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I am 66 years old, work for a large employer, and have excellent health insurance coverage through my job. I am planning to keep working for a few more years and would like to keep the coverage that my employer offers. How does the Marketplace affect me?

It doesn’t.  You can keep your employer-sponsored health insurance coverage as long as that is an option for you.  Since you are already eligible for Medicare because you are over age 65, you should sign up for Medicare when you stop working or if you lose your employer coverage before then.  Once you decide when you want to stop working, you should contact the Social Security Administration about how and when to enroll in Medicare to be sure you don’t have a gap in coverage.

I received a Form 1095-C in the mail. What’s that?

Large employers must offer health insurance to their full time workers or pay a penalty.  These employers also must provide their employees with Form 1095-C to document that health coverage was offered.   Every employee of a large employer who was eligible for health coverage this year should receive a form 1095-C next year in January.  Even if you declined to sign up for your health plan at work, you will still receive a form 1095-C.  Information on this form will also be reported to the IRS.

Form 1095-C will indicate your name and the name of your large employer, the months during the prior calendar year when you were eligible for coverage, and the cost of the cheapest monthly premium you could have paid for coverage under your employer’s health plan. If you worked for a large employer that did not offer its full time employees health coverage, Form 1095-C will also indicate that.

Keep this form with your tax records.  You may need this form if you were offered health coverage by your employer and you did not sign up for it.  If you signed up for Marketplace coverage instead and received a premium tax credit, information on Form 1095-C will help you determine whether you were eligible for the tax credit (for example, if the cost of your employer health plan was more than 9.56% of your income in 2018.)

If you were uninsured during the year even though your employer offered you health coverage that year, you will be eligible for an exemption from the tax penalty in 2018 if you experienced a hardship that prevented you from enrolling in coverage.  You can claim the hardship exemption directly on your 2018 tax return when you file.  You will not be required to submit documentation of the hardship with your tax return, though you should retain any documentation for your own tax records.

My employer offers a plan with very limited benefits. It only covers preventive services and a few doctor visits each year. However, this plan option is free. If I sign up for it, will that satisfy the individual mandate to have coverage?

Yes, most group health plans offered by an employer are considered “minimum essential coverage.” Some limited benefit plans (for example, dental only plans) are not considered minimum essential coverage.  Your group health plan materials should indicate whether the plan is considered “minimum essential coverage.”  If it is and if you enroll in the plan, you will have met the requirement to have coverage and won’t owe a tax penalty.  However, the plan you described probably does not meet the standard for “minimum value.”  If this is the only plan your employer offers, you may be able to qualify for premium tax credits to help pay for Marketplace coverage.  The premium tax credits could help you afford coverage that would be more comprehensive.

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.

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.

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.

I’m offered health benefits at work, but they’re not very good. I’m applying for better coverage and subsidies in the Marketplace. The application asks whether I’m offered job-based health coverage that meets minimum value. What does that mean?

The term “minimum value” means that your job-based plan would cover at least 60% of an average group of people’s covered health costs.   In addition, employer plans must provide substantial coverage for hospitalization and for physician care to meet the “minimum value” test.  Most employer plans will meet this test, but some may not.  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 health benefits to me and my family. The company pays the entire cost of my coverage but contributes nothing toward the cost of covering my family. We can’t afford to enroll my spouse and kids. Can they get coverage and subsidies in the Marketplace instead?

You can always shop for health coverage in the Marketplace. However, your employer-provided coverage is considered “affordable.” That’s because the affordability of employer sponsored coverage is only measured with respect to self-only coverage. Because your employer pays the entire cost of the employee-only coverage, you are technically considered to have affordable coverage (even though practically speaking, it was unaffordable to you.) As a result, neither you nor your spouse and children are eligible to apply for premium tax credits in the Marketplace. Sometimes this rule is referred to as “the family glitch.”

There are some other things you should know. First, depending on your family income, your children might qualify for the Children’s Health Insurance Program in your state. Check with your state Marketplace to find out if your children may be eligible for CHIP.

Second, if you find you cannot afford to get coverage for your spouse and/or children, you should know that starting in 2019, there is no tax penalty for not having health insurance.

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