[First published in 2018. Completely rewritten in 2021.]
When you enroll in health insurance through the ACA exchange (healthcare.gov or the one run by your state), you have two choices with regard to your income: (a) Give an estimate of your annual income and submit documentation to support your estimate; or (b) Skip the income estimate and pay the full premium.
If you choose (a), and the exchange accepts your documentation, you may qualify for a premium subsidy upfront. When you ask the government to pay part of your premium, they have to check to make sure you are eligible for the money. If you choose (b), you don’t have to submit any documentation when you enroll. They just let you in when you’re paying the full freight. If you qualify for a premium subsidy based on your actual income when the year is over, you’ll get it as a tax credit when you file your tax return.
I always chose (b) before because when I paid the full premium to the insurance company, I could use the expected tax credit to reduce my taxes. Paying more to the insurance company and paying less to the government became a wash. It was a lot easier to pay the insurance company than paying taxes. The insurance company takes credit cards. They automatically charge the card every month.
This choice backfired big time in 2020. The American Rescue Plan passed in March 2021 said if you received a subsidy upfront in 2020, you got to keep 100% of it, no matter how high your income turned out to be. The lower you estimated your income when you enrolled, the more subsidy you received, and you didn’t have to pay back any of it. However, if you didn’t ask for any subsidy upfront, and your actual income disqualified you, you would receive nothing on the tax return.
Although this change only affected one year, it showed that the government treated the income estimate given at the time of enrollment more than merely an estimate. They were willing to base the subsidy only on the income estimate. If you’re able to justify a low income estimate, you should jump through the hoops to justify it.
Even if you aren’t short on cash, there are other advantages in estimating a low income during enrollment and receiving the subsidy upfront.
Cap On Repayment
Not having to pay back the excess subsidy was a deal only for 2020. Starting again in 2021, when your actual income is higher than your estimate, you’ll have to pay back the difference between what you received and what you actually qualify for on your tax return. But there’s a cap. If your actual income is a lot higher than your estimate, you’re only required to pay back up to a limit. You get to keep any additional subsidy above the payback limit. See Cap On Paying Back ACA Health Insurance Subsidy Premium Tax Credit.
You should get as much subsidy as possible upfront just in case you have a large unexpected income. You may be able to benefit from the repayment cap.
Cost-Sharing Reductions
If your income is at 250% of the Federal Poverty Level (FPL) or below, you qualify for Cost-Sharing Reductions (CSR) in the form of a lower deductible, lower co-pays, and/or a lower out-of-pocket maximum on your health insurance. CSRs come in three tiers. You get a small reduction at 250% of FPL. Larger reductions come in at 200% and 150% of FPL. For example, a normal Silver plan in my area has a $4,500 deductible and an $8,500 out-of-pocket maximum. If your income is under 200% of FPL, the Silver plan with the CSR has a $700 deductible and a $1,800 out-of-pocket maximum. That’s a big difference.
| Deductible | Out-of-Pocket Maximum | |
|---|---|---|
| Regular Silver Plan | $4,500 | $8,500 |
| Silver Plan with CSR | $700 | $1,800 |
You get into the better Silver plan with CSR only when you can justify upfront that your estimated annual income will be at 250% of FPL or below. You won’t get your deductible or out-of-pocket maximum adjusted after the fact if you wait until you file your tax return. If you can justify an income estimate at 250% FPL or below, don’t wait.
250% of FPL for a household of two people in the lower 48 states is about $43,000 in 2021.
Minimum Income Threshold
ACA premium subsidy has a minimum income threshold. The minimum threshold is 100% of the Federal Poverty Level (FPL) in states that didn’t expand Medicaid and 138% of FPL in states that did. See which states expanded Medicaid in Status of State Medicaid Expansion Decisions: Interactive Map from Kaiser Family Foundation.
100% FPL for a household of two people in the lower 48 states is $17,240 in 2021. 138% is $23,791. If there’s any chance that your income will fall below the minimum threshold, you should get your subsidy upfront at the time of enrollment. If you received the subsidy upfront and then your income unexpectedly falls below the minimum, you’ll still qualify for the premium tax credit on your tax return. If you didn’t receive the subsidy upfront, you won’t qualify for the premium tax credit on the tax return when your income is below the minimum threshold.
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David Ann Arbor says
The disadvantage of not getting the premium subsidies now is also that if you accidentally get more premiums than you were supposed to get, there was a cap on how much of that premium you actually had to pay back in taxes. The cap varies based on income, but I think on the upper end it is around $750.
Harry Sit says
The repayment cap is listed on page 16 of Form 8962 instructions. For married filing jointly it’s:
– $600 for income < 200% FPL
– $1,500 for income < 300% FPL
– $2,550 for income < 400% FPL
– unlimited for income >= 400% FPL
Your estimated income has to be like $20k lower than the actual income (but still within 400% FPL) to have that much excess premium subsidy.
Heather says
This is really interesting. How are you supposed to prove a negative (having no other health insurance)? What documentation can be submitted for that other than a written statement saying, “I have no health care anywhere.” LOL Honestly, I don’t understand that one…
Interesting comparison though – definitely food for thought.
Harry Sit says
They wanted a letter from an employer or a government agency stating the coverage ended with the date it ended.
PAUL COLLINSON says
Very interesting and thought provoking.
Looking forward to hearing how this all shakes out come tax filing time!
Mark says
If you don’t go for the subsidies now, you also won’t get the subsidized prescription drug costs. And there is a cap on how much you have to pay back if your income estimate is off. Definitely better off justifying your income to them now.
Harry Sit says
What are the subsidized prescription drug costs? Do you mean the cost sharing reductions for enhanced Silver plans? That only applies for income 250% FPL or below. Our estimated income is higher. The repayment cap won’t apply unless your income estimate is quite a ways off. See reply to comment #1.
dan23 says
Interesting that they ask for the proof in the 250-400% level also (if I understand your post correctly, you ultimately put in >400% income to not have to go through proof process). I would think that absent some kind of misbehavior in prior years, they would only do it when you get the extra deductible copay adjustments in the plan itself that happens <250% for silver plans. I also wonder how strict they can be with the proof when someone is near the 250 level and that makes a difference between getting copay/deductible adjustment, where they do not make you whole after filing taxes if you miss the cutoff.
In case you know the answer to this, what happens if you put in for an <250% silver plan that has the adjusted deductibles copays etc., and you end up underestimating your income (and end up over 250%). Is there extra repayment beyond the premium subsidies. Does this change as you get closer to 400 (example: estimate 240%, end up 390%)?
Harry Sit says
I originally gave an estimate slightly under 400% FPL. I updated it to above 400% FPL.
I don’t know how rigorously they validate or challenge the income estimates or whether they give extra scrutiny at different FPL thresholds for cost-sharing reductions. Because 250% FPL only gives you 73% Actuarial Value versus the normal 70%, it’s not that a big deal. The more substantial reductions come at 200% FPL and 150% FPL, when you get 87% and 94% Actuarial Value. Anyway as long as they approve your estimate, you are not required to repay the cost-sharing reductions no matter how high your actual income becomes.
Eric says
My story is the same to a tee, and I also elected to defer the tax credit in order to collect credit card rewards. Since our annual premium is about $30,000 the points and awards were a nice bonus.
Charlie says
Interesting about being able to pay 30K on your credit card. Hopefully, you’re getting enough bang for the buck to have you outlay 2,500/month versus taking the APTC.
Our insurer (Blue plan) only accepts a credit card payment if you print out a barcode and take it to CVS. I believe CVS will only let you pay a max of $500. So if your premium is 2,000, I supposed you’d have to go there four different days assuming they even allow that.
John says
I think if you don’t go for the subsidies now, your deductible may be higher. At least it is true for Washington state.
Harry Sit says
Only if your estimated income is at or below 250% FPL and only if you choose a Silver plan. Our estimated income is higher and we are choosing a Bronze plan.
Brian says
I haven’t fully wrapped my mind around the scenario you’ve proposed, but I’m gonna enter both scenarios into our tax program – (1) take the advance premium tax credit now compared to (2) defer the tax credit until later – to see if the ultimate tax liability results in a wash.
My wife and I have used the ACA Exchange since the beginning. Through tax-efficiently withdrawing from our investments, we’ve kept our MAGI below the 250% FPL to qualify for really good rates (for Silver HMO plans at $108/mo this year).
However, to pay the full amount each month (this year for example) to defer the subsidy would’ve required us to pull an additional $1,500/mo (the subsidy amount) in order to pay the full premium, which would have resulted in us failing the MAGI thresholds. At tax filing time we would’ve claimed that higher MAGI, which would then disqualify us from getting a reimbursed premium.
I’ll have to read through your scenario again to see what I might be missing.
(As I indicated, we’re in our fifth year using Healthcare.gov, & providing estimated income each year, but never have received that “conditionally eligible” notice, nor having to submit additional evidence. Just lucky, I guess.)
Harry Sit says
If you qualify for cost-sharing reductions because your income is under 250% FPL and you prefer a Silver plan, you can only get the cost-sharing reductions by qualifying up front. As noted in reply to comment #5, the better cost-sharing reductions come when you make your income 200% FPL or below. So maybe do some bunching: make it close to 400% FPL for one year and make it 200% or below for the next 3-4 years as opposed to staying between 200% and 250% FPL every year.
KD says
Harry, in the past you have shown that loss of ACA subsidy is basically a 10% tax on marginal dollar increase of income. Can you please also investigate the age effect and illustrate that this tax rate is much higher as you age because the age rating of ACA premiums? Basically, lowering income during 55 to 65 age band results in higher subsidy than say 45 to 55 age band for the same plan. Hence, early retirees/ career pivotees are better off with managing higher income in initial years. Of course, we hope that ACA willl remain the law of the land in the future. I played around and found for 42 yr old cheapest bronze plan for 40K income with 2 people household and only one on ACA was 100 bucks a month but the same plan was zero dollars if change age to 52 and keep everything else the same
Harry Sit says
Between 300% and 400% FPL, you are expected to pay about 10% of your income toward the 2nd lowest Silver plan. The remainder will be your premium tax credit. Within that income range, for every $10 in more income, your premium tax credit is reduced by $1. This doesn’t change with age, or whether you choose a Bronze plan or Silver plan. At different income ranges, the percentages are different; the principle is the same.
What you observed in pricing can happen depending on the relative pricing between a Bronze plan and the benchmark Silver plan. Between an older person and a younger person of the same income, the older person will receive a higher premium tax credit than the younger person because the unsubsidized premium is higher for the older person. When the higher premium tax credit is enough to pay the entire cost of a Bronze plan, the Bronze plan is free to the older person. When the older person increases his or her income by $10, the premium tax credit is reduced by $1 but it still may be enough to cover the cost of the Bronze plan. When that happens, the older person doesn’t face the equivalent 10% tax for increasing income if he or she chooses the Bronze plan.
So if they choose a Bronze plan, an older person can afford to increase income (but still stay under 400% FPL) more than a younger person. However, because an older person is expected to have more medical expenses, he or she may spend more in deductible and co-insurance than the younger person when they choose a Bronze plan.
John says
Harry,
You mentioned citizens but I believe ACA subsidies are also available to permanent residents? Also is the 250% FPL important because you are then eligible for Medicare?
Harry Sit says
It’s possible they asked for citizenship documents because I said we were citizens. They would ask for other documents if I chose a different status.
https://www.healthcare.gov/immigrants/lawfully-present-immigrants/
Medicare is available only to people 65 or older. Medicaid tops out at 138% FPL in states that expanded it, lower in other states. ACA is still relevant when you are under 65 with income above 138% FPL.
Alexander Farber says
I think you may be leaving some of the Foreign TC on the table with this. I understand that you get this credit only if you paid taxes and not the other way around. Hence, underestimating the income (but still less than <400%) and owing the tax credit back allows you to collect higher FTC.
Harry Sit says
Non-refundable credits such as the foreign tax credit are applied before the refundable credits such as the ACA premium tax credit. Therefore the amount of ACA tax credit you receive doesn’t affect the amount of foreign tax credit you get.
KD says
Harry, thanks for pointing this out. I believe this will be something I will need to remember when we get to ACA marketplace in the future.
KR says
I wonder what they will accept as proof of income. Let’s say I quit working at the end of 2018, so I won’t have any W-2 income in 2019. If I am only living off of dividends/income and portfolio distributions, what proof can I give on income?
Charlie says
Similar to KR, we were asked to “prove income” for a future period.
Background: We first signed up for ACA about a year ago, our first year in ACA is 2018. I had left a job late in 2017 and projected about 40K income for 2018 which would be mostly IRA withdrawals/conversions, etc. I had W-2’s for 2017 and prior years. I could take SS, but will try to wait until my FRA.
Since the source of our income is my IRA, I submitted a copy of my IRA brokerage statement and wrote on the top page “Projected Income = $40,000 to be Withdrawn During 2018” along with my application number. After they reviewed it we were approved, no other issues. Our income will probably be higher so I anticipate having to pay back a small amount of the premium tax credit. I knew that going in.
In the meantime, for 2018 we had an HSA eligible Bronze plan with ZERO premium and it has 6K/12K deductible which is fine for us. My COBRA would have been 18K in PREMIUMS alone! So ACA was a no-brainer for us. The HSA eligible plan allows me to take 7,900 out of my IRA and contribute to HSA. This is subtracted from MAGI for ACA (and tax) purposes.
We were not asked to prove citizenship nor lack of other health insurance for 2018. We haven’t submitted for our 2019 plan, so we shall see. Looks like we will probably go with the same plan, project a higher income (50-55K) and pay around $150/month premium. I could keep the income lower, but am trying to do Roth conversions during the next few years so I will be closer to the 400% FPL only for this reason.
Thanks for the article and great discussion!
KR says
Thank you, Charlie!! I am guessing you probably had other income as well (e.g.: interest/dividends from taxable accounts), but it’s good to know they were satisfied with just the IRA comment!
Charlie says
KR,
Absolutely correct on some other income sources from taxable accounts. The bulk, however, will be the IRA Distributions and knowing how government contractors operate, sometimes less is more 🙂 – part of the KISS method.
On a semi-related topic, I keep reading how great these silver plans are that have CSR’s. Maybe that depends on geography and age, but I really haven’t come across anything close to being of interest to us. Maybe others have had success. Ones I’ve seen have higher premiums with some limited additional benefits. I guess I’ll continue to self-insure for our 6K/12K deductibles.
Charlie says
Here’s a little update. I just went through the re-enrollment process for 2019. As soon as I clicked “Submit” I got a notice to verify income used in the application (just like last time). I’ve done the same as last time, submitted a copy of my IRA statement and a short letter explaining the estimated income will come from distributions from the IRA.
Charlie says
I’m wondering if anyone else has considered this?
The “common wisdom” is to do Roth conversions for early retirees. I agree with the overall strategy. The complicating/limiting factor, however, is the MAGI Limitation which is part of ACA.
So for a married couple in 2019, MAGI must not go over 400% FPL which is $65,840 (except for AK/HI). One of the reasons for doing Roth conversions is to take advantage of lower tax rates. The 12% tax bracket (MFJ) applies to taxable income (different from MAGI) from $19,401 to $79,850. Then the 22% bracket is $78,951 to $168,400.
If you want to do a common wisdom Roth conversion of 100K, you’ll go over the ACA MAGI cliff.
What are some options here? Don’t take a subsidy and pay full freight on your health insurance? Is there an analysis to evaluate this?
Has anyone found reasonably priced health insurance options outside of ACA plans such as temporary plans or something else?
Harry Sit says
Bunching the conversion is one option. If you are going over, go over more in just one year but keep it under in other years. Convert in a bear market when asset values are low. See Income Bunching Under Obamacare ACA Premium Subsidy.
GramaD says
I think I may have just encountered a reason to NOT take the advance subsidy. I’m an SCorp owner with marketplace insurance. I took advance premium tax credits (APTC) through 2018, and figured I could take the Self Employed Health Insurance deduction if I had to pay the full premiums at tax time.
My income went over the cliff in late November, so now I pay back all APTC, $20K.
My interpretation of Pub 974 is that I can’t use the $20k on 1040 line 29, but instead it has to go on Sched A. So I got punished for taking the advance subsidy, right??
Harry Sit says
If you pay back the advance credit, it’s as if you didn’t receive it to begin with.
GramaD says
So now I’ll consider having my SCorp make a large employer contribution to my 401k (I’m the SCorp owner), hoping I can get my AGI back under the cliff and so not pay back the $20K APTC. But my accountant and I are both confused about how to handle the health insurance deduction.
Since I used the APTC through 2018, I paid ~$100 myself (bronze plan). What do we put in W2 box 14: the $20,000 full cost of premiums before subsidy, or the $100 I actually paid?
And what goes on 1040 line 29?
If we only show $100 actually paid on line 29, then we fall off the cliff and have to pay back the $20K. Which means I didn’t get to deduct my self-employed health insurance. Or else it might go to Sched A, I don’t know.
I’m trying to follow Pub 974 and Form 8962 but getting so confused.
If I can’t claim the self-emp health insur deduction because I used the advanced subsidy during the year, then I’m back to my original point of being punished for that.
GramaD says
I was hoping that was the answer! Thank you!
Can I add part 2? – next time I see that I’ll go over the cliff for MAGI, can I pre-pay all of my next year’s Marketplace insurance, no APTC? For instance, in December 2018, I could have pre-paid for all 2019 and included it on my 2018 W2. That would mean 2 years of health insurance on one W2. Would this be a business expense and the 12-month-rule for business expenses might apply? That approach could get me under the cliff for the current year, and would be worth foregoing any subsidy the next year if I know my income will stay up.
I just don’t know if pre-paid health insurance for SCorp owner is really considered as a business expense. And so far, I haven’t found instruction for Line 29 that says only current tax year premiums are deductible.
Harry Sit says
The exchange only charges monthly on the first of each month. At best you can prepay only one month. I don’t know even that works.
GramaD says
But a person pays the health insurance company directly, not the exchange, right? My monthly bills come from the insurance company, even though I got the insurance on the exchange. I’ve prepaid the insurer many months worth of exchange premiums before and they were happy to take it!
If I don’t take any advance subsidy (i.e. initially estimate income to be >400%), and pay for the whole year at once, it’s obviously a large deduction. So I just wonder if I pre-paid for 2019 on Dec 31 2018, am I supposed to deduct it on 2018 return as a business expense with 12-month rule?
Thank you for your responses!
Harry Sit says
You can make additional deposits into an escrow account linked to your mortgage for future property tax but you are not really paying property tax when you make the deposit. I’m afraid prepaying insurance would be seen the same way. No bill, no expense.
GramaD says
Thanks, I can see your point. I’ll review Pub 535 for the invoice requirement.
GramaD says
If my SCorp makes a large employer contribution to my 401k (I’m the SCorp owner), I hope I can get back under the cliff and so not pay back the APTC. But my accountant and I are both confused about how to handle the health insurance deduction. Since I used the APTC through 2018, I paid ~$100 myself (bronze plan). What do we put in W2 box 14: the $20,000 full cost of premiums before subsidy, or the $100 I actually paid?
And what goes on 1040 line 29?
If we only put down $100 actually paid, then we fall off the cliff and have to pay back the $20K. Which means I didn’t get to deduct my self-employed health insurance.
I’m trying to follow Pub 974 and Form 8962 but getting so confused.
If I can’t claim the self-emp health insur deduction because I used the advanced subsidy during the year, then I’m back to my original point of being punished for that.
Harry Sit says
From the IRS: S Corporation Compensation and Medical Insurance Issues.
The full unsubsidized premium is treated as wages in W-2 box 1. Then on your personal return you calculate how much you are eligible for the premium tax credit and deduct the remainder as self-employed health insurance premium. For example out of your $20,000 full premium you may be eligible for $15,000 in premium tax credit. Then you deduct $5,000. Calculating the split by hand isn’t easy but the tax software will do it easily if you give the inputs in the right place.
GramaD says
My CPA and his tax software claim that an SCorp can only reimburse for the subsidized premium actually paid during 2018, not the full unsubsidized premium as you say. So my line 29 is only $100 instead of $20K.
I didn’t anticipate this, and thought it would be handled as you’re saying instead.
I’ve been checking IRS notices and instructions and I can’t find where it says to put the value of full, unsubsidized premiums on the W-2 and on line 29. Where did you find this instruction, please? It would be immensely helpful to my CPA!
Thank you again!