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Enroll on-exchange if your income is uncertain Enroll in Medicaid if you're eligible. For people who aren't eligible for Medicaid but who have uncertain incomes, it's generally a good idea to enroll through the exchange during open enrollment.
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Read More »Enroll in Medicaid if you’re eligible. For people who aren’t eligible for Medicaid but who have uncertain incomes, it’s generally a good idea to enroll through the exchange during open enrollment. If you do, and your income ends up being in the subsidy-eligible range for the year, you can notify the exchange of your new income and start claiming premium tax credits at that point. And when you reconcile your premium tax credit on your tax return, you’ll be able to claim the tax credit for each month of the year, since you were enrolled in an exchange plan throughout the year. Prior to 2020, there was no provision to allow people enrolled in plans outside of the exchange to switch to an on-exchange plan if their income changed mid-year and made them newly-eligible for premium tax credits, since an income change was only considered a qualifying event if the enrollee already had a plan in the exchange. But that changed as of 2020, as off-exchange enrollees now have the option to switch to the exchange mid-year if their income changes to a subsidy-eligible level. In that case, however, the subsidies would only be available on a pro-rated basis for the months that the person ends up having on-exchange coverage, rather than for the entire year (regardless of income, subsidies cannot be used to offset premiums for plans purchased outside the exchange). And it’s also important to remember that switching to an on-exchange plan mid-year will generally result in your deductible and out-of-pocket costs resetting to $0 at that point. If you’re switching to the on-exchange version of your off-exchange plan, the carrier might agree to transfer your accumulated out-of-pocket costs, but they are not required to do so. Some people who don’t qualify for premium subsidies prefer to shop outside the exchange because they want to purchase a silver plan and are able to get lower-priced silver plans outside the exchange. That continues to be true in many states, so this is a decision that enrollees have to make on a case-by-case basis. You can switch from Medicaid to a private plan and vice versa if your income fluctuates during the year You can switch between Medicaid and a subsidized plan if your income fluctuates, as long as you’re in a state that has expanded Medicaid. Medicaid enrollment is available year-round, and conversely, loss of Medicaid is a qualifying event that allows you to enroll in an exchange plan. Efforts have been made to minimize this “churning” in order to provide more stability for low-income insureds, but the estimate was that half of adults with incomes below 200% of the poverty level would switch between subsidized private insurance and Medicaid at least once a year due to income fluctuations. During the COVID pandemic, Medicaid eligibility redeterminations have been suspended. This continues through the end of the COVID public health emergency. As a result, states have not been removing people from Medicaid, even if their income increased to a non-eligible level. Routine eligibility redeterminations will resume after the COVID public health emergency ends.
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On the other hand, if your subsidy is underpaid throughout the year (ie, your income ends up lower than you projected, but still subsidy-eligible), you’ll be able to claim the rest of your premium tax credit when you file your tax return. If you receive an advance premium tax credit and then your income actually ends up being under 100% of the poverty level, you do not have to pay back the subsidy; this is confirmed in the Form 8962 instructions (line 6, on page 8, under “Estimated household income at least 100% of the federal poverty line”; here’s what 100% of the poverty level translates to in terms of dollars). But note that IRS Publication 974 does include a caveat, clarifying that the exception from the subsidy repayment rules for people with income under the poverty level “does not apply if, with intentional or reckless disregard for the facts, you provide incorrect information to the Marketplace for the year of coverage. You provide information with intentional disregard for the facts if you know that the information provided is inaccurate. You provide information with a reckless disregard for the facts if you make little or no effort to determine whether the information provided is accurate and your lack of effort to provide accurate information is substantially different from what a reasonable person would do under the circumstances.” In other words, you cannot intentionally misrepresent your income as being over the poverty level and then avoid having to repay the subsidy that was paid on your behalf throughout the year. But it’s unclear how well that particular provision is able to be enforced. In implementing the (now defunct) 2019 rule that prevented a person from receiving a premium subsidy based on an attested income above the poverty level when government data show otherwise, HHS noted that “Particularly to the extent funds paid for APTC (for tax filers whose income ends up being under the poverty level) cannot be recouped through the tax reconciliation process, it is important to ensure these funds are not paid out inappropriately in the first instance.” On the other hand, if you pay full price for a private plan – expecting your income to increase – and then your income ends up being below 100% (139% in states that have expanded Medicaid) of the poverty level, there is no tax credit available to assist you, even if you’re in a state that has expanded Medicaid. You have to enroll in Medicaid when you’re eligible – there’s no provision for switching to Medicaid retroactively and recouping premiums you paid for private coverage. So make sure you’re enrolled in a “metal” exchange plan during open enrollment (with premium subsidies if your projected income at that point makes you eligible) – or Medicaid if you’re eligible – and then keep the exchange updated during the year if your circumstances change. Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.
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