Can I Get Obamacare If My Spouse Has Insurance?

The Affordable Care Act (ACA), often referred to as “Obamacare,” was enacted to broaden access to health insurance coverage across the United States. The ACA establishes health insurance marketplaces where consumers can explore various health plans and potentially receive financial assistance to help with costs.

Impact of Spouse’s Employer-Sponsored Insurance

Whether an individual can obtain health insurance through the ACA marketplace if their spouse has employer-sponsored insurance depends on specific affordability and minimum value rules. Generally, if an employer offers health coverage that is considered “affordable” and provides “minimum value” to an employee, that employee and their family members were historically not eligible for Premium Tax Credits (subsidies) on the ACA marketplace. An employer-sponsored plan is deemed to provide “minimum value” if it covers at least 60% of the total cost of covered benefits, including substantial coverage for physician and inpatient hospital services. The determination of “affordable” has typically been based on the employee’s contribution for self-only coverage, not the cost of adding family members.

This prior interpretation led to what was commonly known as the “family glitch.” Under the rules in effect from 2014 through 2022, if an employee’s self-only coverage was considered affordable, the entire family was generally ineligible for marketplace subsidies, even if the cost of adding family members to the employer plan was prohibitively expensive. The affordability threshold, which is the maximum percentage of household income an employee can be required to pay for self-only coverage, is adjusted annually; for example, it was 9.02% for plan years beginning in 2025.

To address the “family glitch,” the U.S. Treasury Department and Internal Revenue Service (IRS) issued a final rule in October 2022, effective for the 2023 plan year. This new rule establishes a separate affordability test for family members. Now, family members (spouses and dependents) may qualify for Premium Tax Credits on the ACA marketplace if the employer-sponsored family coverage is deemed unaffordable, even if the employee’s self-only coverage is considered affordable.

Determining Eligibility for Financial Assistance

Once an individual or family determines they might be eligible to seek coverage through the ACA marketplace, the next step involves understanding the criteria for financial assistance. The ACA offers two primary forms of financial help: Premium Tax Credits (PTC) and Cost-Sharing Reductions (CSR). Eligibility for these subsidies is primarily based on a household’s Modified Adjusted Gross Income (MAGI) relative to the Federal Poverty Level (FPL) and the size of the household. MAGI, for ACA purposes, starts with Adjusted Gross Income (AGI) from Form 1040, with certain additions such as non-taxable Social Security benefits, tax-exempt interest, and foreign-earned income.

Premium Tax Credits are designed to lower the monthly premium costs for health insurance plans purchased through the marketplace. These credits can be taken in advance to reduce the monthly payments directly to the insurer, or they can be claimed when filing federal income taxes. The amount of the tax credit is determined by a sliding scale, meaning individuals and families with lower incomes generally receive larger credits. Households with income between 100% and 400% of the FPL may be eligible for these tax credits if they do not have access to affordable, minimum value employer-sponsored coverage.

Cost-Sharing Reductions help lower out-of-pocket costs, such as deductibles, co-payments, and co-insurance, for those with lower incomes who enroll in Silver-level plans on the marketplace. These reductions increase the actuarial value of a Silver plan, effectively making the plan cover a larger percentage of medical costs. Eligibility for Cost-Sharing Reductions generally applies to individuals and families with household incomes up to 250% of the FPL. While Premium Tax Credits reduce premiums, Cost-Sharing Reductions directly reduce the amount a person pays when they receive medical care.

Information Needed for Your Application

Before beginning an application on the Health Insurance Marketplace, gathering specific information and documents for each household member is advisable. Essential personal details include names, dates of birth, and Social Security Numbers for everyone applying for coverage. For eligible immigrants, relevant document numbers are also necessary.

Income information is a significant component of the application, as it determines eligibility for financial assistance. Applicants will need to provide an estimated household income for the coverage year, including details from various sources such as wages, self-employment income, Social Security benefits, and unemployment income. Documents like recent pay stubs, W-2 forms, or tax returns can help in estimating income.

Information related to tax filing is also required, specifically how the household plans to file federal income taxes for the coverage year. This includes indicating whether they will file jointly, separately, or if any dependents will be claimed. If anyone in the household currently has health insurance, or is eligible for job-based coverage, policy numbers and details about the employer’s plan (including whether it meets affordability and minimum value standards) will be requested. The marketplace application will ask for employer contact information for each person in the household who has a job.

Submitting Your Application

Once all necessary information has been gathered, the next step is to submit the application to the Health Insurance Marketplace. The primary platform for this is HealthCare.gov, which serves most states, while some states operate their own marketplace websites. The application process generally involves creating an account, which is the first step to accessing the online portal.

Applicants will then proceed to input the previously collected personal, household, income, and health insurance information into the online forms. The system will use this data to determine eligibility for marketplace plans and any potential Premium Tax Credits or Cost-Sharing Reductions. After eligibility is determined, individuals can review the available health plans in their area, compare options, and select a plan that aligns with their needs and budget.

The marketplace system will then show how any approved subsidies can be applied to reduce the monthly premiums of the chosen plan. The final step involves confirming the selected plan and completing the enrollment process. It is important to note that coverage typically begins only after the first premium payment is made to the selected insurance company.