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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Affordable Group Coverage a Dilemma for this Family

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Question: My son and I buy health insurance through my husbands work. My husband is covered 90% and we are covered 0%. Our annual income is $55,000 and we pay $7,000/ year in health insurance w/ a $1,500 deductible per person. Can my son and I apply for Cover California in October or are we screwed because my husbands part of insurance doesn’t exceed 9.5% of his income. Is my best hope his company decides to not have health insurance to their employees so we can apply for Cover California?

Answer: You and your son will be able to purchase health insurance in the Covered California insurance marketplace, but you will not be eligible for a premium subsidy if your husband is offered “affordable” group health insurance by his employer. As you say, it would be better for your family if your husband’s employer did not offer group coverage.


OK- so my situation is very similar with, I hope, an important difference. I am self employed. Does this make any difference? In other words, could we use my “employer” health plan rather than my husbands to justify that the cost of healthcare is not affordable for our family? My husband’s employer pays 100% of his healthcare but to add myself and our 2 children would cost $1000/month. In my case- my self-employed health insurance costs just me $500 and to add the kids (who are currently uninsured) would put it around $750/month which would put us beyond the 9.5 threshold of “affordable insurance”. Is this workable?

The employer does not have the right to exclude spouse and dependent coverage. He can only choose not to contribute to their coverage. So even though the employee would have to pay 100% of the spouse and dependent coverage, they could be ruled to have “affordable” group coverage available. It is what it is. I’m not saying it’s fair.

Right, but what if the employer only offers employee “ONLY” coverage meaning the plan does not cover spouse or dependents. Even if was deemed affordable (less than 9.5%)the spouse and dependents would still have to pay 100% of the cost of insurance because they are not covered under the company group plan. Does this mean that the employee is still responsible to cover his or hers family and dependents at 100% when they would qualify for a subsidy through the exchange?

Not if the employee’s contribution to the employee-only coverage was less than 9.5% of his or her income.

Thanks Phil,

What if the husband is offered employee “only” coverage. Wouldn’t that trigger the spouse and dependents to receive a subsidy through covered California?



Sorry, Jose. I forgot the “not”. It should read: “..you will NOT be eligible for a premium subsidy if your husband is offered “affordable” group health insurance by his employer.

You are right, Mike. I’m sorry I further confused this issue by forgetting the “not”. It should read: “..you will NOT be eligible for a premium subsidy if your husband is offered “affordable” group health insurance by his employer.

Dear Phil, Enjoy your articles but in this one do you mean that the family will NOT be eligible for a premium subsidy?

So you will get a premium subsidy even if the husband is offered “affordable” group insurance?



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