This article covers how an offer of employer-sponsored coverage and a Medicaid or CHIP denial affects a consumer's eligibility for Marketplace enrollment, Special Enrollment Periods, and financial assistance.
Key Terms
Key Terms
Employer-Sponsored Coverage (ESC): Health coverage offered to an employee through their employer. An offer of ESC can affect eligibility for Marketplace financial assistance if the ESC is considered affordable and provides minimum value.
Minimum value: A standard requiring that an employer-sponsored health plan pay at least 60% of the total allowed cost of benefits.
Special Enrollment Period (SEP): A time outside of Open Enrollment when a consumer can enroll in or change their Marketplace coverage due to a qualifying life event.
Medicaid/CHIP denial SEP: A SEP available to consumers who were referred to their state Medicaid or CHIP agency and were ultimately found ineligible outside of Open Enrollment.
If a consumer is found not eligible for Medicaid or CHIP and has an offer of employer-sponsored coverage, can they still enroll in a Marketplace plan and receive financial assistance?
Having an offer of employer-sponsored coverage does not affect a consumer's eligibility to enroll through the Marketplace or access a SEP, but it can affect eligibility for financial assistance. A SEP exists specifically for consumers denied Medicaid or CHIP. To qualify for the Medicaid/CHIP denial SEP, the consumer must have applied for Marketplace coverage during Open Enrollment or through a SEP, been referred to their state Medicaid/CHIP agency, been ultimately determined ineligible, and be otherwise eligible for Marketplace coverage. If qualified, the consumer has 60 days from the date of the Medicaid or CHIP denial to enroll.
Does an offer of employer-sponsored coverage affect financial assistance eligibility for a consumer who qualifies for the Medicaid/CHIP denial SEP?
Yes. A consumer who qualifies for the Medicaid/CHIP denial SEP but has an offer of ESC that is considered affordable and provides minimum value does not qualify for APTC or cost-sharing reductions (CSRs).
In 2026, ESC is considered affordable if the employee premium for self-only coverage is less than 9.96% of household income. Consumers whose ESC is not affordable or does not provide minimum value qualify for APTC and CSRs, if otherwise eligible.
My client does not file taxes jointly with their spouse. Are they eligible for financial assistance through the Marketplace?
Generally, married couples must file taxes jointly to be eligible for Marketplace financial assistance. However, two exceptions apply:
Exception 1 — Domestic abuse, domestic violence, or spousal abandonment: The consumer may enter "single" on their Marketplace application and would then be eligible for PTC and CSRs if they qualify based on income.
Exception 2 — Head of household filing status: If the consumer will file using the head of household filing status, they must enter "married" on their Marketplace application. The consumer would then be eligible for PTC and CSRs if they qualify based on income and other factors.
Additional Resources
For additional help, please contact Producer Support, which is available by chat directly from your account, by phone at (866) 568-9649, or by email at [email protected].