Can’t afford health insurance but don’t qualify for Medicaid?

Are you having trouble affording health insurance? You’re not alone. Many people struggle to cover the cost of their plan without help – especially people who make too much income to qualify for Medicaid. As the public health emergency ends and Medicaid eligibility requirements change, many are trying to find coverage that fits their budget.

The good news is there are resources out there to help people pay for their plan. We’ll help you figure out where to find them and determine if you’re eligible.

If you can’t afford insurance, you have the option of going without, but we don’t recommend it. Health insurance can help you save on care, protect you in case of an emergency and may include added perks (like discounts for fitness clubs) and benefits (like wellness programs to help you feel your best). In some states, having insurance is legally required – as of 2023, residents of California, Massachusetts, New Jersey, Rhode Island, Vermont and Washington D.C. could face tax penalties if they are uninsured. Regardless of whether you live in a state where insurance is required, there are options available to help make health insurance affordable.

How to get help paying for your health insurance

The Affordable Care Act (ACA) created government subsidies to help low- and middle-income people pay for health insurance. They help offset the cost of monthly plan premiums, coinsurance, copays and deductibles. There are two types of subsidies – premium tax credits and cost-sharing. You can apply for these health insurance subsidies through your state’s health insurance marketplace.

Health insurance tax credits

Premium tax credits pay a portion of your monthly health insurance premiums. The credit can be sent directly to your health plan each month, or you can claim it on your federal tax return (if you can pay full price for your plan in the exchange).

To determine if you’re eligible for a tax credit, the government will look at the size of your household, overall income and average cost of health coverage in your area.

Health insurance subsidy

A cost-sharing subsidy can help offset out-of-pocket health care expenses like deductibles, coinsurance and copays. For example, if your health plan has a $50 copay for an office visit, your cost-sharing subsidy might decrease that copay to $30. It also limits your out-of-pocket maximum.

To qualify for a health insurance subsidy, you must meet the income requirements and be enrolled in an ACA-compliant plan in the silver category. People who are eligible for the cost-sharing subsidy almost always qualify for premium tax credits. But not everyone who is eligible for premium tax credits is eligible for the cost-sharing subsidy.

How to qualify for subsidized health care

To be considered for subsidized health care, the government will look at your income in comparison to the federal poverty line (FPL). Requirements vary by program, but people who qualify typically have a household income between 100% and 400% of the FPL.

To calculate the percentage of your income in relation to the FPL you should:

• Determine your modified adjusted gross income
• Divide by the poverty guideline income level for your household size
• Multiply that number by 100
• Add a percentage sign

For example: If your income is $35,000 and you are in a three-person household, divide $35,000 by $24,860 (100 percent of FPL for a family of three in 2023) which equals about 1.41. Multiply by 100 to get the percentage. Your income level is 141% of the federal poverty guidelines, or 141% FPL.

In 2021, The American Rescue Plan Act (ARPA) expanded eligibility for health insurance subsidies and tax credits to make health insurance even more affordable. So if you weren’t able to afford coverage in the past, it could be possible now.

You may not qualify for a health insurance subsidy if you can get coverage elsewhere, have a household income that’s outside the qualification limits or for a variety of other reasons. But you can consider other ways to shop for insurance or virtual care options until you can afford more comprehensive coverage.

Browse your state’s marketplace

When it comes to shopping for health insurance, your first stop should be your state’s health insurance marketplace. Some states will have their own marketplace, like Minnesota’s MNsure. Other states, like Wisconsin, don’t have their own and go directly through the federal exchange at HealthCare.gov.

Don’t lose hope if you didn’t qualify in the past. The Affordable Care Act (also known as Obamacare) has evolved over the years to make health care more accessible for low-income households.

Shop insurance companies directly

When you shop for off-exchange health insurance rather than a marketplace, you may find plans offered directly by an insurer that aren’t available on state or federal marketplaces.

Consider telemedicine

You don’t always need to see a doctor in person to get the care you need. A Virtuwell visit is never more than $59. And if they can’t treat you there is no charge.

Have more questions about your individual health insurance options?

Our experts will help you find a health plan you’re confident in – no matter your situation.