Resources?
Resources are money and property you own. For disability-based Medicaid, you and your family must have very low resources:
- If you are single, the most you can have is $4,000 in resources.
- For couples, the limit is $6,000.
Some resources don’t count towards disability-based Medicaid’s resource limit, like the home you live in, one car, and any money you have in an ABLE account.
If your family’s resources are below the limit, disability-based Medicaid might cover you.
Do You Have Very Low Income?
To qualify for disability-based Medicaid, you must have countable income that is $1,215 per month or less ($1,644 or less for couples).
For disability-based Medicaid eligibility, not all of your income is counted. The way your income is counted for disability-based Medicaid is very similar to SSI’s countable income calculation:
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Most of your unearned income is counted.
- Important: SSI and NJ SNAP benefits are not counted for disability-based Medicaid eligibility.
- Less than half of your earned income is counted.
This means that if you have a disability determination, you might be able to get a job and make $1,800 per month or more without losing your disability-based Medicaid, because more than half of your earned income wouldn’t be counted.
If you live alone, try this tool to see if your countable income is below disability-based Medicaid’s income limit.

Your Monthly Earned Income | $ |
Your Monthly Unearned Income (not including SSI) | $ |
Your Monthly Impairment Related Work Expenses (IRWEs) | $ |
$1,215 | |
$20 | |
$65 | |
$914 | |
![]() | |
Your Monthly Countable Income | |
Your Annual Countable Income | |
![]() | |
$14,580 | |
Federal Poverty Guideline | |
Your Countable Income as a Percent of FPG |
If you live with others, some of their income may be counted and you should call a Health Benefits Coordinator at 1-800-701-0710 or 1-800-701-0720 (TTY) or visit an outreach and enrollment site in your county to talk about whether you qualify for Medicaid coverage.
If your income is low enough and you meet all other requirements, you should sign up for Medicaid.
If you work, look into Medicaid's NJ WorkAbility program. NJ WorkAbility has a higher income limit than disability-based Medicaid and doesn't have any resource limit, though you may have to pay a monthly premium. Learn more about NJ WorkAbility.
Another option is Medically Needy Medicaid. Under this program you have to pay the first part of your medical costs each month, before Medicaid starts paying for your health care expenses (sometimes called a spend-down, this is similar to having a monthly deductible). The amount you have to pay depends on how much income you have. Talk about this option with a Health Benefits Coordinator at 1-800-701-0710 or 1-800-701-0720 (TTY) or visit an outreach and enrollment site in your county.
Note: If you work, NJ WorkAbility may be a better option than Medically Needy Medicaid.
More Ways to Qualify for Medicaid if You Have a Disability
There are other ways to qualify for Medicaid if you have a disability. You might qualify for income-based Medicaid if:
- Your disability does not meet Social Security’s definition of disability. Disability-based Medicaid is only for people who have disabilities meeting this standard.
- You have more resources than are allowed by disability-based Medicaid.
- You make enough money that you would have to pay a monthly premium for NJ WorkAbility.
You might qualify for disability-based Medicaid instead of income-based Medicaid if:
- You make more money at work than income-based Medicaid allows. In that case, you could apply for Medicaid's New Jersey WorkAbility program.
- You also get Medicare. Income-based Medicaid doesn’t cover people getting Medicare, but disability-based Medicaid does. It may even help pay your monthly Medicare premiums.
- You are 65 years old or older.
Learn more about income-based Medicaid and NJ WorkAbility.
How to Sign Up
Before you apply, NJHelps lets you check if you might qualify for Medicaid or other state and federal programs.
You can apply for Medicaid:
- Online using NJ FamilyCare Quickstart, or
- At an outreach and enrollment site in your county.
NJ FamilyCare lists the information and documents you may need when you apply. For help with your application, talk with a Health Benefits Coordinator at 1-800-701-0710 or 1-800-701-0720 (TTY).
Staying on Medicaid
Usually, once approved for Medicaid, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, or household size changes, let your county Board of Social Services know within 10 days of the change. You can do this in person, by phone, or by email. When you report your changes, the county tells you whether you continue to get Medicaid or if you have new health coverage options, like individual coverage with subsidies or NJ WorkAbility.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
How Health Benefits Work
Try It
NJ WorkAbility
Look at NJ WorkAbility if:
- You are at least 16 years old
- You have a disability
- You work, and
- You are a citizen or eligible immigrant.
Is It Right for You?
Medicaid, also called NJ FamilyCare, is government-funded health coverage for people in certain situations. You may qualify if you:
- Have low income, no matter how much you have in resources or whether you have a disability. Learn more about income-based Medicaid.
- Get Supplemental Security Income (SSI) benefits or qualify for SSI’s 1619(b) rule, which helps people who used to get SSI. In either case, you automatically get Medicaid coverage and don’t need to worry about the rules discussed here. Learn more in DB101’s SSI article.
- Have low income, low resources, and a disability. Learn more about disability-based Medicaid.
- Have a disability and work, even if your income is higher. Medicaid's NJ WorkAbility program is explained on this page.
Answer the questions on this page to see if you might qualify for NJ WorkAbility. If so, it’s a good option to consider because it lets you earn a lot more money and still get Medicaid’s comprehensive coverage.
Note: Some NJ WorkAbility rules changed on April 1, 2023. For example, the resource limit was removed, so now you can save up more money and don't have to worry about losing coverage!
Do You Meet NJ WorkAbility’s Basic Requirements?
To qualify for NJ WorkAbility, you must:
- Live in New Jersey
- Be 16 years old or older
- Have a permanent disability
- Be working, and
- Be a U.S. citizen or meet specific noncitizen requirements.
If you live in New Jersey, are at least 16 years old, working, have a disability, and are either a U.S. citizen or a non-citizen who qualifies, NJ WorkAbility might be an option for you.
Medicaid’s rules for immigrants:
- Undocumented immigrants do not qualify for full Medicaid coverage, but they may qualify for Medicaid coverage for emergency services.
- Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
- Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for the same programs that U.S. citizens can get.
Do You Have a Disability That Meets Social Security’s Standards?
To qualify for NJ WorkAbility, you must have a disability that meets Social Security’s definition of disability. For adults, Social Security says you have a disability if:
- You have a physical or mental impairment or combination of impairments, and
- Your condition has lasted or is expected to last for at least 12 months.
Note: For NJ WorkAbility, Social Security’s disability rules related to earned income do not apply.
If you currently get disability benefits, like Social Security Disability Insurance (SSDI), you already meet Social Security’s disability standards. If not, New Jersey's Disability Determination Service (DDS) checks to see if your disability qualifies for Medicaid.
If you already have a disability determination from Social Security or think that your disability meets Social Security’s standards, NJ WorkAbility might be an option for you.
Is Your Income Below NJ WorkAbility’s Income Limits?
NJ WorkAbility has two income limits: an Unearned Income Threshold and a Total Earned Income Potential level.
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Unearned Income Threshold: Your unearned income must be at or below $1,215 per month for individuals ($1,644 for couples).
- Note: The NJ WorkAbility program does not count Social Security Disability Insurance (SSDI) or Railroad Retirement System benefits as income, if they are based on your own work history .
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Total Earned Income Potential: If you do not have unearned income, your earned income must be at or below $73,692 per year for individuals ($99,396 for eligible couples where both people qualify for NJ WorkAbility).
- Note: If you have unearned income, the maximum earned income level will be lower.
Get more information about the NJ WorkAbility income limits. If you have any questions, call the Division of Disability Services (DDS) at 1-888-285-3036.
If you meet all requirements, you should apply for NJ WorkAbility.
How to Apply
You can apply for Medicaid's NJ WorkAbility program:
- Online using NJ FamilyCare Quickstart, or
- At an outreach and enrollment site in your county.
NJ FamilyCare lists the information and documents you may need when you apply. For help with your application, talk with a Health Benefits Coordinator at 1-800-701-0710 or 1-800-701-0720 (TTY).
Staying on NJ WorkAbility
Usually, once approved for NJ WorkAbility, you continue to qualify as long as your situation doesn’t change. If your income, immigration status, residency, disability status, or household size changes, let your county Board of Social Services know within 10 days of the change. You can do this in person, by phone, or by email.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
Try It
Medicare
If you get Medicare, you may be able to get:
- Employer-sponsored coverage at the same time
- Medicaid or NJ WorkAbility at the same time
- Help paying for Parts A, B, and D
- Parts A, B, and D in a combined plan, or
- A supplement plan to cover more medical expenses.
What Options Are Right for You?
When you work, some of the money you earn automatically comes out of your paycheck and helps fund Medicare, a national public health insurance program.
If you or your spouse worked enough time while paying Medicare taxes, you qualify for Medicare:
- When you turn 65
- After you get Social Security Disability Insurance (SSDI) benefits for two years, or
- If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).
If you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record, you also qualify for Medicare.
If you qualify for Medicare, you can choose from two options:
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Original Medicare, including Part A, which helps pay for medical care you get while you’re in a hospital; Part B, which helps pay for medical care you get outside of a hospital, like when you go to the doctor’s office; and Part D, which helps pay for prescription drugs. You also have the option of getting a private Medicare supplement policy, which covers some expenses that Parts A and B do not cover.
- After you get SSDI or CDB for two years, you automatically get Medicare Parts A and B. Otherwise, you may need to sign up, depending on your situation.
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A Medicare Advantage plan, which combines Parts A, B, and D into a single plan run by a private company. There are many different Medicare Advantage plans to choose from.
- If you want a Medicare Advantage plan, you need to sign up during your initial Medicare enrollment or during the annual open enrollment period between October 15 and December 7 each year.
Most people don’t have to pay a premium for Part A, but they do have to pay monthly premiums for Parts B and D, or for Medicare Advantage plans. For this reason, nobody is required to get them.
Answer the questions on this page to see if it makes sense for you to get Original Medicare or a Medicare Advantage plan, and also whether you might qualify for programs that can help you pay your monthly premiums, copayments, co-insurance, and deductibles.
Do You Qualify to Get Medicare and Other Coverage at the Same Time?
If you qualify to get Medicare at the same time as you get employer-sponsored coverage, Medicaid, or Medicaid's New Jersey WorkAbility program, having those other benefits may impact your Medicare decisions:
- If you also qualify for Medicaid or Medicaid's NJ WorkAbility program, they may help pay for some medical expenses that Parts B and D don't pay for. And Medicaid (but not Medicaid's NJ WorkAbility program) may also help pay for the Part B and D premiums, copayments, and deductibles.
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If you also qualify for employer-sponsored coverage, you may wish to decline Part B and Part D coverage, so that you don’t have to pay their premiums. However, your private coverage must meet certain standards, or else you may have to pay monthly penalties if you choose to sign up for Parts B and D later.
- Important: Before you decline Part B, ask your employer-sponsored coverage to see if you would have to pay monthly penalties if you sign up for Part B in the future. Before you decline Part D, ask if your private insurance is considered creditable coverage by Part D. If it isn't, you would have to pay monthly penalties for Part D if you sign up later. If you have any questions about this, contact the State Health Insurance Assistance Program (SHIP).
You may have other options as well, such as retirement benefits, Veterans (VA) benefits, or military (TRICARE) benefits. Learn more about how Medicare interacts with other types of coverage.
Can You Get Help Paying for Medicare Parts A and B?
While Medicare offers good coverage, it is not as low-cost as Medicaid. Depending on the care you need, you may have to pay large copayments, co-insurance, or deductibles. And, for Part B, you may have to pay a monthly premium (usually $164.90 per month or a bit less, depending on your situation).
However, if you have low income and low resources, you may qualify for a Medicare Savings Program (MSP). New Jersey offers three Medicare Savings Programs:
- The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of the Federal Poverty Guidelines (FPG) or less ($1,215 per month or less if you live alone). QMB helps pay for your Part B premium, copayments, and deductibles. Note: If you have disability-based Medicaid coverage, you automatically qualify for QMB.
- The Specified Low-Income Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,458 per month or less if you live alone). SLMB helps pay for the Part B premium, but does not help with anything else.
- The Qualified Individual-1 program, also called QI-1, helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,641 per month or less if you live alone). QI-1 helps pay for the Part B premium, but does not help with anything else.
For MSPs, less than half of your earned income is counted. That means you might qualify even if you think your income is over the limits.

Your Monthly Earned Income | $ |
Your Monthly Unearned Income (not including SSI) | $ |
Your Monthly Impairment Related Work Expenses (IRWEs) | $ |
$1,215 | |
$20 | |
$65 | |
$914 | |
![]() | |
Your Monthly Countable Income | |
Your Annual Countable Income | |
![]() | |
$14,580 | |
Federal Poverty Guideline | |
Your Countable Income as a Percent of FPG |
The resource limit for QMB, SLMB, and QI-1 is $9,090 if you live alone and $13,630 if you live with someone else.
To apply for an MSP, download an application, complete it, attach copies of the required documents (not originals), and mail it to the address on the application form. You can also use this application to apply for help with the cost of prescription drugs and hearing aids, and for other special benefits programs.
Learn more about Medicare Savings Programs in New Jersey. For more details or assistance, call the State Health Insurance Assistance Program (SHIP) at 1-800-792-8820 or the New Jersey Division of Aging Services at 1-800-792-8820.
Can You Get Help Paying for Medicare Part D?
Part D helps you pay for your medications, but there are some expenses for you, such as the monthly premium, a deductible, copayments, and co-insurance.
If you cannot afford these costs, you may qualify for the Low Income Subsidy (LIS), which is also called “Extra Help.” The Low Income Subsidy has two levels:
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The full subsidy is for people who also get Medicaid coverage or who are in a Medicare Savings Program. You may also qualify if your countable income is less than $19,683 per year and your resources are less than $9,090 if you are single (the limits are higher for larger households).
- With the full subsidy, you don't have to pay a Part D premium or deductible, and there may be lower copayments.
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The partial subsidy is for people who can’t get the full subsidy, but have less than $21,870 in annual countable income and less than $15,160 in resources, if you are single (the limits are higher for larger households).
- With the partial subsidy, you pay 0%, 25%, 50%, or 75% of the Part D premium, depending on your income, and only have to pay a $104 deductible before you get help paying for drugs. You have to pay co-insurance and copayments for your medications, but they're lower than without the partial subsidy.
Note: Not all of your income and resources are counted when you apply for the Low Income Subsidy. You can apply even if you don’t think you qualify.
Apply for the Low Income Subsidy at your local Social Security office.
You can also save money by finding a better Part D plan for the medications you take. Use the Medicare Plan Finder to find the right Part D plan for you.
Do You Want a Medicare Supplement Plan That Covers Costs that Original Medicare Doesn't?
If you get Original Medicare with Parts A, B, and D, you can choose to get a private Medicare supplement (sometimes called a Medigap plan) to cover some of the expenses that Medicare Parts A, B, and D don’t cover. For example, a Medicare supplement could cover things like your co-insurance payments for Part B.
You have to pay a monthly premium for a Medicare supplement, in addition to your premiums for Part B and D. The amount you have to pay depends on the plan.
Learn more about Medicare supplements or find one in your area.
Do You Want a Medicare Advantage Plan That Combines Parts A, B, and D?
With Medicare Advantage (sometimes called “Part C”), you can get all of your Medicare benefits combined into a single plan run by a private company. As long as a company follows Medicare’s rules, it can have more flexibility in the benefits it offers, how it organizes payments, and how much the plan costs. Also, Medicare Advantage plans have an out-of-pocket maximum, unlike Original Medicare.
The amount you pay depends on your plan, but most plans make you pay as much as the Part B premium costs, plus an additional amount for extra benefits and prescription drug coverage. A Medicare Savings Program and the Low Income Subsidy may help you pay for your Medicare Advantage plan.
Use the Medicare Plan Finder to see which Medicare Advantage plans might be best for your needs.
You can only make changes to your Medicare coverage, such as changing your Part D plan, adding a Medicare supplement plan, or switching to Medicare Advantage, during open enrollment, which is from October 15 to December 7 of each year.
If you have any changes you want to make, make sure to do them during this time period, or else you have to wait another year.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
How Health Benefits Work
Try It
Employer-Sponsored Coverage
Look at employer-sponsored coverage if:
- Your employer, your parent's employer, or your spouse's employer offers it
- You meet the employer’s requirements, and
- You can't get Medicaid.
Is It Right for You?
To get private health insurance, a premium must be paid every month. Many employers offer to pay part, or all, of this monthly premium as a job benefit for employees, their children until they turn 26 years old, and their spouses. Employer-sponsored health coverage is the most common type of coverage in the U.S.
Answer the questions on this page to see if you can get employer-sponsored coverage. If you can, you probably should because you won’t qualify for subsidized individual coverage.
Can You Get Medicaid?
If you qualify for Medicaid, it is usually your best choice, even if you can get health insurance from an employer. That’s because Medicaid usually has no monthly premium and the copayments for services tend to be much lower than private insurance copayments. Also, Medicaid may cover some services that employer-sponsored coverage doesn't pay for.
If you can’t get Medicaid, employer-sponsored coverage might be a good option for you.
You may qualify for Medicaid if you are in one of these situations:
- Your family’s income is at or below 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four). The income limits are higher if you are 18 or younger or are pregnant. There are no limits to how much money or other resources you have. Learn more about income-based Medicaid.
-
You have a disability or are elderly:
- Medicaid for people with disabilities and seniors may offer additional services, but it has more eligibility requirements, such as having a disability, having low resources, and different income rules. (If you get Supplemental Security Income (SSI) benefits, you qualify automatically.) Learn more about disability-based Medicaid.
- Medicaid's New Jersey WorkAbility program lets people with disabilities who make more money than the income limits for other types of Medicaid get Medicaid coverage. However, you may have to pay a monthly premium. Learn more about NJ WorkAbility.
Does Your Employer, Your Spouse’s Employer, or Your Parent’s Employer Offer Coverage?
Many employers offer health coverage as a job benefit, but they aren't required to. Contact your employer’s Human Resources department to check what benefits are offered.
If an employer offers health coverage as a job benefit for employees, the employer also has to offer the same health coverage to the employees’ children until they turn 26. An employer may also let the employee’s spouse join the plan, but they are not legally required to do so.
If your employer, your parent’s employer, or your spouse’s employer offers health coverage, it might be a good option for you.
Can You Get the Coverage Your Employer Offers?
Employers offer health coverage for employees and their families only if their employees meet certain requirements, such as:
-
The employee must work a certain number of hours each week (called the active work requirement).
- Example: Your wife’s employer only gives health benefits to employees who work 30 or more hours per week.
-
The employee must have worked for the employer for a certain amount of time (called the waiting period). A waiting period cannot be longer than 90 days.
- Example: Your father’s employer offers health coverage to employees who have worked there for at least 90 days.
-
You must sign up during open enrollment.
- Example: After you are hired, you have to sign up for your employer-sponsored coverage during your first month on the job. If you don’t, you have to wait until the next open enrollment period to sign up for coverage.
If your employer, your parent’s employer, or your spouse’s employer offers coverage and you can get that coverage, you probably should.
If you can get employer-sponsored coverage, it may mean you can't get tax credits on GetCoveredNJ. It depends on whether the employer-sponsored plan is considered "affordable."
When an employer offers coverage for the employee:
- If it costs less than 9.12% of the employee's household's total income and meets bronze-level standards, it's "affordable." The employee won't qualify for government help through tax subsidies to reduce the premium on an individual plan.
- If it costs more than 9.12% of the household’s total income, it's not affordable and the employee may qualify for tax subsidies to get a plan on GetCoveredNJ.
When an employer offers coverage for the employee and the employee's spouse and children:
- If the coverage for the entire family costs less than 9.12% of the employee's household’s total income and meets bronze-level standards, it's "affordable." Nobody in the family will qualify for subsidies on GetCoveredNJ.
- If it costs more than 9.12% of the household’s total income, it's not affordable and the spouse and children may qualify for subsidies on GetCoveredNJ. However, the employee will not qualify for subsidies unless the cost of insurance for the employee alone is more than 9.12% of the household’s total income.
Note: Before 2023, the spouse or children of an employee would not qualify for subsidies on GetCoveredNJ 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." This changed starting in 2023.
Getting Medicare and Employer-Sponsored Coverage at the Same Time
If you get Medicare and also have employer-sponsored coverage, you should learn how your benefits work together.
If you get Original Medicare coverage, you can get Medicare Part A, which usually has no monthly premium, and both Parts B and D, which do have monthly premiums.
If you have private coverage that covers the same things Parts B and D cover, you can choose not to get them so that you don't have to pay their premiums. But it's important to make sure you won't have problems later:
- Before you decline Part B, ask your employer-sponsored coverage to see if you would have to pay monthly penalties if you sign up for Part B in the future.
- Before you decline Part D, ask if your private insurance is considered creditable coverage by Part D. If it isn't, you would have to pay monthly penalties for Part D if you sign up later. If you have any questions about this, contact the State Health Insurance Assistance Program (SHIP).
How to Sign Up
Talk to the employer’s Human Resources department to learn how to sign up. An employer may offer more than one plan. Every option must cover the Essential Health Benefits, but usually there are other trade-offs between plans. For example, you may have to pay a higher monthly premium for one plan and higher copayments when you visit a doctor for another plan.
Sign up for coverage when it is first offered; otherwise, you may have to wait until the annual open enrollment period, which is usually near the end of the year. Certain changes in family or coverage status may trigger a special enrollment period. For example, if you get married or have a child, your new spouse or baby will be able to sign up with your employer-sponsored coverage without waiting until open enrollment.
If You Have to Stop Working Temporarily
In certain situations, you may be able to leave your job for a while, but keep getting your employer-sponsored coverage until you return to work.
If you work for any government agency or for a private employer with 50 or more employees, the Family and Medical Leave Act (FMLA) lets you take up to 12 weeks of unpaid leave per year for certain family and medical reasons, such as the birth of a child or to care for a sick family member. During this leave, your employer must continue to offer the same health coverage at the same cost as you would get while working. Learn more about the FMLA.
If you serve in the uniformed services, the Uniformed Services Employment and Reemployment Rights Act (USERRA) protects your job and health coverage for up to 24 months while you are serving. Learn more about USERRA.
COBRA and New Jersey Continuation Coverage
COBRA and New Jersey Continuation Coverage let most employees and family members keep getting the same health plan they got through an employer after losing employer-sponsored coverage.
COBRA
COBRA is a federal law that says that companies with 20 or more employees have to let ex-employees keep getting the same health coverage they had as employees. How long you can get coverage through COBRA depends on your situation. No matter what though, you have to pay the entire premium for COBRA, including any amount that your employer paid in the past. Your plan could be a lot more expensive than you realize.
COBRA used to be important because it was so hard for individuals, especially people with disabilities, to get an individual insurance plan. Now, GetCoveredNJ makes that much easier and often much cheaper. That said, there are times when COBRA might make sense, like if you’ve already paid the full deductible or out-of-pocket maximum for the year with your employer-sponsored coverage.
The bottom line: Do not sign up for COBRA without comparing it with your other options.
New Jersey Continuation Coverage
While COBRA only applies to companies with 20 or more employees, New Jersey Continuation Coverage is for employees of smaller companies. The rules for New Jersey Continuation coverage are similar to COBRA, but there are some differences. The best way to find out if you qualify for New Jersey Continuation coverage is to ask the employer or benefits administrator.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
How Health Benefits Work
- The Basics
- Income-Based Medicaid
- Disability-Based Medicaid
- NJ WorkAbility
- Medicare
- Employer-Sponsored Coverage
- Individual Coverage on GetCoveredNJ
- FAQs
- Pitfalls
- Next Steps
Try It
Individual Coverage on GetCoveredNJ
Look at individual coverage if:
- You can't get Medicaid
- You can’t get Medicare, and
- You can’t get employer-sponsored coverage.
Is It Right for You?
With individual coverage, an individual or family pays a monthly premium and the plan agrees to pay some of the costs of approved medical services when needed, including preventive care, lab tests, surgery, or prescription drugs. If you have low to moderate income, the government may help you pay for your monthly premium and get a plan with lower copayments.
Answer the questions on this page to see if it might make sense for you to get individual health coverage. If it does, sign up using GetCoveredNJ, the easiest place to comparison shop for an individual plan and the only place where you might be able to get help from the government to pay for your private insurance.
Do You Have Any Better Options?
If you can get Medicaid, Medicare, or employer-sponsored coverage, you don’t qualify for government help to pay for an individual plan. That means they are usually a better choice than getting an individual plan, because they cost less.
Can You Get Medicaid?
Medicaid is a government health program for people with low income. It’s a great program that usually has no monthly premium and copayments for services that are usually much lower than copayments required by individual plans. Also, Medicaid may cover some services that an individual plan doesn't cover.
If you can’t get Medicaid, individual coverage might be a good option for you.
You may qualify for Medicaid if you are in one of these situations:
- Your family’s income is at or below 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four). The income limits are higher if you are 18 or younger or are pregnant. There are no limits to how much money or other resources you have. Learn more about income-based Medicaid.
-
You have a disability or are elderly:
- Medicaid for people with disabilities and seniors may offer additional services, but has more eligibility requirements, such as having a disability, having low resources, and different income rules. (If you get Supplemental Security Income (SSI) benefits, you qualify automatically.) Learn more about disability-based Medicaid.
- Medicaid's New Jersey WorkAbility program lets people with disabilities who make more money than the income limits for other types of Medicaid get Medicaid coverage. However, you may have to pay a monthly premium. Learn more about NJ WorkAbility.
Can You Get Medicare?
Medicare is a government health program for seniors (65 years old or older) and people with disabilities. To get Medicare coverage, you or a family member must have worked for a certain number of years and met other eligibility rules.
If you get Medicare, you cannot get government help to pay for an individual health plan. You can still buy an individual plan through GetCoveredNJ, but you have to pay the entire premium yourself. Note: If you get Medicare and want more coverage than it offers, look into Medicare Advantage or Medicare supplement policies. GetCoveredNJ does not offer these.
If you can’t get Medicare, individual coverage might be a good option for you.
Can You Get Employer-Sponsored Coverage?
Many employers offer private health coverage as a job benefit for employees, their children until they turn 26, and their spouses. If your employer offers you health coverage that would cost you less than 9.12% of your household’s income and that coverage meets bronze-level standards, you won't qualify for government help paying for an individual plan. If you can get employer-sponsored coverage, but sign up for an individual plan anyway, you will have to pay the full premium.
Note: Before 2023, the spouse or children of an employee would not qualify for subsidies on GetCoveredNJ 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." This changed starting in 2023. Learn more about affordability rules for family members and how it affects eligibility for tax credits on GetCoveredNJ.
If you can’t get employer-sponsored coverage, individual coverage might be a good option for you.
When an Individual Plan Is Your Best Option
You should get an individual plan through GetCoveredNJ if you cannot get health coverage from:
- Your job
- Your spouse’s job
- Your parent’s job
- Medicaid, or
- Medicare.
The government may make your individual plan more affordable if you cannot get health coverage from any of the above options:
- You may get a tax subsidy to help pay your monthly premium.
- You may also qualify for a plan with lower expenses, such as smaller copayments, if your family’s income is at or below 250% of the Federal Poverty Guidelines (FPG) ($33,975 for an individual; $69,375 for a family of four).
Note: There is no 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.
When GetCoveredNJ looks at your income, they count most of your earned and unearned income. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.
Try GetCoveredNJ's shop and compare Tool.

Your family size: | |
Income limits for your family: | |
$14,580 | |
$5,140 | |
$13,590 | |
$4,720 | |
Income-based Medicaid, adults (138% FPG) | |
NJ FamilyCare, children, free (200% FPG) | |
NJ FamilyCare, children, premium (355% FPG) | |
Subsidized private plans, reduced fees (250% FPG) | |
Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Note: Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG).
|
Carefully compare your options when you get an individual plan. All plans must cover the Essential Health Benefits. However, the amount you have to pay for your premium and other fees, such as copayments, co-insurance, and deductible depends on your exact plan.
There are four levels of plan:
- Platinum plans have the highest monthly premiums and the lowest fees when you get medical care.
- Gold plans have slightly lower premiums and slightly higher fees when you get medical care.
- Silver plans have lower premiums. The fees for medical services depend on your family’s income. If your income is at or below 250% of FPG, the fees may be as low as a gold or platinum plan.
- Bronze plans have the lowest monthly premiums and the highest fees when you get medical care.
You may see these plans listed with percentage ratings (60%, 70%, 73%, 80%, 87%, or 90%). The higher the percentage rating, the lower the fees you have to pay when you get medical care.
The bottom line: If your income is at or below 250% of FPG, sign up for a silver plan. Otherwise, think about how much you typically spend on medical care to decide which metal plan is best.
How to Sign Up
GetCoveredNJ is a one-stop shop where you can compare plans and figure out which is right for you. And it is the only place where you can get government help to pay for your individual plan.
Start out by comparing your options with GetCoveredNJ's shop and compare Tool, so that you can make an informed decision when you are ready. If you find GetCoveredNJ confusing or think there is a mistake, get help by calling GetCoveredNJ at 1-833-677-1010 or get local help.
Open Enrollment
Open enrollment for individual plans has ended for this year. People in certain situations can still sign up for a health plan under special enrollment rules.
Usually, you can only sign up for an insurance plan through GetCoveredNJ during a specific time called open enrollment:
- To get an individual plan that covers you during 2023, you must sign up between November 1, 2022 and January 31, 2023.
- If you do not sign up during that time, you are not usually allowed to sign up for an individual plan through GetCoveredNJ until another year has passed.
Special Enrollment
You can sign up for an individual plan through GetCoveredNJ even though it is not the usual open enrollment period if:
- Your household income is at or below 150% of FPG
- You lose other health coverage you had
- Your health coverage is not meeting its obligations
- Your income changes and you gain or lose eligibility for government help paying for your coverage
- You become a legal resident of the U.S.
- You move
- There was a mistake in your enrollment, or
- In other life-changing circumstances, such as having a child or getting married.
Note: American Indians do not have these restrictions on enrollment.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
Try It
Frequently Asked Questions
Where can I sign up for health coverage?

How you sign up depends on the type of coverage you get:
-
For Medicaid and NJ WorkAbility, you can apply:
- Online using NJ FamilyCare Quickstart, or
- By downloading an application, printing it, filling it out, and mailing it in, or
- At an outreach and enrollment site in your county.
- For Medicare, you automatically get coverage if you’ve been getting SSDI for two years. Otherwise, you may need to sign up.
- For employer-sponsored coverage, talk to your employer’s Human Resources department.
- For individual coverage, apply at GetCoveredNJ. GetCoveredNJ first checks if you qualify for Medicaid and, if not, lets you compare individual plans and see if the government will help with tax credits.
If my job offers me health coverage, can I still qualify for Medicaid or get subsidies for an individual plan on GetCoveredNJ?

You can qualify for Medicaid if your family’s income qualifies, even if your job offers insurance.
You cannot get subsidies for purchasing an individual health plan through GetCoveredNJ if your job offers you affordable insurance.
Does it matter how I qualify for Medicaid?

In most cases, no. The actual medical coverage you get from Medicaid is the same, no matter how you qualify. Generally speaking, the big difference is that people with disabilities get extra ways to qualify and, if you have a disability and start working, you can earn a lot more while still getting Medicaid coverage through Medicaid's New Jersey WorkAbility program.
What is the most money I can make and still get Medicaid? 

For income-based Medicaid, the main income rules are:
- If your family’s income is at or under 138% of the Federal Poverty Guidelines (FPG) ($20,120 per year for an individual; $41,400 for a family of four), you may qualify.
- If you are 18 or younger and your family’s income is at or under 200% of FPG ($60,000 per year for a family of four), you may qualify and won't have to pay a monthly premium.
- If you are 18 or younger and your family’s income is between 200% and 355% of FPG ($106,500 per year for a family of four), you may qualify if you pay a monthly premium.
- If you are pregnant and your family’s income is at or under 205% of FPG ($61,500 per year for a family of four), you may qualify. The unborn baby is counted as a family member.
Income-based Medicaid, sometimes called "Medicaid expansion," is based on your Modified Adjusted Gross Income (MAGI), which includes most of your earned and unearned income. MAGI doesn't include some types of income, like Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect income-based Medicaid eligibility.
If you have a disability, you may be able to get Medicaid coverage if your income is a lot higher than this, thanks to the Medicaid's New Jersey WorkAbility program. Learn more about NJ WorkAbility.

Your family size: | |
Income limits for your family: | |
$14,580 | |
$5,140 | |
$13,590 | |
$4,720 | |
Income-based Medicaid, adults (138% FPG) | |
NJ FamilyCare, children, free (200% FPG) | |
NJ FamilyCare, children, premium (355% FPG) | |
Subsidized private plans, reduced fees (250% FPG) | |
Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Note: Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG).
|
What is NJ FamilyCare?

NJ FamilyCare is the state program that oversees Medicaid and CHIP (Children’s Health Insurance Program) in New Jersey.
Both Medicaid and CHIP are sometimes called NJ FamilyCare. The names can be interchangeable.
I’m an immigrant. Can I get Medicaid?

It depends on your situation:
- Undocumented immigrants do not qualify for full Medicaid coverage, but may qualify for Medicaid coverage for emergency services.
- Most immigrants who have been lawfully present for less than five years do not qualify for full Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
- Immigrants who have been lawfully present for five years or longer and some other noncitizens who meet specific noncitizen requirements qualify for the same programs that U.S. citizens can get.
What happens to my Medicaid coverage if I go back to work?

There are different health coverage options as your income goes up:
- Depending on how much your income goes up, your Medicaid may continue, unchanged.
- If you got Supplemental Security Income (SSI) before you started earning more, you can usually keep Medicaid thanks to SSI’s 1619(b) rule.
- If you have a disability and work, you can also consider the Medicaid's New Jersey WorkAbility program, which offers Medicaid coverage if you pay a monthly premium. Once you are covered by NJ WorkAbility, you can keep your coverage no matter how much you earn.
- If your employer offers it, you may be able to get employer-sponsored coverage.
- If your employer does not offer coverage, you should consider private individual coverage. You may get government help to pay for an individual plan on GetCoveredNJ. Note: There is no 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.
The bottom line: There is a coverage option for almost everybody. Do not worry that getting a job will leave you without health coverage.
Who qualifies for Medicaid's NJ WorkAbility program? 

To qualify for Medicaid's NJ WorkAbility program, you must:
- Be 16 years or older, live in New Jersey, and be a U.S. citizen or a qualified immigrant
- Be working
-
Have a disability that meets Social Security’s medical standards.
- Note: For NJ WorkAbility, SSA’s disability rules related to income do not apply.
-
Have unearned income at or below $1,215 per month for individuals.
- The NJ WorkAbility program does not count Social Security Disability Insurance (SSDI) or Railroad Retirement System benefits as income.
- Have earned income at or below $73,692 per year for individuals.
Note: The income limit is higher for couple where both people have disabilities and are working. Get more information about the NJ WorkAbility income limits.
Note: NJ WorkAbility used to have a resource limit. The rules changed on April 1, 2023 and this limit was removed. That means you can save up more money and don't have to worry about losing coverage!
How many programs does Medicare offer?

Medicare has three main parts:
- Medicare Part A helps pay for medical care you get while you’re in a hospital.
- Medicare Part B helps pay for medical care you get outside of a hospital.
- Medicare Part D helps pay for prescription drugs.
Medicare Advantage (also called Medicare Part C) is a way to get a single combined plan including Parts A, B, and D through a private company. With Medicare Advantage plans, you may have less flexibility, but your costs could be lower.
How do I become eligible for Medicare?

If you or your spouse worked enough time while paying Medicare taxes, you qualify for Medicare Parts A and B:
- When you turn 65
- When you’ve been getting Social Security Disability Insurance (SSDI) benefits for two years, or
- If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).
Note: If your disability began before you turned 22 years old and you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record, you start getting Medicare.
Does Medicare pay for all of my medical expenses?

No. Medicare only helps pay for care that it considers reasonable and necessary. If you need a service that Medicare doesn’t cover, you have to pay for it yourself, unless you have other coverage, such as Medicaid, employer-sponsored coverage, or a Medicare supplement (Medigap) policy.
For certain services, you pay a deductible, copayment, or co-insurance before Medicare begins to help pay for that service. For Medicare Part B or Part D, or for Medicare Advantage, you may have to pay a monthly premium.
You may qualify to get help paying for your Medicare premiums, copayments, and deductibles if you have low income. Medicare Savings Programs help pay for Part B coverage and the Low Income Subsidy (LIS) helps pay for Part D coverage.
Can I have Medicare and another health coverage at the same time?

Yes. Other coverage that you can have with Medicare include:
- Medicaid
- Medicaid's New Jersey WorkAbility program
- Employer-sponsored coverage
- Continued coverage through COBRA
- Retirement plans
- Veterans (VA) benefits
- Military (TriCare for Life) benefits, or
- Individual health insurance.
Learn more about how Medicare interacts with other types of coverage.
How much does employer-sponsored health coverage cost and who pays for it?

You may pay nothing, a percentage of the cost, or whatever amount your employer doesn't pay.
Employers are supposed to offer plans that cost the employee, for the employee’s policy alone, less than 9.12% of the employee’s household income for the monthly premium. Also, that coverage must meet bronze-level standards for copayment, co-insurance, and deductible expenses.
If your employer offers a plan that does not meet these standards, you may qualify for government help through tax subsidies to reduce the premium on an individual plan.
Note: The coverage your employer offers must meet affordability standards for the employee, but not for the family. It may be very expensive for family members to join an employer-sponsored health plan. Before 2023, the spouse or children of an employee would not qualify for subsidies on GetCoveredNJ 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." This changed starting in 2023. Learn more about affordability rules for family members and how it affects eligibility for tax credits on GetCoveredNJ.
Can I get coverage through my parent’s employer-sponsored insurance?

Yes, if you are under 26 and cannot get health coverage through your own employer. Employers who offer coverage to their employees must also offer it to their children under the age of 26.
Employers do not have to offer coverage to the spouses of employees, but many do.
Note: While employers must offer this coverage to children, the employee may be required to pay for all of it.
I have a disability. Can I really get insurance that covers my medical problems?

Yes. Plans cannot deny people coverage. When you apply for insurance, they cannot reject your application and they cannot say that they won’t cover medical needs related to your disability. They also cannot charge you more because you have a disability.
Additionally, all plans must cover the Essential Health Benefits (EHBs), which means that they offer comprehensive coverage, including chronic disease management, rehabilitative and habilitative services and devices, and mental health and substance abuse coverage, just to name a few.
How does the government help people pay for individual coverage?

Depending on your situation, you may qualify to have the government help pay for your individual health plan through tax credits. Here's how it works:
- When you sign up at GetCoveredNJ, you give details about your family's situation. GetCoveredNJ reviews that information instantly. If your family qualifies for government help to pay for individual coverage, GetCoveredNJ tells you and lists insurance options for you.
- Your insurance options list the full cost of the monthly premium, how much of that premium the government pays each month, and how much you pay each month. The government helps pay for the premium by giving you a tax credit every month, so you don't have to think about it during the year. All you have to do is make sure you keep paying your part of the premium.
- In January or February, the government sends you a form listing your total health coverage tax credits for the previous year. You need this form at tax time, because it is possible the government paid more or less than it should have for your health coverage. If so, this is sorted out when you file your taxes.
Do I have to get a silver level plan on GetCoveredNJ if I want government help paying for my insurance?

No, but depending on your income, you may get more help from the government if you get a silver-level plan:
- The government may help pay for your premium through tax credits. That means you would pay less each month. You might get this help no matter what metal your plan is.
- If you make 250% of the Federal Poverty Guidelines (FPG) or less and get a silver plan, the government also pays to reduce your copayments, co-insurance, deductible, and out-of-pocket maximum. That means you pay less each time you need medical services. If you get this help, your silver plan might actually be as good or better than many platinum or gold plans. If you do not get a silver plan, the government does not help you with these expenses.
When GetCoveredNJ looks at your income, they count most of your earned and unearned income. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.

Your family size: | |
Income limits for your family: | |
$14,580 | |
$5,140 | |
$13,590 | |
$4,720 | |
Income-based Medicaid, adults (138% FPG) | |
NJ FamilyCare, children, free (200% FPG) | |
NJ FamilyCare, children, premium (355% FPG) | |
Subsidized private plans, reduced fees (250% FPG) | |
Subsidized private plans (no income limit) | -- |
If your family's income is at or below the limit for a program, you may qualify if you meet other program rules.
Note: Different programs sometimes use slightly different numbers for the Federal Poverty Guidelines (FPG).
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What happens if I sign up for an individual plan and then my income changes and I can no longer afford it?

Usually, when you sign up for a plan through GetCoveredNJ, you need to stay on the plan for the entire calendar year. So, if you are signed up for 2023, then you can’t leave that plan until 2024.
However, in certain situations you may be able to change plans mid-year:
- If your income changes and you gain or lose eligibility for government help paying for your coverage
- If your health provider is not meeting its obligations
- If you move, or
- In other life-changing circumstances, such as having a child or getting married.
The first one is the key. If your income goes down and you can’t afford your plan anymore, report your change in income to GetCoveredNJ. You may qualify to get Medicaid or to have the government increase how much it pays for your current insurance (meaning that you have to pay less).
Note: American Indians do not have these restrictions and can change up to once a month.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
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Benefits and Work Estimator
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Common Pitfalls
Not getting health coverage because you think it's too expensive
Almost everyone has a health coverage option, even if you have a disability. The exact coverage that’s right for you depends on things like your family’s income, whether you can get employer-sponsored coverage, your age, where you live, and whether you have a disability.
If you can get employer-sponsored coverage or public health coverage, like Medicare or Medicaid, they are probably your best options.
If you can’t, you should look into getting an individual plan through GetCoveredNJ, where the government may help you pay a plan's expenses. Note: There is no 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 starting in 2019 there is no tax penalty if you don't have coverage.
Getting an individual plan without using GetCoveredNJ
GetCoveredNJ is the best way to get an individual plan. You are still allowed to get insurance through an insurance broker, but there are four big reasons it is better to use GetCoveredNJ:
- It’s the only place where you can get government help paying for your premiums and other health expenses.
- It automatically checks if you or your family might qualify for a public health coverage program, like Medicaid, and lets you know how to apply for it instead of an individual plan.
- GetCoveredNJ has customer services representatives available over the phone at 1-833-677-1010. You can also get local help.
- It’s totally free — there are no commissions and no hidden fees.
Not understanding the expenses involved with private health coverage
When making decisions about health coverage and comparing different plans, make sure you understand all of a plan’s costs, which can include:
- Premiums, a monthly amount that has to be paid whether or not you use medical services. If you have employer-sponsored coverage, your 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 through tax subsidies if your income is low enough.
- Copayments, a set amount you have to pay for a 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 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 begins to pay for certain services, including hospital care, emergency room visits, and brand-name prescription drugs. After you pay the deductible, you do not have to pay it again until the next calendar year.
Not looking into Medicaid because you think you don’t qualify
Medicaid used to be mainly for people with disabilities, seniors, children, and pregnant women. Now, it is for anybody with low income (at or below 138% of the Federal Poverty Guidelines (FPG), $20,120 for an individual; $41,400 for a family of four). No matter how much money you have in the bank or what your health situation is, you could qualify.
Not working because you think you’ll lose Medicaid coverage
In the past, people feared that if they got a job while they were on Medicaid, they’d lose their coverage, because they would no longer have low enough income to qualify.
Now, if you lose one health coverage option, there should be another one you can get. If you lose your Medicaid coverage, you will become eligible for Medicaid's New Jersey WorkAbility program, employer-sponsored coverage, or private individual coverage. And, if you can’t afford individual coverage, the government may help you pay for it.
The bottom line: There is a coverage option for most people. Do not worry that getting a job will leave you without health coverage.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
Try It
Next Steps
Learn more about Medicaid
- Visit the NJ Medicaid website.
- Visit or call your local NJ FamilyCare outreach and enrollment site.
- It's important to know the type of Medicaid you have, and where it is being administered. When in doubt, call the nearest New Jersey Medical Assistance Customer Center (MACC) office.
- If you have a disability, talk with a Health Benefits Coordinator at 1-800-701-0710 or 1-800-701-0720 (TTY) to learn more about health programs for people with disabilities.
Apply for Medicaid or NJ WorkAbility
You can apply for Medicaid or Medicaid's NJ WorkAbility program:
- Online using NJ FamilyCare Quickstart, or
- At an outreach and enrollment site in your county.
NJ FamilyCare lists the information and documents you may need when you apply. For help with your application, talk with a Health Benefits Coordinator at 1-800-701-0710 or 1-800-701-0720 (TTY).
Learn more about Medicare
- Visit Medicare.gov.
- Use the Medicare Plan Finder to compare Part D and Medicare Advantage plans.
- See how Medicare interacts with private health coverage in How Medicare works with other insurance.
- Call the State Health Insurance Assistance Program (SHIP) at 1-800-792-8820.
- Call Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY). The line is open 24 hours a day, 7 days a week.
- Read Medicare & You, Medicare’s official handbook, which explains benefits, costs, services, health plans, and prescription drug plans.
Learn more about employer-sponsored coverage
To learn more about employer-sponsored coverage, talk to your employer’s Human Resources department. It will know about the specifics of the health coverage options it offers.
Learn more about individual coverage
- Visit GetCoveredNJ, which has a lot of great information introducing your options.
- Call GetCoveredNJ at 1-833-677-1010.
- Get local help from GetCoveredNJ.
- To get an idea of what your premium might be, check out GetCoveredNJ's shop and compare Tool.
Benefits Planning Services
If you're currently on SSI, SSDI, or CDB benefits, and you're looking for a job, a trained Benefits Planner can help you avoid problems with your job plan. If you need help or have questions about your situation, you can call the Ticket to Work Help Line at 1-866-968-7842 or 1-866-833-2967 (TTY) Monday through Friday from 8:00 a.m. – 8:00 p.m. EST.
View DB101's full list of experts who can help you understand different benefits.
Learn more
What Benefits Do I Get?
How to see which Social Security benefits you get.
Long-Term Services and Supports
Learn about programs that can help you live in your own place in the community.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.