ACA Marketplace Plan Basic Outline

ACA Marketplace Enrollment Information

Premium Tax Credit and Cost-Sharing Reductions (Subsidy)

Qualify for lower health coverage costs

ACA Coverage Requirements

The Affordable Care Act of 2010 (ACA) requires insurers to provide coverage for an Essential Health Benefits (EHB) package in 10 benefit categories, effective the first plan year on or after January 1, 2014. These requirements apply to all fully insured health plans offered in the Individual and Small Group insured markets (both inside and outside of Exchanges). EHB requirements do not apply to ASO plans (regardless of group size), fully insured Large Group plans or any grandfathered plans.

The Act defines certain categories of benefits as "Essential Health Benefits." The categories of essential health benefits are:

Ambulatory patient services - Emergency services - Hospitalization - Maternity and newborn care - Mental health and substance use disorder services, including behavioral health treatment - Prescription drugs - Rehabilitative and habilitative services and devices - Laboratory services - Preventive and wellness services and chronic disease management - Pediatric services, including oral and vision care

What’s In Scope and Out of Scope
The requirement to add Essential Health Benefits applies to all non-grandfathered Individual plans and non-grandfathered, fully insured Small Group plans inside and outside of Exchanges.

The following plans are not required to add Essential Health Benefits:
Large Group fully insured
Self-funded (ASO) plans
Grandfathered plans

Exceptions to maintaining minimum essential benefits
January 1, 2014, all U.S. residents are required to maintain minimum essential coverage unless the individual falls into one of the exceptions. More information, visit

Open enrollment period - Nov 1 to Dec 15

Important dates for enrollment
• Nov 1: First day you can enroll in an insurance plan. Coverage will start on Jan 1
• Dec 15: Last day to enroll in or change plans for new coverage to start Jan 1
• Jan 1: Coverage starts for those who enroll or change plans by Dec 15

If you don’t enroll in a plan by December 15, you can’t enroll in a ACA health insurance plan for the following calendar year unless you qualify for a Special Enrollment Period (qualifying life event*). It's important to remember if you don't buy health insurance coverage you will be responsible for 100% of the cost of your medical care. 

*Qualifying Life Event: A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of some qualifying life events are moving to a new state or loss of job coverage.

Individual Mandate
2018 and earlierFederal law requires most people to have qualifying health insurance or pay a penalty. Learn about whether you're exempt from the mandate, the penalty if you don't have coverage, and types of qualifying health coverageSource: TDI

If you don’t have coverage in 2018, you’ll pay the higher of these two amounts:

2.5% of your yearly household income
$695 per person ($347.50 per child under 18)

The fee is sometimes called the "penalty," "fine," "individual responsibility payment," or "individual mandate."

Special enrollment period 

After open enrollment ends on December 15, you won't be able to get health coverage through the Marketplace until the next annual enrollment period, unless you have a qualifying life event*. It's important to remember if you don't buy health insurance coverage you will be responsible for 100% of the cost of your medical care. 

*Qualifying Life Event
A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. The following life events will generally qualify you for a special enrollment period.

Examples of some qualifying life events:

  • Marriage or divorce
  • Having a baby, adopting a child, or placing a child for adoption or foster care
  • Moving your residence, gaining citizenship, leaving incarceration
  • Losing other health coverage due to losing job-based coverage, COBRA expiration, aging off a parent’s plan, losing eligibility for Medicaid or CHIP, and similar circumstances.
    - Important: Voluntarily ending coverage doesn’t qualify you for a Special Enrollment Period. Neither does losing coverage that doesn’t qualify as minimum essential coverage.
  • For people already enrolled in Marketplace coverage: Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions.
  • Gaining status as member of a federally recognized tribe or shareholder in an Alaska Native Claims Settlement Act (ANCSA) Corporation. Members of federally recognized Indian tribes can enroll in or change plans once a month throughout the year.
  • You may also qualify for a Special Enrollment Period if you had a complex situation related to applying for Marketplace coverage.

Your options outside Open Enrollment

For tax years 2014-2018 only
Penalty - Fee you pay if you don't have health coverage

See if you qualify for Health coverage exemptions

Renewing members

  • The Marketplace redetermines subsidy eligibility for all on-Exchange members every year. 
  • Renewing members must keep your income and household information up to date at
  • These updates may change the coverage or savings you are eligible for in the Marketplace.
  • Be sure you use the same user name and password as last year to log into your Marketplace account on

ACA Health Insurance Basics

Coverage is based on “metal levels” – Bronze, Silver, Gold, or Platinum and Catastrophic.

Each metal level having an actuarial value of 60%, 70%, 80%, and 90%.

  • Bronze: Your health plan pays 60% on average. You pay about 40%
  • Silver: Your health plan pays 70% on average. You pay about 30% *
  • Gold: Your health plan pays 80% on average. You pay about 20%
  • Platinum: Your health plan pays 90% on average. You pay about 10%
  • Catastrophic: Catastrophic coverage plans pay less than 60% of the total average cost of care on average. They’re available only to people who are under 30 years old or have a hardship exemption.

Plans cover “essential” benefits and certain preventive services, covered at 100%. Some plans may cover more than the minimum essential health benefits. This additional coverage will be reflected in the plan’s actuarial value.

Plans could vary in the way co-pays, coinsurance, and deductibles are applied, which means that two plans at the same metal level could cost individuals with the plans in different ways.

 * Silver plan coverage varies based on your cost sharing reduction. All of the ACA subsidies are based on the cost of the second-lowest silver plan, meaning the second least costly plan with an actuarial value of 70% - cost-sharing subsidies may only apply to silver level plans – likely making this the most popular level of plan.

Individuals enrolled through the Marketplace may be eligible for a Advance Premium Tax Credit and Cost-sharing reductions.

Advance Premium Tax Credit:
When you buy health insurance coverage in the Marketplace, you may be able to get a premium tax credit that lowers what you pay in monthly premiums. This will depend on your household size and income.

Cost-Sharing Reductions:
When you apply for coverage in the Marketplace, you'll learn if you’re eligible for savings on out-of-pocket costs. Whether you qualify to save on out-of-pocket costs will depend on your household size and income.

- - Out-of-pocket savings apply only to Silver plans.

When you enroll in coverage through the Marketplace, you may be able to save money on out-of-pocket costs, including deductibles, copayments, and coinsurance. This is sometimes called “cost-sharing reductions.” The Marketplace cost-sharing reduction lowers the amount you have to pay for out-of-pocket costs like deductibles, coinsurance, and copayments.

How to estimate your income

For most people, you can use your household’s adjusted gross income for this estimate. If you know your adjusted gross income this year, use that and take into account any changes you expect next year.

Estimate your income for the people in your household, based on what you think you’ll receive next year:

Wages - Salaries - Tips - Net income from any self-employment or business - Unemployment compensation - Social Security payments

In addition, Rental income - Interest - Dividends - Capital gains - Annuities - Alimony - and some Retirement and Pensions

When you fill out the Marketplace application, a number called “modified adjusted gross income” (MAGI) will be used to determine your eligibility for lower costs on Marketplace coverage, and for Medicaid and the Children’s Health Insurance Program (CHIP). Generally, your household’s adjusted gross income plus any tax-exempt Social Security, interest, and foreign income you have. This will be determined when you apply through the Marketplace or your state agency. For Medicaid, it also matters if you’ve had a change in household income since your last tax return. When you apply you’ll need to tell them your household income now and estimate the amount for next year earnings, taking into account changes that you know about. Source:

When you use the Health Insurance Marketplace, you may be eligible for premium tax credits and other savings on a private insurance plan.

Save money in the Marketplace 3 ways (based on income and family size):
1. Lower costs on your monthly premiums
2. Qualify for lower out-of-pocket costs for copayments, coinsurance, and deductibles.
3. Qualify for free or low-cost coverage through Medicaid* or the Children's Health Insurance Program CHIP**.
When you fill out your Health Insurance Marketplace application, you'll find out how much you can save. Most people who apply will qualify for lower costs of some kind. Source:

*Medicaid in Texas - Each state has different rules about who qualifies for Medicaid. You can find out whether you can get Medicaid in Texas. Learn more about Medicaid in Texas.
**CHIP in Texas - Texas CHIP covers uninsured children in families with moderate incomes that are too high to qualify for Medicaid. You can find out whether your children qualify for Texas   CHIP. Learn more about Texas CHIP.

Are you eligible

When Open Enrollment starts, fill out an application to see how much you and your family are eligible for if you qualify. Gather this information before you apply:

Savings depend on income and tax household size

If your income falls within the following ranges, you'll generally qualify for a premium tax credit. The lower your income is within these ranges, the bigger your credit.

- Will you save on health coverage? Run a quote to determine if you're eligible.

Need help? Contact us, we're happy to help! 

“Affordable” plans and the percent standard

Starting with the 2019 calendar year, there's no penalty for not having coverage. Note: This change will take effect with 2019 taxes, which are filed in early 2020. See details.

2019 savings depend on income
& tax houshold size

           $12,140  to   $48,560 for individuals
           $16,460  to   $65,840 for a family of 2
           $20,780  to   $83,120 for a family of 3
           $25,100  to $100,400 for a family of 4
           $29,420  to $117,680 for a family of 5

Runquote to see if your eligible for a PTC

2018 income range:

$12,060 to $48,240 for individuals
$16,240 to $64,960 for a family of 2
$20,420 to $81,680 for a family of 3
$24,600 to $98,400 for a family of 4
$28,780 to $115,120 for a family of 5

2017 income range:

$11,880 to $47,520 for individuals
$16,020 to $64,080 for a family of 2
$20,160 to $80,640 for a family of 3
$24,230 to $97,200 for a family of 4
$28,440 to $113,760 for a family of 5

2016 income range:

$11,770 to $$47,080 for individuals
$15,900 to $63,720 for a family of 2
$20,090 to $80,360 for a family of 3
$24,250 to $97,000 for a family of 4

The MINIMUM VALUE standard

The Transitional Reinsurance Program - Reinsurance Contributions


Section 1341 of the Affordable Care Act established a transitional reinsurance program to stabilize premiums in the individual market inside and outside of the Marketplaces. The transitional reinsurance program will collect contributions from contributing entities to fund reinsurance payments to issuers of non-grandfathered reinsurance-eligible individual market plans, the administrative costs of operating the reinsurance program, and the General Fund of the U.S. Treasury for the 2014, 2015, and 2016 benefit years. Source and more

What are Health coverage exemptions

  • Exemptions are tied to the tax year during which you didn’t have health coverage, not the year you fill out the exemptions application. Health coverage exemptions for the current tax year. You’ll claim these exemptions with your tax return in the following year.   Source: - Read more on all exemption areas


Who doesn't have to pay the fee

Contact directly to determine if you have to pay a fee or not based on your circumstance.

A health plan meets the minimum value standard if it pays at least 60% of the total cost of medical services for a standard population and offers substantial coverage of hospital and doctor services. In other words, in most cases a plan that meets minimum value will cover 60% of covered medical costs. You’d pay 40%. Most job-based plans meet the minimum value standard
. Learn more.

If you qualify and apply to receive a Subsidy, provide the following agent information on your application:

- Insurance Agent: Susan Speciale
- National Produce Number (NPN): 1635661

A job-based health plan is considered "affordable" if your share of the monthly premiums for the lowest-cost self-only coverage that meets the minimum value standard is less than a "percent" of your household income.

You may pay more than "percent" of your household income on monthly premiums if you’re enrolled in your employer’s spouse or family coverage. But affordability is determined only by the amount you’d pay for self-only coverage. Learn more.