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Premium Assistance & Cost Sharing Reductions

Are individuals enrolled in retiree coverage eligible for the premium tax credit?

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Individuals enrolled in an employer-sponsored plan, including retiree coverage, are not eligible for the premium tax credit, even if the employer plan is unaffordable or fails to provide minimum value. The individual may be eligible for a premium tax credit for another family member who enrolls in Marketplace coverage and is not enrolled in the employer plan

The individual may be eligible for the premium tax credit if the individual declines the coverage from a former employer, such as COBRA or retiree coverage, even if it is affordable and provides minimum value.

Can an individual get the premium tax credit subsidy if the individual is eligible for COBRA?

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If the individual declines the COBRA coverage, even if it is affordable and provides minimum value, the individual may be eligible for the premium tax credit.

 

What if income lowers and the person doesn’t notify Covered California?

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If a tax filing unit’s income changes, and the filer should have received a higher amount, this additional credit would be included in their tax refund for the year. On the other hand, any excess amount that was overpaid in premium credits would have to be repaid to the federal government as a tax payment. However, there are limits on the excess amount to be repaid for those below 400% of the Federal Poverty Level.

Consumers are required to self-report changes in income to Covered California within 30 calendar days from the date of the change.  Consumers can report these changes via the online application or by calling the Covered California Service Center.

What is the limit on repayment of excess premium assistance?

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If an individual’s income changes, any excess amount that was overpaid in premium assistance would have to be repaid to the federal government as a tax payment. However, there are limits on the excess amounts to repaid and is as follows:

If Household Income Is: The Dollar Limit for Single Filers Is: The Dollar Limit for Joint Filers Is:
Less than 200% of the FPL $300 $600
At Least 200% of the FPL but less than 300% of the FPL $750 $1,500
At Least 300% of the FPL but less than 400% of the FPL $1,250 $2,500

 

Are premium tax credits and cost sharing reductions available outside the exchange?

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No.

“In some areas, premium rates are so low that the premium assistance tops out below 400 percent of FPL.” Explain please.

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Premium tax credits are calculated based on an individual’s “fair share” of premium. “Fair share” increases with income, and ranges from 3.5% of income at 139% of FPL to 9.5% of income at 400% of FPL.

Individuals will pay their “fair share” of premium, or the total premium, whichever is less.

If someone has a grandfathered plan, can they cancel that plan to get premium assistance with Covered CA?

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Yes, an individual can cancel their Grandfathered plan and enroll in Covered California. Subsidy eligibility will be determined by the regular criteria, and not related to any previous enrollment in an (individual) Grandfathered plan.

If an employee is eligible for an employer-sponsored plan, but declines coverage, can the employee and family enroll in a Covered California plan? Can they receive subsidies?

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The employee and family can enroll in a Covered California plan at full cost. If the employer-sponsored coverage is of minimum value, and is affordable to the employee, then the employee will not be eligible for subsidies. If the dependents are eligible for the employer coverage, and the coverage is of minimum value, and is affordable to the employee, then the dependents will not be eligible for subsidies.

Is there a table which breaks out income levels for subsidies instead of using the Covered California calculator?

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Yes. You can find a table of eligibility by FPL here:

https://www.claremontcompanies.com/wp-content/uploads/2013/10/Job-Aid_Program-Eligibility-by-FPL_8.13.17_FINAL.pdf

Can the wife qualify for premium assistance if the husband earns $100k but is on Medicare and her income is $24k?

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Firstly, Covered California recommends that individuals with mixed eligibility situations such as this use the online calculator at www.coveredca.com.

The husband is ineligible for Covered California if he is on Medicare.

In order for either a husband or wife to be eligible for subsidies, they must file taxes jointly. The wife’s eligibility for subsidies will be determined by the household income (MAGI).