If you are self-employed, in between jobs, or don’t have coverage options through your employer — to name just a few common situations — now’s the time to learn about financial help and enroll in a plan that’s right for you during the Open Enrollment Period.

In fact, as part of health care reform, you have to have health insurance, or you’ll probably pay a government tax penalty.  But besides that, having coverage helps protect you and your family from significant health care debt if you have a serious illness or an unexpected accident or injury.

Open Enrollment Period Timeline

November 15 until February 15, 2015, is the three-month Open Enrollment Period to sign up for health insurance for 2015.

If you don’t have health care coverage from an employer, Medicaid, Medicare or another source, you’ll need to buy insurance for yourself and/or your family before this Open Enrollment window closes.

If you have 2014 coverage for yourself or your family through Healthcare.gov or a state-run “exchange,” you had until December 15, 2014, to change your plan before you would be automatically re-enrolled in the plan you have now (or a similar plan). Even after automatic re-enrollment, you’ll have the opportunity to make changes to your plan until the end of Open Enrollment on February 15, 2015.

After Feb. 15, 2015, most people won’t be able to buy health insurance again until the next annual Open Enrollment Period (fall 2015) or unless they have a qualifying life event, like getting married, having a child or switching jobs.

Many Americans Still Don’t Know Financial Help Is Available

The Affordable Care Act (or ACA, sometimes called Obamacare) could make it easier for you and your family to afford health coverage. Unfortunately, according to a survey taken by the Henry J. Kaiser Family Foundation, a noted health policy organization, about 9 out of 10 Americans were not aware of the Open Enrollment Period this year.

In addition, of those polled, more than half didn’t know that the ACA provides financial help to working families as well as to low-income households to pay for health insurance.

In yet another report —this one issued by the U.S. Department of Health and Human Services — we learned that nearly 7 out of 10 people who bought Affordable Care Act (Marketplace) plans in 2013 are paying $100 or less each month for their coverage.  The lower monthly premium costs were a welcome surprise for individuals and families who submitted an application to healthcare.gov and were found to be eligible for financial help from the federal government.

Health insurance income guidelines infographic

Understanding and Applying for ACA Financial Help

If you choose and pay for your own health insurance directly (not through your employer), do you know whether you might qualify for some type of help paying for it?  And did you know that financial help for insurance coverage isn’t just for those who are unemployed or struggling? Even people who would describe their individual or family income as “decent” or “average” may qualify for some form of financial help.

When you visit DiscoverHighmark.com, you’ll learn more about what to expect when you submit your application for health insurance.  You’ll even find a link that takes you to the Marketplace (healthcare.gov) so you can apply there for financial help, then return to Highmark and shop with us directly.  Other ways to apply for financial help include visiting healthcare.gov or getting assistance from a licensed Highmark insurance representative, an insurance agent or another third party.

The application process takes about 30 minutes online on average (more if you have a large family), as you’ll need to supply information about your household members and their income.  Once you receive your financial eligibility results, you can compare and shop for plans within your budget.

The Federal Government Offers Two Kinds of Financial Help

In general, there are two kinds of subsidies (financial help) the government offers to help make health insurance more affordable for individuals and working families: Advanced Premium Tax Credits, and Cost-Sharing Reductions.

If you are eligible for one, or both, you will need to purchase an ACA-compliant insurance plan in order to use your subsidy.

Highmark is one of the many insurance companies certified to issue ACA plans.  You can shop for Highmark ACA plans directly through DiscoverHighmark.com, or when you shop in the Health Insurance Marketplace.

1) The Advanced Premium Tax Credit (APTC)

Many working families and individuals are likely to qualify for the government’s Advanced Premium Tax Credits.  An APTC is one form of financial help.  This is sometimes called a “subsidy” or just plain old “tax credit.”

Unlike some credits you can claim only when you file your federal taxes, the APTC can be used right away — at the time you purchase an ACA plan — to lower your monthly premium costs.

If you qualify for an APTC, you can choose how much of your tax credit you want to apply to offset your insurance premium each month on any metal-level, ACA plan. You can apply all, or only some, of your APTC to your monthly health insurance premium.

If you choose to apply only some of the APTC each month, you will receive any that’s leftover at the end of the tax year, when you file your annual federal income tax return. 

Income Ranges to Qualify for an APTC

If your estimated 2015 household income falls within the following ranges and meets other eligibility criteria, you’ll generally qualify for an APTC.  By “income” we mean adjusted gross income — typically the amount you’d report on federal and state tax returns, including wages on W2 and 1099 forms (or pay stubs), tips, and interest and dividends, for example.

Find out in about a minute if you might qualify for an APTC by using Highmark’s Tax Savings Estimator tool.  Even if you’re shopping on DiscoverHighmark.com, you’ll need to also visit the Marketplace, which will determine your actual eligibility for the APTC.

At the time you accept your APTC, you can choose how much of it you’d like to apply to lower your monthly premium cost on any metal-level, ACA plan.  Generally, the lower your income is within these ranges, the bigger your credit.

Tax Credit Eligibility Chart

If there are seven people in your family, an income between $36,030 and $144,120 qualifies you; if there are eight, an income between $40,090 and $160,360 makes you eligible. Incomes that qualify for tax credits are higher in Alaska and Hawaii.

2) The Cost-Sharing Reduction (CSR)

Another type of financial help is called a Cost-Sharing reduction (CSR).

CSRs help lower the amount you might pay for out-of-pocket health plan costs — such as deductibles, coinsurance and copayments — at the time you receive care. You can generally get a CSR if your income is below a certain level; you purchase an Silver-level ACA plan; and meet other eligibility factors.

If you’re an American Indian or Alaska Native and a member of a federally recognized tribe, you may qualify for additional cost-sharing reductions on all metal level plans.

Income Ranges to Quality for a CSR

If your estimated 2015 household income falls in these ranges, it’s likely that you’ll save on out-of-pocket costs on a Silver-level, ACA plan.

  • $11,670 to $29,175 for an individual
  • $15,730 to $39,325 for a family of 2
  • $19,790 to $49,475 for a family of 3
  • $23,850 to $59,625 for a family of 4
  • $27,910 to $69,775 for a family of 5
  • $31,970 to $79,925 for a family of 6
  • $36,030 to $90,075 for a family of 7
  • $40,090 to $100,225 for a family of 8

Incomes that qualify for cost-sharing reductions are higher in Alaska and Hawaii.

It’s worth noting that these incomes are based on Federal Poverty Level (FPL) guidelines issued in 2014.  The FPL is a sliding scale issued by the government and it changes each year.  It’s used to figure out who qualifies for different forms of financial help, and how much help their household is likely to need.  Healthcare.gov and the IRS can help you learn more about who’s included in your household and how income is calculated.

Reminder: The APTC and CSR are only available if you’re buying health insurance for yourself and/or your family on your own.  These kinds of financial help are not available for people who receive insurance from small businesses or large company group plans.

Next Steps on Exploring Financial Help for Health Coverage

There’s a lot to know about buying health insurance.  Finding coverage that works for your budget and your health care needs is confusing, but Highmark has tools and resources that can help.

If you bought health insurance for yourself or your family for 2014, or if you checked your eligibility for financial help last year when buying a plan on healthcare.gov, it’s a good idea to check or re-confirm your eligibility this year, as FPL guidelines and some plans may have changed. Check your eligibility if you’ve had any changes in income or household status, and know that. Highmark is here to help if you have questions.