ACA... Some questions.

[robinb]

Again, cost of other available coverage is only a factor regarding eligibility for subsidies. Almost anyone can purchase from the ACA marketplace and pay full premium.

Her work's higher cost qualified her for a full subsidy.

 

[robinb]

Again, cost of other available coverage is only a factor regarding eligibility for subsidies. Almost anyone can purchase from the ACA marketplace and pay full premium.

Her work's higher cost qualified her for a full subsidy.

Edited, From AI

Under the ACA, employer-sponsored health insurance is considered "affordable" if the employee's share of the lowest-cost, self-only plan premium is less than 9.02% of their household income in 2025 (9.96% in 2026). In 2025, workers pay on average $6,850 annually for family coverage and $1,440 for individual coverage.
HealthCare.gov +3

Key Aspects of Employer-Sponsored Coverage Costs

• Affordability Definition: If premiums exceed 9.02% (2025) of household income, the coverage is unaffordable, potentially allowing workers to qualify for subsidized Marketplace plans.
• Average Costs: In 2025, total annual family premiums averaged $26,993, with employees contributing about 25% of that cost.
• Individual Costs: Workers generally pay about 16% of the premium for single coverage, averaging around $1,440 annually, while employers pay the remainder.
• Minimum Value Requirement: To comply with the ACA, employer plans must pay at least 60% of total medical costs (60% actuarial value).
• The "Family Glitch" Fix: As of 2023, families can qualify for Marketplace subsidies if the cost of covering the whole family exceeds the affordability percentage, even if self-only coverage is considered affordable.
  KFF +4

 

[lanejudy]

Her work's higher cost qualified her for a full subsidy.

Right. That’s what I said. The OP asked 2 questions, and most replies are lumping them into 1 answer.

1 - can the sister purchased from the ACA if the spouse’s employer offers coverage? YES, almost anyone can purchase from the ACA even if there are other options available. It is possible (though maybe too expensive for the budget) to purchase ACA without a subsidy. That may end up being someone’s “best” option.
2 - can the sister still qualify for subsidies on the ACA? That depends on multiple factors including the cost of the other option and the family’s income.

Many responses have claimed one can only purchase from the ACA if the cost of other options is high enough. That ONLY pertains to receiving a subsidy, not eligibility to purchase at full premium.

 

[lanejudy]

@leebee another thing for your sister to consider is deductibles/OOP max and whether the employer’s policy would count both her and her husband together (family deductible) or each separately (individual deductible). When 1 person in the family has high medical expenses, having deductible that can be met by anyone helps the rest of the family have lower OOP when they only occasionally need medical care.