Important Coverage Information
Estimating Your Income
When applying for health coverage through the Marketplace, you must estimate your total household income for the entire year you are seeking coverage, not just what you earned last year. Household income includes earnings for you, your spouse and any dependents you plan to claim on your federal tax return if the dependent makes more than $15,750. A common starting point is your Adjusted Gross Income (AGI) from your most recent federal tax return, which can be found on Form 1040, Line 11. You may also need to include certain types of non-taxable income such as tax-exempt Social Security benefits, tax-exempt foreign income, or tax-exempt interest. Your estimate should reflect any expected changes during the year, such as job changes, raises, changes in work hours, self-employment income, retirement withdrawals, or changes in household size. If your income is difficult to predict, you should make your best reasonable estimate based on past earnings and expected trends. It is important to update your Marketplace application if your income or household changes during the year, as this may affect your eligibility for financial assistance.
Reporting Income Changes
Your Marketplace subsidy (also known as Advance Premium Tax Credit) is based on the estimated household income you report for the coverage year. Because this income is only an estimate at the time of enrollment, it is very important to update your Marketplace application if your income changes during the year. ​Marketplace income is an estimate for the entire calendar year, not just what you have earned so far. If your income changes later in the year, it is still important to update the application so the Marketplace can adjust your subsidy accordingly. ​We recommend reviewing your estimated household income at least once or twice during the year to make sure it is still accurate. If your income has changed, our office can assist with updating your Marketplace application to help keep your subsidy amount aligned with your expected annual income. Household income includes earnings for you, your spouse and any dependents you plan to claim on your federal tax return if the dependent makes more than $15,750. A common starting point is your Adjusted Gross Income (AGI) from your most recent federal tax return, which can be found on Form 1040, Line 11. You may also need to include certain types of non-taxable income such as tax-exempt Social Security benefits, tax-exempt foreign income, or tax-exempt interest. Your estimate should reflect any expected changes during the year, such as job changes, raises, changes in work hours, self-employment income, retirement withdrawals, or changes in household size. If your income is difficult to predict, you should make your best reasonable estimate based on past earnings and expected trends. It is important to update your Marketplace application if your income or household changes during the year, as this may affect your eligibility for financial assistance.
Household Changes
When enrolled in Marketplace coverage, it is important to report any household changes as soon as they occur. Your household includes you, your spouse if married, and any dependents you plan to claim on your federal tax return. Changes such as marriage, divorce, birth or adoption, a dependent moving in or out, or changes in who you claim on your taxes can impact your eligibility and the amount of financial assistance you receive. Because subsidies are based on both household size and income, failing to report these changes may result in incorrect subsidy amounts and could require repayment when filing your federal taxes. Keeping your household information up to date helps ensure your coverage and financial assistance remain accurate.
Estimated Quote Costs
Any premium amount provided prior to enrollment is an estimate only based on the information available at the time the quote is prepared. Final premium amounts are determined by the Marketplace and the insurance carrier once the application is submitted and processed. Premiums may change based on updated income, household size, age, location, eligibility determinations, or carrier calculations. Quote estimates are not a guarantee of final cost or coverage.
Employer Coverage
If you have access to health insurance through an employer, you may not qualify for financial assistance (subsidies) through the Marketplace if the employer-sponsored plan is considered affordable and meets minimum value standards. Even if you choose not to enroll in your employer’s plan, simply having access to qualifying job-based coverage can make you ineligible for Marketplace subsidies. If you currently have a Marketplace plan and later receive an offer of employer coverage, it is important to update your Marketplace application. This may affect your eligibility for financial assistance, even if you have not yet enrolled in the employer plan. In some cases, you may still choose to enroll in a Marketplace plan. However, you would likely be responsible for the full premium without financial assistance. Additionally, individuals who are eligible for or enrolled in other qualifying coverage, such as Medicaid, TRICARE, or VA health benefits, are generally not eligible to receive Marketplace subsidies. You cannot receive financial assistance through the Marketplace while also having access to these types of coverage.
Filing Taxes Jointly
If you are married and enrolled in Marketplace coverage with financial assistance, you are required to file your federal taxes as Married Filing Jointly in order to remain eligible for subsidies. The Marketplace calculates financial assistance based on total household income, which includes both spouses. If married individuals choose to file separately, they are typically not eligible for Advance Premium Tax Credits (APTC) and may be required to repay any subsidy received when filing their taxes. Because of this, it is important to understand how your tax filing status can impact your eligibility for financial assistance and overall cost of coverage.
Prescription Coverage
Prescription drug coverage is determined by the insurance carrier’s formulary and may change at any time. Coverage, medication tier placement, prior authorization requirements, and copay amounts can vary based on factors including the specific plan selected, pharmacy pricing, and the member’s medical diagnosis. Not all medications are covered, and coverage is not guaranteed. We recommend confirming prescription coverage, requirements, and estimated costs directly with the insurance carrier and pharmacy prior to filling any medication.
Provider Networks
Provider network participation is subject to change and is determined by the insurance carrier and the provider’s contractual agreements. Network information provided is not a comprehensive list and is not guaranteed. A provider’s network status may change at any time. We recommend confirming participation directly with your provider and the insurance carrier prior to scheduling services to ensure care will be considered in-network.
Payment Responsibility Notice
Policyholders are responsible for ensuring that all premium payments are made on time and in full directly to the insurance carrier. Coverage is not considered active until the required premium has been successfully processed by the carrier. Failure to make timely payments may result in loss of coverage, cancellation, or termination of the policy. Davis and Davis Financial Solutions is not responsible for missed, delayed, or declined payments, or for any resulting loss of coverage due to nonpayment. Additionally, in some cases a third party (such as an employer, family member, or other individual) may choose to pay premiums on behalf of the policyholder. Please note that the policyholder remains the owner of the insurance policy, and only the policyholder (or an authorized representative) may request changes to the policy, including cancellations, terminations, or billing updates. Davis and Davis Financial Solutions cannot make changes, stop payments, or terminate coverage at the request of a third-party payer without explicit authorization from the policyholder. If a third party chooses to stop making payments, it remains the policyholder’s responsibility to ensure premiums are paid to avoid cancellation or termination. Any payment disputes or arrangements between the policyholder and a third party must be handled directly between those parties.
Form 1095-A & Tax Filing
If you had a Marketplace plan and received a premium tax credit (subsidy), you will receive Form 1095-A from the Marketplace. This form is typically mailed by mid-February and may also be available in your Marketplace account as early as mid-January. You will need this form to complete your federal tax return. If you received a subsidy, you are required to file a federal tax return, even if you would not normally be required to file based on your income. If needed, our office can assist in providing a digital copy of your 1095-A. However, the official form is issued directly by the Marketplace. Please note that Davis and Davis Financial Solutions does not provide tax advice. For assistance with filing your taxes or completing forms related to your 1095-A, we recommend consulting a licensed tax professional.