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Covered California Q&A

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.

Do I Have to Take Spouse's Employer Plan?

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Question: My wife recently learned that her employer will be offering coverage for her (50% employer contribution) and spouse coverage with no subsidy. It is a Silver plan and the premiums are going to be higher than if I just stayed with my Bronze plan on the exchange. We do not receive any premium assistance. Am I allowed under ACA to keep my Bronze plan through the Exchange, or do I have to accept the employer-offered spouse coverage Silver plan the my wife's employer?

Answer: It is your responsibility to notify Covered California that your spouse has been offered employer-based health insurance. However, since you are not receiving premium assistance, there is no penalty for not reporting the change. You can remove your wife from your Covered California plan and continue on your own, if that works better for you. Know that you will be ineligible for premium assistance through Covered California, regardless of your household income, as long as your spouse is offered employer-based health insurance.


Colleen, this is an IRS ruling as it affects subsidies. A group health plan would have to specifically exclude spouses and dependents from coverage for the dependents to be eligible for subsidized individual coverage. Currently only SHOP and California Choice offer the employer the option of insuring employees only. Therefore, virtually all spouses and dependents on California group plans would have to take the employer-based coverage or opt out for individual coverage without premium assistance.

Phil, Quick question on this scenario—your answer on this was that deps generally should be enrolling on employer coverage if offered. Is this across the board, is this a change, does it matter whether the employer is offering any kind of contribution for deps? I was surprised that deps may not be eligible for premium assistance, even when there is no employer contribution?

Wendy, You are conforming to the ACA law and IRS guidelines in choosing individual coverage through Covered California rather than your spouse’s group coverage as long as you understand that you are ineligible for premium assistance while you have access to “affordable” employer-based coverage.

I have been covered thru Covered California Blue Shield Silver 87 PPO plan with premium assistance.

I recently married on 05/16/15. I reported this “life -changing event” to Covered California including the increase in the annual household income with my spouse’s income and my income combined. Additionally, I informed Covered California that my spouse has health insurance thru her employer. If she adds me onto her employer plan, the cost to us would be less than 9.5% of our total annual household income which is considered “affordable” coverage.

As a result, Covered California informed me that because of the new amount of household income, I no longer qualify for premium assistance. I was also informed by Covered California that I would no longer qualify for coverage on the Blue Shield Silver 87 PPO plan and that I was eligible to change to the Blue Shield Silver 70 PPO plan but without any premium assistance.

After comparing the coverage offered by my spouse’s employer plan to the Blue Shield Silver 70 PPO plan, changing to the Blue Shield Silver 70 PPO plan was my preferred choice of coverage.

I was informed by both Blue Shield and Covered California that because “open enrollment period” is closed but the change is considered a “life-changing event”, this change in plans had to be done thru Covered California and not directly through Blue Shield.

Covered California changed my coverage to the Blue Shield Silver 70 PPO plan. The change went thru their system with 06/01/2015 as the effective date of coverage.

Here is my question: Under all the circumstances I have described above, can I be covered under Blue Shield Silver 70 PPO plan without any possibility of being penalized by any agencies governing and/or enforcing the laws, rules, and regulations under the Affordable Care Act, Obamacare Healthcare Act, ( i.e. I.R.S., etc..), or do I have to go on my spouse’s employer health plan which is considered “affordable”? Because throughout all of this, I made multiple inquiries to both Covered California and Blue Shield to confirm that this change is allowable. Each time the call would be addressed by a different representative with conflicting answers.

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