Life change? You may qualify for a Special Enrollment Period
Open Enrollment for 2023 ended on January 15, 2023, but you may still be able to enroll in or change Marketplace coverage if you’ve had certain life events or income. Life events that may qualify include getting married, having a baby, moving, or losing health coverage. Get a full list of qualifying life changes.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2023-03-21 15:00:552023-03-21 15:00:56Life change? You may qualify for a Special Enrollment Period
The tax filing deadline is April 18, 2023. If anyone in your household had a Marketplace plan in 2022, use Form 1095-A, Health Insurance Marketplace® Statement to file your federal taxes. You’ll get this form from the Marketplace, not the IRS. Check your Form 1095-A to make sure your information is correct. Keep it with your other important tax information.
Check your online account for Form 1095-A
If you didn’t get your Form 1095-A in the mail, or you can’t find it, check your HealthCare.gov account:
You’ll use the 1095-A form to “reconcile” — check if there’s any difference between the premium tax credit you got and the amount you qualify for on your taxes.
Before you start, check the form to make sure the information is right. If you filed your taxes with an incorrect form, you may need to file an amended tax return using the correct information.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2023-03-06 14:03:062023-03-06 14:03:06File your taxes using Form 1095-A, Health Insurance Marketplace® Statement
Congratulations on getting covered for 2023! Get answers to some common questions about health insurance, like how to find a doctor and learn what prescriptions are covered.
What prescriptions are covered by my plan?
Your plan will help pay the cost of certain prescriptions.
Your plan’s list of covered drugs is called a “formulary.”
Visit your plan’s website, call their Member Services, or review your Summary of Benefits and Coverage for a list of covered drugs.
How can I find a doctor in my plan?
Most plans give you the best price on services when you go to an “in-network” health care provider who has a contract with the plan.
You may be able to visit doctors who aren’t in your plan’s network, but you may pay more.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2023-02-08 14:02:122023-02-08 14:02:12Get to know your Marketplace health plan
If you had Marketplace coverage at any point in 2022, or got premium tax credits last year, here’s what you need to know about filing your federal taxes.
If there’s a difference between the amount of premium tax credit you used during the year and the amount you actually qualify for, it will impact your refund or the amount of taxes you owe.
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Enrollment in ACA marketplace plans has surged, thanks to expanded eligibility for ACA marketplace subsidies. Leading that surge: buyers with higher incomes.
Enrollment climbed as more buyers gained subsidy eligibility
After the American Rescue Plan (ARP) expanded eligibility for premium subsidies in the ACA marketplace in 2021, enrollment in 2022 plans increased by 21%. Enrollment in 2023 plans is on pace to grow by another 13%, to about 16.4 million by the time the open enrollment period ends in all states. Plainly, Americans who lack access to affordable employer-sponsored health plans, Medicaid, or Medicare are recognizing that the ARP made health plans in the ACA marketplace far more affordable.
The ARP increased premium subsidies in the ACA marketplace at every income level and removed the income cap on subsidy eligibility, which had been 400% of the Federal Poverty Level (FPL) since the ACA marketplace launched in 2014. In 2023, 400% FPL is $54,360 for an individual and $111,000 for a family of four. Enrollees with income above that level used to pay the full premium without subsidy. Now they receive premium subsidies if the unsubsidized benchmark Silver plan premium would cost them more than 8.5% of annual family income.
The table below shows the enrollment increase at each income level for 2022 plans in the 33 states that use HealthCare.gov, the federally run exchange. While enrollment in 2022 coverage rose by double-digit margins at all reported income levels, the growth rate increased with income and was highest at incomes over 400% FPL – i.e. among those formerly ineligible for subsidies. (Information about 2023 enrollees’ income is not yet available.)
A note on one data limitation: the chart combines enrollment by those with incomes below 100% FPL and above 400% FPL because that’s the way CMS reported income in 2021, when enrollees with incomes over 400% FPL were not eligible for subsidies. In 2022, 146,297 enrollees in HealthCare.gov states had income below 100% FPL, while 655,944 reported income above 400% FPL – so likely almost all of the increase in that combined category is attributable to enrollees with incomes above 400% FPL.
An obvious surge in enrollment at income levels over 400% FPL
In 2022, the first year in which there was no income cap on subsidies, enrollment at incomes above 400% FPL more than doubled. When you look at premiums with and without subsidies for enrollees of different ages, as shown below, it’s not hard to see why.
Coverage is much more affordable at incomes above 400% FPL than it was prior to 2022 – far more so than many people who looked at marketplace offerings before they became subsidy eligible probably recognize. Note also that the number of enrollees who did not report income plummeted. That’s doubtless because the ARP dramatically reduced the number of enrollees who earn too much to obtain a subsidy.
Let’s take a closer look at one of the ACA’s hottest markets: Houston, Texas. Enrollment in 2022 coverage in Texas increased by 42%, and enrollment in 2023 plans is on pace to increase another 32%. The chart below shows what premiums now look like for couples of different ages with an annual income of $74,000 – slightly above the 400% FPL threshold – compared to what those couples would pay if they were ineligible for subsidies, as they would have been in years before 2022.
The source for all premiums quoted below is the “See plans and prices” tool on HealthCare.gov.
Impact of the American Rescue Plan on ACA premium subsidies
Monthly premiums paid with and without ARP subsidy increases: Houston, TX in 2023
Married 40-year-olds, annual income $74,000 (404% FPL)
Legal status
Lowest-cost Bronze
Lowest-cost Silver
Lowest-cost Gold
ARP in effect
$261
$523
$393
No ARP
$624
$887
$756
Married 63-year-olds, annual income $74,000 (404% FPL)
Legal status
Lowest-cost Bronze
Lowest-cost Silver
Lowest-cost Gold
ARP in effect
$0
$522
$222
No ARP
$1,441
$2,047
$1,747
Notice that the premiums that the older couple will pay (after subsidy) for Bronze and Gold plans are much lower than those paid by the 40-year-olds. That’s because premiums before subsidies are credited rise with age: At age 64, they are three times the premium for a 21-year-old and more than twice the premium for a 40-year-old.
But subsidies are structured so that everyone with the same income pays the same amount for the benchmark Silver plan: An enrollee with income at >400% of FPL receives a subsidy in a fixed amount that enables the enrollee to pay not more than 8.5% of their income for the benchmark, regardless of age. So the subsidy for the older couple is bigger than for the younger couple.
When the subsidy gets bigger, it covers a larger share of the premium for plans that cost less than the benchmark plan. Since the “spread” between the benchmark plan’s premium and the premiums for cheaper plans (one Silver and many Bronze plans) increases in proportion to the age of enrollees, older enrollees get bigger savings on cheaper plans.
Louise Norris has more on how the ARP has decreased premiums for older enrollees. For eligible higher income and older enrollees, the ARP subsidy boosts are not just an “8.5% solution.” Coverage, including sometimes Gold coverage, is often available for much less.
What do the lowest-cost Bronze, Silver and Gold plans shown above look like? Below are some key features. Note that in ACA marketplace plans, select features may not be subject to the deductible, meaning you don’t have to pay full price before you meet your deductible (i.e. a service may be free or you may pay only a co-pay).
The lowest-cost Bronze plan in this market from Blue Cross Blue Shield of Texas, has a deductible of $7,400, and an annual out-of-pocket maximum of $9,100 (the highest allowable by law). Primary care doctor visits are free regardless of whether the plan’s deductible has been met, and generic drug prescriptions are $5, also before the deductible.
The lowest-cost Silver plan, from Ambetter, has a $5,800 deductible and an $8,900 out-of-pocket max. Primary care visits are $40 and generic drug prescriptions are $20, both before the deductible, and other services (urgent care, specialist visits) are also not subject to the deductible.
The lowest-cost Gold plan, from Blue Cross Blue Shield, has a deductible of $1,100, an out-of-pocket max of $9,100. Primary care doctor visits are free and generic drug prescriptions of $5, neither subject to the deductible.
Bargains are Gold-plated in Texas and a handful of other states
The tables also show an extra benefit in the Texas marketplace. In 2022, the Texas legislature unanimously passed a law, signed by Gov. Greg Abbott, instructing the Department of Insurance to issue regulations that would ensure that insurers price Gold plans lower than Silver plans. How can that be?
Well, most marketplace enrollees have incomes below 200% FPL, and below that threshold, Cost Sharing Reduction (CSR) subsidies give Silver plans lower out-of-pocket costs than Gold plans. In Texas in 2022, 88% of Silver plan enrollees had income below 200% FPL. So, setting Gold plan premiums below Silver premiums is a major benefit to enrollees with incomes above 200% FPL, for whom Gold plans have lower out-of-pocket costs than Silver.
At least six states have taken measures to have Gold plans consistently priced below or on a rough par with Silver, and in other states and regions, insurers have done so on their own. This post by Charles Gaba spotlights states and counties in which the economic upsides for Gold plans are most extreme.
Pricing CSR directly into Silver plan premiums is a practice known as “silver loading,” which began in 2018 after the federal government stopped paying insurers separately for the value of CSR. Silver loading creates discounts in Bronze as well as Gold plans – often wiping out the Bronze premium entirely, as the chart above illustrates in the case of the 63-year-olds. Insurers in all states except Mississippi and Indiana practice Silver loading to some degree.
When premiums go high, so does subsidy eligibility
At an income of $150,000 per year for a couple of 40-year-olds – more than 800% FPL for a two-person household – the unsubsidized benchmark Silver plan in Houston costs less than 8.5% of income. The premium would be the same if the ARP were not in effect.
Married 40-year-olds, annual income $150,000(819% FPL)
Legal status
Lowest-cost Bronze
Lowest-cost Silver
Lowest-cost Gold
ARP in effect
$624
$886
$756
No ARP
$624
$886
$756
For two 60-somethings, however, the benchmark premium rises so high that it’s more than 8.5% of income even for a couple earning $150,000. Subsidies therefore kick in even at this high income.
Married 63-year-olds, annual income $150,000(819% FPL)
Legal status
Lowest-cost Bronze
Lowest-cost Silver
Lowest-cost Gold
ARP in effect
$455
$1,061
$761
No ARP
$1,441
$2,047
$1,747
Those prohibitively high unsubsidized premiums may seem like an extreme case, but they’re not unusual for older enrollees. Providing affordable insurance to people who retire or are laid off before they’re eligible for Medicare is a major function of the ACA marketplace. In 2022, 28% of all enrollees were aged 55-64.
The ARP of course made plans significantly more affordable at every income bracket below 400% FPL as well. Examples of how the subsidy increases affect enrollees at various income levels are laid out in this post.
Will high-earner enrollment continue to surge?
The American Rescue Plan was originally designed as COVID-19 relief, and the subsidy increases in the ACA marketplace were only granted through 2022. The Inflation Reduction Act, enacted in August 2022, extended the increased subsidies through 2025. Beyond that point, their future is uncertain, though they have plainly helped to reduce the uninsured population nationwide.
At least through 2025, if you need to find insurance in the individual market and have not yet examined your options, you’re likely to be pleasantly surprised – particularly if you were jolted by unsubsidized premiums in the past and now find yourself eligible for subsidized coverage.
Andrew Sprung is a freelance writer who blogs about health care policy and ACA implementation at xpostfactoid and at healthinsurance.org. His articles have appeared in publications including Health Affairs, The American Prospect, USA Today, The New York Times, The Incidental Economist, Mother Jones, The Atlantic and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Health Care Digital Media Award and holds a Ph.D. in English literature from the University of Rochester.
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https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2023-01-26 13:00:002023-01-26 14:02:40FARMERS INSURANCE® ANNOUNCES $500,000 COMMITMENT TO SUPPORT SAN DIEGO MILITARY FAMILIES
Tax season is here. If anyone in your household had a Marketplace plan in 2022, you’ll need Form 1095-A, Health Insurance Marketplace® Statement, to file your federal taxes.
Where’s my Form 1095-A?
You should get Form 1095-A in the mail by early February.
Keep it with your important tax information, like W-2 forms and other records.
Form 1095-A comes from the Marketplace, not the IRS.
It may be available online in your HealthCare.gov account even sooner. Learn how to find it.
How to use Form 1095-A
Before you do anything, make sure Form 1095-A is correct. It includes information about any Marketplace plans that members of your household had last year.
If anything about your coverage or household is wrong, contact the Marketplace Call Center. Don’t file your federal taxes until you’re sent a corrected version.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2023-01-25 19:00:002023-01-26 14:02:53Check your mail for Form 1095-A
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2023-01-13 17:57:002023-01-14 13:59:39Farmers Insurance® Responds to Major Storm System and Tornadoes in Alabama and Georgia
If you missed the January 15 deadline for Marketplace coverage for 2023, you may still have options. You might qualify for a Special Enrollment Period, or you can apply for health coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
Find out if you qualify for a Special Enrollment Period
You may be able to enroll in 2023 Marketplace coverage during a Special Enrollment Period if you have limited income, or if you had certain life events, like:
Medicaid and CHIP are free or low-cost health programs that cover things like hospital stays, doctor services, and prescription drugs for children and some adults, including people with low income, pregnant people, and people with disabilities.
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There are only a few days left to get health coverage for 2023. Open Enrollment for Marketplace health plans ends January 15. Act now to enroll in health coverage that meets your needs and budget. Coverage starts February 1.
Enroll or change health plans by January 15
New to HealthCare.gov?Create an account to fill out an application for the first time.
Already have an account? Log in to update your application, compare plans, and change or renew for 2023. Even if you were automatically re-enrolled, it’s important to:
Update any income and household changes. Otherwise, your savings might not be correct.
Compare plans. There may be new plans and prices that better meet your needs and budget.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2023-01-04 19:00:002023-01-06 14:04:58Don’t miss out! Sign up for 2023 Marketplace coverage
Before you can start using your new 2023 Marketplace coverage, you have to pay your first premium. Your premium is the amount you pay every month directly to the health insurance company (not the Marketplace).
Here’s how. (Follow your insurance company’s instructions carefully. You may be able to pay online at HealthCare.gov.)
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Attention: The January 15 deadline to apply for, re-enroll in, or change 2023 health insurance will be here soon. This holiday season, don’t leave health insurance and the peace of mind that comes with it off your shopping list.
Important dates to know
January 15, 2023: Deadline to apply for and enroll in 2023 coverage.
February 1, 2023: Coverage starts.
Beat the Jan 15 deadline: Act now
New to HealthCare.gov? Create an account to fill out an application for the first time.
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Your last chance to apply for, re-enroll in, or change 2023 Marketplace health coverage is almost here. The deadline is December 15. That’s just 6 days away. Act now – don’t miss out on health coverage that meets your needs and budget.
How to apply & enroll
If you’re new to HealthCare.gov: Create an account and complete an application.
If you have 2022 Marketplace coverage: Log in to your account to update your application, compare plans, and change or renew your plan for 2023. Even if you may be re-enrolled automatically, it’s important to:
Update income or household changes. Some changes can affect the cost savings you get.
Compare plans and prices. There might be another plan that’s a better fit for your health care needs and budget.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2022-11-29 13:59:132022-11-29 13:59:13Time’s running out: Sign up by Dec 15 for coverage that starts Jan 1
In case you missed it during a frenzied election season, the annual open enrollment period for ACA marketplace plans (which are ACA-compliant health coverage) in 2023 kicked off on November 1. You may also have missed that last year, the American Rescue Plan Act made coverage in private plans sold in the ACA marketplace far more affordable than it used to be, and that the improved premium subsidies will continue at least through 2025, thanks to the Inflation Reduction Act passed in August 2022.
If you’re a citizen or legally present noncitizen, are under 65, can’t get health coverage through your employer or your spouse’s employer, and are not on disability Medicare, you really should check out what’s available to you in the ACA exchanges. HealthCare.gov, the federal exchange that serves 33 states, reports that four out of five people who enroll can find a plan for $10 per month or less (though many will choose a plan that costs more).
Your income matters when it comes to health plan selection
While you may be pleasantly surprised by what the ACA exchanges have to offer, it’s best not to be too surprised. That is, it’s important to go in with some awareness of what you’re likely to get at different income levels.
The most basic rule is, the higher your income, the more you’ll pay for coverage, ranging from zero in the lowest income brackets (for Medicaid or free private-plan coverage) to 8.5% of household income for a benchmark Silver plan if your income is well above average.
Before you shop, it’s good to absorb two rules of the road:
Small differences in projected income can have a large impact on available benefits.
The income you report is an estimate for the coming year – and so for many people, there’s some built-in wiggle room.
The poet Robert Frost said that writing poetry without rhyming was like playing tennis without a net. Applying for ACA coverage without knowing the income levels at which benefits change is like playing tennis without any lines. And when you don’t see the lines, it’s easy to hit the ball out.
Rule 1: Know some key income break points
In the ACA application, your estimate of your gross (before-tax) household income for the coming year will place you in one of several income brackets, defined as a percentage of the federal poverty level (FPL). (The ACA application slightly modifies the “Adjusted Gross Income” you see on your annual tax form.) How much you’ll pay – and in some cases, the kind of coverage available to you – depends on what bracket you’re in. Let’s look at some key “break points” where benefits shift.
100% FPL – the minimum income required to qualify for private plan coverage in 11 states
$13,590 per year for a single person
$18,310 for a two-person household,
$23,030 for a family of three
$27,750 for a family of four
It’s a cruel reality that in 11 states* – Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, and Wyoming – most adults who estimate household income below the 100% FPL threshold get no help from the government in obtaining health coverage.
As first drafted, the ACA made Medicaid available to most adults with an income below 138% FPL. In 2012, however, the Supreme Court ruled that the federal government couldn’t force states to expand Medicaid eligibility in that way. The states listed above have refused to date to go along, and in those states, most adults with incomes below 100% FPL get no help paying for any kind of coverage. (In the November election, South Dakota voted by referendum to adopt the expansion, and Medicaid enrollment under the ACA eligibility rules will begin there in July 2024.)
In a drafting inconsistency that turned out to be lucky, the ACA pegged the minimum income for subsidy eligibility in the marketplace at 100% FPL rather than 138% FPL. So, in states that have not expanded Medicaid, having an income of at least 100% FPL moves you out of the “no help” territory.
As discussed in more detail below, a low income is often an uncertain income, and applicants in the “nonexpansion” states with income likely to be anywhere near the 100% FPL threshold should leave no stone unturned to get a good-faith estimate of next year’s income over the eligibility threshold. Knowing the threshold is the key first step – especially since marketplace coverage with low out-of-pocket costs is available for free to applicants with income in the 100-150% FPL range.
138% FPL – the upper income threshold for Medicaid in most states
$1,563 per month for a single person
$2,106 for a two-person household
$2,648 for a family of three
$3,191 for a family of four
In the 38 states** that have enacted the ACA’s Medicaid expansion, most citizens and legally present noncitizens*** with income below 138% FPL qualify for Medicaid. That makes them ineligible for marketplace coverage.
Medicaid eligibility is determined on a monthly basis, which means (in expansion states) that if your income drops suddenly – after a job loss, for example – and isn’t likely to recover soon, you become eligible.
For most people near this income level, Medicaid is a good option, as there’s almost never a premium (a few states charge a small one at the top of the income bracket) and out-of-pocket costs range from zero to minimal.
Some people with income near the Medicaid eligibility threshold may prefer marketplace coverage, however – which, in some markets at least, allows for a wider choice of doctors and hospitals. While out-of-pocket costs are higher in the marketplace’s private plans than in Medicaid, they are comparatively low in Silver plans at low incomes, thanks to a secondary subsidy called cost sharing reduction (CSR) that attaches to Silver plans for lower income enrollees (more on CSR below). And the two cheapest Silver plans in each region are free to enrollees with income up to 150% FPL.
Since marketplace eligibility and subsidy level is calculated on an annual income basis, an applicant who’s suffered a sudden loss of income may qualify for Medicaid by citing current monthly income – or for marketplace coverage by estimating annual income. The HealthCare.gov application enables the latter when current monthly income is low (or high), providing a section in which you can estimate total annual income and/or a total for the coming year that may be different from income in the current year.
There is one particular case in which an applicant might want to stay out of Medicaid. In more than 20 expansion states, any Medicaid enrollee who is over age 55 is potentially subject to Medicaid Estate Recovery upon their death. If the deceased enrollee owns any significant assets, the state may seek to recover from their estate the value of the services that Medicaid covered, or, if the state contracted with a Medicaid managed care organization, all of the money that the state paid to that organization to administer the person’s coverage.
Once again, knowledge of a key income threshold may in some cases give cause to steer toward one side or the other of it.
200% FPL – the maximum income at which strong Cost Sharing Reduction (CSR) enriches benefits.
$27,180 per year for a single person
$36,620 for a family of two
$46,060 for a family of three
$55,500 for a family of four
(Note that these income limits are applicable for 2023 coverage; they rise annually.) At incomes up to 200% FPL, cost sharing reduction – which attaches only to Silver plans – raises the value of a Silver plan to a roughly Platinum level (a bit above Platinum at income up to 150% FPL, a bit below at 150-200% FPL). Above the 200% FPL threshold, the value of CSR drops off sharply, and it’s not available at all at incomes above 250% FPL.
At incomes below 200% FPL, CSR makes a big difference in the out-of-pocket costs you’re exposed to. In 2022, deductibles in CSR-enhanced plans average just $146 for people with income up to 150% FPL, and $756 for those with incomes in the 150-200% FPL range. That’s well below the average deductible for Gold plans ($1,600) and in a different universe from Bronze plans ($7,051).
Perhaps more to the point for our “know your thresholds” mantra, Silver plan deductibles take a major jump at the 200% FPL threshold, to an average of $3,215 for enrollees with income in the 200-250% FPL range.
Equally important is the annual cap on maximum out-of-pocket (MOOP) costs that attaches to plans at different metal levels – and, for Silver plans, at different income levels. Up to 200% FPL, the highest allowable MOOP for Silver plans in 2023 is $3,000. In 2022, MOOP in Silver plans averages $1,208 at incomes up to 150% FPL and $2,591 in the 150-200% FPL range. Again, there’s a big jump at the 200% FPL threshold, to an average of $6,436 at the weakest CSR level.
The median MOOP in 2022 for Gold plans is $7,500, according to the Commonwealth Fund, and $8,500 for Silver with no CSR (close to this year’s maximum allowable, $8,700). Bronze MOOP is comparable to Silver.
Bottom line: Affordable marketplace coverage is far more comprehensive for a single person estimating an income of $27,000 per year – a little under 200% FPL – than for the same person estimating an income of $28,000. The strong CSR available at incomes up to 200% FPL is really valuable.
Rule 2: How income estimates affect eligibility
During the ACA’s annual open enrollment period (Nov. 1 – Jan. 15 in HealthCare.gov states), benefits for the coming year are based on an estimate of future gross (pre-tax) income, modified in some cases by deductions. Those who qualify for a special enrollment period outside of open enrollment also estimate their income for the year in progress.
The estimate may be straightforward adults with one stable job and a fixed salary. For others, including most low-income people, the estimate may involve considerable uncertainty – and therefore allow for wiggle room. That’s the case if you’re paid by the hour, and/or rely in large part on tips, or work more than one job, or are partly or wholly self-employed.
If you underestimate your income and take your full subsidy, in the form of an advance premium tax credit (APTC) used to pay your premiums as they are billed (you can opt to take only a portion of it in advance for this purpose), you will owe the difference between the APTC you received and the APTC to which you prove to have been entitled at tax time in the year following (early 2024 for 2023 coverage). CSR will not be clawed back after the fact. The exchange may reduce your APTC and CSR going forward, however, if outside data sources – such as a regular paycheck – indicate that your income is higher than estimated.
What if you’re hovering near the 100% FPL threshold in a nonexpansion state, or near the 138% FPL threshold in an expansion state and you don’t want Medicaid? There is no downside to a good-faith estimate that errs on the optimistic side. If you live alone and estimate your 2023 gross income at $14,000 (a little over 100% FPL), and eventually, your tax return shows it to have been, say, $12,000, your subsidies will not be clawed back (unless the estimate is made with “intentional or reckless disregard for the facts”).
And while you may be asked as part of the application process to document your income, your estimate will not be disallowed if outside data sources indicate that your real income is lower than estimated. See this post for more tips on making sure that you’re fully accounting for all allowable income sources.
Your income estimate must be made in good faith. But if you have good cause to be genuinely uncertain how much you earn, you are fully within your rights to use your knowledge of the ACA’s income break points to your advantage.
* * *
* One nonexpansion state – Wisconsin – offers Medicaid to adults with income up to 100% FPL, as opposed to the 138% FPL threshold in expansion states. Wisconsin therefore has no “coverage gap” – those who lack affordable access to other insurance are eligible either for Medicaid (up to 100% FPL) or subsidized marketplace coverage (over 100% FPL).
** Alaska and Hawaii have different FPLs, viewable on pages 3-6 here.
*** Washington, D.C. extends Medicaid eligibility to 215% FPL. New York and Minnesota run Basic Health Programs – Medicaid-like low-cost programs – for residents with income in the 138-200% FPL range, as well as for legally present noncitizens who are time-barred from Medicaid eligibility. Connecticut extends Medicaid eligibility to parents with incomes up to 160% FPL.
**** Legally present noncitizens who have been in the U.S. for less than five years are ineligible for Medicaid, but eligible for free Silver marketplace coverage if their income is in the 0-150% FPL range.
Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid.His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Digital Media Award. He holds a Ph.D. in English literature from the University of Rochester.
https://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance.png512512wpmaddoxinshttps://www.maddoxinsured.com/wp-content/uploads/2020/12/maddox-insurance-agency.pngwpmaddoxins2022-11-28 14:19:492022-11-29 13:59:07Applying for ACA coverage? Know the ropes (between income levels).
December 15 is the deadline to apply for, renew, or change your Marketplace health insurance for 2023 coverage that starts January 1. Don’t delay – visit HealthCare.gov now!
Update & compare, even if you want to keep the same plan
Even if you’re happy with your current plan, update your application with any expected income and household changes for 2023. There may be new plans that better fit your needs.
Updating your information makes sure you get the right amount of savings.
Act now to get coverage that starts January 1, 2023
New to HealthCare.gov? Create an account to fill out an application.
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Act by December 15 to have coverage starting January 1. There’s less than a month left to enroll in or change Marketplace health insurance for coverage that starts January 1, 2023.
The last day to enroll in or change plans for 2023 coverage is January 15 when Open Enrollment ends. For coverage to start:
January 1, 2023: Enroll by December 15, 2022
February 1, 2023: Enroll by January 15, 2023
Apply & enroll today
New to HealthCare.gov? Create an account to fill out an application for the first time.
Get help now if you have questions or need help applying.
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Act by December 15 for Marketplace coverage that starts January 1, 2023. Before you enroll or renew coverage, browse plans and get an idea of what your costs may be. Just answer a few quick questions – you don’t even have to log in!
Ways to save on a 2023 Marketplace plan
See if you can save on Marketplace premiums , or qualify for Medicaid or Children’s Health Insurance Program (CHIP) coverage. Just enter:
Your state
The number of people in your household (even if they don’t need health coverage)
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Open Enrollment starts today! You have until January 15, 2023 to apply for new health coverage or change your health plan for 2023. If you enroll by December 15, 2022, your coverage will start January 1, 2023. Avoid a gap in coverage by acting quickly to find a plan that meets your household’s needs and budget.
Life change? You may qualify for a Special Enrollment Period
Life change? You may qualify for a Special Enrollment Period
Open Enrollment for 2023 ended on January 15, 2023, but you may still be able to enroll in or change Marketplace coverage if you’ve had certain life events or income. Life events that may qualify include getting married, having a baby, moving, or losing health coverage. Get a full list of qualifying life changes.
Do I qualify for a Special Enrollment Period?
My income changed. Am I eligible for Medicaid or CHIP?
Learn more about 2023 coverage options.
File your taxes using Form 1095-A, Health Insurance Marketplace® Statement
The tax filing deadline is April 18, 2023. If anyone in your household had a Marketplace plan in 2022, use Form 1095-A, Health Insurance Marketplace® Statement to file your federal taxes. You’ll get this form from the Marketplace, not the IRS. Check your Form 1095-A to make sure your information is correct. Keep it with your other important tax information.
Check your online account for Form 1095-A
If you didn’t get your Form 1095-A in the mail, or you can’t find it, check your HealthCare.gov account:
If you still can’t find your form, contact the Marketplace Call Center.
How to “reconcile” using Form 1095-A
Get to know your Marketplace health plan
Congratulations on getting covered for 2023! Get answers to some common questions about health insurance, like how to find a doctor and learn what prescriptions are covered.
What prescriptions are covered by my plan?
How can I find a doctor in my plan?
How do I use my coverage?
Health insurance and taxes
If you had Marketplace coverage at any point in 2022, or got premium tax credits last year, here’s what you need to know about filing your federal taxes.
ACA marketplace enrollment in 2022 plans surged at higher incomes
In this article
Enrollment in ACA marketplace plans has surged, thanks to expanded eligibility for ACA marketplace subsidies. Leading that surge: buyers with higher incomes.
Enrollment climbed as more buyers gained subsidy eligibility
After the American Rescue Plan (ARP) expanded eligibility for premium subsidies in the ACA marketplace in 2021, enrollment in 2022 plans increased by 21%. Enrollment in 2023 plans is on pace to grow by another 13%, to about 16.4 million by the time the open enrollment period ends in all states. Plainly, Americans who lack access to affordable employer-sponsored health plans, Medicaid, or Medicare are recognizing that the ARP made health plans in the ACA marketplace far more affordable.
The ARP increased premium subsidies in the ACA marketplace at every income level and removed the income cap on subsidy eligibility, which had been 400% of the Federal Poverty Level (FPL) since the ACA marketplace launched in 2014. In 2023, 400% FPL is $54,360 for an individual and $111,000 for a family of four. Enrollees with income above that level used to pay the full premium without subsidy. Now they receive premium subsidies if the unsubsidized benchmark Silver plan premium would cost them more than 8.5% of annual family income.
The table below shows the enrollment increase at each income level for 2022 plans in the 33 states that use HealthCare.gov, the federally run exchange. While enrollment in 2022 coverage rose by double-digit margins at all reported income levels, the growth rate increased with income and was highest at incomes over 400% FPL – i.e. among those formerly ineligible for subsidies. (Information about 2023 enrollees’ income is not yet available.)
A note on one data limitation: the chart combines enrollment by those with incomes below 100% FPL and above 400% FPL because that’s the way CMS reported income in 2021, when enrollees with incomes over 400% FPL were not eligible for subsidies. In 2022, 146,297 enrollees in HealthCare.gov states had income below 100% FPL, while 655,944 reported income above 400% FPL – so likely almost all of the increase in that combined category is attributable to enrollees with incomes above 400% FPL.
An obvious surge in enrollment at income levels over 400% FPL
In 2022, the first year in which there was no income cap on subsidies, enrollment at incomes above 400% FPL more than doubled. When you look at premiums with and without subsidies for enrollees of different ages, as shown below, it’s not hard to see why.
Coverage is much more affordable at incomes above 400% FPL than it was prior to 2022 – far more so than many people who looked at marketplace offerings before they became subsidy eligible probably recognize. Note also that the number of enrollees who did not report income plummeted. That’s doubtless because the ARP dramatically reduced the number of enrollees who earn too much to obtain a subsidy.
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Enrollment Increase by Income 2021-2022
HealthCare.gov states
Source: 2022 Marketplace Open Enrollment Public Use Files / CMS.gov
The enrollment surge, illustrated
Let’s take a closer look at one of the ACA’s hottest markets: Houston, Texas. Enrollment in 2022 coverage in Texas increased by 42%, and enrollment in 2023 plans is on pace to increase another 32%. The chart below shows what premiums now look like for couples of different ages with an annual income of $74,000 – slightly above the 400% FPL threshold – compared to what those couples would pay if they were ineligible for subsidies, as they would have been in years before 2022.
The source for all premiums quoted below is the “See plans and prices” tool on HealthCare.gov.
Impact of the American Rescue Plan on ACA premium subsidies
Monthly premiums paid with and without ARP subsidy increases: Houston, TX in 2023
Married 40-year-olds, annual income $74,000 (404% FPL)
Married 63-year-olds, annual income $74,000 (404% FPL)
Notice that the premiums that the older couple will pay (after subsidy) for Bronze and Gold plans are much lower than those paid by the 40-year-olds. That’s because premiums before subsidies are credited rise with age: At age 64, they are three times the premium for a 21-year-old and more than twice the premium for a 40-year-old.
But subsidies are structured so that everyone with the same income pays the same amount for the benchmark Silver plan: An enrollee with income at >400% of FPL receives a subsidy in a fixed amount that enables the enrollee to pay not more than 8.5% of their income for the benchmark, regardless of age. So the subsidy for the older couple is bigger than for the younger couple.
When the subsidy gets bigger, it covers a larger share of the premium for plans that cost less than the benchmark plan. Since the “spread” between the benchmark plan’s premium and the premiums for cheaper plans (one Silver and many Bronze plans) increases in proportion to the age of enrollees, older enrollees get bigger savings on cheaper plans.
Louise Norris has more on how the ARP has decreased premiums for older enrollees. For eligible higher income and older enrollees, the ARP subsidy boosts are not just an “8.5% solution.” Coverage, including sometimes Gold coverage, is often available for much less.
What do the lowest-cost Bronze, Silver and Gold plans shown above look like? Below are some key features. Note that in ACA marketplace plans, select features may not be subject to the deductible, meaning you don’t have to pay full price before you meet your deductible (i.e. a service may be free or you may pay only a co-pay).
Bargains are Gold-plated in Texas and a handful of other states
The tables also show an extra benefit in the Texas marketplace. In 2022, the Texas legislature unanimously passed a law, signed by Gov. Greg Abbott, instructing the Department of Insurance to issue regulations that would ensure that insurers price Gold plans lower than Silver plans. How can that be?
Well, most marketplace enrollees have incomes below 200% FPL, and below that threshold, Cost Sharing Reduction (CSR) subsidies give Silver plans lower out-of-pocket costs than Gold plans. In Texas in 2022, 88% of Silver plan enrollees had income below 200% FPL. So, setting Gold plan premiums below Silver premiums is a major benefit to enrollees with incomes above 200% FPL, for whom Gold plans have lower out-of-pocket costs than Silver.
At least six states have taken measures to have Gold plans consistently priced below or on a rough par with Silver, and in other states and regions, insurers have done so on their own. This post by Charles Gaba spotlights states and counties in which the economic upsides for Gold plans are most extreme.
Pricing CSR directly into Silver plan premiums is a practice known as “silver loading,” which began in 2018 after the federal government stopped paying insurers separately for the value of CSR. Silver loading creates discounts in Bronze as well as Gold plans – often wiping out the Bronze premium entirely, as the chart above illustrates in the case of the 63-year-olds. Insurers in all states except Mississippi and Indiana practice Silver loading to some degree.
When premiums go high, so does subsidy eligibility
At an income of $150,000 per year for a couple of 40-year-olds – more than 800% FPL for a two-person household – the unsubsidized benchmark Silver plan in Houston costs less than 8.5% of income. The premium would be the same if the ARP were not in effect.
Married 40-year-olds, annual income $150,000 (819% FPL)
For two 60-somethings, however, the benchmark premium rises so high that it’s more than 8.5% of income even for a couple earning $150,000. Subsidies therefore kick in even at this high income.
Married 63-year-olds, annual income $150,000 (819% FPL)
Those prohibitively high unsubsidized premiums may seem like an extreme case, but they’re not unusual for older enrollees. Providing affordable insurance to people who retire or are laid off before they’re eligible for Medicare is a major function of the ACA marketplace. In 2022, 28% of all enrollees were aged 55-64.
The ARP of course made plans significantly more affordable at every income bracket below 400% FPL as well. Examples of how the subsidy increases affect enrollees at various income levels are laid out in this post.
Will high-earner enrollment continue to surge?
The American Rescue Plan was originally designed as COVID-19 relief, and the subsidy increases in the ACA marketplace were only granted through 2022. The Inflation Reduction Act, enacted in August 2022, extended the increased subsidies through 2025. Beyond that point, their future is uncertain, though they have plainly helped to reduce the uninsured population nationwide.
At least through 2025, if you need to find insurance in the individual market and have not yet examined your options, you’re likely to be pleasantly surprised – particularly if you were jolted by unsubsidized premiums in the past and now find yourself eligible for subsidized coverage.
Andrew Sprung is a freelance writer who blogs about health care policy and ACA implementation at xpostfactoid and at healthinsurance.org. His articles have appeared in publications including Health Affairs, The American Prospect, USA Today, The New York Times, The Incidental Economist, Mother Jones, The Atlantic and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Health Care Digital Media Award and holds a Ph.D. in English literature from the University of Rochester.
FARMERS INSURANCE® ANNOUNCES $500,000 COMMITMENT TO SUPPORT SAN DIEGO MILITARY FAMILIES
Check your mail for Form 1095-A
Tax season is here. If anyone in your household had a Marketplace plan in 2022, you’ll need Form 1095-A, Health Insurance Marketplace® Statement, to file your federal taxes.
Where’s my Form 1095-A?
How to use Form 1095-A
Farmers Insurance® Responds to Major Storm System and Tornadoes in Alabama and Georgia
Open Enrollment is over: What are your options?
If you missed the January 15 deadline for Marketplace coverage for 2023, you may still have options. You might qualify for a Special Enrollment Period, or you can apply for health coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
Find out if you qualify for a Special Enrollment Period
Find out if you’re eligible for Medicaid or CHIP
Last chance: Open Enrollment ends soon!
There are only a few days left to get health coverage for 2023. Open Enrollment for Marketplace health plans ends January 15. Act now to enroll in health coverage that meets your needs and budget. Coverage starts February 1.
Enroll or change health plans by January 15
Get help with enrollment
Don’t miss out! Sign up for 2023 Marketplace coverage
Your last chance to enroll in, renew, or change your Marketplace health coverage for 2023 is almost here. The deadline is January 15.
Review, update, & compare, even if you want to keep your plan
Check out the new plans even if you were happy with your 2022 coverage. There might be another plan that better fits your needs and budget.
Start now—the January 15 deadline is almost here
Pay your premium to start your coverage
Before you can start using your new 2023 Marketplace coverage, you have to pay your first premium. Your premium is the amount you pay every month directly to the health insurance company (not the Marketplace).
Here’s how. (Follow your insurance company’s instructions carefully. You may be able to pay online at HealthCare.gov.)
Pay your monthly premiums to start your coverage
Learn more about how to complete your enrollment and pay your premium.
Don’t delay! Open Enrollment ends in 1 month
Attention: The January 15 deadline to apply for, re-enroll in, or change 2023 health insurance will be here soon. This holiday season, don’t leave health insurance and the peace of mind that comes with it off your shopping list.
Important dates to know
Beat the Jan 15 deadline: Act now
Questions? Help is available
Get help applying for Marketplace health insurance.
Time’s running out: Sign up by Dec 15 for coverage that starts Jan 1
Your last chance to apply for, re-enroll in, or change 2023 Marketplace health coverage is almost here. The deadline is December 15. That’s just 6 days away. Act now – don’t miss out on health coverage that meets your needs and budget.
How to apply & enroll
Applying for ACA coverage? Know the ropes (between income levels).
Topics covered in this article
In case you missed it during a frenzied election season, the annual open enrollment period for ACA marketplace plans (which are ACA-compliant health coverage) in 2023 kicked off on November 1. You may also have missed that last year, the American Rescue Plan Act made coverage in private plans sold in the ACA marketplace far more affordable than it used to be, and that the improved premium subsidies will continue at least through 2025, thanks to the Inflation Reduction Act passed in August 2022.
If you’re a citizen or legally present noncitizen, are under 65, can’t get health coverage through your employer or your spouse’s employer, and are not on disability Medicare, you really should check out what’s available to you in the ACA exchanges. HealthCare.gov, the federal exchange that serves 33 states, reports that four out of five people who enroll can find a plan for $10 per month or less (though many will choose a plan that costs more).
Your income matters when it comes to health plan selection
While you may be pleasantly surprised by what the ACA exchanges have to offer, it’s best not to be too surprised. That is, it’s important to go in with some awareness of what you’re likely to get at different income levels.
The most basic rule is, the higher your income, the more you’ll pay for coverage, ranging from zero in the lowest income brackets (for Medicaid or free private-plan coverage) to 8.5% of household income for a benchmark Silver plan if your income is well above average.
Before you shop, it’s good to absorb two rules of the road:
The poet Robert Frost said that writing poetry without rhyming was like playing tennis without a net. Applying for ACA coverage without knowing the income levels at which benefits change is like playing tennis without any lines. And when you don’t see the lines, it’s easy to hit the ball out.
Rule 1: Know some key income break points
In the ACA application, your estimate of your gross (before-tax) household income for the coming year will place you in one of several income brackets, defined as a percentage of the federal poverty level (FPL). (The ACA application slightly modifies the “Adjusted Gross Income” you see on your annual tax form.) How much you’ll pay – and in some cases, the kind of coverage available to you – depends on what bracket you’re in. Let’s look at some key “break points” where benefits shift.
100% FPL – the minimum income required to qualify for private plan coverage in 11 states
It’s a cruel reality that in 11 states* – Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, and Wyoming – most adults who estimate household income below the 100% FPL threshold get no help from the government in obtaining health coverage.
As first drafted, the ACA made Medicaid available to most adults with an income below 138% FPL. In 2012, however, the Supreme Court ruled that the federal government couldn’t force states to expand Medicaid eligibility in that way. The states listed above have refused to date to go along, and in those states, most adults with incomes below 100% FPL get no help paying for any kind of coverage. (In the November election, South Dakota voted by referendum to adopt the expansion, and Medicaid enrollment under the ACA eligibility rules will begin there in July 2024.)
In a drafting inconsistency that turned out to be lucky, the ACA pegged the minimum income for subsidy eligibility in the marketplace at 100% FPL rather than 138% FPL. So, in states that have not expanded Medicaid, having an income of at least 100% FPL moves you out of the “no help” territory.
As discussed in more detail below, a low income is often an uncertain income, and applicants in the “nonexpansion” states with income likely to be anywhere near the 100% FPL threshold should leave no stone unturned to get a good-faith estimate of next year’s income over the eligibility threshold. Knowing the threshold is the key first step – especially since marketplace coverage with low out-of-pocket costs is available for free to applicants with income in the 100-150% FPL range.
138% FPL – the upper income threshold for Medicaid in most states
In the 38 states** that have enacted the ACA’s Medicaid expansion, most citizens and legally present noncitizens*** with income below 138% FPL qualify for Medicaid. That makes them ineligible for marketplace coverage.
Medicaid eligibility is determined on a monthly basis, which means (in expansion states) that if your income drops suddenly – after a job loss, for example – and isn’t likely to recover soon, you become eligible.
For most people near this income level, Medicaid is a good option, as there’s almost never a premium (a few states charge a small one at the top of the income bracket) and out-of-pocket costs range from zero to minimal.
Some people with income near the Medicaid eligibility threshold may prefer marketplace coverage, however – which, in some markets at least, allows for a wider choice of doctors and hospitals. While out-of-pocket costs are higher in the marketplace’s private plans than in Medicaid, they are comparatively low in Silver plans at low incomes, thanks to a secondary subsidy called cost sharing reduction (CSR) that attaches to Silver plans for lower income enrollees (more on CSR below). And the two cheapest Silver plans in each region are free to enrollees with income up to 150% FPL.
Since marketplace eligibility and subsidy level is calculated on an annual income basis, an applicant who’s suffered a sudden loss of income may qualify for Medicaid by citing current monthly income – or for marketplace coverage by estimating annual income. The HealthCare.gov application enables the latter when current monthly income is low (or high), providing a section in which you can estimate total annual income and/or a total for the coming year that may be different from income in the current year.
There is one particular case in which an applicant might want to stay out of Medicaid. In more than 20 expansion states, any Medicaid enrollee who is over age 55 is potentially subject to Medicaid Estate Recovery upon their death. If the deceased enrollee owns any significant assets, the state may seek to recover from their estate the value of the services that Medicaid covered, or, if the state contracted with a Medicaid managed care organization, all of the money that the state paid to that organization to administer the person’s coverage.
Once again, knowledge of a key income threshold may in some cases give cause to steer toward one side or the other of it.
200% FPL – the maximum income at which strong Cost Sharing Reduction (CSR) enriches benefits.
(Note that these income limits are applicable for 2023 coverage; they rise annually.) At incomes up to 200% FPL, cost sharing reduction – which attaches only to Silver plans – raises the value of a Silver plan to a roughly Platinum level (a bit above Platinum at income up to 150% FPL, a bit below at 150-200% FPL). Above the 200% FPL threshold, the value of CSR drops off sharply, and it’s not available at all at incomes above 250% FPL.
At incomes below 200% FPL, CSR makes a big difference in the out-of-pocket costs you’re exposed to. In 2022, deductibles in CSR-enhanced plans average just $146 for people with income up to 150% FPL, and $756 for those with incomes in the 150-200% FPL range. That’s well below the average deductible for Gold plans ($1,600) and in a different universe from Bronze plans ($7,051).
Perhaps more to the point for our “know your thresholds” mantra, Silver plan deductibles take a major jump at the 200% FPL threshold, to an average of $3,215 for enrollees with income in the 200-250% FPL range.
Equally important is the annual cap on maximum out-of-pocket (MOOP) costs that attaches to plans at different metal levels – and, for Silver plans, at different income levels. Up to 200% FPL, the highest allowable MOOP for Silver plans in 2023 is $3,000. In 2022, MOOP in Silver plans averages $1,208 at incomes up to 150% FPL and $2,591 in the 150-200% FPL range. Again, there’s a big jump at the 200% FPL threshold, to an average of $6,436 at the weakest CSR level.
The median MOOP in 2022 for Gold plans is $7,500, according to the Commonwealth Fund, and $8,500 for Silver with no CSR (close to this year’s maximum allowable, $8,700). Bronze MOOP is comparable to Silver.
Bottom line: Affordable marketplace coverage is far more comprehensive for a single person estimating an income of $27,000 per year – a little under 200% FPL – than for the same person estimating an income of $28,000. The strong CSR available at incomes up to 200% FPL is really valuable.
Rule 2: How income estimates affect eligibility
During the ACA’s annual open enrollment period (Nov. 1 – Jan. 15 in HealthCare.gov states), benefits for the coming year are based on an estimate of future gross (pre-tax) income, modified in some cases by deductions. Those who qualify for a special enrollment period outside of open enrollment also estimate their income for the year in progress.
The estimate may be straightforward adults with one stable job and a fixed salary. For others, including most low-income people, the estimate may involve considerable uncertainty – and therefore allow for wiggle room. That’s the case if you’re paid by the hour, and/or rely in large part on tips, or work more than one job, or are partly or wholly self-employed.
If you underestimate your income and take your full subsidy, in the form of an advance premium tax credit (APTC) used to pay your premiums as they are billed (you can opt to take only a portion of it in advance for this purpose), you will owe the difference between the APTC you received and the APTC to which you prove to have been entitled at tax time in the year following (early 2024 for 2023 coverage). CSR will not be clawed back after the fact. The exchange may reduce your APTC and CSR going forward, however, if outside data sources – such as a regular paycheck – indicate that your income is higher than estimated.
What if you’re hovering near the 100% FPL threshold in a nonexpansion state, or near the 138% FPL threshold in an expansion state and you don’t want Medicaid? There is no downside to a good-faith estimate that errs on the optimistic side. If you live alone and estimate your 2023 gross income at $14,000 (a little over 100% FPL), and eventually, your tax return shows it to have been, say, $12,000, your subsidies will not be clawed back (unless the estimate is made with “intentional or reckless disregard for the facts”).
And while you may be asked as part of the application process to document your income, your estimate will not be disallowed if outside data sources indicate that your real income is lower than estimated. See this post for more tips on making sure that you’re fully accounting for all allowable income sources.
Your income estimate must be made in good faith. But if you have good cause to be genuinely uncertain how much you earn, you are fully within your rights to use your knowledge of the ACA’s income break points to your advantage.
* * *
* One nonexpansion state – Wisconsin – offers Medicaid to adults with income up to 100% FPL, as opposed to the 138% FPL threshold in expansion states. Wisconsin therefore has no “coverage gap” – those who lack affordable access to other insurance are eligible either for Medicaid (up to 100% FPL) or subsidized marketplace coverage (over 100% FPL).
** Alaska and Hawaii have different FPLs, viewable on pages 3-6 here.
*** Washington, D.C. extends Medicaid eligibility to 215% FPL. New York and Minnesota run Basic Health Programs – Medicaid-like low-cost programs – for residents with income in the 138-200% FPL range, as well as for legally present noncitizens who are time-barred from Medicaid eligibility. Connecticut extends Medicaid eligibility to parents with incomes up to 160% FPL.
**** Legally present noncitizens who have been in the U.S. for less than five years are ineligible for Medicaid, but eligible for free Silver marketplace coverage if their income is in the 0-150% FPL range.
Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Digital Media Award. He holds a Ph.D. in English literature from the University of Rochester.
Two weeks left to get Marketplace coverage that starts Jan 1
December 15 is the deadline to apply for, renew, or change your Marketplace health insurance for 2023 coverage that starts January 1. Don’t delay – visit HealthCare.gov now!
Update & compare, even if you want to keep the same plan
Act now to get coverage that starts January 1, 2023
Don’t miss out: Get Marketplace insurance that starts Jan 1
Act by December 15 to have coverage starting January 1. There’s less than a month left to enroll in or change Marketplace health insurance for coverage that starts January 1, 2023.
The last day to enroll in or change plans for 2023 coverage is January 15 when Open Enrollment ends. For coverage to start:
Apply & enroll today
Get help now if you have questions or need help applying.
Check out 2023 Marketplace coverage options – find out if you can save
Act by December 15 for Marketplace coverage that starts January 1, 2023. Before you enroll or renew coverage, browse plans and get an idea of what your costs may be. Just answer a few quick questions – you don’t even have to log in!
Ways to save on a 2023 Marketplace plan
Get savings & apply now
Farmers Insurance Exchange First U.S.-based Insurer to Become Signatory of the United Nations Principles for Sustainable Insurance
Apply & enroll in 2023 coverage today
Open Enrollment starts today! You have until January 15, 2023 to apply for new health coverage or change your health plan for 2023. If you enroll by December 15, 2022, your coverage will start January 1, 2023. Avoid a gap in coverage by acting quickly to find a plan that meets your household’s needs and budget.
How to apply & enroll online
While there are other ways to enroll in Marketplace coverage for 2023, applying online at HealthCare.gov is usually faster and easier.
Here’s how to start a new application or update an existing one online:
If you have questions, help is available. Remember, you can only get premium tax credits and other savings if you enroll in a Marketplace plan.