Am I eligible for ACA health insurance?
How do I know if I qualify for coverage through the ACA marketplace?
The Affordable Care Act (ACA) Marketplace, also known as the Health Insurance Marketplace, offers health insurance plans for individuals and families who do not have access to affordable health coverage through an employer, Medicaid, or Medicare. To determine if you qualify for coverage through the ACA Marketplace, you’ll need to consider several factors, including your income, residency, citizenship status, and current health coverage options. Here's what you need to know:
1. Eligibility Criteria for ACA Marketplace Coverage
You may qualify for ACA Marketplace coverage if you meet the following conditions:
A. Residency and Citizenship Requirements:
You must live in the United States and be a legal resident.
You must be a U.S. citizen or a lawfully present immigrant. This includes people with green cards, refugees, and individuals with other legal immigration statuses. Temporary visitors, such as those on student or tourist visas, are not eligible for Marketplace coverage.
You must live in a state that participates in the federal or state ACA Marketplace. Most states participate in the federal marketplace, but a few states have their own marketplaces.
B. Current Health Coverage:
You cannot be eligible for Medicare. If you qualify for Medicare, you are not eligible for ACA Marketplace coverage.
If you have access to affordable employer-sponsored coverage, you may not qualify for subsidies or premium tax credits through the ACA Marketplace. "Affordable" is generally defined as your share of the annual premiums for self-only coverage not exceeding 9.12% of your household income in 2024.
If you are eligible for Medicaid or the Children’s Health Insurance Program (CHIP), you will typically not be eligible for Marketplace subsidies, but you can apply for these programs through the Marketplace.
2. Income Requirements for Financial Assistance (Subsidies)
While anyone can purchase a plan through the ACA Marketplace, you may qualify for financial assistance if your income falls within certain ranges. There are two main types of financial assistance:
A. Premium Tax Credits:
Premium tax credits reduce the monthly cost of your health insurance premiums.
You generally qualify for premium tax credits if your household income is between 100% and 400% of the federal poverty level (FPL).
For 2024, this range is approximately $14,580 to $58,320 for an individual and $30,000 to $120,000 for a family of four.
In some states, if your income is below 100% of the FPL, you may qualify for Medicaid instead of a Marketplace plan.
B. Cost-Sharing Reductions (CSRs):
Cost-sharing reductions lower your out-of-pocket costs, such as deductibles, copayments, and coinsurance, when you use healthcare services.
You qualify for CSRs if your income is between 100% and 250% of the FPL.
To receive cost-sharing reductions, you must enroll in a Silver-level plan.
3. Special Enrollment Periods (SEPs)
The ACA Marketplace has an annual Open Enrollment Period, but if you miss it, you may qualify for a Special Enrollment Period (SEP) if you experience a qualifying life event, such as:
Losing health coverage: This includes losing employer-sponsored insurance, Medicaid, or CHIP coverage.
Change in household: Examples include marriage, divorce, the birth of a child, or adoption.
Change in residence: Moving to a new state or ZIP code may qualify you for a SEP.
Other qualifying events: Changes in income, gaining citizenship or lawful presence, or leaving incarceration can trigger a SEP.
If you qualify for an SEP, you can enroll in or change your Marketplace plan outside of the Open Enrollment Period.
4. Who Might Not Qualify for Marketplace Coverage:
Medicare-eligible individuals: If you are eligible for Medicare, you cannot use the Marketplace to get a health plan or receive subsidies. You must enroll in Medicare.
Undocumented immigrants: Individuals who do not have legal immigration status are not eligible for Marketplace coverage or financial assistance.
5. What Happens If You Don’t Qualify for ACA Marketplace Coverage?
If you don’t qualify for Marketplace coverage or subsidies based on your income or current health coverage, there may be other options:
Medicaid: If your income is below the Medicaid eligibility threshold in your state, you may qualify for Medicaid. You can apply through the Marketplace to be directed to your state’s Medicaid program.
Children’s Health Insurance Program (CHIP): If your children need health insurance, they may qualify for CHIP, even if you don’t qualify for Medicaid or Marketplace subsidies.
Employer-sponsored coverage: If your employer offers affordable health insurance, you may need to rely on that coverage rather than the Marketplace.
6. How to Apply for ACA Marketplace Coverage
You can apply for ACA Marketplace coverage through tsunamihealth.com, over the phone, or by mail. During the application process, you will provide information about your household size, income, and current health coverage to determine your eligibility for coverage and subsidies.
Key Takeaways:
You may qualify for ACA Marketplace coverage if you live in the U.S., are a legal resident, and do not have access to affordable health coverage through your employer, Medicaid, or Medicare.
Financial assistance is available in the form of premium tax credits and cost-sharing reductions if your household income is between 100% and 400% of the federal poverty level.
You can apply for coverage during the Open Enrollment Period or a Special Enrollment Period if you experience a qualifying life event.
For help determining if you qualify for ACA Marketplace coverage or to explore your plan options, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
