When you complete your Marketplace health coverage application, the system will ask if you want to apply for financial assistance. If you answer yes, the Marketplace will ask for information about your household income and any health coverage that has been offered to you. It is important to include income for all household members and any health coverage that has been offered, even if you have chosen not to enroll in that coverage.
The Marketplace will first assess if you are eligible for financial help. To be eligible, you must not be offered any other health coverage that is considered affordable by Marketplace rules, or that meets the minimum value standard. You must also meet eligibility criteria to shop through the Marketplace, including that you live in Oregon, are lawfully present in the United States – except Deferred Action for Childhood Arrivals (DACA) status – and are not currently incarcerated.
If you are eligible to shop through the Marketplace and apply for financial help, the system will use your household income and where you live to determine how much financial help you may qualify for. Assistance is available on a sliding scale – the higher your income, the less assistance you will qualify for. There are two types of financial assistance: cost-sharing reductions and premium tax credits.
Cost-sharing reductions (CSRs)
Cost-sharing reductions lower the out-of-pocket costs for health care that you are expected to pay. Plans may reduce your deductible, co-pays and co-insurance, or the out-of-pocket maximum.
Cost-sharing reductions are available to people who earn up to 250 percent of the federal poverty level and can be used only on Silver level plans. On Silver level plans, health insurance companies typically cover at least 70 percent of the cost of covered health benefits. Cost-sharing reductions reduce these out-of-pocket costs for enrollees. They are available in three steps:
|
Household income level |
Insurance company pays |
Enrollee pays |
| 100% to 150% of the FPL* | 94% | 6%
|
| 151% to 200% of the FPL | 87% | 13% |
| 201% to 250% of the FPL | 73%
| 27%
|
There are two important notes for cost-sharing reduction eligibility:
- In Oregon, people who earn less than 138 percent of the federal poverty level generally qualify for the Oregon Health Plan (OHP). If you do not qualify for OHP benefits due to immigration status, you may qualify for financial help through the Marketplace.
- American Indians and Alaska natives may qualify for additional cost-sharing reductions and take advantage of these savings on any Bronze, Silver, or Gold plan through the Marketplace.
Premium tax credits
Premium tax credits are savings you can get to reduce the cost of monthly premiums. If you qualify, you can use some, all, or none of the tax credits you qualify for throughout the year to reduce the amount you pay for your monthly premium.
When calculating premium tax credit eligibility, the Marketplace will first determine what monthly insurance premium amount is considered affordable for you. The Marketplace will then compare this amount to the premium of the second-lowest cost Silver plan where you live. If that premium is more than what is considered affordable to you, you will qualify for premium tax credits. The premium tax credits are designed to make the second-lowest cost Silver plan in your area affordable for you. You can use your premium tax credits on any plan through the Marketplace. Bronze level plans have lower premium costs, but typically have higher out-of-pocket costs. Silver level plans have moderate premiums and moderate out-of-pocket costs. Gold level plans have higher premiums but lower out-of-pocket costs. It is important to remember that cost-sharing reductions are available only on Silver level plans, even though you may use premium tax credits on any plan level.
Understanding financial help
This blog is intended to give you an overview of financial help through the Marketplace, but you won't be an expert. We do not expect you to calculate your eligibility on your own. You can get a quick peek into your potential financial assistance eligibility and the effect on plan costs available to you at OregonHealthCare.gov/WindowShop. And if you are completely confused or overwhelmed, don't worry! Health coverage experts are available to help you for free. Find local help at OregonHealthCare.gov/GetHelp.