Understanding Who’s Eligible for Marketplace Coverage
The Affordable Care Act (ACA) opened the door for millions of Americans to access affordable health insurance. But one of the most common questions people ask is simple: Do I qualify?
The good news is that ACA coverage is available to most U.S. residents, but the details depend on your household size, income, current insurance options, and life circumstances.
In this guide, we’ll break down the key factors that determine eligibility so you can see whether you qualify and how to take the next steps.
Basic ACA Eligibility Rules
At the most basic level, you qualify for ACA Marketplace coverage if you meet these requirements:
- You live in the United States
- You are a U.S. citizen or a lawfully present immigrant
- You are not currently incarcerated
- You are not enrolled in Medicare
That means almost all individuals and families can shop for a plan through the Marketplace. But to receive financial help like subsidies that lower your monthly premiums or reduce out-of-pocket costs, additional factors come into play.
Household Size Doesn’t Impact Eligibility
Your household size is only an eligibility factor for subsidies when compared to your household income level. It does not impact your eligibility to enroll in a plan on the Healthcare Marketplace. For ACA purposes, your household includes you, your spouse, and any dependents you claim on your federal tax return.
Even if some of your dependents don’t need insurance, they’re still counted when determining subsidy eligibility. And eligibility doesn’t stop there:
- Individuals can apply alone. You don’t need to be married or have dependents to qualify for ACA coverage.
- If your spouse has job-based coverage, you may still qualify. Depending on whether the employer plan is considered affordable, one spouse can stay on the employer plan while the other applies for an ACA plan.
- Children can sometimes be covered separately. In some households, kids may enroll in ACA coverage or in CHIP while parents use other insurance.
- There’s no cap on household members. Large families can all be listed on one Marketplace application, and each person’s eligibility is determined together.
Household Income and Eligibility to Enroll
Many people assume they earn too much to qualify, but that’s not the case. There is no strict upper income limit that makes you ineligible for ACA coverage. Even households with very high incomes can still enroll in a Marketplace plan. The only difference is that higher earners may not qualify for subsidies and will pay the full premium themselves.
However, the ACA does use your modified adjusted gross income (MAGI) to help determine eligibility for Marketplace subsidies, which can save you money on your health insurance coverage.
Employer Coverage and the “Family Glitch” Fix
In the past, families were disqualified from receiving subsidies on ACA plans if one member of the household had the option of using an employer-offered healthcare plan. Unfortunately, this made health insurance unaffordable for many families, since employer-offered healthcare plans were often reasonably priced for individuals, but that price skyrocketed once you added dependents.
This problem, called the “family glitch,” has since been fixed, which has opened the door for many more families to access affordable coverage through the Marketplace.
Employer coverage is considered affordable if the cost of the employee-only plan is less than about 9% of your household income. If you have an offer of affordable health insurance from your employer, you may not be eligible for subsidies on the Marketplace. However, the other members of your household may still qualify for Marketplace subsidies and other savings.
Qualifying for a Special Enrollment Period
Normally, you can only sign up for ACA coverage during open enrollment (which is generally November 1 through December 15). But certain life events can trigger a Special Enrollment Period (SEP), which gives you a 60-day window to apply for healthcare coverage. These events include:
- Marriage or divorce
- Birth or adoption of a child
- Losing other health coverage (such as job-based insurance or COBRA)
- Moving to a new area with different Marketplace options
- A change in immigration status
- Death in the household
Medicaid and CHIP Eligibility
In many states, ACA applications are also used to determine eligibility for Medicaid or the Children’s Health Insurance Program (CHIP). These programs work alongside the Marketplace to ensure that even the lowest-income households and children have a path to coverage.
- Medicaid is designed to provide free or low-cost coverage for individuals and families with limited incomes. Depending on where you live, you may qualify if your income falls below a certain percentage of the federal poverty level. In states that expanded Medicaid under the ACA, eligibility is generally broader and more inclusive.
- CHIP, on the other hand, is meant for children in families who earn too much to qualify for Medicaid but still need financial assistance to afford health insurance. In some states, CHIP also covers pregnant women.
Because income thresholds vary by state, some families may discover that parents qualify for Marketplace coverage, but their children are eligible for CHIP. Others may find that the entire family qualifies for Medicaid instead of ACA plans. This is why completing an ACA application is so useful, because it automatically checks your eligibility across all programs and directs you to the right place for coverage.
Additional FAQs About ACA Eligibility
Can I get ACA coverage just for my children?
Yes. Children can be covered under an ACA plan even if parents use different insurance, and in some cases kids may qualify for CHIP while parents stay on Marketplace or employer coverage.
Do I qualify if I’m self-employed?
Yes. Self-employed individuals can apply for ACA coverage the same way as anyone else, and their household income determines subsidy eligibility.
Can college students enroll separately?
Students can apply for their own ACA plan if they aren’t claimed as dependents, or they may be covered under a parent’s plan until age 26.
What if I move to another state?
A move to a new state automatically creates a Special Enrollment Period, allowing you to reapply and choose coverage available in your new location.
Get Expert Guidance from MBhealth
ACA eligibility rules can feel complicated, but you don’t have to figure it out alone. Whether you’re unsure about your household size, your income, or how your employer coverage affects subsidies, MBhealth Insurance Agency can help. We’ll review your situation, explain your options in plain language, and guide you to the plan that best fits your needs and budget.
Call (314) 544-5400 or schedule your no obligation consultation today to find out if you qualify for ACA health insurance and how to make the most of your coverage.
