What should I know about Health Insurance Marketplace plan savings?

Contents

• What is the Affordable Care Act and the Health Insurance Marketplace?
• What are the ways I can save money on a Health Insurance Marketplace plan?
• What are my rights and responsibilities with Health Insruance Marketplace plan savings?

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What is the Affordable Care Act and the Health Insurance Marketplace?

The Affordable Care Act (ACA), also known as Obamacare, is a law that was created to extend health-insurance to uninsured Americans. The Act created the Health Insurance Marketplace where individuals, families, and small businesses can shop for health care coverage. The Marketplace offers healthcare plans to people who cannot get health insurance through an employer or the government.

 

The ACA also included ways for people with lower incomes to save on the health insurance they buy through the Marketplace. These savings come from:

• premium tax credits, and 

• cost-sharing reductions.

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What are the ways I can save money on a Health Insurance Marketplace plan?

If your income is within a certain range, you may qualify for savings on Health Insurance Marketplace plan. The savings are also called subsidies. The type of savings you qualify for and amount of savings you get will depend on:

• Your income,

• The cost of available insurance coverage,

• Where you live, and 

• Your family size.

 

What are premium tax credits? 

If your income is between 100% and 400% of the federal poverty level, you are eligible for a tax credit. These credits are to help cover the cost of paying the premium for your Health Insurance Marketplace plan. You can use your tax credit for most plans in the Health Insurance Marketplace. 

 

To get a premium tax credit, you must:

• Apply and shop for a bronze, silver, gold, or platinum plan in the Health Insurance Marketplace,

  • You cannot use a premium tax credit for a catastrophic plan.

• Have an income between 100% and 400% of the federal poverty level,

  • If you are an immigrant who is legally in the U.S., but cannot get Medicaid, you might be able to get a tax credit if your income is below the federal poverty level.

• Not be eligible for affordable coverage through an employer-sponsored plan, 

• Not file taxes as Married Filing separately, unless:

  • You are a survivor of domestic violence, or 

  • Your spouse has abandoned you, but you are still married.

• Not be eligible for government health coverage, like Medicare, Medicaid, or TRICARE,

• Not be claimed as dependent by another person. 

 

If you qualify for a premium tax credit, the Marketplace will send the money directly to your insurance company. You will pay a lower premium each month. 

 

What are cost-sharing reductions?

If your income is between 100% and 250% of the federal poverty level, you may be able to save on your out-of-pocket costs for Health Insurance Marketplace plans. The costs include:

• Deductible,

• Copay, and

• Coinsurance.

 

These savings are called “cost-sharing reductions” (CSRs). Although the federal government stopped funding CSRs, they are still available to consumers on the Health Insurance Marketplace. 

 

To get a cost-sharing reduction, you must:

• Apply and shop for a Silver plan in the Health Insurance Marketplace,

• Have an income within the income range (between 100% and 250% of the federal poverty level),

• Not be eligible for affordable coverage through an employer-sponsored plan, and

• Not be eligible for government health coverage, like Medicare, Medicaid, or TRICARE.

 

If you qualify and you enroll in a Silver plan, you will have:

• A lower deductible,

• Lower copays or coinsurance payments, and 

• A lower “out-of-pocket” maximum. 

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What are my rights and responsibilities with Health Insurance Marketplace plan savings?

If you are eligible, you have the right to any premium tax credits and/or cost-sharing reductions. You are responsible for applying for a plan on the Health Insurance Marketplace.  

 

You are responsible for reporting any changes in your income or household size. 

 

If you disagree with a Marketplace decision, you have the right to appeal that decision. 

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Contents

• How can I apply for Marketplace savings?
• Can I appeal Marketplace savings decisions?

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How can I apply for Marketplace savings?

After you apply for coverage on the Marketplace, you will get an Eligibility Determination Notice. This notice will tell you: 

• What kind of coverage each member of your household is eligible for, and 

• What the next steps are to get coverage and savings, including:

  • Deadlines, and 

  • Documents you need to file.

 

You qualify for a premium tax credit if your Eligibility Determination Notice says, you are “eligible for advance payments of the premium tax credit to help pay for a Marketplace plan.”

 

You qualify for cost-sharing reductions if: 

• Your Eligibility Determination Notice says you “Can choose a health plan with lower copayments, coinsurance, and deductibles" and 

• Is followed by (04), (05), or (06).

 

To get those savings you must choose a Silver plan.

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Can I appeal Marketplace savings decisions?

You can appeal Health Insurance Marketplace decisions, including:

• Your eligibility for cost-sharing reductions or a premium tax credit,

• The amount of savings you are eligible for, 

• If your savings amount is reduced,

• Your eligibility for advance payments of the premium tax credit (APTC), 

• The amount of APTC you're eligible for, 

• Your eligibility for a Special Enrollment Period, 

• Your eligibility to buy a Marketplace plan,

• Your eligibility to choose a Catastrophic plan, or 

• Your eligibility for an exemption from the requirement to have health insurance. 

 

After you apply for coverage, you will get an eligibility notice. This notice explains what savings you qualify for. This notice also gives you appeals instructions and tells you how many days you have to appeal.

 

You can file an appeal:

• Online, or

• By mail or fax. Fill out a Marketplace Appeal Request form. 

  • Fax the form to 877-369-0130.

  • Mail to:

Health Insurance Marketplace

Attn: Appeals

465 Industrial Blvd.

London, KY 40750-0061

 

The Marketplace Appeals Center must give you a decision within 90 days of getting your request. 

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