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Subsidies and Eligibility Explained
Digging deeper into who qualifies for subsidies
Every law that Congress passes is long and confusing. The Affordable Care Act (Obamacare) was no different. One of the most important things that you definitely need to understand about the ACA though is what a subsidy is and if you are eligible.
Subsidy Basics
Do I qualify for a subsidy?
HMOs are cheaper but offer no coverage whatsoever for providers that are out-of-network.
PPOs offer greatly enhanced benefits for in-network providers but some coverage is offered for out-of-network as well.
If you answer yes to these 4 questions, most likely yes:
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Do you plan to file taxes for 2023?
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Do you have a valid social security number or permanent resident card?
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Are you not offered affordable coverage through your employer or a spouse's employer, or are you self-employed?
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Are you less than 65 years old?
How are ACA subsidies calculated?
It depends on your situation. PPOs offer more flexibility and can prevent you from having to change doctors, however the cost savings of an HMO can make them a better option for many.
The factors determining subsidy amount are:
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# of Applicants
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Age of Applicants
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# in Household
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County of Residence
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Income
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Plan choice
How much of a subsidy will I qualify for?
Each carrier has a unique list of in-network providers and drug formularies.
If you have a provider or drug you need, it is very important to double check before enrolling.
The easiest thing you can do is speak to an agent.
The formula is incredibly complex so the best way to find out how much of a subsidy you qualify for and your policy options is to get a quote here.
It takes about 2 minutes to get a quote and less than 10 to fully enroll.
I'm not sure if I qualify for a subsidy. Is there someone I can ask?
While some agencies may charge a consultation fee, all advice and help that is offered at Elevate Insurance Solutions is completely free of charge.
This year is more confusing than ever so having a licensed professional on your side is essential.
Yes! Please contact us anytime.
While getting a quote yourself is a fairly quick process, reaching out to a licensed professional is still the fastest and most reliable option.
Employer-Sponsored Coverage
Can young adults get Marketplace coverage?
Yes! Even if you are offered employer coverage you are able to enroll in a Marketplace plan, however it will be very expensive.
If you are offered employer coverage of any kind, whether you enroll or not, you are not eligible for a subsidy.
Yes! In fact, college students who earn more than $1000 per month can file taxes independently and will almost always qualify for free ACA coverage in a plan that is better than even the best employee-sponsored parent's plan. Contact us for more information.
I recently lost my job and am offered COBRA. Does that prevent me from getting a subsidy?
Yes! You can enroll in Marketplace coverage however it will likely not be subsidized.
If you are offered benefits through your employer, you cannot get a subsidy with an ACA plan unless it is deemed not "Affordable" or "Minimum Essential Coverage"
No! As long as you don't actually enroll in COBRA, it will not prevent you from getting a Marketplace subsidy.
I am turning 65 but I like my Marketplace plan. Can I keep it instead of Medicare?
If the monthly cost of your employer-sponsored health insurance plan for just you is over 9.78% of your monthly income, it is deemed "unaffordable" by the ACA.
At that point you may indicate you are NOT offered affordable employer coverage on your Marketplace application.
Unfortunately you can not. Once you turn 65, you no longer qualify for a subsidy through the Marketplace.
If you need help with enrolling in Medicare, please feel free to reach out.
I have a child on Medicaid, but I am not on it. Can I enroll in ACA coverage?
Minimum Essential Coverage refers to the minimum standards a plan must fulfill for it to count as full coverage.
It gets complicated so if you think that the benefits you are offered may not qualify, it is likely easiest to reach out to a licensed agent who can help.
Yes! As long as you are not eligible for Medicaid yourself, you can absolutely apply for Marketplace coverage.
If you are unsure if you are eligible for Medicaid, contact us and we can look into your specific situation.
Am I eligible to enroll in coverage at any time?
Yes! Even if you are offered employer coverage you are able to enroll in a Marketplace plan, however it will be very expensive.
If you are offered employer coverage of any kind, whether you enroll or not, you are not eligible for a subsidy.
Yes! In fact, college students who earn more than $1000 per month can file taxes independently and will almost always qualify for free ACA coverage in a plan that is better than even the best employee-sponsored parent's plan.
Contact us for more information.
No! The only time that you can apply for new coverage is Open Enrollment. This period started November 1st and ends January 15th.
Outside of Open Enrollment, to enroll in new coverage, you must have a "Qualifying Life Event."
What is a Qualifying Life Event?
Yes! You can enroll in Marketplace coverage however it will likely not be subsidized.
If you are offered benefits through your employer, you cannot get a subsidy with an ACA plan unless it is deemed not "Affordable" or "Minimum Essential Coverage"
No! As long as you don't actually enroll in COBRA, it will not prevent you from getting a Marketplace subsidy.
If you have a Qualifying Life Event (QLE), it opens a 60-day Special Enrollment Period (SEP) window that allows you to change or add coverage. Some examples of QLEs are:
- loss of other coverage
- change in household size
- change in residence
- drastic change in income
- turning 26
What is a Special Enrollment Period?
If the monthly cost of your employer-sponsored health insurance plan for just you is over 9.78% of your monthly income, it is deemed "unaffordable" by the ACA.
At that point you may indicate you are NOT offered affordable employer coverage on your Marketplace application.
Yes! In 2021, if you had received one week or more of Unemployment benefits, you will be able to get fully subsidized, top-tier health insurance coverage.
In 2022, this will no longer be the case.
A Special Enrollment Period is the 60-day window created by a Qualifying Life Event that allows you to change coverage or add a new policy.
The Marketplace is saying I do not apply for a subsidy. What can I do?
Minimum Essential Coverage refers to the minimum standards a plan must fulfill for it to count as full coverage.
It gets complicated so if you think that the benefits you are offered may not qualify, it is likely easiest to reach out to a licensed agent who can help.
Yes! As long as you are not eligible for Medicaid yourself, you can absolutely apply for Marketplace coverage.
If you are unsure if you are eligible for Medicaid, contact us and we can look into your specific situation.
There are many reasons that you may not qualify for a subsidy.
The application process can be confusing so it could be you are not filling out the application correctly. If you feel you do qualify for a subsidy, contact us for a free consultation.
I missed my employer's enrollment period, so I don't have coverage. Can I get Marketplace coverage during Open Enrollment?
Technically yes, but it will be very expensive.
If you are offered employer coverage of any kind, whether you enroll or not, you are not eligible for a subsidy.
The health insurance plans my employer offers are too expensive for me. Can I get Marketplace coverage?
Yes, but it will likely be more expensive than your employer-sponsored plan.
If you are offered benefits through your employer, you cannot get a subsidy with an ACA plan unless it is deemed not "Affordable" or "Minimum Essential Coverage."
What is considered "Affordable" employer coverage?
If the monthly cost of your employer-sponsored health insurance plan for just you is over 9.78% of your monthly income, it is deemed "unaffordable" by the ACA.
At that point you may indicate you are NOT offered affordable employer coverage on your Marketplace application.
What is Minimum Essential Coverage?
Minimum Essential Coverage refers to the minimum standards a plan must fulfill for it to count as full coverage.
It gets complicated so if you think the benefits you are offered may not qualify, it is likely easiest to reach out to a licensed agent who can help.