Qualifying For Affordable Healthcare Coverage
The Affordable Care Act (Obamacare) has expanded healthcare coverage and protections for millions of Americans. Under this law, health insurance companies who participate in the marketplace must comply with ACA guidelines.
- No Pre-existing: You can no longer be denied health coverage based on your health condition or terminate coverage when you have one.
- Extended Coverage to Age 26: You can remain on your parent’s healthplan until you turn 26 even if you are not a full-time student.
- No Cost Preventive Care: All health plans must cover preventive care services at no cost to the member. This includes preventative services, immunizations, birth control, and cancer screenings.
- No Limits on Coverages: Insurance companies can no longer impose dollar limits on Essential Health Benefits.
- 80/20 Rule: Insurance companies are required to spend 80% of your premium dollars on actual medical expenses and not on overhead or profit.
Who’s Eligible for Coverage through the Marketplace
To be eligible for coverage through a Marketplace, individuals and households must:
- Live in the United States (U.S.) in a state served by the Marketplace where they’re applying;
- Be U.S. citizens, U.S. nationals, or lawfully present immigrants for the entire time they plan to have coverage; and
- Not be incarcerated (unless pending disposition of charges).
How Can I Find Affordable Health Insurance?
There are several ways to get financial help for health insurance:
Premium Tax Credit: The Premium Tax Credit is a subsidy that can help reduce the cost of health insurance for those who qualify based on their income and other factors. If you are eligible for the Premium Tax Credit, it is typically applied directly to your monthly insurance premium. You can apply for the Premium Tax Credit when you enroll in a health insurance plan through the Health Insurance Marketplace.
Cost-sharing Reductions: Cost-sharing reductions are additional subsidies that can help reduce out-of-pocket costs, such as deductibles, copayments, and coinsurance. These subsidies are available to individuals and families with incomes up to 250% of the federal poverty level who enroll in a Silver-level health plan through the Health Insurance Marketplace.
Medicaid: Medicaid is a state-run program that provides health coverage to low-income individuals and families. Eligibility requirements vary by state, but in general, Medicaid is available to those with incomes up to 138% of the federal poverty level. If you qualify for Medicaid, you may be able to get free or low-cost health coverage.
Children’s Health Insurance Program (CHIP): CHIP is a program that provides low-cost or no-cost health coverage to children in families with incomes too high to qualify for Medicaid, but too low to afford private insurance. Eligibility requirements vary by state, but in general, CHIP is available to children in families with incomes up to 200% of the federal poverty level.
Employer-sponsored coverage: If you are employed, your employer may offer health insurance as part of their benefits package. Many employers offer subsidies or other financial assistance to help reduce the cost of premiums.
To determine your eligibility for financial assistance, you can visit Healthcare.gov and use the Marketplace application to estimate your subsidy amount. You can also work with a licensed health insurance agent or broker to help you navigate the enrollment process and find a plan that meets your needs and budget.
Affordability Programs: Cost-Sharing Reductions
- Some consumers who apply for coverage through the Marketplace and qualify for premium tax credit might be also qualify for extra savings called cost-sharing reductions (CSRs).
- To be eligible for CSRs based on income, consumers must:
- Have a household income between 100 percent and 250 percent of the FPL;
- Be eligible for PTC; and
- Enroll in a Silver plan through the Marketplace.
- AI/AN consumers with income between 100 percent to 300 percent of the FPL can enroll in a "zero cost-sharing plan" through the Marketplace and have no out-of-pocket costs – like deductibles, copayments, and coinsurance – when they get care.
- AI/AN consumers at any income level can enroll in a "limited cost-sharing plan" through the Marketplace and will have no out-of-pocket costs when they receive care from an Indian health care provider.
- Limited and zero cost-sharing plans are available to AI/AN consumers in any plan category.
- To be eligible for CSRs based on income, consumers must:
