Understanding it and enrolling in
your new health care plan
RLee Insurance Solutions LLC
How does the ACA improve my health
• Provides health insurance to those that were once considered ‘uninsurable’ with pre-
exiting health conditions.
• Provides for certain protections and rights to make your coverage fairer and easier to
• Provides for a health care Marketplace for an easier shopping experience.
• Holds insurance companies accountable for rate increases.
• Makes it illegal for health insurance companies to arbitrarily cancel your health
• Covers young adults under 26.
• Provides free preventive care.
• Ends lifetime and years dollar limits.
• Guarantees your right to appeal
Questions? Call 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325)
What will my new policy cover?
All private health insurance plans offered in the Marketplace will offer the same set of essential health benefits. These are
services all plans must cover.
The essential health benefits include at least the following items and services:
• Ambulatory patient services (outpatient care you get without being admitted to a hospital)
• Emergency services
• Hospitalization (such as surgery)
• Maternity and newborn care (care before and after your baby is born)
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and
• Prescription drugs
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or
chronic conditions gain or recover mental and physical skills)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services
OK so how do I start ?
First thing you need to figure out if you qualify for a federal subsidy…
• If your income is between 138% - 400% of the federal poverty level then you may qualify for
a federal subsidy, premium assistance tax credit. It was put into place to help reduce the cost
of premiums; this subsidy may only be applied to “on exchange” plans. Since you can only
use your subsidy with plans that are “on exchange” and you must enroll through the
government website Healthcare.gov or go enroll through a third-party site that has a broker
link to the federal site. In some case if the mid-level silver plans in your area are below
certain guidelines, (2.03%-9.66%) of the applicant's wages, it could affect their ability to
qualify for a subsidy.
• If your income is above 138% - 400% of the federal poverty level, you may apply for either
“on exchange” or “off exchange” plans. If you choose to enroll in a “on exchange” plan, then
you must go through the Healthcare.gov or a broker linked site to enroll. Plans that are “off
exchange” may be purchased through various web sites.
• Lastly if your income is below 138% of the poverty level you do not qualify for a subsidy and
in many cases, you can enroll for Medicaid through Healthcare.gov or your State web site.
You may also choose to buy an “off exchange” plan since no subsidy is involved.
Just what is a subsidy?
The ‘subsidy’ or Advance Premium Tax Credit (APTC) is actually an advance on next years
tax return based on your ‘projected’ income for this year. You can choose to use this tax
credit in any one of 3 different ways.
1. You can use the entire monthly credit to reduce your out-of-pocket expense for you
monthly health premium.
2. You could use only a portion of your credit and pay more out of pocket for your health
premiums each month, you would then get the remainder at the end of the year with a
high tax return, this is a good option if you are unsure of the coming year’s income.
3. You could choose to not use your monthly tax credit at all and receive the entire amount
at the end of the year on your tax return.
*Keep in mind if you misjudge your income for the year, you could be a position where you
would owe part of your APTC back to the government. Always report any change in income
levels as soon as possible the Federally Facilitated Marketplace at 1-800-318-2596, they
can adjust your monthly APTC to the appropriate amount for you.
How to calculate my subsidy?
• First determine how many in your
• Second calculate your modified
adjusted gross income(MAGI).
• Third use a subsidy calculator to
enter these numbers and find
**IMPORTANT** It's important to remember that
qualifying incomes levels are linked to the price of
silver plans in YOUR area. If more affordable silver
plans are available the amount you can make and
still get a subsidy will be reduced.
Family size 100% 138% 250% 400%
1 $13,590 $18,347 $33,975 $54,360
2 $18,310 $25,268 $45,775 $73,240
3 $23,030 $31,781 $57,575 $92,120
4 $27,750 $38,295 $69,375 $111,000
5 $32,470 $44,809 $81,175 $129,880
6 $37,190 $51,322 $92,975 $148,760
7 $41,910 $57,836 $104,775 $167,640
8 $46,630 $64,349 $116,575 $186,520
2022 Federal Poverty Levels based on number in household
Where do I find my MAGI?...
Basically, this is the income you make before
all of your deductions, and adding back a few
that you have taken, like interest from
student loans and IRA contributions.
What are Federal Cost-Sharing Subsidies?
Individuals with a household income of 138-250 percent of the federal poverty line,
who enroll in a plan through the exchange, Healthcare.gov, are eligible for a cost
sharing subsidy. Under the 2022 federal poverty guidelines, the annual income
thresholds to qualify are: $18,754 for individuals; $25,268 for couples; $31,781 for a
family of three; and $38,295 for a family of four.
Cost sharing subsidies are designed to minimize out-of-pocket costs by reducing the
amount individuals have to pay for deductibles, co-payments or co-insurance, and
maximum out of pocket expenses. The amount of the reduction depends on the
insured’s household income.
For those with incomes between 138% and 200% of poverty, a 2/3 reduction applies.
For others, the reduction in the limit is either ½ or 1/3, depending on income. The
precise amount by which an individual’s out of pocket maximum is reduced by this
assistance depends on what the maximum is for the plan in which they are enrolled.
• To receive a Cost-Sharing subsidy you have to have a Silver Plan, as these are the
only eligible plans for this subsidy.
My spouse is offered health insurance at work,
but it is unaffordable for the whole family. Do
This scenario is referred to as the “Family Glitch”. Employers often cover at least 50%
of the health premium for the employee, but not the spouse or whole family. This can
leave insurance premiums outside the reach of many of their employee’s families.
• Starting November 1st, 2022, the HHS issued new guidance for applying the
affordability rule to families. If the cost of the employer offered plan exceeds 9.12%
of the employee's gross income the employee can applying for a subsidy on the
• If the employer plan is within the 9.12% for the employee, the employee would not
qualify for a subsidy, BUT if the cost for a spouse and/or family plan exceeds 9.12%
of the HOUSHOLD income the spouse and family WOULD qualify for a federal
subsidy and buy a plan from the Marketplace.
• If the employer offers more than one plan, the least expensive plan would be the
one used in testing for affordability.
But which plan?
The new plans will be labeled with “metallic” names, bronze, silver,
gold, and platinum. There is also one more plan labeled “catastrophic”
but only certain folks may apply for them.
• Each plan will have a deductible, an amount you must pay before
benefits are triggered.
• After you have satisfied the deductible, you will have to pay a co-pay,
or coinsurance, a set percentage of your bill.
• The good news each plan does have a maximum amount listed that
you would have to pay. Should your health expenses exceed the
maximum out of packet amount your plan will generally pay all
remaining medical expenses.
A catastrophic plan generally requires you to pay
all of your medical costs up to a certain amount,
usually several thousand dollars. Costs for
essential health benefits over that are generally
paid by the insurance company.
These policies usually have lower premiums than
a comprehensive plan, but cover you only if you
need a lot of care. They basically protect you
from worst-case scenarios.
• Only people under 30 may apply for them.
• You may apply for a hardship exemption if
*Not a subsidy eligible plan
Generally speaking, the Bronze Plan is
intended to have the lowest premium of the 4
new categories of plans but charge the
highest out-of-pocket costs for healthcare
services. For people without group insurance
from an employer or other group, the Bronze
plan is the minimum health insurance plan in
which they can enroll that will satisfy the
Affordable Care Act’s mandate for people to
purchase health insurance.
• Plans often have high deductibles.
• Co-pay is at the 60/40 level
The Silver Plans have lower out-of-pocket
costs than the Bronze Plans but higher out- of-
pocket costs than both the Gold and Platinum
Plans. All Silver Plans share the same
minimum health benefits but the way they
charge out-of-pocket costs can differ
• Subsidies in your state are based on Silver
plans in your state.
• Co-pay is at the 70/30 level
The Gold Plan is one of the two plan types
that an insurance company must offer in
order to participate in a health insurance
exchange. A health insurance exchange is a
state marketplace for health insurance plans
meeting the ACA requirements.
One of the issues that the government intends
to monitor is whether Gold and Platinum
plans attract more sickly enrollees and drive
• These plans have the second lowest out-of-
pockets of the metallic plans.
• Co-pay is at the 80/20 level
Since the Platinum Plan has the most
generous cost-sharing for enrollees, it is
expected that these plans will typically have
the highest premiums when compared to the
Bronze, Silver, and Gold plans.
It will be important to compare premiums
among different insurance companies
offering Platinum Plans. Moreover,
deductibles and copayments will also differ
among Platinum Plans. This is perfectly
acceptable as long as the Platinum Plan
covers 90% of healthcare expenses for a
• Co-pay is at the 90/10 level
Located just off IN 26 in Lafayette
Indiana, we are easy to find with ample
parking and our facility is handicapped
accessible. Click here for easy Directions
34 Executive Dr.
Lafayette, IN 47905
Email: [email protected]
Our office Location