Many Families With Unaffordable Employer Coverage Now Eligible for Covered California Subsidies

If having the family on your employer-sponsored health plan has been a financial hardship, or outright impossible to afford, help may be on the way.

The federal government recently fixed a controversial Treasury Department rule tied to the Affordable Care Act that denied assistance to many families whose workplace coverage busted their budgets.

Because of the so-called family glitch, if a worker had access to employee-only coverage deemed affordable under federal guidelines, a spouse or dependents could not get help to buy a health plan through Covered California, the state’s ACA insurance marketplace, even if it was not affordable to put them on the employer plan.

This affected an estimated 5.1 million people nationally, more than half of them children, since employers often contribute only to an employee’s premium, leaving workers to pay full fare for other family members.

Under a new rule that took effect Dec. 12, if the cost of having you and your family on a workplace plan exceeds an affordability threshold — set at 9.12% of household income for 2023 — your spouse and dependents could qualify for financial aid to purchase insurance through Covered California. Affordability will be determined by how much you would have to pay to have them — and you — on your employer’s cheapest health plan.

ACA insurance subsidies come in the form of federal tax credits that can be taken upfront or settled with the IRS when you file your taxes the following year.

Estimates from the UCLA Center for Health Policy Research and the UC Berkeley Labor Center show that 391,000 Californians previously excluded from subsidies in Covered California would be eligible for them under the new rule. Of those, an estimated 149,000 would likely enroll in a Covered California plan. Those switching from an employer-sponsored plan would save an average of $1,478 per person this year, according to the two centers.

“Fixing the family glitch is a critical step in really delivering on the promise of the ACA,” says Jessica Altman, executive director of Covered California. “If you don’t have affordable coverage from another source, the marketplace is where you should be able to come for affordable coverage.”

So, if you are paying too much to cover your family members on your employer’s health plan, it is definitely worth finding out whether you can get a tax credit to help pay their premiums on a Covered California plan. But finding the answer is complicated and will take considerable legwork.

If you have steady employment, last year’s income will probably be a good proxy for 2023, adding any pay raise you expect in the coming year. You’ll also need to calculate how much you would pay for your employer’s lowest-cost health plan — both for employee-only coverage and for family coverage. If the cost for you alone is under the 9.12% threshold, you will not qualify for a subsidized Covered California plan, even if your spouse and dependents do. That means a family could be split between two policies, with separate deductibles and different provider networks.

You also need to determine whether the lowest-cost plan offered by your employer meets the minimum coverage standard under the ACA. That means it must cover at least 60% of your total allowed medical expenses during the year and provide sufficient coverage for hospital and physician services. If it does not meet those requirements, you and your family might be able to get a subsidized plan through Covered California, depending on your income.

If two spouses have access to employer coverage, you’ll need to perform this exercise for both options.

Is your head spinning yet? You’re not alone.

“This stuff is just really complicated,” says Kevin Knauss, an insurance agent in Granite Bay. “And how can we possibly expect families that are doing all kinds of different things — kids, Christmas — to really focus on this stuff?”

But don’t ignore the new rule, because you could be leaving money on the table. Covered California has a worksheet to help calculate your eligibility for subsidies. Your human resources department might be willing to help you fill it out. Or you could seek professional help, whether an insurance agent or other certified enroller. You wouldn’t need to pay a penny for either.

To find an insurance agent or certified enroller, log on to Covered California’s website (www.coveredca.com) and click on the “Support” tab. Or call 800-300-1506. Covered California has a very useful FAQ all about the fix to the family glitch.

The enrollment period for 2023 coverage started on Nov. 1 and runs through Jan. 31. If you buy coverage this month, it will start on Feb. 1.

The family glitch fix isn’t the only new thing with Covered California. Starting this year, you can put a dependent parent or stepparent on your health plan, as long as they are not eligible for or enrolled in Medicare.

And, in case you missed it, Congress extended through 2025 the supplemental tax credits that increase aid to people who were already getting some before and are available to many middle-class households that did not previously qualify for financial assistance.

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

Knauss said he talked to a man in Marin County who was seeking a Covered California health plan for his family of four and qualified for a monthly subsidy of $1,400, even though he makes $200,000 a year. Being over 60 and living in Northern California, an expensive region, pushed his family’s premium to a level that opened the door for significant financial assistance, Knauss said.

If you are already enrolled in Covered California, don’t simply renew coverage for this year. Prices and provider networks can change from year to year, and there might be a new, cheaper option in your region. So shop around.

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

Happy hunting.

Jessica Altman is the daughter of Drew Altman, who is president and CEO of KFF. KHN is an editorially independent program of KFF.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Bernard J. Wolfson:
bwolfson@kff.org,
@bjwolfson