Congressional Research Service Report: 'Health Insurance Premium Tax Credit & Cost-Sharing Reductions'
Summary
Certain individuals without access to subsidized health insurance coverage may be eligible for the premium tax credit (PTC) established under the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) and amended under the American Rescue Plan Act of 2021 (ARPA, P.L. 117-2) to include several temporary provisions. The dollar amount of the PTC varies from individual to individual, based on a formula specified in statute. Individuals who are eligible for the PTC may be required to contribute some amount toward the purchase of health insurance.
In order to be eligible to receive the premium tax credit in 2021, individuals must have annual household income at or above 100% of the federal poverty level; not be eligible for certain types of health insurance coverage, with exceptions; file federal income tax returns; and enroll in a plan through an individual exchange. Exchanges (or marketplaces) are not insurance companies; rather, exchanges serve as marketplaces for the purchase of health insurance. They operate in every state and the
The PTC is refundable, so individuals may claim the full credit amount when filing their taxes, even if they have little or no federal income tax liability. The credit also is advanceable, so individuals may choose to receive advanced payments of the credit (or APTC). APTCs are provided on a monthly basis to coincide with the payment of insurance premiums, automatically reducing consumer costs associated with purchasing insurance. The credit is financed through permanent appropriations authorized under the federal tax code.
Individuals who receive premium credit payments also may be eligible for subsidies that reduce cost-sharing expenses. The ACA established two types of cost-sharing reductions (CSRs). One type of subsidy reduces annual cost-sharing limits; the other directly reduces cost-sharing requirements (e.g., lowers a deductible). Individuals who are eligible for CSRs may receive both types. Although applicable health plans must provide these CSRs, such plans no longer receive direct payments to reimburse them for the cost of providing the subsidies to eligible consumers.
The ARPA makes temporary changes to the PTC and to CSRs. Its provisions amend statute to
* expand eligibility for and the amount of the PTC applicable to certain exchange plans for tax years 2021 and 2022;
* suspend the requirement, for tax year 2020, that individuals pay back PTC amounts that were provided in excess; and
* expand eligibility for and the calculation of both the PTC and CSRs for individuals who receive unemployment compensation during calendar year 2021.
This report describes current law (including the ARPA's temporary changes) and applicable regulations and guidance, specifically how the PTC and CSR requirements apply in 2021.
Background
Certain individuals and families without access to subsidized health insurance coverage may be eligible for a premium tax credit (PTC). This credit, authorized under the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) and amended under the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2), applies toward the cost of purchasing specific types of health plans offered by private health insurance companies./1
Individuals who receive PTC payments also may be eligible for subsidies that reduce cost-sharing expenses./2 To be eligible for the PTC and cost-sharing reductions (CSRs), individuals and families must enroll in health plans offered through health insurance exchanges and meet other criteria.
Exchanges operate in every state and the
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American Rescue Plan Act of 2021
This report reflects provisions enacted under the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) that make temporary changes to the premium tax credit (PTC) and cost-sharing reductions (CSRs). The ARPA's provisions amend statute to
* expand eligibility for and the amount of the PTC applicable to certain exchange plans for tax years 2021 and 2022;
* suspend the requirement, for tax year 2020, that individuals pay back PTC amounts that were provided in excess; and
* expand eligibility for and the calculation of both the PTC and CSRs for individuals who receive unemployment compensation during calendar year 2021.
This report describes current law and applicable regulations and guidance, specifically how the PTC and CSR requirements apply in 2021. As of the date of publication of this report, the
Sources:
Notes: Following ARPA enactment, the
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Health insurance companies that participate in the individual and SHOP exchanges must comply with numerous federal and state requirements. Among such requirements are restrictions related to the determination of premiums for exchange plans (rating restrictions). Insurance companies are prohibited from using health factors in determining premiums. However, they are allowed to vary premiums by age (within specified limits), geography, number of individuals enrolling in a plan, and smoking status (within specified limits)./4
Premium Tax Credit
The dollar amount of the PTC is based on a statutory formula and varies from individual to individual. Individuals who are eligible for the premium credit generally are required to contribute some amount toward the purchase of their health insurance.
The PTC is refundable, so individuals may claim the full credit amount when filing their taxes even if they have little or no federal income tax liability. The credit also is advanceable, so individuals may choose to receive the credit in advance of filing taxes on a monthly basis to coincide with the payment of insurance premiums (technically, advance payments go directly to insurers). Advance payments (or APTC) automatically reduce monthly premiums by the credit amount. Therefore, the direct cost of insurance to an individual or family APTCs generally will be lower than the advertised cost for a given exchange plan.
Eligibility
In order to be eligible to receive the PTC, individuals must meet the following criteria:
* file federal income tax returns;
* enroll in a plan through an individual exchange;
* have annual household income at or above 100% of the federal poverty level (FPL)/5 for tax year 2021;/6 and
* not be eligible for minimum essential coverage (see the "Not Eligible for Minimum Essential Coverage" section in this report), with exceptions.
These eligibility criteria are discussed in greater detail below.
File Federal Income Tax Returns
Because premium assistance is provided in the form of a tax credit, such assistance is administered by the
Married couples are required to file joint tax returns to claim the premium credit, with some exceptions. The calculation and allocation of credit amounts may differ in the event of a change in tax-filing status during a given year (e.g., individuals who marry or divorce)./7
Enroll in a Plan Through an Individual Exchange
Premium credits are available only to individuals and families enrolled in plans offered through individual exchanges; premium credits are not available through SHOP exchanges. Individuals may enroll in exchange plans if they (1) reside in a state in which an exchange was established; (2) are not incarcerated, except individuals in custody pending the disposition of charges; and (3) are citizens or have other lawful status./8
Undocumented individuals (individuals without proper documentation for legal residence) are prohibited from purchasing coverage through an exchange, even if they could pay the entire premium. Because the ACA prohibits undocumented individuals from obtaining exchange coverage, these individuals are not eligible for the PTC. Although certain individuals are not eligible to enroll in exchanges due to incarceration or legal status, their family members may still receive the PTC as long as those family members meet all eligibility criteria.
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Actuarial Value and Metal Plans
Most health plans sold through exchanges established under the ACA are required to meet actuarial value (AV) standards, among other requirements. AV is a summary measure of a plan's generosity, expressed as the percentage of medical expenses estimated to be paid by the insurer for a standard population and set of allowed charges. In other words, the higher the percentage, the lower the cost sharing, on average, for the population. AV is not a measure of plan generosity for an enrolled individual or family, nor is it a measure of premiums or benefits packages. An exchange plan that is subject to the AV standards is given a precious metal designation: platinum (AV of 90%), gold (80%), silver (70%), or bronze (60%).
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Have Annual Household Income at or Above 100% of the Federal Poverty Level
Individuals generally must have household income (based on FPL) that meets a minimum level to be eligible for the PTC in 2021, as specified under the ARPA./9
Household income is measured according to the definition for modified adjusted gross income (MAGI)./10
An individual whose MAGI is at or above 100% FPL may be eligible to receive the PTC for tax year 2021./11
Table 1 displays the income levels that correspond to the eligibility criteria for the PTC in 2021 (using poverty guidelines updated by the
Content omitted: Table 1. Income Levels Applicable to Eligibility for the Premium Tax Credit for 2021, by Selected Family Sizes
In addition to individuals who meet the applicable income levels listed in Table 1, the ARPA provides special access to individuals who receive unemployment compensation (UC)./13
It deems individuals who receive UC for any week in calendar year 2021 to have met the PTC income eligibility criteria for tax year 2021. For these individuals, the ARPA also temporarily adjusts the calculation of the PTC amount (see the discussion about this calculation in the "Determination of Required Premium Contributions and Premium Tax Credit Amounts" section of this report).
Not Eligible for Minimum Essential Coverage
To be eligible for a premium credit, an individual may not be eligible for minimum essential coverage (MEC), with exceptions (described below). The ACA broadly defines MEC to include Medicare Part A; Medicare Advantage; Medicaid (with exceptions); the State Children's Health Insurance Program (CHIP); Tricare; Tricare for Life, a health care program administered by the
However, the ACA provides certain exceptions regarding eligibility for MEC and PTC. An individual may be eligible for premium credits even if he or she is eligible for any of the following sources of MEC:
* the individual (non-group) health insurance market;/15
* an employer-sponsored health plan that is either unaffordable or inadequate;/16 or
* limited benefits under the Medicaid program./17
Medicaid Expansion
Under the ACA, states have the option to expand Medicaid eligibility to include all non-elderly, nonpregnant individuals with incomes up to 138% FPL./18
If an individual who applied for premium credits through an exchange is determined to be eligible for Medicaid, the exchange must have that individual enrolled in Medicaid instead of an exchange plan. Therefore, in states that implemented the optional Medicaid expansion to include individuals with incomes at or above 100% FPL (or any state that decided to expand eligibility to individuals irrespective of the ACA's Medicaid expansion provisions), premium credit eligibility begins at the income level at which Medicaid eligibility ends.
Determination of Required Premium Contributions and Premium Tax Credit Amounts
Required Premium Contribution Examples
The amount of the PTC varies from individual to individual. Calculation of the credit is based on the annual household income (i.e., MAGI) of the individual (and tax dependents), the premium for the exchange plan in which the individual (and any dependents) is enrolled, and other factors.
For simplicity's sake, the following formula illustrates the calculation of the credit: Standard Plan Premium - Required Premium Contribution = Premium Tax Credit Amount Premiums are allowed to vary based on a few characteristics of the person (or family) seeking health insurance. Standard Plan refers to the second-lowest-cost silver plan (see text box in the "Eligibility" section of this report) in the person's (or family's) local area. Required Premium Contribution refers to the amount that a premium credit-eligible individual (or family) may pay toward the exchange premium. The required premium contribution is capped according to household income, with such income measured relative to FPL (see Table 1). The cap requires lower-income individuals to contribute a smaller share of income toward the monthly premium for the standard plan, compared with the requirement for higher-income individuals. The required premium contribution caps typically are updated through
However, the ARPA temporarily replaces those caps./19
The ARPA caps that apply in 2021 are lower than the percentages that applied just prior to enactment of the law (see Figure 1)./20
The amount of the credit for a given individual is calculated as the difference between the premium of the plan in which the individual enrolls and his or her required contribution. Given that the premium and required contribution vary from person to person, the premium credit amount likewise varies. An extreme example is when the premium for the standard plan is very low, the tax credit may cover the entire premium and the individual may pay nothing toward the premium. The opposite extreme scenario, for some higher-income individuals, is when the required contribution exceeds the premium amount, leading to a credit of zero dollars, meaning the PTC-eligible individual (or family) would pay the entire premium amount.
Content omitted: Figure 1. Cap on Required Premium Contributions for Individuals Who Are Eligible for the Premium Tax Credit in 2021
Section 9661 of the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) applies these percentages to tax years 2021 and 2022. Prior to ARPA enactment, the percentages for 2021 ranged from 2.07% to 9.83%, as indicated in Revenue Procedure 2020-36. By reducing the percentages to the current range of 0.0% to 8.5%, the ARPA reduced the required premium contributions for credit-eligible individuals. In effect, these reduced percentages result in larger credit amounts compared with what they would have been prior to ARPA enactment.
To illustrate the premium credit calculation for 2021, consider a premium credit eligible individual living in
A similar calculation is used to determine the required premium contribution for a family. For instance, consider a couple and one child residing in
In addition to calculating a given individual's credit amount according to the formula discussed above, the ARPA includes a special rule specifically for UC beneficiaries. As discussed in the "Eligibility" section of this report, ARPA deems individuals who receive UC for any week in calendar year 2021 to have met the PTC income eligibility criteria for tax year 2021. The law also disregards household income (i.e., MAGI as applicable to the PTC) that exceeds 133% FPL.
Income at or below that level qualifies for a zero-dollar premium for the standard plan (see Figure 1), similar to the preceding calculations for the hypothetical individual and family with incomes at 150% FPL.
Generally, the arithmetic difference between the premium and the individual's (or family's) required contribution is the tax credit amount provided to the individual (or family). Therefore, factors that affect either the premium or the required contribution (or both) will change the premium credit amount; such factors include age, family size, and choice of metal plan.
Reconciliation of Advance Premium Tax Credit Payments
As mentioned previously, an eligible individual (or family) may receive advance payments of the premium credit to coincide with when insurance premiums are due. For such an individual, the advance premium tax credit (APTC) is provided on a monthly basis and the amount is calculated using an estimate of income. When an individual files his or her tax return for a given year, the total amount of APTC he or she received in that tax year is reconciled with the amount he or she should have received, based on actual income, as determined on the tax return.
If an individual's income decreased during the year and he or she should have received a larger tax credit, the additional credit amount will be included in the individual's tax refund for the year or used to reduce the amount of taxes owed.
If an individual's income increased during the year and he or she received too much in APTC payments, the excess amount generally will be repaid in the form of a tax payment, with a temporary exception. The ARPA suspends the requirement to repay excess APTC for the 2020 tax year./22
On
Individuals who would have had to pay back an excess amount and have not yet filed their 2020 tax returns are not required to file an excess amount on their returns or to file Tax Form 8962. (Form 8962 is the form used by a tax filer to claim the PTC. Using the form, the tax filer calculates the PTC amount based on the actual income level from the tax return and reconciles the PTC amount with the total APTC amount already received, which was calculated using an income estimate.) Individuals who would have had to pay back an excess amount and already filed their 2020 tax returns are not required to file an amended return. The
For individuals with incomes below 400% FPL(other than tax year 2020), any repayment amount is capped, with greater tax relief provided to individuals with lower incomes (see Table 2).
Content omitted: Table 2. Annual Limits on Repayment of Excess Premium Tax Credits, 2021
Preliminary Tax Credit Data
The
The following data provide summary statistics about two overlapping populations: tax households that received APTC, and households that claimed the credit on their individual income tax returns./25
Tax Year 2018
For tax year 2018, around 6 million tax returns indicated receipt of advance payments of the tax credit, totaling to almost
The remaining difference represents households that received the correct amount in APTC.
The SOI data indicate that approximately 5.4 million tax returns for the 2018 tax year claimed a total of nearly
These eligible households represent those who received advance payments of the credit and those who claimed the credit after the end of the tax year./28
The
Enrollment Data
HHS regularly publishes data on persons selecting and enrolling in exchange plans, including individuals who were determined eligible for the PTC. For plan year 2020, HHS made reports and public-use files available with national enrollment data, as well as limited data by state, county, and zip code./30
During the 2020 open enrollment period, approximately 87% of all exchange enrollees were eligible for the tax credit./31
As of the publication date of this report, HHS had not yet published comparable data for plan year 2021.
Cost-Sharing Reductions
An individual who qualifies for the PTC, is enrolled in a silver plan (see text box above, "Actuarial Value and Metal Plans"), and has annual household income no greater than 250% FPL (a temporary exception is provided for individuals who receive UC; see below) is eligible for cost-sharing reductions (CSRs)./32
The purpose of these CSR subsidies is to reduce an individual's (or family's) expenses related to cost-sharing requirements under the silver plan; such requirements may include deductibles, co-payments, coinsurance, and annual cost-sharing limits./33
There are two types of CSRs, and the level of assistance for each varies by income band (see descriptions below). Individuals who are eligible for cost-sharing assistance may receive both types of subsidies, as long as they meet the applicable eligibility requirements.
In addition to individuals who meet the CSR eligibility requirements described below, the ARPA provides special access to individuals who receive UC. It deems individuals who receive UC for any week in calendar year 2021 to have met the CSR income eligibility criteria for plan year 2021./34
The ARPA also disregards any household income above 133% FPL in 2021, which provides UC beneficiaries with the greatest level of cost-sharing assistance (see description of CSRs by income band below).
The ACA requires the HHS Secretary to provide full reimbursements to insurers that provide CSRs. Federal outlays for such reimbursements totaled the following amounts:
* FY2014:
* FY2015:
* FY2016:
* FY2017:
* FY2018-FY2020:
Although the ACA authorized the cost-sharing subsidies and payments to reimburse insurers, it did not address the financing for such payments.
The court barred the
Despite the administrative decision to terminate CSR payments, such decision provides no relief to insurers that continue to be required under federal law to provide CSRs to eligible individuals.
In response, health insurers increased premiums to offset this loss in reimbursements (if permitted by state insurance regulators); this practice is referred colloquially as silver loading./37
As part of the legal challenges related to CSR payments, the
The practice of silver loading is protected under federal law through plan year 2021./39
Reduction in Annual Cost-Sharing Limits
Each metal plan limits the total dollar amount an insured consumer will be required to pay out of pocket for use of covered services in a plan year (referred to as an annual cost-sharing limit in this report). In other words, the amount an individual spends in a given year on health care services covered under his or her plan is capped./40
For 2021, the annual cost-sharing limit for self-only coverage is
One type of cost-sharing assistance reduces such limits (see Table 3). This CSR reduces the annual limit faced by premium credit recipients with incomes up to and including 250% FPL; greater subsidy amounts are provided to those with lower incomes. In general, this cost-sharing assistance targets individuals and families that use a great deal of health care in a year and, therefore, have high cost-sharing expenses. Enrollees who use very little health care may not generate enough cost-sharing expenses to reach the annual limit.
Content omitted: Table 3. ACA Cost-Sharing Reductions: Reduced Annual Cost-Sharing Limits, 2021
For example, consider the hypothetical individual who resides in
Reduction in Cost-Sharing Requirements
The second type of CSR also applies to premium credit recipients with incomes up to and including 250% FPL. For eligible individuals, the cost-sharing requirements (for the plans in which they have enrolled) are reduced to ensure that the plans cover a certain percentage of allowed health care expenses, on average. The practical effect of this CSR is to increase the actuarial value (AV) of the exchange plan in which the person is enrolled (Table 4). In other words, enrollees face lower cost-sharing requirements than they would have without this assistance. Given that this type of CSR directly affects cost-sharing requirements (e.g., lowers a deductible), both enrollees who use minimal health care and those who use a great deal of services may benefit from this assistance.
Content omitted: Table 4. ACA Cost-Sharing Reductions: Increased Actuarial Values
To be eligible for cost-sharing subsidies, an individual must be enrolled in a silver plan, which already has an AV of 70% (see text box above, "Actuarial Value and Metal Plans"). For an individual who receives the CSR referred to in Table 4, the health plan will impose different cost-sharing requirements so that the silver plan will meet the applicable increased AV. The ACA does not specify how a plan should reduce cost-sharing requirements to increase the AV from 70% to one of the higher AVs. Through regulations, HHS requires each insurance company that offers a plan subject to this CSR to develop variations of its silver plan; these silver plan variations must comply with the higher levels of actuarial value (73%, 87%, and 94%)./42
When an individual is determined by an exchange to be eligible for CSRs, the person is enrolled in the silver plan variation that corresponds with his or her income.
Consider the same hypothetical individual discussed in the previous section. Since this person's income is at 150% FPL, if he or she receives this type of subsidy, the silver plan in which he or she is enrolled will have an AV of 94% (as indicated in Table 4), instead of the usual 70% AV for silver plans.
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View tables, footnotes and full text of the report at https://crsreports.congress.gov/product/pdf/R/R44425
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