Eligibility to Buy a Marketplace Plan

The Health Insurance Marketplace® is a service that helps people shop for and enroll in health insurance. The Marketplace is run by the federal government under the auspices of the Affordable Care Act, also known as Obamacare, which brought health insurance to millions of Americans who were previously uninsured. People who qualify for a Marketplace plan receive premium assistance in the form of advance tax credits that lower their monthly premiums. Some people also qualify for other cost-sharing reductions such as lower out-of-pocket costs for deductibles, copayments and coinsurance. Even greater savings are available to people who purchase a Silver plan (Marketplace plans are categorized under different “metal levels,” Bronze, Silver, Gold, and Platinum, as well as catastrophic plans for some people).

Sounds great, but not everybody qualifies to purchase health insurance through the Marketplace (either the federal Marketplace found at HealthCare.gov or state-run Marketplaces such as Covered California). What does it take to be eligible to buy a Marketplace plan? What if you are an immigrant? What if you are in jail? Can convicted felons join the Marketplace? Below we attempt to answer these questions by breaking down some of the main rules for eligibility to buy your health insurance from the Marketplace.

You must live in the United States.

If you are considered a resident of the U.S. by the IRS for tax purposes, then you will also be considered as living in the United States for Marketplace purposes. There are different ways to meet the IRS definition of resident:

• Be a U.S. citizen

• Be a lawful permanent resident of the United States at any time during the calendar year. If you have a “green card,” then you are a lawful permanent resident, meaning you can live and work in the U.S. permanently without fear of deportation or removal based on your immigration status. This status will last unless you voluntarily renounce and abandon it in writing or your immigrant status is administratively or judicially terminated by USCIS or a federal court.

• Be physically present in the U.S. for 31 days during the current year and 183 days during the current year and the two years immediately prior. The 183-day figure is calculated by counting all the days you were physically present in the current year, one-third of the days you were present in the prior year, and one-sixth of the days you were present in the year before the prior year. This is known as the “substantial presence test.”

You must be a U.S. citizen or national or be lawfully present in the U.S.

This can include being a lawful permanent resident/Green Card holder, as well as an asylee, refugee, or lawful temporary resident. If you were paroled into the U.S. or are here on a valid non-immigrant status, such as a student visa or worker visa, you are also considered lawfully present in the U.S. Other immigrants who can qualify for health insurance through the Marketplace include:

• Cuban/Haitian entrants
• Conditional entrants granted entry before 1980
• Battered spouses, children or parents
• Victims of trafficking and their spouse, children, siblings or parents
• Those granted withholding of deportation or removal under the immigration laws or the Convention against Torture
• Those granted Deferred Enforced Departure
• Those on Deferred Action Status (except that DACA residents may not apply)
• Those with an administrative order staying removal issued by the Department of Homeland Security
• Members of a federally-recognized Indian tribe or an American Indian Born in Canada
• Residents of American Samoa

You can also qualify to use the Marketplace if you are currently an applicant for any of the following immigration statuses:

• Temporary Protected Status with Employment Authorization
• Special Immigrant Juvenile Status
• Victim of Trafficking Visa
• Adjustment to LPR Status
• Asylum (with employment authorization or under the age of 14 and have had an application pending for at least 180 days)
• Withholding of Deportation, or Withholding of Removal, under the immigration laws or the Convention against Torture

Marketplace eligibility is also open to people with the following statuses provided they also have employment authorization (a Work Permit or Employment Authorization Document/EAD):

• Registry Applicants
• Order of Supervision
• Applicant for Cancellation of Removal or Suspension of Deportation
• Applicant for Legalization under Immigration Reform and Control Act (IRCA)
• Legalization under the LIFE Act

You might also be happy to know that information about immigration status is only used to determine eligibility for coverage and not for immigration enforcement purposes.

You must not be incarcerated.

Incarceration means you are serving a term in prison or jail. It does not include probation, parole or home confinement, even if you remain under the supervision of the criminal justice system. It also does not include being incarcerated pending the disposition of charges against you. If you have not yet been convicted of a crime, you can qualify for Marketplace coverage even if you are being kept in jail pending the outcome of your trial. You can enroll in Medicaid while incarcerated, although Medicaid won’t pay for medical care while you are incarcerated.

Once you have been released from prison, you can apply for an insurance plan through the Marketplace. U.S. law imposes many burdens and disqualifications on convicted felons, but accessing health insurance isn’t one of them. In fact, there is a Special Enrollment Period allowing you to sign up for coverage within 60 days after your release rather than waiting for the next open enrollment period to come around.

Free Help Is Available With Insurance Questions or Disputes

The HealthCare.gov website has abundant information regarding eligibility and how to apply for health insurance. If you live in a state that runs its own marketplace, they might have additional resources available to you as well. In California, for example, you can find information at www.coveredca.com and even get connected with a licensed insurance agent or trained advisor who can answer your questions and assist you for free. If you already have insurance but think your claim has been wrongfully denied or that your insurance company is acting in bad faith toward you, then you can seek out a qualified insurance law attorney to look into your case and make sure you get the coverage and benefits that you are entitled to. Find one who will take your case with no upfront fee and will only take a fee out of any financial recovery they obtain for you.