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Demian Suvorov
Demian Suvorov

Do I Have To Buy Health Insurance [EXCLUSIVE]

Health insurance is expensive and can be hard to afford for people with lower or moderate income, particularly if they are not offered health benefits at work. In response, the Affordable Care Act (ACA) provides for sliding-scale subsidies to lower premiums and out-of-pocket (OOP) costs for eligible individuals.

do i have to buy health insurance

Also offered on the Marketplace are Catastrophic health plans with even lower premiums and higher cost sharing compared to bronze plans. Catastrophic plans are generally only available to individuals younger than 30, and premium tax credits cannot be applied to these plans.

In states that have expanded Medicaid under the ACA, adults with income up to 138% FPL are generally eligible for Medicaid and so ineligible for Marketplace subsidies. In the states that have not adopted the Medicaid expansion, adults with income as low as 100% FPL can qualify for Marketplace subsidies, but those with lower incomes are not eligible for tax credits and generally not eligible for Medicaid unless they meet other state eligibility criteria. KFF estimates that 2.2 million Americans living in non-expansion states fall into this coverage gap.

An exception to the rule restricting tax credit eligibility for adults with income below the poverty level is made for certain lawfully present immigrants. Other federal rules restrict Medicaid eligibility for lawfully present immigrants, other than pregnant women, until they have resided in the U.S. for at least five years. Immigrants who would otherwise be eligible for Medicaid but have not yet completed their five-year waiting period may instead qualify for tax credits through the Marketplace. If an individual in this circumstance has an income below 100 percent of poverty, for the purposes of tax credit eligibility, his or her income will be treated as though it is equal to the poverty level. Immigrants who are not lawfully present are ineligible to enroll in health insurance through the marketplace, receive tax credits through the marketplaces, or enroll in non-emergency Medicaid and CHIP.

To receive the premium tax credit, people must apply for coverage through the Marketplace and in their application, provide information about their age, address, household size, citizenship status, and estimated income for the coming year. After submitting the application, people will receive a determination letting them know the amount of premium tax credit for which they qualify. The consumer then has the option to have the tax credit paid in advance, claim it later when they file their tax return, or some combination of the two options.

The advanced premium tax credit (APTC) option allows consumers to have 1/12 of their tax credit paid directly to their marketplace plan insurer each month, reducing the monthly amount the consumer owes. However, because the APTC eligibility determination is based on estimated income, the enrollee is required to reconcile their APTC at tax time the following year, once they know what their actual income was. For people receiving an advanced payment of the premium tax credit in 2023, the reconciliation would occur when they file their 2023 tax return in 2024. If the consumer overestimated their income when they applied, they can receive the unclaimed premium tax credit as a refundable tax credit when they file. If the consumer underestimated their income at the time of application and excess APTC was paid on their behalf during the year, they would have to repay some or all of the excess tax credit when they file. There are maximum repayment limits which vary depending on income, shown in Table 3.

Alternatively, people can opt to pay their entire premium costs each month and wait to receive their tax credit until they file their annual income tax return the following year, although most marketplace participants cannot afford this option. The premium tax credit is refundable, meaning it is available to qualifying enrollees regardless of whether they have federal income tax liability. Everyone who receives an APTC in a tax year is required to file a tax return for that year in order to continue receiving financial assistance in the future.

Cost sharing reductions are determined on a sliding scale based on income. The most generous cost sharing reductions are available for people with income up to 150% FPL. For these enrollees, silver plans that would otherwise have an actuarial value of 70% (meaning the plan would have very high deductibles) are modified to have an actuarial value of 94%. This level of cost sharing reduction plan (sometimes called CSR 94 plans) is similar to a platinum plan, and it substantially reduces the deductibles, copays, and other cost sharing that normally apply in silver plans. Somewhat less generous cost sharing reductions are available for people with income of 151% FPL up to 200% FPL that increase the silver plan actuarial value to 87% (CSR 87 plans) and reduce cost sharing to amounts similar to those found in a gold plan. And for people with income above 200% up to 250% FPL, cost sharing reductions are available to increase the silver plan actuarial value to 73% (CSR 73 plans) and to modestly reduce deductibles and copays from those found under a normal silver plan.

Insurers have flexibility in how they set deductibles and copays to achieve the actuarial value under marketplace plans, including CSR plans. On average, in 2022 federal marketplace plans, annual deductibles in CSR94 plans were $146, compared to $4,753 in a normal Silver plan, while average annual deductible in CSR87 and CSR73 plans were $756 and $3,215, respectively.

Under the federal Affordable Care Act (ACA), companies with 50 or more employees will be assessed a penalty starting in 2015 if they do not offer group health insurance to fulltime workers. Companies with fewer than 50 employees are exempt from the penalty.

For those without affordable group insurance, another option might be one of the health care plans offered by the Minnesota Department of Human Services. These plans have very low, if any, enrollee cost sharing and in Minnesota will cover low income adults as well as children. An individual looking for insurance on MNsure will be screened for eligibility for the Minnesota health care plans. Those deemed eligible will be directed to DHS. Go to Minnesota Department of Human Services to learn more about the Minnesota Health Care Programs available to eligible Minnesotans.

Grandfathered plans are plans that were in effect on March 23, 2010 when the federal Affordable Care Act (ACA) was signed into law. The intent was to allow individuals, families and employers to keep the coverage they had. Grandfathered plans are subject to some of the reforms contained in the ACA: no annual dollar limits on coverage; no preexisting conditions exclusions; no waiting period of more than 90 days; no lifetime limits on coverage; dependent children are covered to age 26. Grandfathered plans are not required to offer the essential benefit set or limit cost sharing or provide preventive care with no cost sharing. Grandfathered plans will lose that status if there are significant changes in benefits, copayments, coinsurance, employer contributions or change in insurance companies. Should this occur, the plan will be subject to all of the requirements of the ACA and Minnesota law.

Help shopping and choosing a health plan is available via navigators, in-person assisters, certified application counselor and licensed insurance agents/brokers, and via the MNsure customer call line at 1-855-366-7873. For more details about MNsure, go to MNsure.

Individual and small group health insurance called Qualified Health Plans (QHPs) will be sold on MNsure. For those with lower incomes but not eligible for Minnesota health care programs, MNsure will determine if they quality for a subsidy to help pay for the insurance. Subsidies are only available for shoppers using the MNsure website. A subsidy will be used to discount your insurance premium.

Medicare coverage is not subject to these market reforms. Go to Minnesota Board on Aging or Minnesota Department of Commerce - Insurance or for more information about Medicare health plans and Medicare supplemental insurance.

You may be able to get short-term health coverage. This temporary coverage can last for up to six months. Preexisting health conditions are not covered. This may be an option to consider if you are between jobs, just graduating from college, or waiting for your group coverage to start. Be sure you understand what is covered and what is not covered. For more information about short term coverage go to Minnesota Department of Commerce.

COBRA, or the Consolidated Omnibus Budget Reconciliation Act, was passed in 1986 and contains provisions which allow employees to continue health coverage for themselves and their dependents after they leave their jobs. COBRA and state law require that if your employer provides you and your dependents with group health coverage, your employer must also allow you and your dependents to continue that coverage at your own expense, should you or your dependents lose your coverage. In most cases, both you and your dependents may elect COBRA or state continuation coverage for up to 18 months, but the time frame varies depending on how you became eligible for continuation coverage. You will most likely have to pay the entire cost of coverage yourself.

The coronavirus pandemic caused major economic and health care disruptions; however, unlike during previous downturns, the coverage expansions put in place by the Affordable Care Act (ACA) served as a safety net for people who lost jobs and access to health coverage. The ACA sought to address the gaps in our health care system that left millions of people without health insurance by extending Medicaid coverage to many low-income individuals and providing subsidies for Marketplace coverage for individuals below 400% of the federal poverty level (FPL). In addition, policies adopted during the pandemic, including the requirement that states maintain continuous enrollment for Medicaid enrollees and the enhanced subsidies in the Marketplace, protected people against coverage losses and improved the affordability of private coverage, making it easier for low-income individuals most affected by the pandemic to gain and retain coverage. As a result, after increasing for three straight years from 2017 to 2019, the number of nonelderly uninsured individuals dropped by nearly 1.5 million from 28.9 million in 2019 to 27.5 million in 2021, and the uninsured rate decreased from 10.9% in 2019 to 10.2% in 2021. 041b061a72


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