Can You Get Marketplace Insurance If Your Spouse Has Insurance?
Explore your options for ACA Marketplace health insurance when your spouse has employer coverage, including eligibility for financial assistance.
The Affordable Care Act (ACA) Marketplace is a platform for individuals and families to explore and enroll in health insurance plans. It aims to make health coverage more accessible to those without employer or government programs. A common question for individuals whose spouse has job-based insurance is whether they can still obtain Marketplace coverage. Understanding these specific considerations and nuances is important for making informed decisions about health coverage.
Basic Eligibility for Marketplace Coverage
To enroll in the ACA Marketplace, individuals must meet requirements. Applicants must be a U.S. citizen, national, or lawfully present immigrant. They must also reside within the United States and cannot be incarcerated.
Individuals eligible for government-sponsored health coverage programs cannot obtain a Marketplace plan. This includes Medicare or most Medicaid plans. If an individual qualifies for these programs, they are expected to enroll through those avenues rather than the Marketplace.
How Spousal Employer Coverage Affects Your Options
The presence of employer-sponsored health insurance for one spouse does not automatically prevent the other spouse from seeking Marketplace coverage. However, eligibility for financial assistance depends on whether the employer-sponsored plan is “affordable” and provides “Minimum Essential Coverage” (MEC). MEC refers to the type of health insurance that satisfies the ACA’s requirement for health coverage, encompassing most employer-sponsored plans, individual major medical plans, Medicare, and most Medicaid plans.
Historically, the “Family Glitch” impacted many families. Prior to 2023, an employer-sponsored plan’s affordability was based solely on the cost of self-only coverage for the employee. If the employee’s individual coverage premium was deemed affordable, all family members were considered to have access to affordable coverage, regardless of the higher cost to add them. This often left family members without affordable health insurance or Marketplace financial assistance.
A regulatory change, effective January 1, 2023, addressed the “Family Glitch.” Now, for Marketplace subsidies, the affordability test for family members is based on the cost of adding the entire family to the employer-sponsored plan, relative to household income. For example, in 2025, if family coverage exceeds 9.02% of household income, the employer-sponsored coverage may be unaffordable for the family. This change allows many families previously impacted by the glitch to qualify for Premium Tax Credits on the Marketplace.
Even if an employer-sponsored plan is affordable and provides MEC under updated rules, an individual can still purchase a Marketplace plan. However, if the employer plan meets affordability and minimum value standards, the individual will not be eligible for Premium Tax Credits or other financial assistance on the Marketplace. Some individuals might still opt for a Marketplace plan for reasons like preferred provider networks or different benefit structures, but they would pay the full premium without subsidies.
Understanding Financial Help for Marketplace Plans
The Marketplace offers two primary forms of financial assistance: Premium Tax Credits (PTC) and Cost-Sharing Reductions (CSR). Premium Tax Credits lower the monthly cost of health insurance premiums. Eligibility for these credits is based on household income relative to the Federal Poverty Level (FPL). Individuals with household incomes between 100% and 400% of the FPL may qualify, though temporary expansions have removed the upper income limit.
A direct link exists between eligibility for Premium Tax Credits and the affordability of employer-sponsored coverage, as determined by previously discussed rules. If an employer’s plan is deemed unaffordable for an individual or family, per the updated affordability test, and their income falls within the qualifying range, they may be eligible for Premium Tax Credits on a Marketplace plan. Conversely, if the employer plan is affordable, individuals cannot receive Premium Tax Credits, even if they choose to enroll in a Marketplace plan.
Cost-Sharing Reductions (CSRs) provide additional financial assistance by lowering out-of-pocket costs associated with a health plan, such as deductibles, copayments, and coinsurance. These reductions are available to individuals with lower incomes who also qualify for Premium Tax Credits and enroll in a Silver-level Marketplace plan. CSRs increase the actuarial value of Silver plans, meaning the plan covers a higher percentage of average medical costs. Accurately estimating household income is important when applying for financial assistance, as it directly impacts the amount of PTC and CSR an individual may receive.