Many families whose employer’s insurance does not match their ability to pay are now eligible for Covered California benefits.

If having a family on an employer-sponsored health plan is financially difficult or completely unable to pay, help may be available.

The federal government recently fixed a controversial Treasury Department rule related to the Affordable Care Act that denied support to many families with workplace insurance that broke the budget. their.

Because of the so-called family breakdown, if an employee has access to employee-only coverage deemed affordable under federal guidelines, spouses or dependents cannot receive assistance. Help to buy a health plan through Covered California, the state’s ACA insurance marketplace, even if it’s not affordable to include them in an employer plan.

This affects the estimate 5.1 million people Nationwide, more than half of them are children, as employers typically only pay premiums for workers, leaving workers to pay the full cost of other family members.

Under one new rules effective December 12, if the cost of getting you and your family on a workplace insurance plan exceeds your affordability threshold — set at 9.12% of household income for the year 2023 — your spouse and dependents may be eligible for financial assistance to purchase insurance through Covered California. Affordability will be determined by how much you’ll have to pay to have them—and you—in your employer’s cheapest health plan.

The ACA insurance benefit in the form of a federal tax credit can be prepaid or settled with the IRS when you file your taxes next year.

estimate from UCLA’s Center for Health Policy Research and UC Berkeley’s Labor Center show that 391,000 Californians who were not previously covered under Covered California will be eligible for benefits under the new rules. Of those, an estimated 149,000 could be enrolled in a Covered California plan. According to the two centers, people switching from an employer-sponsored plan will save an average of $1,478 each this year.

“Fixing family problems is an important step in truly delivering on the ACA promise,” said Jessica Altman, chief executive officer of Covered California. “If you don’t have reasonable coverage from another source, the market is where you can go to get reasonable coverage.”

So, if you’re paying too much to pay for your family members on your employer’s health plan, you should find out if you can get a tax credit to help pay it off. pay their premiums in Covered California or not. But finding the answer is complicated and will take a lot of work.

If you have a steady job, last year’s earnings will likely be a good proxy for 2023, in addition to any pay increases you expect next year. You’ll also need to work out how much you’ll pay for your employer’s lowest-cost health insurance plan — both employee-specific and family coverage. If your costs alone are below the 9.12% threshold, you will not be eligible for the subsidized Covered California program, even if your spouse and dependents are eligible. That means a family can be split between the two policies, with separate deductibles and different provider networks.

You also need to determine if your employer’s lowest-cost plan meets the requirements. minimum standard of insurance according to the ACA. That means it should cover at least 60% of your total allowable medical expenses for the year and provide enough coverage for hospital and physician services. If it doesn’t meet those requirements, you and your family may be able to get a benefit program through Covered California, depending on your income.

If the couple has access to employer coverage, you’ll need to do this exercise for both options.

Do you feel your head spinning? You’re not alone.

“The job is really complicated,” said Kevin Knauss, an insurance agent at Granite Bay. “And how can we expect families that are doing all these different things – kids, Christmas – to really focus on these things?”

But don’t ignore the new rule, because you can leave money on the table. Covered California has a spreadsheet to help calculate your eligibility for benefits. Your human resources department may be available to help you fill out. Or you can seek professional help, whether as an insurance agent or other certified enrollee. You won’t need to pay a dime for either.

To find a certified insurance agent or enrollee, log on to the Covered California website ( and click the “Support” tab. Or call 800-300-1506. Covered California has a Very helpful FAQ All about fixing for household glitches.

The 2023 coverage period begins on November 1 and runs through January 31. If you buy coverage this month, it will start on February 1.

Fixing family errors isn’t new to Covered California. Starting this year, you can order a dependent parent or stepparent in your health plan, as long as they are not eligible for or not enrolled in Medicare.

And, in case you missed it, Congress extended until 2025 Additional tax credits help increase aid for people who have received some money before and are available to many middle-class households that were previously ineligible for financial assistance.

The idea behind expanded financial assistance is to limit the amount people spend on health care insurance premiums to no more than 8.5% of household income, no matter how much they earn.

Knauss said he spoke to a Marin County man who was looking for a Covered California health plan for his family of four and is eligible for a monthly benefit of 1,400 dollars, even though he earns $200,000 a year. Being over 60 and living in Northern California, an expensive area, has pushed his family’s premiums up to levels that open the door to substantial financial assistance, Knauss said.

If you’re already enrolled in Covered California, don’t just renew your coverage for this year. Pricing and carrier networks may vary from year to year, and there may be a new, cheaper option in your area. So shop around.

And whether you’re new or returning to Covered California, know what your medical needs may be. If you have a condition that requires intensive services, you might consider paying higher premiums in exchange for lower deductibles and coinsurance when you seek care.

Have fun hunting.

Jessica Altman is the daughter of Drew Altman, president and chief executive officer of the KFF. KHN is an independent editor program of KFF.

This story is produced by KHNpublish California Health Linean editorially independent service of California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with Policy Analysis and Exploration, KHN is one of the three main activities in Vietnam KFF (Kaiser Family Foundation). KFF is a funded non-profit organization that provides information on health issues to the nation.


This story can be republished for free (detail).


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