Can I get ACA coverage if I’m covered by my spouse’s plan?
Am I eligible for ACA insurance if I’m already covered under my spouse’s employer-sponsored health plan?
Yes, you are eligible to purchase ACA health insurance even if you are already covered under your spouse’s employer-sponsored health plan. However, your eligibility for premium tax credits and other financial assistance in the ACA Marketplace depends on whether your spouse’s employer-provided plan meets the ACA’s affordability and minimum value standards. Here’s what you need to know:
1. Can You Purchase ACA Insurance if Covered by Your Spouse’s Plan?
Yes, you can choose to purchase an ACA plan, even if you are currently covered under your spouse’s employer-sponsored health plan. There’s no rule preventing you from buying an ACA plan while being covered by another insurance plan. However, the main issue is whether you are eligible for subsidies (financial help) to reduce the cost of an ACA plan.
2. Eligibility for ACA Subsidies
Your eligibility for premium tax credits and cost-sharing reductions in the ACA Marketplace depends on whether your spouse’s employer-sponsored plan is considered affordable and provides minimum value under ACA rules.
A. Affordability Rule
Under the ACA, a spouse’s self-only coverage is considered affordable if the employee’s share of the premium for the lowest-cost plan is 9.83% or less of your household income.
If your spouse’s employer-sponsored plan is affordable, you will not be eligible for premium tax credits in the ACA Marketplace, even if family coverage is more expensive.
If the employer plan is unaffordable (meaning it costs more than 9.83% of your household income for self-only coverage), you may be eligible for subsidies in the ACA Marketplace.
B. Minimum Value Standard
The spouse’s employer-sponsored plan must also meet the minimum value standard, meaning it covers at least 60% of the total cost of benefits and includes coverage for hospitalization and physician services.
If the plan meets this standard, you will not be eligible for subsidies. If it doesn’t, you may be eligible for financial help in the ACA Marketplace.
3. Reasons to Choose ACA Insurance Over Spouse’s Employer Plan
There are a few reasons you might choose to purchase an ACA plan instead of staying on your spouse’s employer-sponsored plan, including:
A. Affordability Concerns
If your spouse’s employer-sponsored family coverage is expensive or doesn’t meet your healthcare needs, purchasing an ACA plan might provide more affordable options, especially if you qualify for subsidies.
B. Better Network or Benefits
ACA plans may offer a different network of doctors and hospitals, which might better suit your medical needs. In some cases, an ACA plan may provide benefits that are more aligned with your healthcare requirements, such as specific treatments or services not fully covered by the employer plan.
4. When You Won’t Qualify for Subsidies
If your spouse’s employer plan is considered affordable and provides minimum value, you will not qualify for premium tax credits or subsidies, meaning you will need to pay the full price for an ACA plan. This can make the ACA plan more expensive than your spouse’s employer-sponsored plan, especially when you factor in premiums, deductibles, and out-of-pocket costs.
5. If Your Spouse’s Plan Is Unaffordable
If your spouse’s employer-sponsored plan is unaffordable (costing more than 9.83% of your household income for self-only coverage), you may be eligible for subsidies through the ACA Marketplace. In this case, you can choose to:
Decline the employer-sponsored coverage and purchase an ACA plan for yourself, which may include financial assistance to reduce your premium costs.
Stay on your spouse’s employer plan for basic coverage but opt for an ACA plan if you need more comprehensive coverage.
6. How to Check Your Subsidy Eligibility
To determine whether you qualify for subsidies in the ACA Marketplace, you can:
Use the ACA Marketplace calculator: The ACA Marketplace allows you to enter information about your household income and coverage options to check your subsidy eligibility.
Ask your spouse’s employer: You can ask the employer or HR department for details about the affordability and minimum value of the health plan.
Key Takeaways:
You can purchase an ACA plan even if you are covered by your spouse’s employer-sponsored health plan.
You are only eligible for premium tax credits if your spouse’s plan is considered unaffordable (costs more than 9.83% of household income for self-only coverage) or does not meet minimum value standards.
If your spouse’s plan meets ACA affordability standards, you will not qualify for subsidies, making an ACA plan more expensive.
For help determining whether an ACA plan or your spouse’s employer-sponsored plan is better for you, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
