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I enrolled in a Marketplace policy with premium tax credits in 2018, even though my employer offers health benefits, because the employer coverage was unaffordable (more than 9.56% of my income in 2018). Then mid-year I started a second part-time job. As a result my annual income will be higher than I originally estimated, and, at this higher income, the cost of enrolling in my job-based plan would be less than 9.56% of my income. Unfortunately, I can’t sign up for my employer plan until the next open season. What should I do? When I file my taxes will I be required to pay back my premium tax credits because I had access to affordable job-based coverage after all?

First, you should report your income change to the Marketplace. The Marketplace will determine your new eligibility for premium tax credits, based on your higher income, and adjust the level of subsidy going forward. If you make this adjustment promptly, it’s likely you won’t receive any more advanced premium tax credit during the entire year than you’re eligible for based on your annual income.

As for the new “affordability” of your job-based coverage option, that won’t be taken into account when you file your taxes. As long as the Marketplace determined you were not eligible for affordable job-based coverage when you initially applied for Marketplace coverage and subsidies, that determination will hold for the remainder of the year. The IRS refers to this as a “safe harbor,” and won’t require you to go back and re-compute the affordability of your job-based coverage at year end when you file your taxes.

My family and I are offered health benefits through my job, but we can’t afford to enroll. My employer pays 100% of the premium for workers, but contributes nothing toward the cost of adding my spouse and kids. Can we try to find a better deal in the Marketplace?

You can always shop for coverage on the Marketplace, but your family members won’t be eligible for tax credits to help pay the premium. When people are eligible for employer-sponsored coverage, they can only qualify for Marketplace premium tax credits if the employer-sponsored coverage is considered unaffordable. Coverage is considered unaffordable only if your cost for coverage for yourself, alone, under the employer plan is more than 9.86% of your income in 2019. The cost of adding your spouse and children to family coverage is not taken into consideration.  So although you may feel your family coverage is unaffordable in practical terms, it is considered technically affordable.  Sometimes this situation is referred to as “the family glitch.”

I’m married. I work full-time for a large employer that offers me health benefits, but won’t cover spouses. Is that allowed? Can my spouse apply for coverage and subsidies in the Marketplace?

Large employers are required to offer health benefits to full-time workers and to their dependent children, or face a penalty. However, large employers are not required to offer health benefits to the spouses of full-time workers, so your employer would not have to pay a penalty for refusing to offer coverage to your spouse.  A large employer is one that employees at least 50 workers.

Because your spouse is not offered health benefits through your job, s/he may be eligible to apply for coverage and premium tax credits through the Marketplace.

I’m single and I’m offered health benefits at work. Can I try to find a better deal in the Marketplace?

Usually no. If you are offered health benefits at work and your required contribution costs no more than 9.86 percent of your 2019 household income, you will not be eligible for premium tax credits through the Marketplace. If you are required to pay more than 9.86% of your income to enroll in coverage for a single person under your job-based health plan, then you could qualify for premium tax credits in the Marketplace in 2019.

In addition, if your job based health plan doesn’t meet the standards for minimum value (for example, if it has an annual deductible higher than $7,900 per person, or if it doesn’t cover hospitalization), then you could also qualify for premium tax credits.

When you apply for a premium tax credit in the Marketplace, the application will include a form with questions about the affordability and minimum value of any job-based coverage you may be eligible for. Take that form to your employer and ask them to fill it out. The Marketplace will review the information and let you know whether you qualify for premium tax credit.

My employer health plan has a wellness feature that requires me to pay a higher premium if I don’t meet certain health targets or if I don’t participate at all. I can’t afford the premiums if I don’t participate or miss the mark. Can I leave my employer-sponsored plan and get one on the health insurance Marketplace?

It depends. If your premium contribution with the wellness penalty would be more than 9.86% of your income in 2019, then your employer plan would be considered unaffordable and you would be eligible to apply for premium tax credits in the Marketplace. This test applies whether you are actually penalized or not, and in advance of the penalty being applied (for example, if your employer gives you time to try to meet the health standard that triggers a penalty or reward).

Similarly, if your employer wellness program applies the penalty to the plan cost sharing (for example, people who don’t participate or who can’t meet the health targets have a higher deductible than would otherwise be the case), and if penalty is high enough to reduce the value of your plan below the “minimum value,” then you would be eligible to apply for premium tax credits in the Marketplace. Again, this test applies whether you are actually penalized or not and in advance of the penalty ever being applied.

I live in State A but my small business is in State B. I want to buy group coverage for my employees through the SHOP Marketplace. In what state should I buy health benefits?

You should buy group coverage through the SHOP Marketplace in State B, where your business is located.  If your business is located in a HealthCare.gov state, there is no SHOP Marketplace website.  Instead, you should contact insurers directly or work directly with a broker to buy a small group policy.  Be sure to specify that you want a SHOP policy.

When can small employers enroll in coverage through the SHOP Marketplace?

Small employers can buy coverage for their employees through the SHOP Marketplace at any time during the year.  HealthCare.gov no longer operates a SHOP Marketplace website for small employers, however.  If you want to sponsor small group coverage through the Marketplace for your employees, you can contact Hummingbird Insurance to book an appointment!  In HealthCare.gov states, you can find a SHOP-certified broker using the Find Local Help tool.  Be sure to specify to the insurer or broker that you want a SHOP policy.

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