Category: What To Know

My employer offers a plan with very limited benefits. It only covers preventive services and a few doctor visits each year. I want better coverage. Can I apply for coverage and subsidies in the Marketplace?

You can apply for coverage in the Marketplace and you may qualify for premium tax credits if your employer plan doesn’t meet the Affordable Care Act’s standard for minimum value. If your employer plan only covers preventive services and a few doctor visits, it probably doesn’t meet the minimum value standard, and so you could be eligible for premium tax credits to help buy a Marketplace plan. However, if the mini-med plan is only one choice that your employer offers, and if another plan your employer offers would be affordable and meet the minimum value standard, then you will not qualify for premium tax credits in the Marketplace.

My large employer offers health benefits to me. My spouse works and has coverage through her job. To figure out whether my coverage is affordable, do I just count my income or do I count my spouse’s salary, as well?

If you are considering applying for premium tax credits for coverage in the Marketplace, the test for whether your employer coverage is affordable is based on the cost of self-only coverage in the lowest cost plan your employer offers, compared to your household income (and not just your salary).

I’m eligible for health benefits at work. However, unfortunately, I forgot to turn in my enrollment papers on time during the company open season, so now I’m not covered. Can I get policy in the Marketplace instead? Can I apply for subsidies?

If you missed your opportunity to enroll in your employer plan during the company’s open enrollment season, you can still apply for coverage in the Marketplace during open enrollment. You can also apply for subsidies but you will have to provide information on the health coverage you are eligible for at work, even if you’re not enrolled in the plan. If the plan employer offered meets standards for affordability and minimum value, you will not be eligible for premium tax credits or cost-sharing reductions.

I’m leaving my job and will be eligible for COBRA. Can I shop for coverage on the Marketplace instead?

Yes, leaving your job and losing eligibility for job-based health coverage will trigger a special enrollment opportunity that lasts for 60 days. You can apply for Marketplace health plans during that period. If you enroll in COBRA coverage through your former employer, however, you will need to wait to the next Marketplace Open Enrollment period if you want to switch to a Marketplace plan.

I have COBRA and am finding it hard to afford, but Open Enrollment is over. Can I drop my COBRA and apply for non-group coverage outside of Open Enrollment?

No, voluntarily dropping your COBRA coverage or ceasing to pay your COBRA premiums will not trigger a special enrollment opportunity. You will have to wait until you exhaust your COBRA coverage or until the next Open Enrollment (whichever comes first) to sign up for other non-group coverage.

I have COBRA and it’s too expensive. Can I drop it during Open Enrollment and enroll in a Marketplace plan instead?

During Open Enrollment, you can sign up for a Marketplace plan even if you already have COBRA.  You will have to drop your COBRA coverage effective on the date your new Marketplace plan coverage begins.  After Open Enrollment ends, however, if you voluntarily drop your COBRA coverage or stop paying premiums, you will not be eligible for a special enrollment opportunity and will have to wait until the next Open Enrollment period.  Only exhaustion of your COBRA coverage triggers a special enrollment opportunity.

My employer’s plan is grandfathered so it doesn’t cover preventive services. Can I shop for better coverage in the Marketplace if my job-based plan is grandfathered?

You can always shop for coverage in the Marketplace. However, you can only apply for premium tax credits if your job-based plan – whether it is a grandfathered plan or not – is unaffordable or if it doesn’t meet minimum value. Whether your employer’s health plan meets minimum value will depend on a number of factors. The Marketplace application includes a form with questions about job-based coverage. You should take this form to your employer and has them to fill it out. With that information the Marketplace will determine whether the plan meets minimum value. If it doesn’t, you may be able to qualify for premium tax credits to help pay for Marketplace coverage.

The prescription drug benefit under my employer’s health plan only covers generic drugs. Does that mean it doesn’t have minimum value? Can I shop for better coverage and subsidies on the Marketplace?

Whether your employer’s health plan meets minimum value will depend on a number of factors. Some employer plans might be able to meet the minimum value standard even if they don’t provide coverage for brand name prescription drugs.  The Marketplace application includes a form with questions about job-based coverage. You should take this form to your employer and ask them to fill it out. With that information the Marketplace will determine whether the plan meets minimum value. If it doesn’t, you may be able to qualify for premium tax credits to help pay for Marketplace coverage.

My employer offers a health plan that covers preventive services and some other benefits, but it doesn’t cover inpatient hospital care (or only pays $100 per day for hospitalization). Because I’m offered this policy, does that mean I can’t qualify for subsidized coverage through the Marketplace?

The standard for “minimum value” has been clarified to also require plans to provide substantial coverage for hospitalization and for physician care.  The plan your employer offers would not meet this standard.  If that is the only plan your employer offers to you, then you would be eligible to apply for Marketplace coverage with premium tax credits.  However, if this so-called skinny plan is only one option offered to you, and if other plan choices offered to you by your employer do meet the “minimum value” standard and the affordability standard, then you would not be eligible for premium tax credits through the Marketplace.

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