In this Beyond the Basics webinar presented by the Center on Budget and Policy Priorities on September 16, 2021, Tara Straw, Director of Health Insurance and Marketplace Policy, provides an in-depth review of eligibility rules for premium tax credits—including how offers of employer-sponsored insurance can affect eligibility—as well as how premium tax credits are calculated.

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Premium Tax Credit Eligibility

• What is the Premium Tax Credit (PTC)?
• PTC Eligibility Requirements
• Income Requirements
• Eligible Tax Filing Status
• Exceptions to Joint Filing Requirement for PTC
• Special Rule for Certain Immigrants
• Types of Minimum Essential Coverage (MEC)

Eligibility for Employer-Sponsored Insurance (ESI)

• Eligibility for ESI
• Affordability of ESI
• Minimum Value of ESI
• Health Reimbursement Arrangement (HRA)
• Reconciliation of Overlapping Coverage

Calculation of the Premium Tax Credit

• How is the PTC Calculated?
• Expected Premium Contribution
• Benchmark Plans
• Factors that Affect the Cost of Benchmark Plans & Premiums
• Reporting Changes that Impact PTC
• PTC Repayment Caps

Additional Resources

Yearly Income Guidelines and Thresholds

Employer Coverage & Premium Tax Credit Eligibility Guide

Minimum Essential Coverage Reference Chart

Health Care Assister’s Guide to Tax Rules

In this Beyond the Basics webinar presented on September 14, 2021, Tara Straw, Director of Health Insurance and Marketplace Policy, and Jen Wagner, Director of Medicaid Eligibility and Enrollment, detail the rules used to determine household size and explain what counts as income when determining eligibility for premium tax credits and Medicaid.

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Why Household Size & Income Matter

• ACA Eligibility Overview
• How the federal poverty line (FPL) effects expected premium contribution

Why Tax Filing Status Matters

• Overview of tax filing statuses
• Marital status and premium tax credits (PTC)
• Head of household questions
• Exceptions to the joint filing requirement for PTC

Determining Households for Premium Tax Credits

• Types of tax dependents

Determining Households for MAGI Medicaid

• Medicaid household rules

What Counts as Income for PTC and Medicaid

• Modified Adjusted Gross Income (MAGI)
• Rules for counting income
• Tips for counting self-employment income

Annual vs Monthly Income Counting

• Entering monthly income
• Entering annual income

Examples of Combining Household & Income Rules to Determine Eligibility

Additional Resources

Yearly Income Guidelines and Thresholds

Medicaid Household Rules

Determining Households for Medicaid and CHIP

Determining Households for PTC

Income Definitions for Marketplace and Medicaid Coverage

Self-Employment Income Estimator Tool

Health Care Assister’s Guide to Tax Rules

Eligibility for subsidies in the Marketplace is determined in part by using specific percentages and thresholds that are indexed and change each enrollment year.

In addition, people who received advance premium tax credits (APTC) in the prior enrollment year will need to complete a tax return for that year and will need to use percentages and thresholds applicable to that tax year.

This reference guide lists all the indexed guidelines and thresholds that change each enrollment year.

Coverage Year 2022 / Tax Year 2021

September 2021

↓ View reference guide (PDF)

Coverage Year 2021 / Tax Year 2020

March 2021 (updated to reflect changes to premium tax credits in the American Rescue Plan)

↓ View reference guide (PDF)

Coverage Year 2020 / Tax Year 2019

October 2019

↓ View reference guide (PDF)

Coverage Year 2019 / Tax Year 2018

June 2018

↓ View reference guide (PDF)

Coverage Year 2018 / Tax Year 2017

November 2017

↓ View reference guide (PDF)

Updated September 2021

The Marketplace open enrollment period is the regular time each year when people can newly enroll in a qualified health plan or change to a different plan through the Marketplace. But certain events that occur during the year can trigger a special enrollment period (SEP), when a person may be able to newly enroll in a Marketplace plan or change to a different plan.

This SEP Reference Chart is a tool for those who are helping people enroll in health coverage through a special enrollment period. It focuses on the circumstances that trigger a SEP in the Marketplace, who can trigger a SEP, and the effective date of coverage once a health plan is selected.

Amid the COVID-19 pandemic, and the economic crisis that came about as a result, this abbreviated SEP Reference Chart provides a list of the most common SEPs used during this time.

People who missed their SEP window due to COVID-19 can still enroll in Marketplace coverage using the “FEMA SEP.” This fact sheet explains what the FEMA SEP is and how it works.

Additional Resources

Webinar: Special Enrollment Periods | View webinar

Minimum Essential Coverage Reference Chart | View chart