FAQ

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Lawmakers who drafted the Affordable Care Act knew that enrolling healthy individuals was crucial to balance out the costs of sicker, higher-cost individuals. To achieve this balance, the law included the shared responsibility provision, also known as the individual mandate, which required individuals without minimum essential coverage to pay a tax penalty, unless they were exempt. However, the tax penalty was eliminated under the Tax Cuts and Jobs Act of 2017, leaving the mandate in effect without enforcement. The California v. Texas lawsuit challenges the constitutionality of the mandate without the penalty and seeks to overturn the entire ACA. Some states, including DC, Massachusetts, New Jersey, California, and Rhode Island, have implemented their own individual mandates and penalties for non-compliance. Vermont and Maryland enacted mandates but did not impose any penalties for non-compliance. Call Cygnus Health at (800) 294-4777 to speak with a licensed agent and learn about any potential penalties for being uninsured.

Health insurance plans sold through the health insurance marketplaces and off-exchange in the individual and small group markets must include coverage for physical therapy as per the essential health benefits (EHB) requirements of the Affordable Care Act (ACA). However, chiropractic care is not specified in the EHB rules and its inclusion in individual and small group plans is determined by the state’s benchmark plan and/or state-mandated benefits. Chiropractic care is typically limited to a set number of visits per year, and coverage is based on medical necessity. Rehabilitative and habilitative services are specifically listed in the EHB and must be covered by all ACA-compliant individual and small group plans, but there are typically limits on the total number of visits the plan will cover each year. Insurers cannot impose dollar limits on coverage for essential health benefits but can impose limits on the number of visits. Limits on physical therapy, if included in the benchmark plan, can also be imposed by insurers. State regulations and benchmark plans vary, so it is essential to ask questions to understand the coverage of a health plan. Unsure if your visits to the chiropractor or physical therapist are covered under the Affordable Care Act? Call Cygnus Health at (800) 294-4777 to speak with a licensed agent and find out.

The Affordable Care Act (ACA) mandates health plans to cover a range of preventive care benefits at no cost to patients. These benefits fall under three categories: wide-ranging preventive care, preventive care for women and children, and vaccines for children and adults. In March 2023, a federal judge overturned some aspects of ACA’s preventive services coverage requirement. However, the Department of Justice has appealed the ruling. The ruling does not affect HRSA and ACIP recommendations regarding preventive care for children and women, including contraception, and vaccines for children and adults, but it does affect USPSTF recommendations made since March 23, 2010. The ruling also overturned the requirement that PrEP HIV prevention drugs be covered by the plaintiffs’ health plans. The judge ruled that requiring health plans to cover services recommended by the USPSTF violates the Appointments Clause of the U.S. Constitution and that requiring health plans to cover PrEP is a violation of the plaintiffs’ religious freedom. Even if the court ruling is upheld, health plans would continue to have to cover some cancer screenings at no cost to their enrollees. The ruling is not expected to cause immediate widespread coverage losses for preventive care. Are you curious about the preventive health services coverage mandate under the ACA? Call Cygnus Health at (800) 294-4777 to speak with a licensed agent and get answers to your questions.

If you are not eligible for subsidies, you can purchase health insurance outside the exchange, except for DC. However, if you buy off-exchange, you will not be able to claim tax credits. Thanks to the American Rescue Plan, premium subsidies are now available to more people in 2021 and 2022, and even those who earn more than 400% of the poverty level can be eligible for subsidies. On-exchange and off-exchange plans are all compliant with the ACA, and carriers must pool their individual market plans in a state in a single risk pool for rate-setting purposes. If you are not subsidy-eligible at the beginning of the year, you may want to consider purchasing a plan outside the exchange. However, if your subsidy eligibility changes later in the year, you will need to switch to an on-exchange plan to receive the subsidy. Qualifying events trigger special enrollment periods for switching plans mid-year, but deductibles and out-of-pocket maximums may reset to $0. It’s also important to note that there are health plans sold outside the exchange that are not regulated by the ACA, such as short-term health insurance, limited benefit policies, accident supplements, critical illness plans, and health care sharing ministries. Ensure that the plan you choose is individual major medical coverage and not excepted benefits. Even if you earn too much to qualify for a subsidy, there are benefits to buying insurance through an exchange. Call Cygnus Health at (800) 294-4777 to speak with a licensed agent and learn why.

Yes, Social Security income is considered as part of the calculation to determine eligibility for subsidies. To determine your modified adjusted gross income (MAGI) for subsidy and Medicaid eligibility, start with your adjusted gross income (AGI) from your tax return and add three things if applicable: non-taxable Social Security income, foreign-earned income (and housing expenses if living abroad), and tax-exempt interest income. If you have Social Security income that is not included in your AGI on your tax return, you need to add it to your AGI to calculate the total household income used for subsidy determination. If you’re enrolling in a plan through the exchange and have questions about Social Security being considered income, call Cygnus Health at (800) 294-4777 to speak with a licensed agent.

If you are a legal resident in the United States, but not a citizen and your job doesn’t offer health insurance, you can still get coverage under the Affordable Care Act (ACA). The ACA offers coverage to lawfully present U.S. residents, and you may be eligible for financial help to lower the cost of your coverage and out-of-pocket costs.

If you don’t have an option for coverage through your employer, you may be eligible for a subsidy to help pay your premiums and reduce out-of-pocket costs for your policy. Subsidies are based on your household income. There is normally an upper income limit of 400% of the poverty level above which premium subsidies are not available. However, the American Rescue Plan has eliminated this limit for 2021 and 2022.

Lawfully present recent immigrants with incomes below the poverty level can get premium subsidies, even though premium subsidies aren’t normally available in that case. Most legal permanent residents are not eligible for Medicaid until they have been in the U.S. for five years. Thus, lawmakers included a provision in the ACA that allows recent immigrants with household incomes under 100% of the poverty level to receive exchange subsidies at the level they would if their income was equal to 100% of the poverty level.

However, about 2.2 million Americans have ended up in the Medicaid coverage gap because some states have not accepted federal funding to expand their Medicaid programs. People with income below the poverty level in these states are not eligible for premium subsidies, and they’re not eligible for Medicaid either, unless they meet the strict eligibility guidelines that the states impose. Unfortunately, there is no provision in the ACA to grant premium subsidies to impoverished Americans who aren’t eligible for Medicaid because their states won’t expand Medicaid. If you’re a legal U.S. resident but not a citizen and your job doesn’t offer health benefits, the ACA may be able to help. Call Cygnus Health at (800) 294-4777 to speak with a licensed agent and find out more.

Premium subsidy eligibility is determined by income requirements, and it is not tied to the number of hours you work. The eligibility for a premium subsidy starts at either 100% or 139% of the poverty level, depending on whether your state has expanded Medicaid. Normally, there is an upper cap on subsidy eligibility at 400% of the poverty level, but the American Rescue Plan has eliminated that upper income limit for 2021 and 2022. The law has also made premium subsidies larger for people who were already subsidy-eligible and has reduced the percentage of income that people are expected to pay for the benchmark plan. You can use a subsidy calculator to estimate your premium subsidy.

In most states, Medicaid is available to adults with income up to 138% of the poverty level due to Medicaid expansion. If you are eligible for Medicaid, you are not eligible for premium subsidies, so subsidy eligibility for adults starts at 139% of the poverty level in most states. For 2021 coverage, Medicaid eligibility in most states extends to $17,774 for a single adult, which means premium subsidy eligibility starts above that level. However, in states that have not expanded Medicaid, the lower income threshold for a premium subsidy in 2021 is $12,760. If you are in a state that has not expanded Medicaid and your income is below the poverty level, you are likely not eligible for Medicaid or premium subsidies and are stuck in the coverage gap. Recent immigrants can qualify for subsidies with income below the poverty level since they are ineligible for Medicaid. Wondering if you’re eligible for a premium subsidy to help you buy insurance while working part-time? Call Cygnus Health at (800) 294-4777 to speak with a licensed agent and get answers.

Various forms are used by exchanges, employers, and health insurance companies to report health insurance coverage to the IRS. Additionally, there are two health insurance-related forms that some tax filers need to complete when they file their return. Most Americans do not have to do anything on their tax returns about health insurance. Form 1095-A is the proof of health insurance coverage during the year, and it is used to reconcile premium subsidies on tax returns through Form 8962. It includes details such as the cost of the plan, the cost of the second lowest cost Silver plan in the area, any premium subsidy that was paid on the filer’s behalf, the months of coverage, and the household members who were covered under the plan. Form 1095-A is essential if the filer received a premium subsidy or paid the full price for the coverage through the exchange and wants to claim the premium subsidy on their tax return. Form 1095-B shows who was covered and which months they had coverage, issued by health insurance companies or other entities, for plans that are not on-exchange individual/family coverage. Form 1095-C is sent out by large employers with 50 or more full-time equivalent employees who are required to offer health insurance coverage under the ACA. Need help finding your 1095 tax form? Call Cygnus Health at (800) 294-4777 to speak with a licensed agent who can guide you.

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