Confused about health insurance marketplaces? Here's some guidance

The Washington Post
Posted9/8/2013 7:56 AM

With the opening of the online health insurance marketplaces just a little over a month away, I've been receiving many questions about how they'll work.

Q: It sounds like people who buy health insurance on the marketplaces will have to pay the full premium for that insurance monthly, and subsidies will be paid through tax credits that are received annually as a tax refund. How could any low-income person who is living from paycheck to paycheck afford to do that?


A: They won't have to. When consumers apply for a plan on the health insurance marketplace, also called an exchange, they'll be asked to provide income information to determine whether they're eligible for a premium tax credit. That subsidy will be available to people with incomes up to 400 percent of the federal poverty level. (In 2013, that's $45,960 for an individual and $94,200 for a family of four.) The tax credit is equal to the cost of a midlevel plan minus the person's expected contribution, which ranges from 2 percent to 9.5 percent of income.

If they qualify, consumers can opt to receive the tax credits in advance, and the exchange will send the money directly to the insurer every month; this subsidy will reduce how much people owe upfront. Consumers can also choose to receive the credit when they file their taxes the following year.

It's important to estimate your income as accurately as possible and to contact the exchange during the year if you find you're making more or less than expected, says Cheryl Fish-Parcham, deputy director for health policy at Families USA, a consumer advocacy group. That's because when completing your 2014 taxes, your estimate will be reconciled with what you actually earned. If you've received more than you were due, you may have to repay that amount. (Likewise, if you earned less than expected, you'll get money back.)

If in doubt, consider taking only some of the credit upfront. "If people are worried about reconciliation and the possibility their income could increase, they can take part of [the credit] in advance and get the rest at tax time," Fish-Parcham says.

by signing up you agree to our terms of service

Q: My employer offers affordable health insurance for me for $136 per month, but adding my husband and 22-year-old-daughter will push the premium up to about $2,050 a month. Will we be allowed to buy insurance on the exchange? We probably won't qualify for a subsidy because our annual income will be more than $85,000. I fear that in comparison to the marketplace, the individual plans sold by insurance agents will be inferior and have hidden and costly booby traps.

A: Even if your employer offers health insurance, you can shop for coverage on the exchanges. However, since your income is more than 400 percent of the federal poverty level ($78,120 for a family of three in 2013), you won't be eligible for a premium tax credit if you buy a plan there.

Don't dismiss plans sold outside the exchanges because you don't think they'll provide good coverage. Starting next year, individual and small-group plans, whether they're sold through the online marketplaces or on the private market, all have to meet many of the same standards.

"If you're not eligible for a tax credit, the coverage is going to look very similar inside and outside of the exchange," says Larry Levitt, senior vice president of the Kaiser Family Foundation.


Plans can't turn people down or charge them more because they have pre-existing medical conditions, for one thing, and they must cover 10 comprehensive "essential health benefits." In addition, all plans must generally cap out-of-pocket spending at $6,350 for individuals and $12,700 for families, among other things. The only plans that are exempt from the new rules are those that are grandfathered under the law.

Q: What happens when people don't pay their premiums in a timely manner after they purchased insurance on the new exchange? If they are terminated from the policy, will they be able to reinstate?

A: Consumers who are receiving premium tax credits for coverage on the exchange will get a 90-day grace period to catch up on late premiums, says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities. Other consumers not getting the subsidies may get more or less time, depending on the exchange rules or state law, he says.

Once the grace period has passed, consumers will generally have to wait until the next annual open enrollment period in the fall to re-enroll in coverage. If they're uninsured for more than three months, they might be assessed a penalty for not having insurance coverage; those fines are up to $95 or 1 percent of income in 2014, whichever is greater.

This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente.

Article Comments ()
Guidelines: Keep it civil and on topic; no profanity, vulgarity, slurs or personal attacks. People who harass others or joke about tragedies will be blocked. If a comment violates these standards or our terms of service, click the X in the upper right corner of the comment box. To find our more, read our FAQ.