Premium Assistance for Coverage in Exchanges
about this tool
This tool illustrates health insurance premiums and subsidies for people purchasing insurance on their own in new health insurance exchanges (or “Marketplaces”) created by the Affordable Care Act (ACA). Beginning in October 2013, middle-income people under age 65, who are not eligible for coverage through their employer, Medicaid, or Medicare, can apply for tax credit subsidies available through state-based exchanges.
Additionally, states have the option to expand their Medicaid programs to cover all people making up to 138% of the federal poverty level (which is about $33,000 for a family of four). In states that opt out of expanding Medicaid, some people making below this amount will still be eligible for Medicaid, some will be eligible for subsidized coverage through Marketplaces, and others will not be eligible for subsidies.
With this calculator, you can enter different income levels, ages, and family sizes to get an estimate of your eligibility for subsidies and how much you could spend on health insurance. As premiums and eligibility requirements may vary, contact your state’s Medicaid office or exchange with enrollment questions.
Enter Information About Your Household
The Subsidy Calculator is based on the Affordable Care Act (ACA) as signed into law in 2010, and subsequent regulations issued by Health and Human Services (HHS) and the Internal Revenue Service (IRS).
Premiums in the calculator are illustrative examples in 2014 dollars derived from estimates of average premiums for 2016 from the Congressional Budget Office. We assume an average premium for a single adult enrolled in the second-lowest cost Silver plan to be $4,827 (before subsidies). This estimate was derived by multiplying the CBO estimate for a family premium by 37% (the average ratio of single to family premiums in previous CBO estimates) and then adjusting for assumed inflation and differences over time in the aggregate reinsurance pool to arrive at a 2014 estimate. Premiums could vary from this amount due to assumptions insurers make in setting premiums or the degree of competition in the market, and will also differ based on regional variations in underlying health costs. Premiums for Bronze plans are based on the estimated Silver and ratio of claims expenses between Bronze and Silver plans in the HHS actuarial value calculator.
The premium is adjusted for family size, tobacco usage, and age of the user. Premiums in the calculator vary by age within the three to one limit specified in the law, using age factors from proposed regulations issued by HHS. The calculator assumes a tobacco surcharge of 50% above the premium of a non-smoker, which is the maximum allowed under the law. Actual tobacco surcharges will vary by plan and some states do not permit insurers to vary premiums by tobacco status.
Premium subsidies are based on Silver coverage (which has an actuarial value of about 70%). Enrollees may pay a lower premium for less comprehensive coverage (i.e., a Bronze plan, with an actuarial value of 60%) or may purchase more comprehensive coverage (i.e. a Gold plan, with an actuarial value of 80% or a Platinum plan with an actuarial value of 90%). People receiving subsidies can apply their subsidy toward the purchase of more or less expensive plans, but must pay difference between the premium in the selected plan and the subsidy. Premium subsidies may not cover the cost of a tobacco surcharge.
The law also makes available a catastrophic policy for young adults and those exempted from the requirement to obtain insurance due to affordability. Catastrophic plans are less comprehensive and have a lower premium than other coverage. Eligibility to purchase catastrophic coverage is reflected in the calculator, when applicable. Premium subsidies may not be applied to catastrophic coverage.
Frequently Asked Questions
Does the calculator provide definitive estimates of what people will pay under the health reform law?
No. The calculator is intended to illustrate how families in varying circumstances may be affected by the tax credits and limits on age rating included in the law. Premiums will vary from region to region and based on assumptions insurers make in setting premiums. In addition to what people would pay in premiums, they would also have out-of-pocket expenses for cost sharing (e.g., deductibles and coinsurance), which in some cases would be subsidized based on income. In addition, there are many other factors that could increase or decrease how much people pay, including efforts to make the health care system more efficient and additional revenue measures to finance the federal cost of reform.
How do premium subsidies work?
People purchasing coverage on their own will be eligible for government subsidies (through a tax credit) towards their health insurance premiums based on income. Subsidies will be provided to people with family income between 100% and 400% of the federal poverty level. The most that these families buying subsidized coverage in an exchange will pay towards a health insurance premium will range from 2.0% of income at 100% of poverty to 9.5% of income at 400% of poverty, with amounts at specific income levels specified in a table in the law. Subsidies are tied to a benchmark level of coverage based on actuarial value. And, subsidies will only be available to those purchasing coverage through the exchanges, which includes people who do not have access to alternative insurance (such as Medicaid and affordable employer coverage). When an exchange determines that a person is eligible for a tax credit based on expected income, and that person enrolls in coverage, subsidies will be paid directly to insurers to lower the cost of premiums (and in some cases cost sharing).
What is the poverty level?
The federal poverty level varies by family size. In 2013, it is $11,490 for a single adult and $23,550 for a family of 4. The poverty level is estimated for 2014 based on Congressional Budget Office projections of inflation.
What is included in household income? How do I know what to enter?
The calculator allows users to enter household income in terms of 2014 dollars or as a percent of the federal poverty level. Household income includes incomes of the taxpayer, spouse, and dependents. In determining eligibility for subsidies, exchanges will calculate enrollees’ household incomes using Modified Adjusted Gross Income, or MAGI. The MAGI calculation includes such income sources as wages, salary, interest, dividends, and Social Security. MAGI calculation does not include income from gifts, inheritance, and Survivors Benefits, and some other income sources are partially excluded. More information on MAGI is available here.
How does Medicaid relate to exchange subsidies?
Currently, Medicaid eligibility varies substantially by state, and is generally limited to certain categories of people (e.g., children, parents, people who are disabled, and people age 65 or older). Under health reform, states have the option to expand Medicaid eligibility to all people with incomes below 138% of the poverty level. The calculator notes when people would be eligible for Medicaid under expansion, and when they would be eligible for exchange subsidies if their state does not expand Medicaid. More information on state decisions regarding Medicaid expansion is available here. In other cases, people may be Medicaid-eligible based on their state’s eligibility requirements. As Medicaid eligibility varies from state to state, please contact your state’s Medicaid office with eligibility and enrollment questions.
How do premiums vary by age and health status?
Before the health law goes into effect in 2014, people buying coverage on their own generally face medical underwriting, meaning that they can be turned down for coverage or charged a higher premium based on their health status. Under the reform law, insurers are prohibited from denying coverage or charging higher premiums based on health status. Beginning in 2014, the reform law also limits the degree to which premiums may vary by age , with the premium for a 64 year old being no more than three times that of a 21 year old. This means that premiums for older people may be lower than under the status quo while premiums for younger people may be higher. Under proposed regulations by Health and Human Services (HHS), children under age 21 have slightly lower premiums and families with more than three children under the age of 21 will only be charged premiums for three children.
How do premiums vary by location?
As under the status quo, the health reform law permits premiums to vary by geographic area, reflecting the fact that the cost of living and health care expenses vary significantly by location. As shown here, average health insurance premiums vary quite a bit by state, with the lowest family premium in a state at about 17% below the national average and the highest at about 11% above the average. Premiums also vary by location within states, so the range across communities nationwide is larger than the statewide averages suggest. Premiums in the calculator are based on estimates of average premiums nationwide. Therefore, actual premiums may be higher or lower, depending on where you live.
How do premiums vary by tobacco usage?
Currently, insurers in many states charge higher premiums (in the form of a surcharge) for enrollees who use tobacco. The health reform law allows insurers to charge people who use tobacco up to 50% more in premiums than people who do not use tobacco. Furthermore, the law specifies that exchange subsidies cannot be used to cover the portion of the premium that is due to a tobacco surcharge. The calculator assumes that insurers will charge enrollees the maximum 50% surcharge, but actual surcharges will likely vary. Under the status quo, insurers typically charge an average of 20%. Residents of states that do not permit tobacco surcharges (listed here) may arrive at a more accurate premium estimate by selecting that they do not use tobacco.
What is actuarial value and how does it affect premiums?
The actuarial value of a health insurance policy is the percentage of the total covered expenses that the plan covers, on average for a typical population. For example, a plan with a 70% actuarial value means that consumers would on average pay 30% of the cost of health care expenses through features like deductibles and coinsurance. The amount that each enrollee pays will vary substantially by the amount of services they use. The health reform law specifies a benchmark level of coverage for the purposes of premium subsidies using actuarial values. Premium subsidies will be tied to Silver plans, which have an actuarial value of 70%. Additional subsidies for people making between 100 and 250% of the poverty level limit cost sharing and raise the actuarial value of Silver plans. The calculator also illustrates premiums and subsidies for Bronze plans, which have an actuarial value of 60%. Bronze plans represent the minimum level of coverage most people are required to maintain under health reform, and these plans will have higher cost sharing on average. Regardless of the level of actuarial value, insurers will have to cover a defined set of health care services and cap the total amount of cost sharing required of consumers at defined levels, but can generally otherwise vary the structure and degree of cost sharing so long as minimum actuarial value thresholds are met.
Can premiums be compared to what people are paying today?
Premiums cannot necessarily be compared to what people are paying now. Most people with insurance today have coverage through work, where the employer is paying for a portion of the premium. The premiums and tax credits presented in the calculator apply to people who are buying insurance on their own. The premium calculations are consistent with estimates of premiums under reform prepared by the Congressional Budget Office. However, in many cases coverage will be more comprehensive and accessible than what is typically available today in the non-group market. As a result, 2014 premiums in the calculator cannot necessarily be compared to what people buying insurance on their own were paying before the law.