How the ACA Health Insurance Subsidy Works

The Affordable Care Act (ACA) includes government subsidies to help people pay their health insurance costs. One of these health insurance subsidies is the premium tax credit which helps pay your monthly health insurance premiums. This article will explain how these subsidies work, who is eligible, and how they'll affect your tax return.

Premium subsidies are available in the health insurance marketplace/exchange in every state. The American Rescue Plan made the subsidies larger and more widely available for 2021 and 2022. And the Inflation Reduction Act extended those subsidy enhancements through 2025.

Most exchange enrollees qualify for subsidies. As of early 2023, there were about 15.7 million people enrolled in health plans through the exchanges/marketplaces nationwide, and about 14.3 million of them were receiving premium subsidies.

(Note that the other type of ACA subsidy, cost-sharing reductions, also continue to be available to eligible enrollees in every state, despite the fact that the Trump administration eliminated funding for them in the fall of 2017. Insurers simply add the cost of these subsidies to premiums instead, which are largely offset by correspondingly larger premium subsidies, making coverage even more affordable for many enrollees.)

This article explains what you need to know about the health insurance premium subsidy for people who buy their own coverage, including how to qualify for the subsidy, use it, and reconcile it on your tax return.

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 anywhere else, you can’t get the premium tax credit.

(Note that depending on the state where you live, you may be able to use an approved enhanced direct enrollment entity to enroll through the exchange, instead of enrolling directly in the exchange. This option is not available in every state, but enrolling directly through the exchange is available in every state.)

If you're uncomfortable applying on your own for health insurance through your state's exchange, you can get help from a licensed health insurance broker who is certified by the exchange, or from a Navigator or enrollment assister. These folks can help you enroll in a plan and complete the financial eligibility verification process to determine whether you're eligible for a subsidy. There is no cost for their services.

If you're in a state that uses HealthCare.gov as its exchange (most states do), you can use this tool to find an exchange-certified broker who can help you pick a health plan. If you already know what plan you want and just need someone to help you with the enrollment process, there are also navigators and enrollment counselors who can assist you, and you can use the same tool to find them.

If you're in a state that runs its own exchange, the exchange website will have a tool that will help you find enrollment assisters in your area. If you're not sure whether your state has its own exchange platform or not, you can start at HealthCare.gov and select your state; if your state does not use HealthCare.gov, they will point you to the correct website.

Will I Qualify for the Subsidy?

Prior to 2021, the rule was that households earning between 100% and 400% of the federal poverty level could qualify for the premium tax credit health insurance subsidy (the lower threshold is above 138% of the poverty level if you're in a state that has expanded Medicaid, as Medicaid coverage is available below that level; the majority of the states have expanded Medicaid). Federal poverty level (FPL) changes every year, and is based on your income and family size.

You can look up this year’s FPL here, and this article explains how income is calculated under the ACA. Keep in mind that for subsidy eligibility determination, the prior year's FPL numbers are compared with your projected income for the year you're getting coverage (so for 2024 health coverage, they'll compare your projected 2024 income with the 2023 FPL numbers).

The American Rescue Plan (ARP) and Inflation Reduction Act have changed the rules for 2021 through 2025: Instead of capping subsidy eligibility at an income of 400% of the poverty level, the ARP ensures that households with income above that level will not have to pay more than 8.5% of their income for the benchmark plan.

If the benchmark plan costs more than 8.5% of income, a subsidy is available, regardless of how high the income is. So the ARP and Inflation Reduction Act account for the fact that full-price health insurance premiums are much higher in some areas than in other areas, and are higher for older enrollees. Subsidies are available through at least 2025 to smooth out these discrepancies.

But if a household earning more than 400% of the poverty level can pay full price for the benchmark plan and it won't cost more than 8.5% of their income, there is still no subsidy available.

And again, the prior year's FPL figures are used to determine premium subsidy amounts. For example, if you apply for a 2024 Obamacare plan during open enrollment in the fall of 2023, OR if you apply for 2024 coverage in mid-2024 using a special enrollment period triggered by a qualifying life event, you'll use the FPL figures from 2023.

That's because open enrollment for 2024 coverage will be conducted in late 2023 and very early 2024, before the 2024 FPL numbers will become available.

For consistency, the same FPL numbers are used for the full coverage year, so they continue to be used for people who enroll during special enrollment periods, even after the new poverty level numbers have been published.

The new FPL numbers come out each year in mid-late January, but they aren't used for subsidy eligibility determinations until open enrollment begins again in November, for coverage effective the following year (they do start to be used within just a few months, however, to determine eligibility for Medicaid and CHIP).

Although there is no upper income limit for subsidy eligibility between 2021 and 2025, there is still a lower limit:

• In states that have expanded Medicaid (most of the country), Medicaid is available to adults under age 65 with a household income of up to 138% of FPL. Subsidy eligibility begins above that level.
• In states that have not expanded Medicaid, subsidies are available if income is at least 100% of the poverty level.

For reference, here are the 2024 income levels that correlate with those percentages of the 2023 FPL (the limits are higher in Alaska and Hawaii):

• Household of one: 138% of FPL is $20,120, and 100% of FPL is $14,580
• Household of four: 138% of FPL is $41,400, and 100% of FPL is $30,000

Premium subsidies are not available if household income is below the poverty level, unless a person is a recent immigrant. In ten states that have not expanded Medicaid, this results in a coverage gap for many low-income residents: They are not eligible for Medicaid because their state hasn't accepted Medicaid expansion, and they are not eligible for premium subsidies because their income is below the poverty level.

(Note that North Carolina will expand Medicaid in December 2023, which will reduce the number of states with a coverage gap to nine.)

But even if you meet the income qualifications, you may still be ineligible for a subsidy. That would be the case if:

• The second-lowest-cost silver plan in your area is considered affordable at your income level, even without a subsidy. But this phenomenon is much less common now than it was in the early days of ACA implementation. Average premiums have increased significantly since then, making premium subsidies necessary for most enrollees. This is especially true now that the American Rescue Plan and Inflation Reduction Act have reduced the percentage of income that people have to pay for the benchmark plan between 2021 and 2025.
• You're eligible for an affordable, minimum-value plan from an employer (yours or your spouse's). For 2024, "affordable" means that the coverage costs no more than 8.39% of household income. Note that the family glitch has been fixed as of 2023, which means that an employee's family members can potentially be eligible for subsidies in the exchange (if employer-sponsored health coverage would be unaffordable for the family), even if the employee has access to affordable self-only coverage.
• You're eligible for premium-free Medicare Part A, or for Medicaid/CHIP coverage.
• You're incarcerated, or not living in the U.S. legally.

How Much Will My Subsidy Be?

The exchange will calculate your premium subsidy amount for you. But if you want to understand how that calculation works, you have to know two things:

1. Your expected contribution toward the cost of your health insurance
   You can look this up in the table below, near the bottom of this page. Note that it used to change each year. But Section 9661 of the American Rescue Plan created new set percentages for 2021 and 2022, and those were extended through 2025 by the Inflation Reduction Act.
2. The cost of your benchmark health plan
   Your benchmark plan is the second-lowest-cost silver-tiered health plan available in your area. Your health insurance exchange can tell you which plan this is and how much it costs (the cost of the benchmark plan varies from one person to another, even in the same location, based on the person's age). You can also locate it on your own by simply getting quotes for yourself on the exchange, sorting them by price (that's typically the default), and then looking at the second-lowest-cost silver plan.

See an example of how to calculate your monthly costs and your subsidy amount at the bottom of the page. You can also use the Kaiser Family Foundation's calculator. But know that the exchange will do all of these calculations for you—the example is just to help you understand how it all works, but you don't have to do these calculations to get your premium tax credit!

Can I Save Money By Buying a Cheaper Plan, 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 bronze, silver, gold, or platinum plan listed on your health insurance exchange.

You may not use your subsidy to buy a catastrophic plan, though, and premium subsidies are never available if you shop outside the exchange (if you shop outside the exchange, you won't be able to go back and claim the premium subsidy tax credit when you file your taxes either).

If you choose a plan that costs more than the benchmark plan, you’ll pay the difference between the cost of the benchmark plan and the cost of your more expensive plan—in addition to 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 it costs less than your subsidy, you won’t have to pay anything for health insurance. However, you won’t get the excess subsidy back.

People in many areas have access to bronze or even gold plans with no premiums (or sometimes with just a $1/month premium)—after the application of their premium tax credits—due to the way the cost of cost-sharing reductions has been added to silver plan premiums starting in 2018. And as a result of the American Rescue Plan and Inflation Reduction Act, far more people are eligible for premium-free plans at the bronze, gold, and even silver levels.

If you’re trying to save money by choosing a plan with a lower actuarial value, (like a bronze plan instead of a silver plan), be aware that you’ll likely have higher cost-sharing (deductible, coinsurance, and/or copays) when you use your health insurance.

But in another oddity that began in 2018, gold plans in some areas are actually less expensive than silver plans (since the cost of cost-sharing reductions has been added to silver plan premiums), despite the fact that the gold plans have higher actuarial value.

However, if you have an income below 250% of FPL—and especially if it's below 200% of FPL—consider choosing a silver-tier plan, as the actuarial value of that plan will be even better than a gold plan, or in some cases, even better than a platinum plan.

That's because there’s a different subsidy that lowers copays, coinsurance, and deductibles for people with incomes below 250% of the poverty level. Eligible people can use it in addition to the premium tax credit subsidy, and it's automatically built into the plan for people with eligible income levels. However, it’s only available to people who choose a silver-tier plan.

The American Rescue Plan and Inflation Reduction Act make it easier for lower-income enrollees to afford a silver plan, by enhancing the premium subsidies and thus bringing down the after-subsidy cost of these plans. For people with income up to 150% of the poverty level, the after-subsidy premium is $0 for the lowest-cost and second-lowest-cost silver plan until at least the end of 2025.

(Note that people who are subsidy-eligible and whose income is up to 150% of the poverty level can enroll in coverage at any time of the year, due to the fact that they can get the benchmark plan without having to pay a premium. This will continue as long as the benchmark plan is premium-free for these enrollees, so at least through 2025.)

Do I Have to Wait Until I File My Taxes to Get the Subsidy Since It's a Tax Credit?

You don’t have to wait until you file your taxes. Most enrollees get the premium tax credit in advance, paid directly to their insurance company each month. 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.

This option is only available if you enrolled in a plan through the exchange. If you buy your plan directly from an insurance company, you won't be eligible for up-front premium subsidies, and you also won't be able to claim the subsidy on your tax return.

If your income is so low that you don’t have to file taxes, you can still get the subsidy, although you won't be eligible for a subsidy if your income is below the poverty level (or at or below 138% of the poverty level in states that have expanded Medicaid).

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.

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. Your health insurer applies 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 for health insurance 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.

It will come out even in the end, but if your cash flow is relatively low, you might find the advance payment option more user-friendly. 

What Else Do I Need To Know About How the Health Insurance Subsidy Works?

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. Failing to do this could result in getting too big or too small a subsidy, and having to make significant adjustments to the subsidy amount at tax time.

And if you become eligible for an employer's plan (considered affordable and comprehensive) mid-year, it's essential to understand that you can no longer receive a premium subsidy while you're eligible for the employer's plan. If you don't notify the exchange and the subsidy continues to be paid on your behalf, you'll have to repay it (when you file your taxes) for any month when you were eligible for the employer's plan.

Example of How To Calculate the Health Insurance Subsidy

Keep in mind that the exchange will do all of these calculations for you. But if you're curious about how they come up with your subsidy amount, or if you want to double-check that your subsidy is correct, here's what you need to know:

1. Figure out how your income compares to the FPL (remember you're using projected income for the year the health plan will be in effect, but the FPL numbers for the year before that).
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 expected ACA-specific modified adjusted gross income of $25,000 in 2024. FPL for 2023 (used for 2024 coverage) is $14,580 for a single individual.

1. To figure out how Tom’s income compares to FPL, use:
   income ÷ FPL x 100.
   $25,000 ÷ $14,580 x 100 = 171.
   Tom’s income is 171% of FPL.
2. Using the table below, Tom is expected to contribute between 0% and 2% of his income. We have to determine what percentage of the way along that spectrum he is with an income of 171% of FPL. We do that by taking 171-150 = 21, and then dividing that by 50 (the total difference between 150% and 200% of FPL). 21/50 = 0.42, or 42%.
3. Next, we determine what number is 42% of the way between 0 and 2. This one is pretty easy, since we're starting at 0. We just need to take 2 and multiply it by 0.42, then add the result to 0. We end up with 0.84.
4. Tom is expected to pay 0.84% of his income for the benchmark silver plan.
5. To calculate how much Tom is expected to contribute, use this equation:
   0.84 ÷ 100 x income= Tom's expected contribution.
   0.84 ÷ 100 x $25,000 = $210.
   Tom is expected to contribute $210 for the year, or $17.50 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.
6. Let's say the benchmark health plan on 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 - $210 = $3,690.
   Tom’s premium tax credit subsidy will be $3,690 per year or $307.50 per month.

If Tom chooses the benchmark plan, or another $325 per month plan, he’ll pay about $17.50 per month for his health insurance. If he chooses a plan costing $425 per month, he’ll pay about $117.50 per month for his coverage. But if he chooses a plan costing about $3077 per month or less, he'll pay nothing, since his premium subsidy will cover the full amount of the premium.

Your Expected Contribution Toward Your 2024 Health Insurance Premiums (updated under American Rescue Plan and Inflation Reduction Act)

Summary

The Affordable Care Act (ACA) created premium tax credits, also known as premium subsidies, that help to cover some of the cost of health coverage that people purchase. The majority of exchange enrollees qualify for these subsidies. The subsidies ensure that enrollees don't pay more than 8.5% of their household income for their coverage—and sometimes quite a bit less. On the lower end of the income scale, enrollees qualify for subsidies that are large enough to cover the full cost of their health plan. Since the subsidies are tax credits, they do have to be reconciled on the enrollee's federal tax return.

A Word From Verywell

If you don't have health insurance, it's well worth your while to check and see if you'd be eligible for a premium subsidy (here's a subsidy calculator you can use). You might be pleasantly surprised to find out how large the subsidies can be, and how little you might have to pay in after-subsidy premiums. Open enrollment runs from November 1 to January 15 in most states, and is your opportunity to take advantage of these subsidies and get coverage for yourself and your family.