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As healthcare remains a top concern for employees, HR professionals play a key role in guiding individuals through their insurance options. One significant avenue for obtaining health insurance is through the Health Insurance Marketplace, often referred to as the Marketplace or Exchange. With millions of Americans relying on Marketplace coverage, it is important to understand its current state, the benefits of enrollment, and potential upcoming changes that may impact employees seeking individual coverage.

What is the Health Insurance Marketplace?

The Health Insurance Marketplace, established under the Affordable Care Act (ACA), allows individuals and families to purchase private health insurance plans, often with financial assistance in the form of premium subsidies. These subsidies help lower monthly premiums and, in some cases, reduce out-of-pocket costs for medical services. Coverage options vary by state, but all plans include health benefits, such as preventive care, hospitalization, and prescription drug coverage.

Premium Tax Credit (PTC)

The premium tax credit (PTC) is a federal subsidy designed to help individuals and families without access to subsidized health insurance afford coverage through the Marketplace. It is both refundable (available even to those with little or no tax liability) and advanceable (can be applied monthly to lower insurance premiums).

Eligibility Requirements

To qualify for the PTC, individuals must:

• Be a U.S. citizen, national, or lawfully present resident.
• Not be incarcerated (except those pending trial).
• Lack access to other subsidized health coverage, with some exceptions.
• Have an annual household income of at least 100 percent of the federal poverty level (FPL).

Enhanced Premium Subsidies and Their Impact

The American Rescue Plan Act (ARPA) temporarily expanded the PTC in response to the COVID-19 pandemic. It:

• Removed the 400 percent FPL income cap for eligibility in 2021 and 2022.
• Increased subsidy amounts by lowering the percentage of income individuals must contribute to premiums.

These enhancements were extended through 2025 under the Inflation Reduction Act.

What Happens if Premium Subsidies Expire?

The PTC itself will not expire. Unless Congress extends enhanced subsidies, they will expire at the end of 2025. This would have several consequences, including:

• Increased Premium Costs: Many individuals who currently pay little to no premium may face unaffordable increases.
• Potential Loss of Coverage: Estimates suggest that approximately 3.8 million people could become uninsured each year if subsidies are not renewed.
• Shift Away from Employer-Sponsored Plans: Some small businesses might reconsider offering health insurance if Marketplace coverage remains a viable and more affordable alternative.

What Employers Should Consider

Employers should stay informed about Marketplace changes, as they can impact workforce healthcare decisions. While many companies offer employer-sponsored plans, the affordability and availability of Marketplace coverage can influence employees’ choices, particularly for those in lower-wage positions or part-time roles.

HR professionals should be prepared to:

• Educate employees on their Marketplace options and potential subsidy changes.
• Assess how potential subsidy expirations might affect employee healthcare costs and retention.
• Monitor legislative updates that may impact future subsidy extensions or Marketplace accessibility.

Looking Ahead

As we get well into 2025, discussions about extending premium subsidies will intensify. HR professionals must remain proactive in understanding how these potential policy shifts could influence both individual and employer-sponsored health coverage. By staying informed and providing employees with up-to-date information, HR teams can help individuals make the best healthcare decisions for themselves and their families.

Benefit Allocation Systems (BAS) provides best-in-class, online solutions for: Employee Benefits Enrollment; COBRA; Flexible Spending Accounts (FSAs); Health Reimbursement Accounts (HRAs); Leave of Absence Premium Billing (LOA); Affordable Care Act Record Keeping, Compliance & IRS Reporting (ACA); Group Insurance Premium Billing; Property & Casualty Premium Billing; and Payroll Integration.

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