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ACA Health Insurance Eligibility Requirements

November 2, 2023

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For those looking for health insurance, understanding the eligibility requirements for the Affordable Care Act (ACA) can feel like navigating a complex maze. But, with the current state of our healthcare system, it's essential to know whether or not you qualify. That's why we've put together this guide. We'll help you determine if you're eligible for ACA health insurance and help you compare coverage for ACA health insurance marketplace plans.


Who is eligible for health insurance under ACA?

There are certain eligibility criteria for healthcare coverage under the Affordable Care Act (Obamacare). Here are some eligibility requirements for health coverage plans:

  1. Individuals at varying income levels: The ACA was created to make healthcare more affordable and accessible to individuals regardless of their income. It allows individuals from various income levels to sign up for health insurance coverage.
  2. Household income between 100% and 400% of the Federal Poverty Level (FPL): If your household income falls within this range, you may qualify for a premium tax credit or special subsidies. These financial assistance programs help reduce the cost of health insurance premiums, making coverage more affordable for individuals and families.
  3. Gender and pre-existing conditions: Under the ACA insurers cannot refuse coverage or charge higher premiums based on gender or pre-existing conditions.
  4. No lifetime or annual coverage limits: Before Obamacare, some insurance plans imposed lifetime or annual limits on coverage, resulting in individuals exhausting their benefits if they had a serious or chronic health condition. Under the ACA, such limits are prohibited, ensuring individuals can access the necessary health care without worrying about reaching coverage limits.
  5. Young adults up to age 26: One of the popular provisions they added when they determined who is eligible for health insurance under ACA allows young adults to remain on their family's health insurance plan until they reach the age of 26. This provision provides a valuable opportunity for young adults who may not have access to employer-sponsored insurance or cannot afford individual coverage.

Who is not eligible for ACA insurance?

Most people who live in the U.S. are qualified to receive health care under Obamacare; however, certain exceptions apply. This includes:

  • Those who do not reside in the United States
  • Those who have been incarcerated
  • Non-citizens or nationals without a legal presence in the States
  • Medicare holders will be ineligible for coverage through this program

If you are not a U.S. citizen or national but legally live in the United States, you may be eligible for Obamacare if your immigration status is one of these:

  • Refugee
  • Asyless
  • Battered spouse, child, and parent
  • Non-immigrant status, including those with worker visas and student visas
  • Temporary protected status (TPS)
  • Victim of trafficking, with a spouse, child, sibling, or parent
  • Lawful permanent resident or green card holder
  • Cuban or Haitian entrant
  • Immigrant paroled into the U.S.
  • Immigrants granted conditional entrance before 1980
  • Those granted withholding of deportation or withholding of removal, under the Convention against Torture and Other Cruel, Inhuman, or Degrading Treatment, or Punishment (CAT), or immigration laws
  • Deferred enforced departure (DED)
  • Deferred action status, excluding Deferred Action for Childhood Arrivals (DACA)
  • Lawful temporary resident
  • People who are eligible for exemptions from the U.S. Department of Homeland Security's administrative order include members of a federally recognized Indian tribe and American Indians born in Canada
  • An American Samoa resident

In the next section, we'll cover more on who is eligible for health insurance under ACA based on income.

Is the ACA based on income?

The amount you spend on insurance and the savings you receive will depend on your household income. The federal poverty level is used to determine if you're eligible for a subsidy using your Modified Adjusted Gross Income (MAGI) to decide on the amount of savings you're eligible for. MAGI is not a number that appears on any of the documents filed with the IRS.

If your household income is between 100% and 400% of the federal poverty level, you're likely eligible for a premium subsidy. If your income is lower than the federal poverty level, you may not be eligible for discounts on an ACA plan or Medicaid based solely on financial status. Learn more about your eligibility for certain health plans.

What are the four levels of coverage offered under the Affordable Care Act?

Obamacare health plans are divided into four tiers: bronze, silver, gold, and platinum. The cost of premiums for each tier differs. The lower the premium is on a plan, the more you'll be expected to pay when receiving care.

These categories, often referred to as "metal plans," help individuals compare different insurance options based on their expected costs and benefits. The four categories are:

  1. Bronze: Bronze plans have the lowest premiums but higher out-of-pocket costs. A bronze plan covers about 60% of healthcare costs, while the remaining 40% is the individual's responsibility through deductibles, copayments, and coinsurance. Bronze plans are suitable for individuals who want the lowest monthly premiums but are willing to pay more when they receive medical care.
  2. Silver: Silver plans provide a moderate level of coverage and are designed to balance monthly premiums and out-of-pocket costs. A silver plan covers roughly 70% of healthcare costs, whereas the individual is responsible for the remaining 30%.
  3. Gold: Gold plans have higher monthly premiums but lower out-of-pocket costs compared to bronze and silver plans. On average, a gold plan covers about 80% of healthcare costs, and the individual is only responsible for the remaining 20%. Gold plans may be suitable for those who anticipate higher health care needs and are willing to pay higher premiums for more comprehensive coverage and lower out-of-pocket costs.
  4. Platinum: Platinum plans have the highest monthly premiums but the lowest out-of-pocket costs. A platinum plan covers about 90% of healthcare costs, leaving the individual responsible for the remaining 10%. Platinum plans are ideal for individuals who anticipate frequent medical care and are willing to pay higher premiums for comprehensive coverage with minimal out-of-pocket expenses.

All ACA plans must provide a minimum set of health benefits, including preventive care, emergency services, prescription drugs, maternity care, mental health services, and more, regardless of their chosen health plan category. Remember, you can use our comparison tool to compare plans.

Our powerful tool lets you compare plans side by side, so you can find a health insurance plan that provides financial security and peace of mind for you and your family. To learn more about who is eligible for health insurance under ACA, call us today to speak to a licensed insurance agent at 1-800-314-5594 (open Monday - Friday from 8 a.m. to 8 p.m. EST).

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