How To Get Help Paying for Health Insurance

Are you having trouble affording health insurance? You're not alone.

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Health insurance can be so expensive that many low and middle-income people can’t afford it without help. The majority of non-retired Americans get their health insurance from an employer, and employers heavily subsidize the cost. Most older, retired Americans get their coverage through Medicare, which is also heavily subsidized. Fortunately, there is also financial help available for people who have to obtain their own coverage.

The Affordable Care Act (ACA) created government subsidies to help low and middle-income people pay for health insurance. These subsidies help pay for monthly health insurance premiums, as well as costs like coinsurance, copays, and deductibles once you have health coverage.

And the American Rescue Plan has made the premium subsidies larger and more widely available for 2021 and 2022, making health coverage even more affordable for millions of Americans.

What Kind of Financial Help Can I Get?

There are three different programs for people who need help paying for health insurance.

  • Medicaid: The first program, if you have a very low income, enrolls you in Medicaid. Most often, Medicaid is provided for free to those who qualify. Eligibility varies from state to state, so you won’t know for sure if you qualify until you apply. In most states, eligibility for Medicaid has been expanded under the ACA, so even if you’ve applied before and been turned down, you should apply again through your state’s health insurance exchange. (You’ll learn more about this later.) The Medicaid website has the most recent income limits for Medicaid and CHIP eligibility, by state (CHIP, the Children's Health Insurance Program, is available for kids and sometimes pregnant women, and the income limits are higher than they are for Medicaid). The ACA eliminated asset tests for Medicaid eligibility for adults under age 65, so eligibility is based on income rather than income and assets combined (asset tests are still used for people age 65 or older).
  • Premium Tax Credits: The second program, which is also income-based, pays a portion of your monthly health insurance premiums (here's how income is calculated for this). It's like getting a discount on the price of health insurance because the subsidy pays part of your cost (or in some cases, all of the cost). This subsidy money is sent from the government directly to your health insurance company on your behalf each month—or you can pay full price for a plan in the exchange and then claim the premium tax credit on your tax return.
    Although premium subsidies make health insurance much more affordable, unlike the Medicaid option above, you’ll likely still have to pay something toward the cost of your health insurance each month (note that some states do charge modest premiums for Medicaid enrollees with income above the poverty level).
    Premium tax credit eligibility is based on income; assets are not taken into consideration. Premium tax credits are based on keeping the after-subsidy cost of the second-lowest-cost silver plan available, but they can be applied to any metal-level plan.
    There is normally an income cap (equal to 400% of the poverty level) for premium subsidy eligibility. But for 2021 and 2022, the American Rescue Plan has eliminated this limit. Households that earn more than 400% of the poverty level can qualify for a premium subsidy if the cost of the benchmark plan would otherwise be more than 8.5% of the household's income.
  • Decreased Cost Sharing: For those with fairly low or modest incomes, the third program decreases your out-of-pocket expenses like deductibles, copays, and coinsurance when you use your health insurance. This benefit is available to people who earn up to 2.5 times the poverty level.
    For example, if you bought a health insurance policy that would otherwise require you to pay a $50 copay each time you see the doctor, your cost-sharing subsidy might decrease that copay to $30 each time you visit the doctor. The decreased cost-sharing program also limits the out-of-pocket maximum you’ll pay if you end up using your health insurance a lot. Since the insurance company pays for a larger percentage of your healthcare expenses, the cost-sharing subsidy is like getting a free upgrade on health insurance.
    Cost-sharing subsidies are only available on silver plans, and are automatically included in all of the available silver plans if your income makes you eligible for them. For those not eligible, the plans that include cost-sharing subsidies don't show up in the available options.

Many lower-income people get help from both the premium tax credit subsidy and the decreased cost-sharing subsidy at the same time, assuming they enroll in a silver plan. People who are eligible for the cost-sharing subsidy will almost always also be eligible for the premium subsidy. But not everyone who is eligible for the premium subsidy is eligible for the cost-sharing subsidy.

In 2021, just under half of all the people enrolled in plans through the exchanges were receiving cost-sharing subsidies. Virtually all of them were also receiving premium subsidies. But far more people—86% of all enrollees—were receiving premium subsidies.

How Do I Get Help Paying for Health Insurance?

You can apply for a health insurance subsidy, as well as for Medicaid, through your state’s health insurance exchange. When you apply for health insurance through your health insurance exchange, the exchange will determine if you’re eligible for Medicaid, or for decreased cost-sharing and/or a premium tax credit.

Will I Qualify for Help Paying for Health Insurance?

Eligibility for a health insurance subsidy is based on your income relative to the federal poverty level. The dollar amount of the federal poverty level changes every year, and varies based on the number of people in your family. As explained here, the exchange will use the poverty level numbers from the prior year to determine your subsidy eligibility (so for health plans effective in 2021, the 2020 poverty level numbers are used).

The lower threshold for premium subsidy eligibility is a household income equal to 100% of the poverty level in states that have not expanded Medicaid, and more than 138% of the poverty level in states that have expanded Medicaid (which is the majority of the states). In states that have expanded Medicaid, adults under the age of 65 are eligible for Medicaid if their income doesn't exceed 138% of the poverty level. For 2021 coverage, 100% of the poverty level for a single person in the continental U.S. is $12,760.

There is normally an upper threshold for premium subsidy eligibility that's set at 400% of the poverty level. But the American Rescue Plan has eliminated this for 2021 and 2022. Depending on how much a person would have to pay for the benchmark plan, subsidies can be available with income well above 400% of the poverty level. Consumer advocates have called on Congress to extend the American Rescue Plan's subsidy provisions, but if that doesn't happen, the "subsidy cliff" would once again exist at 400% of the poverty level starting in 2023.

The closer you are to the poverty level (or 138% of the poverty level in states that have expanded Medicaid), the more subsidies you’ll get, and subsidies will get smaller as your income increases. This is true for premium subsidies as well as cost-sharing subsidies.

What Will Disqualify Me From Getting a Health Insurance Subsidy?

You won’t qualify for a health insurance subsidy if you can get affordable health insurance by other means. For example, if you could get affordable health insurance through your job, but you’d rather have a health plan purchased through your health insurance exchange, you won’t qualify for a subsidy.

The law makes an exception about this if the health insurance your employer offers is lousy, or if the coverage isn’t affordable:

  • The Affordable Care Act defines "affordable" as health insurance that costs you less than 9.83% of your income in 2021 (note that this is calculated based only on the employee's cost for self-only coverage; the cost to add family members is not taken into consideration, which results in the family glitch).
  • If the health coverage available through your job doesn’t provide minimum value, then it won’t disqualify you from getting a subsidy just because it’s available. For a plan to provide minimum value, it has to pay an average of 60% of covered costs, and include "substantial" coverage for inpatient and physician care.

However, if you choose to enroll in employer-offered health insurance even though it’s not affordable or doesn’t provide minimum value, then you won’t be eligible for a subsidy as long as you’re enrolled in the employer's health plan. The government isn’t going to give you help paying for health insurance if you already have job-based health insurance.

You won’t qualify for a subsidy if you’re enrolled in (or in some cases, eligible for) government-sponsored health insurance such as the Children’s Health Insurance Program, the Veterans Administration, Medicaid, or Medicare (note that you can receive premium subsidies if you're eligible for Medicare but would have to pay a premium for Medicare Part A, due to not having enough work history to get premium-free Part A).

You won’t qualify for a subsidy if you’re in prison or if you’re not living in the United States legally.

If you’re married, your tax filing status must be “married filing jointly” in order to qualify for a subsidy. You won’t qualify for a subsidy if your filing status is “married filing separately," except in limited circumstances involving domestic abuse or spousal abandonment.

Ridiculous as it sounds, you won't qualify for a subsidy if your income is less then 100% of FPL, even if you're in a state that hasn't expanded Medicaid (unless you're a recent immigrant who has been in the U.S. for under five years). That's right; the poorest of the poor don't get premium tax credit or cost-sharing subsidies.

That's because the lawmakers who wrote the Affordable Care Act intended that everyone earning less than 138% of FPL get Medicaid. However, the Supreme Court ruled that the federal government couldn't force states to give all of those people Medicaid. This means each state can decide whether or not it will expand Medicaid coverage to everyone earning less than 138% of FPL, or limit it to only the people who qualified for Medicaid under the older, stricter criteria.

And there are still about a dozen states that have chosen to not expand Medicaid eligibility, despite the fact that the federal government will cover 90% of the cost.

If your state has chosen not to expand its Medicaid program and you're living below the poverty line, you're in what's called the Medicaid coverage gap (which was not part of the ACA, and was never expected to be an issue) and you won't be eligible for help paying for health insurance.

If you're in this situation, you may be able to find charity care in your area. Or you may be able to take advantage of a Community Health Center that provides primary care services regardless of your ability to pay. Find your nearest Community Health Center.

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12 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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