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Buying Health Coverage on HealthCare.gov

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    Buying Health Coverage on HealthCare.gov

    Is it Right for You?

    Almost everyone should be able to get health coverage. The question is, which plan is right for you and your family?

    This page looks at options you may have, such as getting public health coverage, like NC Medicaid or Medicare, or getting health insurance through your job. If these options are available to you, they are better choices than getting an individual plan, because they cost less.

    Then, we’ll look at why you might choose to get an individual plan. We’ll focus on getting a plan through HealthCare.gov, the easiest place for most people to shop for an individual plan and the only place where you can get help from the government to pay for your private insurance (if you qualify).

    Other options that are probably better

    The best way to figure out if buying an individual health plan is the right option for you is to sign up for HealthCare.gov and complete an application. HealthCare.gov will tell you what health coverage options are open to you. If you have any of the options below, don’t pay for private insurance through HealthCare.gov.

    Public health coverage

    There are several public health care programs that help people with disabilities, seniors, children, and anybody who has low income. If you or a family member qualifies for these programs, they are usually your best option and you will not be allowed to purchase a government-subsidized individual plan through HealthCare.gov.

    NC Medicaid

    NC Medicaid is a major government-funded health program that helps people with low income. You may qualify for NC Medicaid if you are in one of these situations:

    Health Coverage Income Limits for Your Family
    NC Medicaid and immigrants
    • Undocumented immigrants do not qualify for full NC Medicaid coverage, though they may qualify for NC Medicaid coverage for emergencies.
    • Some non-citizens who have legal immigration status in the United States do not qualify for full NC Medicaid coverage. However, they may qualify for private coverage subsidized by the government.
    • Immigrants who have been legal residents for five years or longer or meet specific noncitizen requirements qualify for all of the same programs that citizens can get.

    Medicare

    Medicare is a health insurance program run by the federal government that covers seniors (65 years old or older) and people with disabilities. In order to get health coverage through Medicare, you must have worked for a certain number of years and met other eligibility rules, detailed in DB101’s Medicare article.

    If you get Medicare, you cannot get government help with paying for an individual health plan. You could still buy an individual plan through HealthCare.gov, but you would have to pay the entire premium yourself. Also, if you want more coverage than what Medicare offers, it is probably better for you to look into whether you might also qualify for NC Medicaid based on having a disability or being elderly, which would help pay your Medicare premiums and other Medicare expenses. Another option is to look at getting a Medicare supplement policy (sometimes called a Medigap policy) or signing up for a Medicare Advantage plan. These options are not available through HealthCare.gov.

    The bottom line about public health coverage options

    If you or members of your family are eligible for a public program, that public program is probably your best option. If you think you might be eligible for a public program, see the other articles in DB101’s Health Care Coverage section.

    Group coverage through your employer

    To get private health insurance, a monthly payment called a premium must be paid every month. Many employers offer to pay part, or all, of this monthly premium as a job benefit for you as an employee, your children until they turn 26 years old, and your spouse.

    If your employer offers you health coverage that would cost you, for your policy alone, less than 9.02% of your income and that coverage meets a certain benefits level, you won't qualify for government help via tax subsidies to reduce the premium on an individual plan. That means that if you decide to purchase an individual health plan, you will have to pay the full premium, which will probably be more than you would pay if you used the coverage provided by your employer. To learn more about employer-sponsored health coverage, read DB101’s article about it.

    Note: Before 2023, the spouse or children of an employee would not qualify for subsidies on HealthCare.gov if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." Learn more about affordability rules for family members and how it affects eligibility for tax credits on HealthCare.gov.

    NC Medicaid and employer-sponsored coverage

    If your family makes 138% of the Federal Poverty Guidelines or less, you can choose to get NC Medicaid through HealthCare.gov even if your employer offers coverage.

    Note: If you work and have been determined disabled according to Social Security Administration (SSA) rules, you may be able to get Health Coverage for Workers with Disabilities (HCWD). Talk to a benefits planner to learn more about HCWD.

    The bottom line about group coverage through your employer

    If your employer provides health coverage, you should not get an individual plan for yourself or your family. In most cases, the group coverage will be your best option.

    However, if your income is at or below 138% of the Federal Poverty Guidelines or if you have a disability, it could be a better choice for you to get NC Medicaid for your entire family.

    When an Individual Plan is Your Best Option

    You should get an individual plan through HealthCare.gov if you cannot get health coverage from:

    • Your job
    • Your spouse’s job
    • Your parent’s job
    • NC Medicaid, or
    • Medicare.

    If you cannot get health coverage from any of the above options, the government may help you pay your monthly premium through a tax credit. If your family’s income is at or below 250% of FPG ($37,650 for an individual; $78,000 for a family of four), the government will also help you get a plan that has lower copayments and other expenses. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

    When HealthCare.gov looks at your income, they will count most types of earned and unearned income you have. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.

    Later, we’ll go into more detail about how much you have to pay.

    Health Coverage Income Limits for Your Family
    Example

    Clarence and Samuel have two small children and live in a two-bedroom apartment. Clarence is 37 years old and makes $55,000 per year as a freelance writer, while Samuel is 42 years old and makes $45,000 per year running his own small bakery, so their combined income is $100,000 per year. Since both of them are self-employed, they cannot get employer-provided coverage and their combined income is 321% of the Federal Poverty Guidelines (FPG), meaning that they and their children don’t qualify for NC Medicaid.

    They went to HealthCare.gov and found a plan that would cover their entire family. Since the government would help pay for their premium, this plan would cost them less than $700 a month. It wasn’t totally free, but it was a pretty good deal and they were satisfied.

    Learn more

    Employer-Sponsored Health Coverage

    Your job, your parent's job, or your spouse's job may offer private health coverage as a benefit.

    Health Coverage for Workers with Disabilities (HCWD)

    HCWD is NC Medicaid for people with disabilities who work.