In general, if you have, or are eligible for, any of the following types of coverage, you would be ineligible for premium tax credits through the Marketplace:
Employer-sponsored coverage, unless the coverage is unaffordable (your required contribution to the premium for self-only coverage in 2018 costs more than 9.56% of household income) or does not meet minimum value (an actuarial value of less than 60%). Special rules apply when the affordability of family coverage is a concern.
Government-sponsored coverage, including Medicare Part A coverage, Medicare Advantage plans, Medicaid coverage and the Children’s Health Insurance Program coverage, Veterans health coverage and TRICARE (coverage for members of the military)
Coverage for Peace Corps volunteers
However, if you have access to other types of coverage, you can still be eligible for premium tax credits, assuming you meet other requirements:
Individual (non-group) health insurance
Student health coverage
Coverage as a dependent under your parent’s group health plan if you are under age 26 and not claimed as a tax dependent by your parent
Retiree health coverage offered by a former employer
On the health insurance Marketplace web site, you will find an Application for Health Coverage and Help Paying Costs. Filling out the application online is the fastest, though you can also submit a paper application or call your Marketplace call center and apply over the phone. The Application will ask you basic information about yourself (and any family members who are applying for coverage with you) including your Social Security number and information about your citizenship or immigration status. It will also ask employment and income information, including what’s on your most recent income tax return. Once you’ve submitted the application, the Marketplace will let you know if you qualify for help paying for Qualified Health Plans it offers. It will also let you know if you (or any members of your family) may be eligible for coverage through Medicaid or the Children’s Health Insurance Program.
To complete the Application for Health Coverage and Help Paying Costs online, you will need to create a secure personal account with a login ID and password.
That’s up to you. You can have 1/12 of your annual premium tax credit paid directly to your health plan each month to reduce your monthly premium right away. Or, if you can afford to, you can pay the entire health plan premium yourself up front and collect the premium tax credit in a lump sum next year when your file your tax return. Or you can have some of the tax credit paid directly to your insurer in advance but save some to claim as a refund when you file your tax return at year end.
Keep in mind that when you apply for the premium tax credit during Open Enrollment, you won’t necessarily know for sure what your income for the coverage year will be, so you will apply based on your best estimate. Later, when you file your tax return, the IRS will compare your actual income to the amount of premium tax credit you claimed in advance. If you underestimated your income and claimed too much premium tax credit, you might have to pay back some or all of the difference. If you didn’t receive all of the premium tax credit you’re entitled to during the year, you can claim the difference when you file your tax return. If you’re uncertain about your income for the coming year, remember that you can modify the amount of premium tax credit during the year if your income changes. So, for example, if you are unemployed now, you can apply for a premium tax credit based on your current low income; then if you get a new job during the year, you can report this increase in income to the Marketplace and reduce the amount of premium tax credit you’re receiving at that time.
Premium tax credits reduce your premium for most Marketplace policies. The amount of the tax credit you may receive depends on your income and the cost of Marketplace health plans in your area. The Marketplace will determine the expected contribution you are required to pay toward the premium for a mid-range (Silver) benchmark plan. The expected contribution will increase on a sliding scale based on your 2019 income. If your income is near the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 2.08 percent of your income in 2019. As your income gets closer to 400% of the poverty level, the expected contribution you would be required to pay toward the benchmark plan is 9.86% of your income. The difference between the premium for the benchmark plan and your expected contribution equals the amount of your tax credit. (You do not have to pay more than the actual premium for the plan.) The Marketplace will tell you what that dollar amount is. You can use that amount to help pay the premium for any Bronze, Silver, Gold, or Platinum plan offered in the Marketplace. The credit cannot be used to pay for a Catastrophic plan.
Premium tax credits may be claimed at the end of the year, or you can apply for an advanced premium tax credit based on your estimated income for the up-coming year. If you elect to receive an advanced credit, the government will pay 1/12 of the credit directly to your insurance company each month and the insurer will bill you for the rest of the premium.
It’s important to keep in mind that when you apply for the premium tax credit during Open Enrollment, you won’t necessarily know for sure what your income for the coverage year will be, so you will apply based on your best estimate. Later, when you file your tax return, the IRS will compare your actual income to the amount of premium tax credit you claimed in advance. If you underestimated your income and claimed too much premium tax credit, you might have to pay back some or all of the difference. If you didn’t receive all of the premium tax credit you’re entitled to during the year, you can claim the difference when you file your tax return. You should report any changes in your income during the year to the Marketplace, so your credit can be adjusted and you can avoid any significant repayments at the end of the year.
You can apply the premium tax credit to any Bronze, Silver, Gold, or Platinum plan offered through the Marketplace. Premium tax credits cannot be applied to Catastrophic plans or to stand-alone dental plans. If you are also eligible for cost sharing reductions, be aware that these can only be obtained through Silver plans offered in the Marketplace.
Premium tax credits are available to U.S. citizens and lawfully present immigrants who purchase coverage in the Marketplace and who have income between 100% and 400% of the federal poverty level. Premium tax credits are also available to lawfully residing immigrants with incomes below 100 percent of the poverty line who are not eligible for Medicaid because of their immigration status. (Generally, immigrants must lawfully reside in the U.S. for five years before they can become eligible for Medicaid.)
In addition, to be eligible for the premium tax credits, individuals must not be eligible for public coverage—including Medicaid, the Children’s Health Insurance Program, Medicare, or military coverage—and must not have access to health insurance through an employer. (There is an exception in cases when the employer plan is unaffordable because the employee share of the premium exceeds 9.86% of the employee’s income in 2019. There is also an exception in cases where the employer plan doesn’t provide a minimum level of coverage.)
Yes. Many insurers that offer policies through the Marketplace also offer identical policies outside of the Marketplace, in the individual health insurance market. These ACA-compliant policies also will meet all ACA standards. They will cover essential health benefits; and they won’t turn you down, charge you more, or limit coverage based on your pre-existing condition. In addition, ACA-compliant policies will only be offered during Open Enrollment, or at other times during the year, only to people who are eligible for a special enrollment period (SEP).
Sometimes people prefer to buy outside of the Marketplace, for example, when they are sure they won’t qualify for financial assistance. However, many other policies that are not ACA-compliant are also for sale outside of the Marketplace, and this can make comparison-shopping more complicated.
Some signs that a health policy is not ACA-compliant include:
The application asks questions about your health status or health history
The policy doesn’t cover essential benefits, such as maternity care or prescription drugs
The policy has annual or lifetime dollar caps on covered benefits
The policy is offered for sale outside of Open Enrollment to people regardless of whether they’re eligible for an SEP, for example, because they recently lost other coverage
Plans that are not ACA-compliant, including short-term health insurance, may have lower premiums because they can exclude people with pre-existing conditions and offer more limited benefits.
If you are shopping outside of the Marketplace and you want an ACA-compliant policy, be sure to specify that to the insurer or broker you’re working with.
Finally, even if you think you won’t qualify for financial assistance, it still might be worthwhile to shop for coverage on the Marketplace. All policies offered through the Marketplace will meet ACA standards; no other non-compliant products are sold there. In addition, if you are not eligible for financial assistance now, but your circumstances change later during the year (for example, your income declines), you can begin receiving financial assistance right away if you are already covered under a Marketplace plan. Or, when you file your tax return at year-end you can claim a premium tax credit to have some of the premium you paid for the Marketplace plan refunded to you. However, if you bought an ACA-compliant policy outside of the Marketplace, and then you become eligible for financial assistance mid-year, you may have to wait until the next Open Enrollment to switch to a Marketplace plan and get financial assistance.
No. Some types of coverage do not qualify as minimum essential coverage. These include hospital indemnity policies (that pay a fixed dollar amount per day when you are hospitalized), discount plans, short-term nonrenewable policies, or plans that provide coverage only for a specific disease (i.e., cancer-only policies). Companies that sell these products, also called “excepted benefits,” are required to notify you if they don’t qualify as minimum essential coverage. If you receive such a notice, at a minimum, ask more questions about how the policy might cover pre-existing conditions or protect you from unaffordable medical bills. Be aware that excepted benefit policies are not an equivalent substitute for Marketplace policies that meet Affordable Care Act standards.
No. Several states have prohibited the sale of short-term policies unless they follow all of the standards that apply to plans sold through the Marketplace — including standards prohibiting discrimination against people based on their pre-existing conditions. These states include California, Hawaii, Massachusetts, New Jersey, New York, and Oregon; other states may consider similar action in the future.