In addition to being eligible for federal subsidies, the policies you purchase at your state or the federal Marketplace include coverage for the essential health benefits, are guaranteed issue, and are generally considered to be the most comprehensive health coverage available.
See if you could qualify for a subsidy for ACA insurance.
In this post we’ll cover:
- Where to get subsidy-eligible ACA-qualifying health insurance in your state
- Whether you (specifically) need minimum essential coverage
- Your options if you aren’t subsidy-eligible and are facing a high premium
Remember, you can generally only enroll in ACA-qualifying health insurance during the annual open enrollment period or if you qualify for a special enrollment period. Find out if you can get health insurance now.
Find Your State’s ACA Insurance Marketplace
Depending on the state you live in, you’ll either access the ACA Marketplace from a state-run website or from the federal ACA website, www.healthcare.gov.
State-run ACA Exchanges and Websites
If you’re a resident of one of these states, you’ll need to access your state’s ACA Exchange to enroll in ACA health insurance.
These states perform all marketplace functions, including health plan management, consumer assistance, eligibility and enrollment, financing, marketing, and outreach.
- California: Covered California
- Colorado: Connect for Health Colorado
- Connecticut: Access Health CT
- District of Columbia: DC Health Link – Has state individual mandate
- Idaho: Your Health Idaho
- Maryland: Maryland Health Connection
- Massachusetts: Massachusetts Health Connector – Has state individual mandate
- Minnesota: MNSURE
- Nevada: Nevada Health Link
- New York: New York State of Health
- Rhode Island: HealthSource RI
- Vermont: Vermont Health Connect – Has state individual mandate beginning plan year 2020
- Washington: Washington HealthPlanFinder
States that use the Federal Marketplace (Healthcare.gov)
For residents of any state not included in the list above, go to www.healthcare.gov to enroll in ACA health insurance.
These states use the federal ACA platform for eligibility and enrollment. You can view an interactive map at the Commonwealth Fund website to learn more about ACA plan management and marketplace administration in your state.
Do You Need Comprehensive Health Insurance?
The answer to whether or not you, specifically, need to carry a comprehensive ACA major medical policy depends on a few things, including:
- What state you reside in
- What your personal healthcare needs are
- How comfortable you are with assuming the risk of paying a potentially large medical bill on your own
In plain language, that means that as of January 1, 2019, if you don’t have major medical coverage or another form of minimum essential coverage, like Medicaid, you won’t owe a federal tax penalty.
However, you may still face a state penalty if you live in a state that has implemented an individual mandate and penalty. So you will want to factor that into your decision about whether or not to forgo ACA coverage.
If you’re not facing a tax penalty, you might want to consider non-ACA health insurance instead of going without any health insurance at all.
Consider the costs of some commonplace injuries:
- Leg Fracture: Without health insurance, surgery to repair a broken leg typically costs $17,000 to $35,000.
- Herniated Disc: Surgery for a herniated disc can cost between $20,000 and $50,000 or more, including surgeon, anesthesiologist and facilities fees.
- Torn ACL: One of the most common knee injuries, torn ACL reconstruction including surgeon’s fee, facility fee, anesthesia and graft (if needed) ranges from $20,000 to $50,000.
Without any health insurance, you’re paying for your healthcare services 100% out of pocket.
And this isn’t just speculation or hypothetical math – as of 2019, 66.5% of all personal bankruptcies that were filed were due to medical issues.
Don’t Qualify for a Subsidy, Can’t Afford ACA Premiums – What to do?
Though ACA premiums began falling in many parts of the country in 2019, the cost of even the lowest-premium Marketplace plans may still be too expensive for many people that are not eligible for ACA subsidies, especially if they’re living in high-premium areas or are older.
The table below shows how just $5,000 in annual income makes a big difference in your premium costs when it results in subsidy-eligibility. ($48,560 being the subsidy cutoff in this scenario).
Comparing 2019 Subsidized vs. Unsubsidized Monthly Premiums
|40-Year Old||Subsidized Premium: $45K income||Unsubsidized Premium: $50K income|
|Bronze||$227 (6% of income)||$340 (8% of income)|
|Silver||$340 (9% of income)||$453 (11% of income)|
|Gold||$402 (11% of income)||$515 (12% of income)|
For many, especially those right on the edge of being subsidy-eligible, the math doesn’t add up. An additional $5,000 in income (subject to federal and state taxes) results in an additional $1,356 in annual premium for a bronze plan. That’s 27% of that additional $5,000 income going towards health insurance premium!
So, what options do you have for lower-cost health insurance, meaning plans with lower monthly premiums?
Short Term Health Insurance
The reason premiums are lower is because there are several limitations to short term medical insurance policies:
- Policies are not guaranteed issue and require medical underwriting, so you can be denied coverage or charged more due to your health status, including pre-existing conditions and family health history.
- They don’t typically cover preventive care like ACA plans and cover few, if any, of the essential health benefits.
- They usually include annual benefit limits (aka “maximums”), unlike ACA policies which do not have annual and lifetime limits for essential health benefits.
- Deductibles may be higher because plans aren’t subject to the ACA’s cap on out-of-pocket costs.
- Policies are not available in all states.
There are also features of short term medical policies that may offset the limitations depending on your situation:
- Less premium for less coverage – These policies may be a good fit if you’re generally healthy and rarely use healthcare services except for an unexpected injury or illness.
- Customizable coverage can include hospital room and board, ER services, diagnostic services and doctor visits. The more healthcare benefits you opt for, the higher your premium.
- They generally have lower premiums, as previously mentioned. Remember, you have control, your premium is based on the benefit level you select.
- You may be able to choose your own doctor without network restrictions. There may be financial incentives for using in-network providers.
- You can apply and enroll year-round in most states if you qualify, making it a viable option if you miss open enrollment.
- Policies are available for 36-month maximum durations in some states, meaning depending on where you live, you may be able to maintain your coverage for that duration without having to reapply, or undergo medical underwriting.
- Add other coverage to work alongside your STM plan, like a hospital indemnity plan or dental insurance, for more coverage and benefits. (Some states require you to have a major medical policy in order to obtain supplemental hospital insurance.)
It’s important to make sure you fully understand the cost-sharing requirements and limitations on any short term policy you’re considering, so read the plan details carefully.
If you have questions make sure to reach out to the carrier to get clarification before you apply.
Compare different short term plans and costs (it only takes a minute).
Summary + Next Steps
Shopping for and buying the best health insurance for you can be overwhelming, especially with such high premium and deductible costs associated with health coverage.
You may want to enroll in an ACA plan from the federal or state-based exchange if you:
- Qualify for subsidies
- Live in a state with a minimum essential coverage individual mandate
- Tend to use a lot of health services throughout the year, particularly those considered essential health benefits
- Have a pre existing health condition
However, if you don’t qualify for subsidies, and premiums are unaffordable, you could consider a limited duration option like short term medical insurance if it meets your health coverage needs and you qualify.
For help understanding and comparing your options, speak to an agent by calling 888-855-6837, or find an agent near you.
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