Individuals may qualify for financial help with premiums and out-of-pocket costs for coverage purchased through a health insurance marketplace. Financial help is available in two forms: a premium tax credit and cost-sharing reductions.
To be eligible for the premium tax credit, the individual must meet all of the following criteria:
- Enrolled in a plan sold through the health insurance marketplace,
- Not eligible for minimum essential coverage, other than coverage offered in the individual market (see below for definitions of minimum essential coverage), and
- Household income between 100 percent and 400 percent of the federal poverty level.
In general, minimum essential coverage includes the following:
- Employer-sponsored coverage, including COBRA continuation coverage and retiree coverage
- Coverage purchased in the individual market, including a plan purchased in a health insurance marketplace
- Medicare Part A coverage and Medicare Advantage plans
- Most Medicaid coverage
- Most Children’s Health Insurance Program coverage
- Veterans health coverage administered by the Veterans Administration
- Most types of TRICARE (coverage for members of the military)
- Self-funded student health coverage that began on or before Dec. 31, 2014 (for later plan or policy years, programs can apply to be recognized as minimum essential coverage, the list of approved plans is available here)
- Coverage for Peace Corps volunteers
- Refugee Medical Assistance from the federal Administration for Children and Families
- Department of Defense health benefit program for civilian employees known as “Nonappropriated Fund” personnel
There may be other types of coverage that qualify as minimum essential coverage.
There are exceptions to the list of minimum essential coverage, in which having or being eligible for some forms of minimum essential coverage do not disqualify an individual for the premium tax credit because of special circumstances. Those exceptions include the following:
- Employer-sponsored coverage: if the coverage is either “unaffordable” or does not meet minimum value standards (“inadequate”), then the individual may still qualify for the premium tax credit.
- Unaffordable means the cost of self-only coverage in the lowest cost plan is more than 9.56 percent of the individual's household income in 2018 (9.69 percent in 2017).
- To provide minimum value, the plan must have an actuarial value of at least 60 percent and include coverage for hospitalization and physician services.
- Children’s Health Insurance Program (CHIP) coverage:
- An individual subject to a waiting period before he or she can enroll in their state’s Children’s Health Insurance Program is not considered eligible for minimum essential coverage and may therefore be eligible for the premium tax credit during the waiting period. NOTE: Not all states have a waiting period for their Children’s Health Insurance Program.
- An individual who is not enrolled in the Children’s Health Insurance Program because he or she hasn’t paid premiums is considered eligible for minimum essential coverage and therefore not eligible for premium tax credit. Similarly, an individual who is not enrolled in Medicaid because he or she hasn’t paid premiums is considered eligible for minimum essential coverage and therefore not eligible for premium tax credits.
- Coverage tied to a certain condition: individuals who may be eligible for Medicare or Medicaid based on disability, blindness or illness are considered eligible for minimum essential coverage only when the agency responsible for eligibility determinations determines the individual eligible for Medicare or Medicaid. Until that time, the individual is eligible for premium tax credit.
- Other coverage, including coverage that may have a substantial premium. In these circumstances, only those who are enrolled in the following coverage are ineligible for the premium tax credits:
- Self-funded student health plan that began on or before Dec. 31, 2014 (for later plan or policy years, programs can apply to be recognized as minimum essential coverage, the list of approved plans is available here)
- Medicare Part A coverage requiring payment of premiums
- Certain TRICARE programs: Young Adult, Retired Reserve, Reserve Select, and the Continued Health Care Benefit Program
There may be other exceptions to minimum essential coverage that allow eligible individuals to apply for premium tax credits, or to be enrolled in the plan and avoid paying a penalty for failing to maintain coverage.