Subsidies and Tax Credits

Federal premium tax credits, CSR plans, state subsidies, and medicaid eligibility

Calculation and eligibility assessment for most federal and state subsidy programs are always performed if the individual/family's household income and size are passed in the request parameters.

• Household Income household_income - the total household income of the quoted applicant(s), similar to what they'd include on their tax return.

• Household Size household_size - the number of applicant(s) applying for coverage; the primary applicant and their dependent(s).

If these two parameters are passed in the Medical Plan Search endpoint request, Ideon's rating engine will automatically evaluate the below subsidy programs.

Federal Premium Tax Credit (PTC)

The Federal Premium Tax Credit (IRS overview) is a refundable tax credit designed to help families within certain income ranges purchase affordable health insurance through the exchange. Ideon follows ACA, IRS, and CMS guidelines to calculate the estimated PTC given the applicant(s) household income and size. At a high level, this calculation is based on the household's income as a percentage of the federal poverty level and income requirements as related to the second-lowest cost Silver plan available in the applicant's marketplace. The results of this calculation are returned in a few parameters in the quote response.

• Estimated PTC meta.premium_tax_credit - the estimated PTC amount the applicant(s) are eligible for.

• Subsidized Premium plans[].premium_subsidized - the full-price premium for the plan minus the Estimated PTC; in other words, what the applicant(s) would pay after PTC assistance.

A couple important notes on the calculations and parameters used:

• Both the number of applicants included for quoting as well as the household_size specified impact the estimated PTC calculation. There is no validation that requires these numbers are equal. The number of applicants determines the cost of the second-lowest cost Silver plan available. The household_size is used to determine the federal poverty line income for the quote.

• If the applicant(s) are eligible for Medicaid or CHIP, together or individually (in the case of a child being eligible for CHIP), they will be considered ineligible for PTC, and vice versa. In the case that the applicant(s) are eligible for Medicaid or CHIP, a PTC of 0 is returned.

  • If a child qualifies for CHIP, but the remaining applicant(s) are not eligible for Medicaid, the child will not be included in the subsequent calculation for PTC.

Marketplace Plans with Dental and Vision Benefits

Some marketplace plans include adult dental and/or vision coverage. In Ideon's dataset, this coverage is typically indicated in the Plan Name: "Standard Expanded Bronze + Vision + Adult Dental", for example. Additionally, if available, it is commonly listed in the "Other Covered Services" section at the end of the SBC document. Given the lack of consistent and comprehensive coverage and premium information for plans of this nature, Ideon does not support premium breakdowns for the separate medical, dental, and vision rate values associated with plans of this nature. Instead, the plan inventory will typically include both base medical plans as well as iterations with adult dental and/or vision coverage, if available.

It is important to note that this can have an impact on the subsidized premium displayed that incorporates the Federal PTC, as detailed above. The Federal PTC program only covers medical premiums; adult dental and vision is not included. If the premium for a plan that includes adult dental and/or vision coverage is less than the PTC subsidy the applicant is eligible for, the applicant would still be required to pay the portion of premium that is attributed to the dental or vision coverage. In these cases, since Ideon does not support the separated medical, dental, and vision rates, Ideon will display a $0 premium_subsidized amount. In reality, the applicant would be required to pay the dental and vision rate portion, typically around $10-20.

Cost-Share Reduction Plans (CSR)

Eligibility for Cost-Share Reduction programs (CMS overview) is primarily evaluated on household income. These programs offer improved deductibles, MOOPs, and benefit cost-shares for Silver plans. Eligibility for a Silver plan's CSR variants is based on the household's income as a percentage of the federal poverty level. Ideon's rating engine automatically returns the best CSR plan variants available to the applicant(s) being quoted if household income and size are provided.

The typical CSR plan variants are -04, -05, and -06, which are appended to the base plan's HIOS ID. For example, a base Silver plan for a high-income individual might have a HIOS ID of 27603CA1150036. Its CSR variants - offering progressively improved benefits for lower income ranges - are 27603CA1150036-04, 27603CA1150036-05, and 27603CA1150036-06. These CSR plan variants will all have the same premiums, but offer improved benefits for lower-income applicants.

Medicaid and CHIP Eligibility

Medicaid and CHIP (CMS overview) are joint federal and state programs that provide health coverage for low-income individuals under age 65. Ideon follows federal and state eligibility rules to evaluate whether or not applicants may be eligible for health insurance through Medicaid or CHIP programs. Eligibility is based on income as a percentage of the federal poverty level and varies by state. If one or more applicants on a quote are eligible for Medicaid and/or CHIP, the meta.eligible_for_chip_medicaid field will be returned as true. In these cases, all available ACA plans will still be quoted.

State Subsidy Programs

Some states offer additional state-funded subsidy programs that act in addition to or alongside ACA PTC and Medicaid/CHIP programs. Ideon's rating engine supports the state subsidy programs in California, New Mexico, Vermont, and New Jersey. These subsidy programs can function similarly to CSRs or as an additional credit/refund amount like the PTC. Subsidy programs that expand CSR access don't require additional fields; the availability of CSR variants is incorporated into the set of quoted plans.

The state subsidy programs that offer additional credits are surfaced in the meta.state_subsidy nullable object in the response. If this field is null, no state subsidy programs supported by Ideon apply to the quote. If the object is included with the eligible, static_amount, and program_name fields, then the specified state subsidy program was evaluated for eligibility.

California

The California state subsidy program is rolled into the CSR variants available in the state. CA offers increased FPL income cap for subsidy eligibility and reduced ratio tiers for eligibility to enhanced CSR plans.

New Mexico

New Mexico offers state subsidies through the SOPA (State Out-of-Pocket Assistance) program, which acts similar to CSRs. Ideon's rating engine evaluates eligibility based on income as a percentage of FPL and returns applicable plans. SOPA program plans can be variants of both Silver and Gold plans and are labeled in the plan name with "Turquoise". Additionally, -90, -95, and -99 are appended to HIOS IDs for the range of variant types.

Vermont

Vermont offers both expanded eligibility for CSR plans as well as a state-funded premium subsidy (the "Vermont Premium Assistance" program). At a high level, the latter subsidy amounts to roughly 1.5% of income if the applicant(s) are within the eligibility threshold for income as a percentage of FPL.

New Jersey

New Jersey offers additional subsidy credits based on income range under the "New Jersey Health Plan Savings" program. The subsidy is a static, tiered amount based on ranges of income as a percentage of the FPL. This amount is doubled if one or more dependents are included with an individual applicant.