To make coverage more affordable, subsidies (aka Advanced Premium Tax Credits) will be available to help those with lower and moderate incomes. These subsidies are generally available to the following people:
Individuals who are not offered insurance through their work;
Those who are not eligible for a public plan like Medicare, Medicaid, or CHIP; and
those with an annual income between 100 and 400 percent of the Federal Poverty Level.
To receive a subsidy:
Individuals must purchase their health insurance through the Health Insurance Marketplace. If an individual qualifies for a credit, the federal government will pay a portion of the monthly premium directly to the chosen insurance company.
The credit is based on family size, income, and age. To see if you qualify for a subsidy, simply CLICK HERE and enter your zip code and ages of those to be covered.
To qualify for a subsidy, you must:
Be a citizen or legal resident of the U.S.
Have a family income between 100 to 400 percent of the federal poverty level
Not have access to a qualified employer-sponsored health plan that provides minimum value (actuarial value of at least 60 percent) and that is affordable (does not cost you more than 9.5 percent of your income)
Not be eligible for public coverage—including Medicaid, the Children’s Health Insurance Program, Medicare, or military coverage. However, in Utah Medicaid has not been expanded which is causing much confusion. Call for guidance if you’re unsure about this.
Use your subsidy to purchase insurance through Climbing Healthcare’s free assistance on the health insurance marketplace.
How much subsidy could I receive?
Plans offered in the health insurance marketplace are categorized by metal level: bronze, silver, gold, and platinum. Subsidies are based on the premium of the second lowest cost silver plan in each state. The amount of the subsidy varies according to the income of the individual or family. Those who qualify will only be required to pay a certain percentage of their income for premiums, as shown below:| Income Level | Premium As A Percentage of Income | Monthly Maximum of Premium | |
| Single | Family of Four | ||
| Up to 133% FPL | 2% of income | $25 | $51 |
| 133%-$150% FPL | 3 to 4% of income | $56 | $115 |
| 150%-200% FPL | 4 to 6.3% of income | $117 | $242 |
| 200%-250% FPL | 6.3 to 8.05% of income | $187 | $387 |
| 250%-300% FPL | 8.05 to 9.5% of income | $265 | $547 |
| 300%-400% FPL | 9.5% of income | $310 | $730 |
Here’s an example:
Johnny is 31 years old and has an annual salary of 200% of poverty or $22,980.
The second lowest cost silver plan in the health insurance marketplace in Johnny’s area costs $3,600 annually.
Johnny will only pay 6.3% of income, or $1,448 annually, to enroll in that plan.
Johnny will receive an annual tax credit of $2,152 ($3,600 premium minus the $1,448 limit on what Johnny must pay)
Beginning January 1, 2014, the Affordable Care Act requires all Americans to have minimum essential health coverage, qualify for an exception, or pay a tax penalty. The penalties are phased in, according to the following schedule:
2014—$95 per uninsured adult and $47.50 per uninsured child (capped at $285 per household) or 1 percent of the household income, whichever is greater.
2015—$325 per uninsured adult and $162.50 per uninsured child (capped at $975 per household) or 2 percent of the household income, whichever is greater.
2016 and beyond—$695 per uninsured adult and $347.50 per uninsured child (capped at $2,085 per household) or 2.5 percent of the household income, whichever is greater.
Most individuals in the United States have health coverage today that will count as minimum essential coverage. They will not need to do anything more than continue their current coverage.
For those who do not have coverage, who discontinue their current coverage, or who want to explore other affordable options, Health Insurance Marketplaces (formerly called exchanges) are open in every state, as of 2014.
These will help qualified individuals find minimum essential coverage that fits their budget and look for potential financial assistance to help with the costs of coverage.
Individuals are guaranteed coverage on a health plan regardless of health status (including pre-existing conditions), age, gender, or other factors that might predict the use of health services. Premium rating may only vary based on the following factors: age, geographic area, number of family members covered and tobacco use.
The Affordable Care Act states that all non-grandfathered plans in the individual and small employer markets both inside and outside of Health Insurance Marketplaces must cover Essential Health Benefits (EHB) beginning January 1, 2014 for new business, and at renewal for existing business. There are ten categories of Essential Health Benefits:
Ambulatory patient services
Emergency Services
Hospitalization
Maternity and newborn care
Mental health and substance abuse
Prescription drugs
Rehabilitative and habilitative services
Lab services
Preventive and Wellness services and chronic disease management
Pediatric services, including oral and vision care
Deductible: The amount you owe for covered health care services before your health insurance begins to pay anything.
Co-pay/Co-payment: The amount an insured individual must pay toward the cost of a particular benefit. For example, a plan might require a $25 co-pay for each doctor’s office visit.
Co-Insurance: At first glance the term Co-Insurance may seem to represent a secondary health insurance plan. However, it does not mean this. Co-Insurance is your responsibility as a % of the cost of covered health care services after the deductible has been met. For example, if you view a summary of benefits for your health plan and it shows 20%, the 20% is the Co-Insurance.
Out-of-Pocket Maximum: The most you pay during a policy period (usually calendar year 1/1 to 12/31) before the health insurance company starts to pay 100% for covered services. Under the Affordable Care Act this limit must now include deductibles, coinsurance, copayments or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits.
Premium: The amount that you pay for your health insurance coverage. Often after a subsidy is applied you may pay very little or zero for your coverage.
Open Enrollment Period: The period of time to enroll into an Affordable Care Act Plan. The Open Enrollment Period currently is November 1, 2015 through January 31, 2016. Outside of the Open Enrollment Period you cannot enroll in coverage unless you have a Qualifying Life Event which may give you a Special Enrollment Period. We do offer short term plans that you can call us about.