Navigator Guide FAQs of the Week: Who is Eligible for Marketplace Coverage?

Navigator Guide FAQs of the Week: Who is Eligible for Marketplace Coverage?
Navigator Guide FAQs of the Week: Who is Eligible for Marketplace Coverage?

The start of the Marketplace Open Enrollment Period in most states was on November 1. There was a timely update made to CHIR’s Navigator Resource Guide just before the commencement of the annual enrollment window. The Navigator Guide, backed by the Robert Wood Johnson Foundation, furnishes a user-friendly online resource for helpers, encompassing over 300 easily searchable frequently asked questions (FAQs), fact sheets for all 50 states and DC, and an “Ask an Expert” function.

Throughout the Open Enrollment period, we will present frequently asked questions (FAQs) from the Navigator Guide regarding Marketplace eligibility, enrollment, financial aid, and other common queries that arise during the sign-up process. This week, we are focusing on who qualifies for Marketplace plans.

Who is eligible to purchase coverage in the Marketplace?

The majority of people are eligible to explore coverage options in the Marketplace. To be qualified, it is necessary to reside in the state where the Marketplace operates, be a U.S. citizen or be lawfully present in the U.S., and not be incarcerated at present.

However, not all individuals eligible to buy coverage in the Marketplace are entitled to subsidies. Eligibility for subsidies is contingent on not being eligible for certain other forms of coverage, such as Medicare, Medicaid, or an affordable employer-sponsored plan. (45 C.F.R. § 155.305; 26 U.S.C. § 36B(c).)

Even though I am eligible for health benefits through my job, can I assess if I can obtain a more favorable arrangement in the Marketplace?

If all other eligibility criteria are met, you can peruse coverage options on the Marketplace during the open or special enrollment periods. However, if you have access to job-based coverage, you might not be eligible for premium tax credits.

Individuals can only be eligible for Marketplace premium tax credits if the employer-sponsored coverage is deemed unaffordable. The unaffordability of the coverage is calculated based on whether the cost for coverage for an individual under the employer’s plan exceeds 8.39 percent of their household income in 2024 (or 9.12 percent of household income for the year 2023). (IRS Rev. Proc. 2023-29.)

Can I purchase a plan on the Marketplace without possessing a green card?

Possibly, yes. To acquire a plan in the Marketplace, it is necessary to have a qualifying immigration status, such as permanent residency (green card), certain types of visas, or refugee status. Additional information about qualifying statuses can be found here.

If one is not lawfully present in the U.S., they are not eligible to purchase a plan via the health insurance Marketplace. Nonetheless, they can explore individual health insurance options outside of the Marketplace, and certain states may offer financial aid based on their income. To obtain coverage, one should approach a state-licensed health insurance company or a licensed agent or broker. The state Department of Insurance can assist in locating one. (45 C.F.R. § 155.305.)

Open Enrollment continues until January 15 in most states. Keep an eye out for additional FAQs of the week and refer to the Navigator Resource Guide for a wide array of FAQs and useful resources.

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