Who is exempted from Minimum Essential Coverage requirements?

  • Members of RELIGIOUS ORGANIZATIONS recognized by the Social Security Administration
  • Members of HEALTH CARE SHARING MINISTRY
  • Members of federally recognized INDIAN TRIBES
  • Individuals with NO TAX FILING REQUIREMENT due to household income being below Federal Poverty Level
  • Individuals without coverage during an annually allowed 3 CONSECUTIVE MONTH PERIOD.
  • Individuals who have been certified by the Marketplace to have suffered a HARDSHIP that makes you unable to obtain coverage.
  • Individuals who are INCARCERATED
  • NON U.S CITIZEN
  • Individuals who are UNABLE TO AFFORD coverage, due to premium being more than 8% higher than household income

Who is Eligible for Premium Credit

No Employer plan available

If Employer plan is available, plan must be unaffordable or less than minimum essential coverage.

Coverage applied for must be through the Public Marketplace

Credit based off where consumer falls on FPL, (must be between 133% – 400%) and cost of area’s lowest Silver plan premium.

Who is Eligible for Cost-Share Subsidy?

No Employer plan available

If Employer plan is available, plan must be unaffordable or less than minium essential coverage.

Coverage applied for must be through the Public Marketplace & a Silver level plan

Credit based off where consumer falls on FPL, (must be between less than 250%)

What is the Employer Marketplace?

Marketplace where Employer’s can select plan options and will be able to _____________. Once the employer is set up, the employees can then compare the choosen options based on cost and benefits that meet thier needs.

Groups with 2-49 full time employees will be able to choose to offer benefits through either a PUBLIC marketplace, called the Small business Health Options Plan (SHOP) or through a PRIVATE Marketplace direct with a private company.

Groups that are deemed “LARGE GROUPS” (50 or more full time equivalent employees) will also have the option to offer coverage via Public or Private Marketplaces but they will not receive tax benefits that are available through the SHOP Marketplace.

What is Minimum Essential Coverage?

Minimum Essential Coverage includues the following:

  • Employer -sponsored coverage, including COBRA & retiree benefits
  • Coverage purchased on individiual market
  • Medicare
  • Medicare Advantage
  • Medicaid
  • Children’s Health Insurance Program (CHIP)
  • Certain Veteran health plans
  • TRICARE

*does not include specialized coverage, such as the following stand-alone coveages,  vision care, dental care, workers compensation plans, disability plans, or coverage only for specifice disease or condition.

What is an Individual & Family Marketplace

These Marketplaces offer coverage to consumers who do not have coverage through an employer plan.

Public Individual Marketplaces are the only place a consumer can access any available premium credits or cost sharing subsidies

What is an “Exchange” or Marketplace”?

Formally refered to as an “EXCHANGE”, a “MARKETPLACE” is a new way to purchase health coverage. An online “store” where consumers can compare comprehensive insurance options based on price and benefits specific to a consumers need. Marketplaces are typically ran by State or Federal Government.

What is Affordable?

Employee monthly contribution for employee only coverage must be less than 9.5% of said employees prior years W2 earnings (box 1 of tax form W2)