The Affordable Care Act Can Help Au Pairs Avoid Medical Debt

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According to the State Department, 14 au pair agencies operate in the U.S. These private companies are required to offer the child care workers who contract with them basic health coverage. But the plans often amount to emergency or travel insurance — not the kind of full coverage ACA health plans offer. / Getty Images

In 2016, Isis Mabel, of Mexico, was in her 20s and wanted to improve her English. On advice from an aunt, she enrolled with an au pair agency to come to the United States to live with a family and care for the children. The job typically pays about $200 a week on top of lodging and meals. Along with her application, the agency requested $360 from Mabel — a one-time charge that was to cover certain costs, including visa fees and health insurance, the agency explained.

That conversation was "super quick," she says, with no details on what the health insurance would cover. When she arrived in the United States, she recalls, a representative of the au pair agency recommended she buy extra insurance to cover injuries that might result from participation in sports, from skiing to swimming in a pool — because even an accident caused by jumping could be considered sports-related, the agency said. Mabel opted to purchase that extra policy for another one-time fee of $180.

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Isis Mabel in Boston in 2016, soon after she came to the U.S. to work with a family as an au pair. Mabel got basic health coverage through her au pair agency, but didn't realize she could buy much more comprehensive health insurance, with subsidized premiums, on the Affordable Care Act marketplace. / Kenneth Sipin/KHN

The summer after she started her au pair job, Mabel's birth control implant expired and she had it removed — a procedure she assumed would be covered by her insurance, given birth control coverage is part of Mexico's universal health care system.

Instead, she says, she got a bill for about $4,500. The health insurance she'd bought through the au pair agency didn't cover contraception or other reproductive health care.

Her health plan was more like emergency travel insurance

According to the State Department, 14 au pair agencies operate in the U.S. These private companies are required to offer their au pairs basic health coverage under State Department regulations. But some of the plans amount to emergency or travel insurance — excluding many types of necessary care, according to Natalia Friedlander, a staff attorney at the Rhode Island Center for Justice, a nonprofit public interest law center.

After an au pair she herself employed had problems with health coverage, Friedlander examined insurance offered by about half those agencies in 2020; her center then posted information online to help au pairs find comprehensive coverage.

In her review, Friedlander discovered that agencies don't always mention to au pairs that they are eligible to enroll in comprehensive coverage on the Affordable Care Act marketplaces, nor that they'd likely qualify for subsidies to help pay their premiums. By failing to enroll in ACA plans, au pairs can wind up with huge medical bills if they need care.

A spokesperson for the State Department says those 14 agencies are subject to the same regulations as other groups that sponsor exchange students and other visitor programs, and must require the au pairs to "have insurance in effect that covers the exchange visitors for sickness or accidents during the period of time that they participate in the sponsor's exchange visitor program."

The criteria laid out in the federal regulations include medical benefits of at least $100,000 per accident or illness, a deductible limit of $500 per accident or illness, and a maximum coinsurance limit of 25% of the cost of covered benefits. But the regulations don't stipulate that the comprehensive coverage required for Americans must be provided.

Federal subsidies can make better ACA insurance affordable

Neither do the rules suggest au pairs or other exchange visitors must be told they have access to ACA marketplace plans — or be told how to find and sign up for them. Mabel and two other former au pairs, whose time working in the program spanned 2014 to June of this year, told us that no one ever mentioned the ACA to them when they signed up for work or after they arrived in the U.S.

We reached out to each of the 14 au pair agencies under the purview of the State Department about the insurance plans they offer employees. Only one responded.

Terence Burke, a spokesperson for Cultural Care Au Pair, said the insurance offered to its au pairs exceeds regulations set up by the State Department to meet medical expenses and other travel coverage, and provides emergency evacuation from the country if needed — another State Department requirement.

"Au pairs with Cultural Care are given detailed information on exactly what is and what is not covered in their insurance coverage. Knowing that information, au pairs are always free to supplement or add to the insurance coverage they must have in accordance with the U.S. State Department regulations and can choose to enroll in an ACA exchange to supplement their medical coverage," he wrote in an email.

Friedlander found that the insurance plans offered to many au pairs before they arrive exclude certain categories of care deemed essential under the ACA. Many, for example, don't cover routine or preventive services, or care for preexisting conditions, mental health, and maternity and reproductive health, she says. Some plans are advertised as "comprehensive," "exceptional" or "worry free," although they do note the coverage exclusions.

In addition, Friedlander says, the insurance coverage summaries or orientation materials she reviewed did not mention ACA marketplace plans as an option.

Au pairs on J-1 visas are classified as foreign nationals living in the U.S. on non-immigrant visas, because they're not on a path to citizenship. The ACA covers such non-immigrants.

"We encourage organizations that facilitate the J-1 visa exchange programs to communicate the opportunity to enroll in quality, affordable healthcare through the Marketplace," says a spokesperson for the Centers for Medicare & Medicaid Services, the federal agency that oversees the ACA marketplaces. "J-1 visa holders are considered lawfully present and are therefore eligible to enroll in a qualified health plan through the Marketplace, and for financial assistance, if otherwise eligible."

CMS notes, however, that anyone seeking subsidies to help cover the cost of premiums must plan to file a federal income tax return for that year.

If the insurance au pairs carry through their agencies doesn't meet the minimum coverage requirements under the ACA, Friedlander says, they are free to enroll in an ACA marketplace plan.

But the enrollment window is strict: People have only 60 days after arrival in the U.S. to sign up for ACA plans, or must otherwise wait for the annual health insurance open enrollment period, which is usually held in the fall.

Friedlander says when she first looked into insurance for her au pair, "I assumed she would have comprehensive coverage." She was surprised, she says, to see large limitations.

Having previously worked at a health insurance-related nonprofit, Friedlander first investigated whether the au pair could enroll in ACA coverage. It took effort, because the ACA marketplace navigators weren't familiar with J-1 visa holders; but ultimately she managed it. Friedlander has since helped two subsequent au pairs enroll.

Au pairs in the U.S. are typically not native English speakers, may be very young and often live with their employers, which leaves many dependent on their host families, Friedlander notes. "That's a situation where they really are reliant on the agencies to provide them information that they need to know while in the United States," she says.

Mabel says the hefty medical bills she was charged changed her experience in the U.S. The amount of money she owed the hospital and doctor, she says, would have been enough to buy round-trip tickets to Mexico to have her implant removed there. To save enough money to pay off her medical debt, she says, she had to curtail most activities, aside from working.

"Basically, the purpose of the exchange — go traveling around — it stopped there, it finished," Mabel says, "because I acquired this responsibility." It took two years to pay off the debt.

"It was my biggest mistake financially ... of my whole life," she says.

For some au pairs the hidden costs are even higher. Estefania Weinbach, of Colombia, says that in 2016, two years after coming to the U.S. to work with the children of a family, she experienced a sharp pain in her abdomen that felt like she was being stabbed. She was diagnosed in a hospital emergency room with endometriosis and was told she would need surgery within weeks.

Weinbach says she was advised by a representative from her au pair agency that the surgery would be covered in her home country; the representative suggested she fly back to Columbia immediately. When Weinbach refused to do that, she says, the agency told her the insurance would cover her surgery expenses up to $7,000.

Ultimately, she was able to find a doctor willing to perform the operation for that payment. But it was a "very traumatic experience," she recalls — one that made her feel "everything is against you."

Kaiser Health News is a national, independent newsroom and program of the Kaiser Family Foundation, and is not affiliated with Kaiser Permanente.

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