Navigator Guide FAQ of the Week: Who Is Eligible To Purchase Coverage Through the Marketplace?

Open Enrollment for marketplace coverage under the Affordable Care Act (ACA) begins today and goes through December 15 in many states. To help assisters and consumers navigate this enrollment season, CHIR has updated its Navigator Resource Guide, with thanks to support from the Robert Wood Johnson Foundation. The Guide is a practical, hands-on resource with over 300 searchable frequently asked questions (FAQs) on topics such marketplace eligibility, premium and cost-sharing assistance, the individual mandate, and post-enrollment issues for individuals.

Throughout Open Enrollment, we will highlight FAQs that are likely to be top of mind for consumers as they apply for and enroll in health coverage. This week, we are focusing on who is eligible to shop for coverage in the ACA marketplace.

Who can buy coverage in the marketplace?

Most people can shop for coverage in the marketplace. To be eligible you must live in the state where your marketplace is, you must be a citizen of the U.S. or be lawfully present in the U.S., and you must not currently be incarcerated.

Not everybody who is eligible to purchase coverage in the marketplace will be eligible for subsidies, however. To qualify for subsidies people will have to meet additional requirements having to do with their income and their eligibility for other coverage. (45 C.F.R. § 155.305; 26 U.S.C. § 36B (c)).

I’m eligible for health benefits at work, but I want to see if I can get a better deal in the marketplace. Can I do that?

Assuming you meet other eligibility requirements, you can shop for coverage on the marketplace during open enrollment or a special enrollment period if eligible, but if you have access to job-based coverage, you might not qualify for premium tax credits.

When people are eligible for employer-sponsored coverage, they can only qualify for marketplace premium tax credits if the employer-sponsored coverage is unaffordable. The way this is calculated, coverage is unaffordable only if your cost for coverage for a single person under the employer plan is more than 9.83 percent of your household income in 2021 (for 2020, it is 9.78 percent of household income). (IRS Rev. Proc. 2020-36)

Can I buy a plan in the marketplace if I don’t have a green card?

Potentially, yes. In order to buy a marketplace plan, you must have a qualifying immigration status, such as permanent residency (green card), certain types of visas, or refugee status. You can find more information about qualifying statuses here.

If you are not a U.S. citizen, a U.S. national, or are not lawfully present status in the U.S., you are not eligible to buy a plan on the health insurance marketplace. However, you can shop for individual health insurance outside of the marketplace. To obtain coverage, contact a state-licensed health insurance company or a licensed agent or broker. Your state Department of Insurance can help you find one. (45 C.F.R. § 155.305).

Note that beginning February 24, 2020, the current policy that determines whether certain immigrants would be considered a “public charge” expanded. The impact of the public charge rule will depend upon your personal circumstances. Please see a qualified immigration lawyer or use the Keep Your Benefits Guide (available in English, Spanish, and Chinese) to check if you may be subject to a public charge determination. The Guide is free and does not ask for any personal information. If you need immigration assistance, please call the Office for New Americans at 1-800-566-7636 to be connected to free or low-cost legal representation/counseling services.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.