Navigator Guide FAQ of the Week: Can I Get Help Paying for Coverage and Care?

Open Enrollment is in full swing in all 50 states and Washington, DC. As consumers consider their coverage options, many will qualify for subsidies to help pay for premiums and out-of-pocket expenses if they enroll in a plan through the marketplace. Throughout the enrollment period, CHIR is highlighting frequently asked questions (FAQs) from our recently updated Navigator Resource Guide. In this installation, we answer FAQs about financial assistance available to individuals and families.

Who is eligible for marketplace premium tax credits?

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 percent and 400 percent 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 most Medicaid, most Children’s Health Insurance Program coverage, Medicare, or military coverage—and must not have access to affordable, adequate health insurance through an employer. There are exceptions to when you can apply for premium tax credits when you have other coverage. For example, there is an exception in cases when the employer plan is unaffordable because the employee’s share of the premium exceeds 9.78 percent of the employee’s household income in 2020 (for 2019, it was 9.86 percent). There is also an exception in cases where the employer plan doesn’t provide a minimum value or actuarial value (the plan’s share must be at least 60 percent of the cost of covered benefits for a standard population).

What income is counted in determining my eligibility for premium tax credits?

Eligibility for premium tax credits is based on your Modified Adjusted Gross Income, or MAGI. When you file a federal income tax return, you must report your adjusted gross income (which includes wages and salaries, interest and dividends, unemployment benefits, and several other sources of income). MAGI modifies your adjusted gross income by adding to it any non-taxable Social Security benefits you receive, any tax-exempt interest you earn, and any foreign income you earned that was excluded from your income for tax purposes.

Note that eligibility for Medicaid and CHIP is also based on MAGI, although some additional modifications may be made in determining eligibility for these programs. Contact your marketplace or your state Medicaid program for more information.

Can I get premium tax credits for health plans sold outside of the marketplace?

No. Premium tax credits are only available for coverage purchased in the marketplace.

I can’t afford to pay much for deductibles and co-pays. Is there help for me in the marketplace for cost-sharing?

Yes. If your income is between 100 percent and 250 percent of the federal poverty level, you may qualify for cost-sharing reductions in addition to premium tax credits. These will reduce the deductibles, co-pays, and other cost-sharing that would otherwise apply to covered services.

The cost-sharing reductions will be available through modified versions of silver plans that are offered on the marketplace. These plans will have lower deductibles, co-pays, coinsurance and out-of-pocket limits compared to regular silver plans. Once the marketplace determines you are eligible for cost-sharing reductions, you will be able to select one of these modified silver plans, based on your income level.

Open Enrollment runs through December 15th in most states. Look out for more weekly FAQs from our new and improved Navigator Guide, or browse hundreds of questions and answers here.

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