1. Health
Send to a Friend via Email

How Does the Health Insurance Subsidy Work?

Understanding the Premium Tax Credit Health Insurance Subsidy

By

Updated January 26, 2014

Health insurance is expensive, and not everyone can afford it. However, the Affordable Care Act requires that you have health insurance from January 1, 2014 onward.

When they wrote the Affordable Care Act, lawmakers knew many people wouldn’t be able to afford the cost of health insurance premiums, so they included subsidies to help. One of those subsidies is the premium tax credit.

The premium tax credit is designed to help people pay their monthly health insurance premiums. But, in order to get that financial help and use it correctly, you have to understand how it works.

How Do I Apply for the Premium Tax Credit Health Insurance Subsidy?

Apply for the premium tax credit through your state’s health insurance exchange. If you get your health insurance somewhere else, you can’t get the premium tax credit.

Find out how to contact your state’s health insurance exchange.

Will I Qualify for the Subsidy?

People making between 100 and 400 percent of federal poverty level can qualify for the premium tax credit health insurance subsidy. Federal poverty level changes every year, and is based on your income and family size. You can look up this year’s FPL here.

Using 2013 FPL levels, you'll qualify as an individual with an income range of $11,490-$45,960, a couple with an income of $15,510-$62,040, and a family of three earning $19,530-$78,120.

If you meet the income qualifications, make sure something else doesn't disqualify you from receiving the subsidy. Learn more in, “Can I Get Help Paying for Health Insurance”; look for the section “What Things Disqualify Me From Getting a Health Insurance Subsidy?”

How Much Money Will I Get?

In order to figure out how much your premium tax credit will be, you have to know two things:

  1. Your expected contribution toward the cost of your health insurance
    Tip: You can look this up in the table at the bottom of the page.
     
  2. The cost of your benchmark health plan
    Tip: Your health insurance exchange can tell you which plan this is and how much it costs. Your benchmark plan is the silver-tiered health plan with the second lowest monthly premiums in your area. The Affordable Care Act classifies health plans based on how much of your health care costs they’re expected to cover. A bronze health plan will cover about 60 percent of the average person’s health care costs. A silver health plan will cover about 70 percent.

 

Your subsidy amount is the difference between your expected contribution and the cost of the benchmark plan.

See an example of how to calculate your monthly costs and your subsidy amount at the bottom of the page.

Can I Buy a Cheaper Plan To Save Money, or Must I Buy the Benchmark Plan?

Just because the benchmark plan is used to calculate your subsidy doesn’t mean you have to buy the benchmark plan. You may buy any plan listed on your health insurance exchange, but your subsidy amount stays the same.

If you choose a more expensive plan, you’ll pay the difference plus your expected contribution. If you choose a plan that’s cheaper than the benchmark plan, you’ll pay less since the subsidy money will cover a larger portion of the monthly premium. If you choose a plan so cheap that costs less than your subsidy, you won’t have to pay anything for health insurance. However, you won’t get the excess subsidy back.

If you’re trying to save money so you choose a plan with a lower value, (like a bronze plan instead of a silver plan), you’ll likely have higher coinsurance and copays when you use your health insurance.

There’s another reason to choose a silver-tier plan. There’s a different subsidy that lowers copays, coinsurance, and deductibles for some low-income people. Eligible people can use it in addition to the premium tax credit subsidy. However, it’s only available to people who choose a silver-tier plan.

Do I Have to Wait Until I File My Taxes to Get the Subsidy?

You don’t have to wait until you file your taxes. You can get the premium tax credit in advance. If your income is so low that you don’t have to file taxes, you can still get the subsidy. However, if you’d rather, you may choose to get your premium tax credit as a tax refund when you file your taxes instead of having it paid in advance.

How Do I Get the Money?

If you choose to get the premium tax credit in advance, the government sends the money directly to your health insurance company on your behalf. You'll never actually lay your hands on the money. Your health insurer credits that money toward your cost of health insurance premiums, decreasing how much you'll pay each month.

If you choose to get the premium tax credit as a tax refund, the money will be included in your refund when you file your taxes. This could mean a big tax refund. But, you'll pay more each month since you’ll be paying both your share of the premium and the share that would be have been covered by the subsidy if you'd chosen the advanced payment option.

Why Wait Until I File My Taxes To Get the Subsidy?

Most people won’t want to wait; they’ll choose the advance payment option. However, consider opting to get the subsidy along with your tax refund if:

  • Your income is very close to 400 percent of FPL.
  • Your income varies from year to year so you’re not sure how much you’ll make.

 

When the subsidy is paid in advance, the amount of the subsidy is based on an estimate of your income for the coming year. If the estimate is wrong, the subsidy amount will be incorrect.

If you earn less than estimated, the advanced subsidy will be lower than it should have been. You’ll get the rest as a tax refund.

If you earn more than estimated, the government will send too much subsidy money to your health insurance company. You’ll have to pay back part or all of the excess subsidy money when you file your taxes. Even worse, if your actual income ended up more than 400 percent of FPL, you’ll have to pay back every penny of the subsidy. This could be thousands of dollars.

If you get your subsidy when you file your income taxes rather than in advance, you’ll get the correct subsidy amount because you’ll know exactly how much you earned that year. You won’t have to pay any of it back.

What Else Do I Need To Know When Applying for a Subsidy?

If your subsidy is paid in advance, notify your health insurance exchange if your income or family size changes during the year. The exchange can re-calculate your subsidy for the rest of the year based on your new information.

Example of How To Calculate the Subsidy:

 

  1. Figure out how your income compares to FPL.
  2. Find your expected contribution rate in the table below.
  3. Calculate the dollar amount you’re expected to contribute.
  4. Find your subsidy amount by subtracting your expected contribution from the cost of the benchmark plan.

 

Tom is single with an income of $22,800 per year. FPL for 2013 is $11,490 for single people.

  1. To figure out how Tom’s income compares to FPL, use: income ÷ FPL x 100.
    $22,800 ÷ $11,490 x 100 = 198.4.
    Tom’s income is 198 percent of FPL.
     
  2. Using the table below, Tom is expected to contribute 4-6.3 percent of his income. Since he’s almost at the top of his category in the table, he uses the 6.3 percent figure.
     
  3. To calculate how much Tom is expected to contribute, use this equation: 6.3 ÷ 100 x income.
    6.3 ÷ 100 x $22,800 = $1,436.
    Tom is expected to contribute $1,436 per year, or about $120 per month, toward the cost of his health insurance. The premium tax credit subsidy pays the rest of the cost of the benchmark health plan.
     
  4. The benchmark health plan at Tom’s health insurance exchange costs $3,900 per year or $325 per month. Use this equation to figure out the subsidy amount: cost of the benchmark plan – expected contribution = amount of the subsidy.
    $3,900 - $1,436 = $2,464.
    Tom’s premium tax credit subsidy will be $2,464 per year or about $205 per month.

 

If Tom chooses the benchmark plan, or another $325 per month plan, he’ll pay $120 per month for his health insurance. If he chooses a plan costing $425 per month, he’ll pay $220 monthly for his health insurance. If he chooses a plan costing $225 per month, he’ll only pay $20 per month for his health insurance.

Table of Your Expected Contribution Percentage:

If your income is Your expected contribution will be
100%-133% of FPL 2% of your income
133%-150% of FPL 3%-4% of your income
150%-200% of FPL 4%-6.3% of your income
200%-250% of FPL 6.3%-8.05% of your income
250%-300% of FPL 8.05%-9.5% of your income
300%-400% of FPL 9.5% of your income

©2014 About.com. All rights reserved.

We comply with the HONcode standard
for trustworthy health
information: verify here.