Do I Qualify for a Low-Cost Marketplace Plan?
By Estagacy Insurance Group ·
The short answer
Many people are surprised by how much help is available. 8 out of 10 people may qualify for health coverage starting at $10/month or less, depending on their income, household and where they live. The only way to know your own situation is to look at your numbers, which is what a quick eligibility check or a call with a licensed agent does.
Qualifying is not about your job title, your health, or whether your employer offers benefits you cannot afford. It mostly comes down to two things: how much your household expects to earn next year, and how many people are in your household.
What counts as household income and household size
The Marketplace looks at your expected income for the coming year, not last year's. That includes wages, self-employment earnings after business expenses, unemployment benefits, and certain other income. For most people, household size means you, your spouse if you file jointly, and anyone you claim as a dependent on your taxes.
Because it is an estimate, it does not need to be perfect. It does need to be honest and realistic. If you are unsure, bring pay stubs, a recent tax return or business records, and we will help you arrive at a sensible number.
Premium tax credits: lowering your monthly bill
The most common kind of financial help is the premium tax credit. It lowers the monthly premium you pay for a Marketplace plan. The amount depends on your income, your household size and the cost of plans where you live.
You can choose to have the credit applied in advance, which means it is sent straight to your insurance plan each month and your bill is lower right away. You can also take some or all of it when you file your taxes instead. Most people take it in advance so coverage is affordable now.
At tax time, the credit you received is compared with what you actually qualified for based on your real income. That is why keeping your estimate up to date matters, which we cover below.
Cost-sharing reductions: lowering what you pay for care
Premiums are only part of the picture. Deductibles, copays and coinsurance are what you pay when you actually use care. For people with lower incomes, cost-sharing reductions can make those costs noticeably smaller.
There is one important catch: cost-sharing reductions only apply to Silver plans. If you qualify and choose a Bronze plan because the premium looks lower, you give up that extra help. We point this out when we compare plans with you, so you can decide with the full picture.
When Medicaid or CHIP may be a better fit
If your household income is lower, you or your children may qualify for Medicaid or the Children's Health Insurance Program, known as CHIP, instead of a Marketplace plan. Rules differ from state to state, and sometimes parents and children in the same family qualify for different programs.
Medicaid and CHIP accept applications any time of year. When we review your situation, we check these programs too, so you are not paying for a plan when a lower-cost option may be available.
Report income changes during the year
Life rarely matches the estimate you made months ago. You might get a raise, lose hours, start a side business or add a family member. When that happens, update your Marketplace application.
If your income goes up and you do not report it, you may have to pay back some of your advance credit when you file taxes. If your income goes down, reporting it may increase your help right away. Either way, a quick update keeps things accurate, and we can walk you through it.
How to find out where you stand
Our short eligibility check takes about 30 seconds and gives you an idea of what you may qualify for. From there, a licensed agent can compare plans with you, check that your doctors and hospitals are in-network, and handle the application by phone, by video or at our Orlando office. Our help is free.
Frequently asked questions
Does my health affect whether I qualify for financial help?
No. Financial help is based on your estimated household income and household size, not your health.
Do cost-sharing reductions work with any plan?
No. They only apply to Silver plans, for people with lower incomes who qualify.
What if my income changes after I enroll?
Report the change to the Marketplace. That keeps your financial help accurate and helps you avoid surprises at tax time.
Helpful pages
Talk with a licensed agent
Free help by phone or video. We compare plans and check your doctors for you.
Free eligibility check
Takes about 30 seconds · Free · No obligation
This article is general information, not tax or legal advice.