Can I Get Marketplace Insurance If My Spouse Has Insurance?

Individuals and families can obtain health insurance through the Marketplace. A common question is whether family members can obtain Marketplace coverage if one spouse has employer-sponsored health insurance. Eligibility depends on specific rules and affordability considerations, especially for plans with financial assistance.

Understanding Marketplace Eligibility with Spousal Coverage

Eligibility for Marketplace health insurance generally requires individuals to be U.S. citizens or lawful residents, not incarcerated, and not eligible for Medicare or Medicaid. When an employer offers health coverage, it impacts whether an employee and their family can receive financial assistance, known as premium tax credits, through the Marketplace. These tax credits help lower the monthly cost of health insurance premiums.

An employer’s coverage offer is “affordable” if the employee’s share of the lowest-cost self-only plan meeting minimum value standards is less than a certain percentage of their household income. For plan years beginning in 2025, this affordability threshold is 9.02% of household income. A plan meets “minimum value” if it covers at least 60% of the total allowed costs of benefits and provides substantial coverage for inpatient hospital and physician services. If the employer’s self-only coverage is affordable and provides minimum value, the employee is generally not eligible for premium tax credits on the Marketplace.

Assessing Affordability for Your Family

Eligibility for family members changed significantly starting January 1, 2023, with the resolution of what was commonly known as the “family glitch.” Previously, if an employer’s self-only coverage was affordable for the employee, all family members were often ineligible for Marketplace subsidies, even if adding them to the employer plan was prohibitively expensive. This created a situation where families could not access affordable coverage.

A final rule issued by the Internal Revenue Service (IRS) in October 2022 addressed this issue. Under revised rules, the affordability of employer-sponsored coverage for an employee’s family members is now determined based on the cost of the entire family coverage through the employer. If the employee’s required contribution for family coverage under the employer’s plan exceeds the affordability threshold (9.02% of household income for 2025), then those family members may become eligible for premium tax credits through the Marketplace. This means spouses and dependents might qualify for Marketplace financial assistance, even if the employee’s individual coverage is affordable.

Steps to Evaluate Your Health Insurance Choices

To make an informed decision, begin by gathering specific financial information. You will need your household income, your tax filing status, and precise details about the employer-sponsored health plan. This includes the monthly premium cost for self-only coverage and the monthly premium cost for family coverage. Your employer’s human resources department or online portal can provide these figures.

Next, visit the official Healthcare.gov website or your state’s health insurance exchange. Input your household information and income details into their application tools to determine if you or your family members qualify for premium tax credits. The system will conduct the necessary affordability calculations based on the information you provide. Once potential savings are identified, thoroughly compare the available Marketplace plans with the employer-sponsored plan. This comparison should extend beyond just monthly premiums to include total estimated out-of-pocket costs, such as deductibles, co-payments, and the maximum out-of-pocket limit. Remember that if you opt for a Marketplace plan, your employer will not contribute to its monthly premium.