Employer-Sponsored Health Coverage

My employer health plan has a wellness feature that requires me to pay a higher premium if I don’t meet certain health targets or if I don’t participate at all. I can’t afford the premiums if I don’t participate or miss the mark. Can I leave my employer-sponsored plan and get one on the health insurance Marketplace?

It depends. If your premium contribution with the wellness penalty would be more than 9.78% of your income in 2020, then your employer plan would be considered unaffordable and you would be eligible to apply for premium tax credits in the Marketplace. This test applies whether you are actually penalized or not, and in advance of the penalty being applied (for example, if your employer gives you time to try to meet the health standard that triggers a penalty or reward).

Similarly, if your employer wellness program applies the penalty to the plan cost sharing (for example, people who don’t participate or who can’t meet the health targets have a higher deductible than would otherwise be the case), and if penalty is high enough to reduce the value of your plan below the “minimum value,” then you would be eligible to apply for premium tax credits in the Marketplace. Again, this test applies whether you are actually penalized or not and in advance of the penalty ever being applied.

While we have made every effort to provide accurate information in these FAQs, people should contact the health insurance Marketplace or Medicaid agency in their state for guidance on their specific circumstances.

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California.