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Yolanda Farrell lay mostly paralyzed in a nursing home, unable to feed or dress herself, when her homeless daughter persuaded her to move out.

Linda Maureen Raye, who relatives say had been living in her car with her dog, used her mother’s Social Security to pay for a one-bedroom Riverside apartment and took over as Farrell’s sole caregiver in 2010.

Over the next two years, according to police and court records, Raye took her elderly mother to the doctor once. As her mother’s health declined, Raye stopped cooperating with a nurse sent to advise her on preventing bedsores.

Yet in 2012, Raye was hired officially: She began collecting about $900 a month from taxpayers under the state’s in-home care program for poor people, according to law enforcement authorities.

By the end of that year, Farrell, an 85-year-old former real estate underwriter who loved to travel, had died of septic shock resulting from severe bed sore infections. Originally charged with murder, Raye, 60, pleaded guilty to elder abuse in September and was sentenced to 11 years in prison.

“She essentially neglected her to death,” said Riverside Police Det. Christian Vaughan, who investigated the case.

California’s frail elderly and disabled residents increasingly are receiving care in their own homes, an arrangement that saves the government money and offers many people a greater sense of comfort and autonomy than life in an institution. Yet caregivers are largely untrained and unsupervised, even when paid by the state, leaving thousands of residents at risk of possible abuse, neglect and poor treatment, a Kaiser Health News investigation found.

The move from nursing-home to in-home care is part of a massive shift across the nation, driven by cost-cutting and patient preference. In California, at least four times more elderly and disabled residents receive in-home care than live in nursing facilities – a rate that is only expected to rise as baby boomers age.

Many families either provide care for relatives without compensation or pay out of pocket for caregivers they find through word-of-mouth, referral agencies or private companies. But a growing number of elderly and disabled people have incomes low enough to qualify for state-funded care under the In-Home Supportive Services program, or IHSS – the same one that paid Raye to care for her mother.

California’s $7.3 billion IHSS program is the largest publicly funded caregiver program in the nation. The caseload has more than doubled since 2001 and now serves about 490,000 low-income clients throughout the state.

Working behind closed doors for an average of about $10 an hour, these caregivers carry immense responsibility but are subject to little scrutiny, according to law enforcement officials, elder abuse investigators, senior care experts and court records. Their lapses sometimes lead to preventable injuries and death.

Many clients are too feeble or afraid to complain or ask for assistance. “We don’t know how many times Yolanda cried for help,” Det. Vaughan said.  “She didn’t have a voice. She was deprived of that.”

Kaiser Health News’ investigation into the IHSS program found that:

* Training for caregivers is minimal and mostly optional. California doesn’t require training for everyone – even in CPR, first aid or preventing injuries. By design, IHSS is not a medical program and caregivers are supposed to confine themselves to tasks such as feeding, dressing or bathing. But some become ad hoc nursing aides, helping to dress wounds and manage medications. The state requires caregivers receive training and authorization from physicians in these cases, but only about one in nine caregivers receives it, officials say.

* Most clients in California, 73 percent, are related to their caregivers, up from 43 percent in 2000. The arrangements assume an inherent trust between client and caretaker – a trust that can go awry when the relationships are dysfunctional, abusive or financially driven. While many states allow some paid family caregiving, most prohibit spouses from taking the job and some bar relatives entirely. California has no such restrictions.

* Screening, though improved in recent years, has potentially dangerous gaps. State law requires criminal background checks and bars people from becoming caregivers if they have been convicted of certain crimes, such as elder and child abuse. But the IHSS program leaves the hiring to clients and gives them wide latitude. Felons convicted of robbery, rape or assault can be paid caregivers if their clients get a waiver from the state.  In the past four years, more than 830 people have received such waivers for caregivers convicted of serious offenses. “They can have criminal records, they can have drug addiction,” said Susan Strick, a prosecutor with the Los Angeles City Attorney’s office. “That’s a problem.”

* Few incidents of abuse and neglect by IHSS workers are documented because authorities aren’t looking for them. County social services workers are supposed to check on the clients once a year on the state’s behalf but are not primarily focused on the quality of care provided. Their main job is to determine whether clients are receiving the proper number of hours of care and whether their needs have changed. And because social workers are assigned hundreds of clients each, their visits are frequently brief – as short as 30 minutes a year.

Counties are also supposed to report to the state “critical incidents” –potential neglect, abuse or self-harm requiring immediate action. But reporting practices vary widely, yielding puzzling results. In fiscal year 2012-2013, for instance, not a single critical incident was reported among the 235,000 clients in Los Angeles, Orange and San Diego counties, the three largest in the state. That same year, smaller Sacramento County reported 1,688 incidents – accounting for most of the problems reported statewide.

“There is no evidence indicating that Sacramento County has a disproportionately higher number of critical incidents than other counties,” a Sacramento county spokeswoman said.

Beyond statistics such as these, nearly all records of IHSS are confidential. So unless a caregiver is criminally prosecuted, the details of any alleged mistreatment are unavailable to the public.  Prosecutors and experts on elder abuse say only a small fraction of problems come to light. When they do, it is sometimes too late.

Neglect and abuse by paid home caregivers happens “far more regularly than we know,” said Paul Greenwood, a national expert in elder abuse and a prosecutor with the San Diego County District Attorney’s office. “We are still scratching the surface.”

Eileen Carroll, deputy director of the California Department of Social Services, which runs IHSS, said the program “works very well for people who are capable and able to self-direct.” She acknowledged that more problems can arise when clients are older than 85, for instance, or have dementia.

In general, she said, the state tries to ensure that clients are receiving the services they need safely in their homes without compromising their independence.

The state recently has made improvements to its quality assurance program and has clarified reporting standards for critical incidents, she said.  But mandating training or increasing oversight further could fundamentally change IHSS from a program based on the consumers’ social needs to one based on their medical needs, she said.

“It’s a slippery slope,” she said. “I don’t think it is in our interest to force recipients and providers to do anything.”

Clients Are The Bosses

The In-Home Supportive Services program has its roots in the 1950s, when a small group of polio patients was moved out of Rancho Los Amigos Hospital, a rehabilitation center in Downey. Officials recognized that it would be less expensive for people to be taken care of in their homes, and the March of Dimes began to pay for domestic help.

The current in-home care program, created by the state legislature in 1973, retained the historical emphasis on supporting clients’ autonomy. The state pays the bills, but the elderly or disabled resident is the boss – responsible for hiring, firing, supervising and training the caregiver.

To be eligible, most clients must qualify for Medi-Cal, the state insurance program for the poor, and be over 65, blind or disabled. They also must show a need for help in the home.

Many swear by the program.

“I get to continue making choices,” said Margaret Belton, 82, who receives help seven days a week from IHSS caregivers at her Pasadena apartment. “When you go into a nursing home, you lose your ability to make decisions.”

Belton, a former nurse with arthritis, diabetes, thyroid problems, hip and knee replacements and a history of falls, said she appreciates being able to train her own providers.

But for others, supervising a caregiver can be a struggle. That is especially true when clients are very old, severely physically or mentally impaired or when the employees are family members with whom clients have difficult relationships.

The IHSS program can be a “perfect scenario for elder or dependent abuse,” said Julie Batz, staff attorney at Legal Assistance for Seniors in Oakland. The clients may trust the providers because they share a history or because they assume that the government has screened and trained them, she said, but “that is not necessarily true.”

Toni Giusto, 54, said she trusted Yvonne Belanger, her domestic partner of many years, with her life. The Oakland woman hired Belanger as her IHSS caregiver in 2000, after an abscess in her neck left her paralyzed from the waist down. Giusto said she needed help with everything – eating, bathing, sitting up.

Instead, Giusto said Belanger locked her in a room. “She wouldn’t give me water or nothing,” she said. Belanger didn’t take her to the doctor, even when she developed bed sores that attracted maggots, Giusto said. Belanger sprayed bug poison on her to get rid of them, according to court papers.

Responding to a call from Giusto’s sister, police came to the house in 2010 and found Giusto with 23 open sores and an abdomen swollen from waste backed up in her bowels, according to court papers. Belanger was convicted of elder abuse and sentenced to county jail. She died last year.

“I was so trusting,” said Giusto, who now lives in a rehabilitation facility in Alameda. “I never thought she could do this to me.”

For some clients, choosing a caregiver is less about trust than about mutual need. The parents of Erica Aguirre, now 29, knew she had a drug problem. But they needed help and she needed money, so they applied to IHSS and hired her.

For about two years, Aguirre said, IHSS paid her to care for her 72-year-old mother, Guadalupe, who has asthma, diabetes, high blood pressure and depression, and her father, Jesus, 69, who has heart problems, diabetes and early dementia.

Guadalupe Aguirre said she and her daughter soon had arguments that ended in yelling and hitting. “I thought she was going to be different than she was,” the mother said in Spanish.

In 2012, Erica Aguirre was charged with physically and verbally abusing her mother. She was convicted and sentenced to 60 days in county jail and drug treatment, according to court documents.

In an interview at the family’s home in South Los Angeles, Erica Aguirre said she is a recovering drug addict and also suffers from depression and anxiety. Despite that, Aguirre said she followed doctors’ instructions and tried to help her parents. She said she quit working as an IHSS caregiver before her criminal case began.

“I tried my best as a caregiver,” she said. But “I wasn’t the appropriate one.”

Deborah Doctor, a legislative advocate at Disability Rights California, said there is nothing to suggest that the IHSS program fosters abuse or that people are less safe at home than they would be in an institution. The best way to ensure a high quality workforce is to pay caregivers better – not to increase regulation, she said.

“I am sure there are some bad actors but the efforts to quantify that have never come up with anything more than a minuscule perspective,” Doctor said.

Focus on Fraud

Martin Hernandez, an IHSS social worker in Los Angeles County, has a tough job.

He has about 440 active cases, including people with multiple sclerosis, diabetes, mental illness and a history of strokes. He is generally expected to visit each client once a year, though occasionally he sees someone who hasn’t been visited in two years.

Even once a year is “not enough to tell who is being harmed and who is not being harmed,” he said. “It’s very hard unless a neighbor calls or you see some kind of physical evidence.”

His colleague, Gloria Daniels, said she has an even higher caseload – 493 clients. “The program is so big that it appears nobody knows what to do,” she said. “We are being told it’s quantity, not quality.”

In Los Angeles County, the most populous county in the nation, social workers have an average of 265 clients each. Under their union contract, their caseloads aren’t supposed to exceed 249. Above that, workers can’t be held to the usual disciplinary standards. But other counties have even higher ratios – in Riverside County, case workers average about 500 clients each.

There are no statewide standards for how many cases a social worker can carry. Carroll said in some smaller counties workers have caseloads as low as 7. In the areas with high caseloads, she said, the state has been urging counties to hire.

“We do want to see cases become better balanced,” she said.  “We do want to see [clients] assessed every year.”

During their visits county workers focus much more on possible fraud than on quality of care, statistics suggest. From 2008 through 2012, workers in the five most populous California counties – Los Angeles, San Diego, Orange, Riverside and San Bernardino – reported 960 cases of fraudulent overpayment to caregivers. During that same period, the workers reported a total of 32 “critical events” – potential neglect, abuse or self-harm.

The state has another limited quality assurance program that aims to ensure clients are safe and that county workers are following proper procedures. Inspectors conduct “desk reviews” of case files and other documents, along with a very small number of home visits. In 2013, just 3.8 percent of IHSS cases were reviewed under the program.

Since last summer, more desk reviews and unannounced visits are taking place, Carroll said.

Case workers – and caregivers – are required by law to report suspected abuse or neglect. But IHSS officials and family members mostly depend on another state agency, Adult Protective Services, to investigate those concerns.

This agency is also spread thin and has limited powers, according to state records and interviews. Even if workers suspect abuse or neglect, they generally can’t remove an adult from the home without his or her permission.

“We cannot force anybody to accept our services,” said Stacey Lindberg, program manager of Adult Protective Services in Orange County. “It is heartbreaking.”

Suffering In Seclusion

The result, in some cases, is prolonged abuse and neglect by IHSS caregivers. Examples can be found in court records throughout the state.

In Fresno, a 26-year-old woman, disabled by a severe spine condition, hired her brother and his wife as IHSS caregivers. Police and prosecutors say the couple, Joe and Denise Roman, didn’t turn her in bed, and her tissue broke down so much that metal rods in her spine became exposed. She died and the caregivers were convicted in 2011 of abusing her.

In Lake Isabella, Kern County, Joseph McCoy was a paid caregiver over many years for his 90-year-old grandmother, who raised him. McCoy left her unattended, and officials discovered her stuck to her sheets with gruesome bedsores in a fly-infested room, according to prosecutors. She died shortly afterward. McCoy was convicted in 2012 of elder abuse.

“This was a really, really horrible case,” said Michelle Domino, Kern County deputy district attorney. “She had clearly been left neglected for some time.”

In Yolanda Farrell’s case, relatives say they are stunned that Linda Maureen Raye even was able to become a paid caregiver for her mother. Farrell was unable to walk and had very limited use of her arms as a result of a bout with polio years earlier. Linda Maureen Raye had longstanding emotional problems, her brother Terrence said. She’d tried to take care of her mother in the past but always found herself overwhelmed. “My mom would always try to believe that she was better,” he said.

Linda Maureen “went behind our backs and convinced my mom that she would be better off being taken care of in a private residence with her,” Terrence Raye said. Later, he said, Linda Maureen told him that she needed the IHSS funds as well as Farrell’s Social Security money.

Terrence Raye said she wouldn’t allow him to visit his mom, or even talk to her, so he called police and adult protection authorities. They interviewed his mother in Linda Maureen’s presence, he said, and told him they found nothing wrong.

The last time he saw Farrell was at Riverside Community Hospital, where she had arrived sickened from ulcers that went to the bone.

“My mom was old enough and in bad [enough] health never to recover,” he said.

Blue Shield of California Foundation helps support KHN coverage of California.

The California Endowment helps support KHN coverage of California.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Donna Giron is frail. She has Crohn’s disease and uses a wheelchair to get around because walking exhausts her.

But she doesn’t want to be in the nursing home where she has lived since May.

Giron, 65, is looking to rent a small house in the industrial town in the Cleveland suburbs where she grew up. Using federal funds from a special project, thousands of elderly and disabled nursing home residents have been able to move into their own homes in recent years. The experimental project has reached people in 44 states, including more than 5,400 in Ohio. It connects people to the medical and living support they need to move into private homes, so that they can live independently.

But often the housing is the sticking point. Giron doesn’t have family members who could take her in, so she’s house-hunting. As she tours one likely prospect, she manages to get out of her wheelchair to maneuver down some stairs; at the bottom, Giron looks out a window at the front porch and says she can picture herself sitting outside watching the neighborhood.

Then, she sees the kitchen.

“Oh, we even got a dishwasher! Oh, my goodness gracious. Yeah, I want this one. I want this one,” she says, laughing.

Despite her health problems, Giron feels out of place in the nursing home, where many residents are older and sicker than she is.

“I’m a very independent woman,” she says. “I have been for most of my life. I mean, I’ve had to be.”

But independence is difficult to achieve. And until recently her health insurance – Medicaid — has been the roadblock. Ohio Medicaid director John McCarthy explains that the federal program that offers health coverage for the poor and disabled is primarily set up to help people live in nursing homes.

“It’s the housing that’s the hard part, because Medicaid will not pay for housing costs, meaning room and board,” McCarthy says. “It will only pay for room and board in institutions.”

If Giron finds a home, she will have to pay rent out of her small pension. But as part of this experimental program, Medicaid will pay for the costs of setting up house: house-hunting, deposits for rent, and the purchasing of household items like furniture. Perhaps most importantly, it provides a transition coordinator to help find the home and connect Giron to services she’ll need, such as home health workers.

“It is a lot of work,” McCarthy says. “These are not easy cases to deal with. It’s not like you just find somebody and move them. It takes a lot of time and effort to make this happen.”

Many in the program are older and disabled like Giron. But most in Ohio are actually younger than 65, often with physical or mental challenges that make finding the right housing particularly difficult.

In every category, though, making it possible for these Medicaid recipients to live on their own saves the state and federal government money. McCarthy and his team estimate that the average costs for an individual in the experimental program (which is called Money Follows the Person) is $49,000. Under traditional Medicaid it costs about $64,000 annually for nursing home care in Ohio.

The state’s Republican administration believes so strongly in this project that it stepped up efforts to transition people into it three years ago, right after the project was funded again, under the Affordable Care Act.

Ohio, Texas and Washington account for 40 percent of the nation’s home placements since the federal project began.

The program is very popular with beneficiaries, policy makers and even some nursing homes, but there are still two big challenges. For one, funding for the program was extended under the Affordable Care Act in 2010 but is set to expire in September 2016.

And, secondly, people like Giron who are waiting to get a home are finding it very difficult to find one that’s affordable.

“I just want my own place,” Giron says. “I don’t want anything fancy. I just want something to call my own. I just want to be in my own home. I just want to live my life normally like most people do. I want to be on my own. I want to be happy.” She starts to cry.

Giron did not end up getting the little, two-story house with the dishwasher. But she did get some good news for the holidays: In late December, she signed a lease for a different place and is slated to move into the home in January.

This story is part of a reporting partnership with Ideastream, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

87 percent of people who selected 2015 plans through HealthCare.gov in first month of open enrollment are getting financial assistance to lower monthly premiums.

What a difference a year makes.

With its technical troubles largely behind it, healthcare.gov enrolled 1.9 million new customers for health insurance between Nov. 15 and Dec. 18. At the same time, another 4.5 million existing policyholders either re-enrolled or were automatically renewed into their existing policy or a similar one beginning Jan. 1.

“We still have a ways to go and a lot of work before Feb. 15,” the deadline for open enrollment, Health and Human Services Secretary Sylvia Burwell told reporters Tuesday. “But we do have an encouraging start.”

Burwell said of those who were re-enrolled, percentages “somewhere in the mid- to high-30s” logged into the system and either renewed their old plans or changed to a different one. The rest were automatically re-upped. About 2 percent of policy holders, she said, could not be auto-renewed because their plan has been discontinued and there is not another one similar enough. Those people, as well as anyone who was auto-renewed, can still change plans until Feb. 15.

Many people will find it financially advantageous to switch plans for a variety of reasons, including increased competition among plans, variations in premiums or benefits, or changes in their financial circumstances that affect the amount of subsidy they may receive.

Meanwhile, Burwell steadfastly refused to answer questions about whether her department is making contingency plans in the event the Supreme Court rules that subsidies are not available in the 37 states where healthcare.gov is operating the exchange. The court announced earlier this week it would hear oral arguments in the case, King v Burwell, on March 4.

“The law of the land is that where we are right now is those subsidies are available and people are shopping, they are coming in, they are getting affordable care,” Burwell said. “We are focused on open enrollment and we are focused on a position where we believe we have a position that will prevail.”

The plaintiffs in that case argue that Congress intended to make subsidies to purchase insurance available only in exchanges “established by a state,” which does not include the federally-run exchange. Backers of the law, including most of the Democrats who wrote it, say the wording was awkward, but the law always intended to make the subsidies available to all, regardless of whether an exchange was state- or federally-run. If the Supreme Court rules that subsidies are not available in the federal exchange, it could cause millions of people to shed coverage.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Andy Pasternak, a family doctor in Reno, Nev., has seen more than 100 new Medicaid patients this year after the state expanded the insurance program under the Affordable Care Act.

But he won’t be taking any new ones after Dec. 31.  That’s when the law’s two-year pay raise for primary care doctors like him who see Medicaid patients expires, resulting in fee reductions of 43 percent on average across the country, according to the nonpartisan Urban Institute.

“I don’t want to do this,” Pasternak said about his refusal to see more Medicaid patients next year. But when the temporary pay raise goes away, he and other Nevada doctors will see their fees drop from $75 on average to less than $50 for routine office visits.

“We will lose money when they come to the office,” he said.

Experts fear other doctors will respond the same way as Pasternak, making it harder for millions of poor Americans to find doctors. The pay raise was intended to entice more physicians to treat patients as the program expanded in many states. In the last year, Medicaid enrollment grew by almost 10 million and now covers more than 68 million people nationwide.

The challenge is to convince physicians not just to continue accepting such patients but to take on more without getting paid what they’re used to, said Dr. J. Mario Molina, CEO of Molina Healthcare, one of the nation’s largest Medicaid insurers.

Charles Duarte, CEO of a large community health center in Reno where some patients already wait two months or more for appointments, foresees increased demand for services at his Community Health Alliance clinics, which are paid more generously by Medicaid and were not eligible for the enhanced pay.

“We will see more patients and longer wait times,” he predicted.

State Impact Differs

Despite the concerns, most states say they’ve seen no evidence the increase has resulted in greater doctor participation — mostly because it was temporary. The bonus boosted pay rates for primary care doctors who saw Medicaid patients to the same level as they are paid by Medicare.

Because Medicaid reimbursement rates for doctors vary by state, however, the pay bump varied from no change in Alaska, Montana and North Dakota, to a 50 percent raise or more in California, New York, New Jersey, Michigan, Florida and Rhode Island, according to the Urban Institute.

Only a handful of states have acted to continue the Medicaid pay boost using their own funds, including Maryland, Alabama, Colorado, Iowa and Mississippi. Connecticut will continue the raise, but not for primary care services done in hospitals.

Nevada and several other states are still considering extending it.

The American Academy of Family Physicians has lobbied Congress to extend the higher pay rate, but has been hampered by lack of data showing the higher fees spurred more doctors to join, said Robert Wergin, president of the academy and a physician in Milford, Neb.

Wergin said he participated in Medicaid before the health law and won’t be deterred from accepting new patients in the rural town in which he practices after the pay raise expires.

Nonetheless, “I believe access as a result of the cuts will be an issue,” he said.

Low reimbursement rates are not the only reason doctors’ avoid Medicaid. High patient no-show rates also make private physicians reluctant about participating, Duarte said.

Kaveh Safavi, global managing director of Accenture Health, said physicians have always gone in and out of the Medicaid program as a business decision. Others participate because they feel a social obligation, especially if they practice in an area where patients don’t have other health care options.

“There are a lot of dynamics at play … though historically, things have not changed [doctors’ participation] as much as when states make payment changes,” he said.

Rhode Island Faces Biggest Cuts

The Urban Institute study found that Rhode Island doctors will face the biggest pay drop next year — 67 percent. Even so, the Rhode Island Medical Society expressed doubt that the change will cause disruption. It notes that some large insurers require doctors in the state who want to treat privately insured patients to see their Medicaid members, too.

“Every little bit helps, but I don’t see this as a deal breaker,” said Steven DeToy, director of governmental public affairs for the society.

Officials with Neighborhood Health Plan of Rhode Island, one of two Medicaid health plans in the state, said they’re not worried about the end of the pay raise.

“We had wide availability of doctors before the pay raise and don’t expect much change when it ends,” said spokesman Tom Boucher.

The pay raise went to doctors working for private managed care plans, as well as those in private practice.

Stephen Zuckerman, senior fellow at the Urban Institute, said the states that will use their own funds to continue the fee increase were typically paying higher-than-average Medicaid rates already. But the most populous states — among them, New York, California and Illinois — are not doing that.

“It’s an open question of whether more doctors will quit Medicaid or stop seeing new Medicaid patients,” Zuckerman said. “But these cuts cannot help.”

Impact Debated

Measuring Medicaid enrollees’ access to care is not simple.

While fewer primary care practices are willing to accept new Medicaid patients, those that do accept them typically offer appointments within a week, according to a separate Urban Institute study. 

But a December report by the Health and Human Services’ Office of Inspector General found that about half of Medicaid doctors listed as participating in managed-care plans don’t have availability or don’t contract with the health plan at all.

Jeff Myers, president of Medicaid Health Plans of America, the trade group, said the plan’s provider directories should be updated but the findings don’t mean patients can’t get care. He pointed to federal documentation showing increasing patient satisfaction.

Other experts note that the pay raise was just one way the health law tried to ensure that newly covered Americans would have a place to get care. Funding to community health centers was also boosted by $11 billion from 2011 to 2015 to help them expand.

“The Medicaid pay boost was never meant to be a silver bullet,” said Leonardo Cuello, director of health policy at the National Health Law Program, an advocacy group for low-income Americans.

Still, the provider fee cuts have him worried. “It won’t sink the ship but … I’m concerned it will contribute to access problems.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Readers have raised many questions about enrolling in Medicare. I answer two recent ones here.

Q. My wife has been automatically re-enrolled in a silver policy on the Oklahoma health insurance marketplace. She will turn 65 and be enrolled in Medicare on May 1, 2015. Can she keep her silver policy when she is enrolled in Medicare? And, if she does, will she automatically lose her premium subsidy? Do we have to cancel the policy or will the insurer do it automatically?

A. Your wife doesn’t have to give up her marketplace policy when she turns 65, but financially it probably doesn’t make sense to keep it, says Tricia Neuman, director of the program on Medicare policy at the Kaiser Family Foundation (KHN is an editorially independent program of the foundation.)

Once she’s eligible for Medicare, your wife will no longer qualify for premium tax credits on the marketplace, making that coverage more expensive.