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Health Care Reform - Making an Informed Decision going into 2025
Beginning in 2014, we transitioned into a new era of health care and individual health insurance with the advent of the Affordable Care Act (ACA). If you need health insurance because you aren’t covered through your job or your spouse’s plan, or you’ve retired but are younger than 65 and not yet eligible for Medicare, you may want to consider signing up for an individual plan under the Affordable Care Act. Our goal is to inform you of your options regarding the Affordable Care Act and help you navigate the process of obtaining coverage and determining eligibility for premium tax credits when purchasing an ACA compliant plan.
What is an ACA compliant plan?
ACA compliant plans are plans that meet certain “Essential Health Benefit” requirements. Three significant mandates included in compliant plans are maternity care, coverage for mental health benefits and coverage for pre-existing health conditions (guaranteed issue). There are only 4 factors used to rate policies in ACA compliant plans:
· Family matrix
· Age
· Smoking
· Geographic area
How do I obtain coverage for an ACA compliant plan?
Coverage can be obtained through any carrier that offers ACA compliant plans but there is a limited open-enrollment period in which to apply for coverage. Open enrollment is from November 1, 2024 - December 15, 2024, for coverage effective January 1, 2025. Applications received from December 16, 2024, through January 15, 2025, will have a February 1, 2025, effective date. Open enrollment ends January 15th, 2025!
Outside of the open enrollment period you may qualify for coverage if you have a qualifying life event and qualify for a Special Enrollment Period (SEP).
What Is a Qualifying Life Event?
· You move to a new area that offers you different plans or isn't covered by your HMO network.
· You get married.
· You have or adopt a child.
· You lose other health coverage due to job loss, a decrease in work hours, end of COBRA coverage or other reasons.
· You become a U.S. citizen.
· Your income changes or some other event changes your income or household status.
· You can prove that your health insurance company violated its contract with you.
· You are no longer covered on a family member's policy because you turned 26, you have legally separated from or divorced your spouse, or the policy holder has passed away.
· You become a member of an American Indian and Alaska Native tribe.
How do I select and apply for a plan?
ACA compliant health insurance plans are available through private health insurance companies. Our website allows you to determine if you qualify for an Advanced Premium Tax Credit (subsidy) then compare plans available in your County you reside in. You can then apply for coverage through our website. Our website offers an Enhanced Direct Enrollment Pathway which allows consumers to apply, enroll, and manage their information throughout the year.
Our website provides a comparison-shopping site for health insurance. Private health insurance companies list their health plans with the Exchange, and you can comparison shop from among the available health plan listings. Plans on the Exchange fall within the following categories to make it easier for consumers to compare plan premiums and coverage options: Catastrophic, Bronze, Silver, Gold and Platinum plans.
If you qualify for a subsidy your premium estimate will be calculated based on the amount of tax credit you are eligible for. You can then easily obtain and compare current rates from carriers offering coverage in your County.
ON-EXCHANGE: You are registering to obtain the premium tax credit. You can get this as an advance to assist with paying your monthly premiums or you can receive a lump sum credit when you file your tax return.
OFF-EXCHANGE: You are going straight to the carrier and not registering through the Exchange for the Advance Premium Tax Credit.
Things to know:
Individual health plans utilize separate provider networks than group plans! The key to selecting an individual plan is verifying that providers you are willing to see are participating providers with that carrier’s individual network.
Individual plan options are HMO / EPO plans. It is critical that you review and select a plan that includes participating providers you are willing see. There are NO out of network benefits.
Carrier options available include: Cross Blue Shield of Texas, Community Health Choice, AmBetter, Aetna/CVS, United, Oscar, Molina
(Brightway and Friday Health exited the Texas Market in 2023)
Remember, the government is not in the health insurance business! They are in the “helping you pay your premium business” if you qualify for tax credits based on your income and family size. If you register through the Exchange, your coverage is still provided through one of the private carriers that participate in the Exchange. Plan designs are the same on or off the Exchange.
How do I determine if I qualify for an advanced premium tax credit (subsidy)?
Qualification for a premium tax credit depends on the estimated household income you put on your application. It is based on your IRS tax filing and your Modified Adjusted Gross Income (MAGI). For most applicants this will be your Adjusted Gross Income reflected on Line 11 on Form 1040.
2024 ACA Income Limits for Tax Credit Subsidies
|
Family Size
|
Lowest eligible income**
100% FPL
|
CSR Tier 1 limit
150% FPL
|
CSR Tier 2 limit
200% FPL
|
CSR Tier 3 limit
250% FPL
|
*APTC Tax Credit Subsidy Maximum Income Limit
|
|
1
|
$15,060
|
$22,590
|
$30,120
|
$37,650
|
*Determined
|
|
2
|
$20,440
|
$30,660
|
$40,880
|
$51,100
|
by
|
|
3
|
$25,820
|
$38,730
|
$51,640
|
$64,550
|
family members
|
|
4
|
$31,200
|
$46,800
|
$61,400
|
$78,000
|
and
|
|
5
|
$36,580
|
$54,870
|
$73,160
|
$91,450
|
age(s)
|
|
Each add’l:
|
$5,380
|
|
|
|
|
*APTC tax credit subsidies are available for almost all eligible tax filers. This is due to the American Rescue
Plan Act (ARPA) 2021-2022. Premium contribution is now capped at 8.5% of Modified AGI for those with higher incomes. Premiums for plans are determined by family members & ages, so the “maximum income” limit is different for each scenario.
To calculate your monthly premium and estimate your potential subsidy use the "Quote Now" feature.
We can assist with reviewing carrier and plan options available. Once you have found a plan that is suitable for your needs and determine if you qualify for a subsidy, you are ready to apply. We can assist with applying for your advance premium tax credit and help you navigate through the Exchange.
There is no cost to the applicant when working with an agent!
A licensed health insurance agent can assist you with making an informed decision and
guide you through the application process. We are available at 281-485-0088.