Individual Open Enrollment: Marketplace Subsidies, Medicaid and CHIP


Tis the season for Open Enrollment!  Under the Affordable Care Act (ACA), uninsured individuals are required to buy insurance or face a tax penalty.  Individuals can enroll in the health insurance marketplace during the open enrollment period which began on November 1 and will end on January 31, 2017.  Today we are covering some basic information about marketplace subsidies, medicaid, and CHIP.
When you use a health insurance Marketplace, you may be able to get lower costs on monthly premiums or out-of-pocket costs, or get free or low-cost coverage.  Subsidized coverage—or coverage that’s obtained through financial assistance from programs to help people with low and middle incomes—is available to individuals and families with household incomes up to 400 percent of the federal poverty level and who are not offered affordable coverage through their employers.
You can save money in the Marketplaces three ways. All of them depend on your income and family size.

  1. You may be able to lower costs on your monthly premiums through tax credits when you enroll in a private health insurance plan.
  2. You may qualify for lower out-of-pocket costs for copayments, coinsurance and deductibles.
  3. You or your child may get free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP).

Tax Credits for Premiums
The most widely available subsidy is the Advance Premium Tax Credit, which helps cover the gap between the cost of their premium and what they can afford to pay.
The ACA requires households participating in the Marketplaces to put a certain percentage of their income toward the cost of health insurance. The exact percentage households need to pay is graduated up to 400 percent of the federal poverty level (FPL), with people at that percentage level required to pay the most and people at 100 percent of the federal poverty level required to pay the least. For more information on the premium tax credit, contact us.
The percentage of income that households are required to pay, however, may not be enough to cover the cost of the insurance policy. The Advanced Premium Tax Credit covers the amount between what households are required to pay and the cost of the insurance policy.
Premium tax credits are both refundable and advanceable. A refundable tax credit is available to a person even if he or she has no tax liability. An advanceable tax credit allows a person to receive assistance at the time that he or she purchases insurance rather than paying his or her premium out of pocket and waiting to be reimbursed when filing an annual income tax return.
Reduced Out-of-pocket Costs
In addition to the Advance Premium Tax Credit, households that earn up to 250 percent of the federal poverty level may be eligible for cost-sharing subsidies. These subsidies are designed to help lower out-of-pocket costs.
Health insurance companies offering coverage through the Marketplace must lower the amount you pay out of pocket for essential health benefits if your household income is within a certain amount.
Reduced cost-sharing is only applicable to silver plans. If you qualify for out-of-pocket savings, you must choose a silver plan to get the savings.
Medicaid Eligibility
Medicaid is the nation’s health insurance program for low-income individuals and families. To qualify for Medicaid, individuals must be low-income or must have incurred health expenses that have caused them to “spend down” their incomes to Medicaid eligibility levels.
Under the ACA, states have the option of expanding Medicaid to households making up to 138 percent of the poverty line. However, these are the minimum thresholds for Medicaid expansion. The rules for Medicaid eligibility are different for each state. States can choose to offer Medicaid to households with a higher income. Conversely, states can choose not to participate in the Medicaid expansion. To determine your eligibility for Medicaid under the ACA, visit your state’s Medicaid Web page.
CHIP Eligibility
CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers parents and pregnant women. Each state offers CHIP coverage and works closely with its state Medicaid program.
The benefits covered through CHIP are different in each state, but all states provide comprehensive coverage, including:

  • Routine check-ups
  • Immunizations
  • Doctor visits
  • Prescriptions
  • Dental and vision care
  • Inpatient and outpatient hospital care
  • Laboratory and X-ray services
  • Emergency services

States may choose to provide additional CHIP benefits. Each state program has its own rules about who qualifies for CHIP. To see if you or your children qualify, visit
For more information about individual insurance and health care reform, or for help getting started, contact AUI.

We do more than cover small businesses and individuals with the right insurance policies and benefit plans – what motivates our team is helping you save more so you can invest more in your team, family, and goals.

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