Orlando Harmon
If you're a U.S. resident for tax purposes, you're eligible for Marketplace insurance coverage. This includes U.S. citizens and those who owe permanent allegiance to the U.S., such as non-citizen nationals born in American Samoa or with parents who are American Samoan. Eligibility for advance tax credits and cost-sharing reductions is determined annually before the start of the new coverage year. Life events like moving, having a baby, or changes in household income may qualify you for a special enrollment period, allowing you to adjust your coverage outside of the regular open enrollment period. Additionally, small businesses with 50 or fewer full-time employees can explore the SHOP Marketplace for providing health coverage to their employees, with some states extending this to businesses with up to 100 employees.
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What You'll Learn
US residency
To be eligible for Marketplace insurance, you must be a US citizen or national or be lawfully present in the United States. Lawfully present immigrants can get Marketplace coverage and may qualify for premium tax credits and other savings on Marketplace plans. Non-citizens with certain approved visas are also eligible for Marketplace coverage.
The term "lawfully present" includes immigrants who have "Qualified Non-Citizen" immigration status, humanitarian statuses or circumstances (including Temporary Protected Status, Special Immigrant Juvenile Classification, refugees and asylees, Convention against Torture, victims of trafficking), or legal status conferred by other laws (temporary resident status, LIFE Act, Family Unity individuals). Refugees and asylees do not have a 5-year waiting period for Marketplace coverage.
If you live in a US territory, you cannot get health coverage through the Marketplace unless you also qualify as a resident in any of the 50 states or Washington, DC.
Each state's Marketplace has its own enrollment instructions. During the Marketplace open enrollment period each year, you can change your coverage during a special enrollment period if you experience a life event like moving or having a baby. You may also qualify for a special enrollment period if your household income is below a certain amount.
The amount you pay for your health insurance may depend on where you live, your income, and the size of your household.
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Income level
The Federal Poverty Level (FPL) is another critical metric used to determine eligibility for Marketplace savings. The FPL is updated annually by the Department of Health and Human Services (HHS) and varies based on family size. For 2025, the FPL is $15,060 for a single adult and $31,200 for a family of four, with higher thresholds in Alaska and Hawaii.
If your income is above 400% of the FPL, you may qualify for the premium tax credit, which reduces your monthly premium for a Marketplace plan. Those with incomes between 100% and 400% of the FPL are eligible for this credit in all states and will pay between 0% and 8.5% of their income for a mid-level plan premium. If your income is below 100% of the FPL, you likely won't qualify for savings on a Marketplace plan but may be eligible for Medicaid or CHIP.
Cost-sharing subsidies are another form of financial assistance available to those with incomes between 100% and 250% of the poverty level. These subsidies help reduce out-of-pocket costs when utilizing healthcare services. Enhanced cost-sharing subsidies are offered to Native Americans at higher income levels.
When estimating your income for Marketplace eligibility, include all household income, such as wages, interest, dividends, and Social Security. You can use the Health Insurance Marketplace Calculator to input your household income in 2025 dollars or as a percentage of the FPL. It's important to report any income changes promptly, as failing to do so may result in missing out on savings or owing money when filing your tax return.
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Household size
When determining your eligibility for Marketplace insurance, your household size is an important factor to consider. This includes everyone you include on your tax return as a dependent, as well as yourself. Even if you don't claim someone as a dependent on your taxes, they may still be considered part of your household for insurance purposes.
Your spouse, domestic partner, and any unmarried children under 26 years old are typically considered part of your household. This includes biological, adopted, step, and foster children, as well as children for whom you are the legal guardian or who live with you and depend on you for support. If you're filling out a Marketplace application, you'll need to include the people in your household who need health coverage, even if they file taxes separately.
It's important to accurately report your household size when applying for Marketplace insurance. This is because the size of your household impacts the amount of financial assistance you may be eligible to receive. A larger household size may qualify you for more savings, as it's assumed that you have more people to support with your income.
When determining your household size, you should include anyone who is considered a tax dependent. This includes children and relatives who live with you and depend on you for support, even if they don't need health coverage. Additionally, if you're pregnant, you may include your unborn child in your household size, which can impact your eligibility for certain programs or savings.
It's worth noting that there are some people who don't count towards your household size, even if you claim them as dependents on your taxes. This includes children who are 26 years or older and other relatives, such as parents or grandparents, who may be claimed as dependents due to specific circumstances. Additionally, roommates, landlords, and foster children placed with you by a government agency don't impact your household size, even if you include them on your tax return.
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Life events
Moving
If you move to a different location, you may be able to change your coverage during a special enrollment period. This special enrollment period is only available to applicants who already had minimum essential coverage for at least 60 days before the move.
Losing health coverage
If you lose your health coverage, you may qualify for a Special Enrollment Period. This includes losing Medicaid or CHIP coverage, or losing coverage through your employer or a family member.
Getting married
If you get married, you may qualify for a Special Enrollment Period.
Having a baby or adopting a child
If you have a baby, adopt a child, or place a child for foster care, you may qualify for a Special Enrollment Period. Your coverage can start from the day of the event, even if you enroll up to 60 days afterward.
Income changes
If your income changes, you may be able to qualify for a Special Enrollment Period, especially if your household income falls below a certain amount.
Other life events
Other life events that may qualify you for a Special Enrollment Period include gaining membership in a federally recognized tribe, becoming a U.S. citizen, or starting or ending service in certain government programs.
It's important to note that eligibility for Marketplace Insurance also depends on other factors, such as your citizenship status and residence, as well as the specific rules and guidelines of the state where you reside.
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Tax credits
The Premium Tax Credit is a refundable credit that helps eligible individuals and families cover the premiums for their health insurance purchased through the Health Insurance Marketplace. The size of the Premium Tax Credit is based on a sliding scale, with generally larger credit amounts available to those with lower household incomes. The credit is "refundable" because, if the credit amount is more than the tax liability, the user will receive the difference as a refund.
To get this credit, you must meet certain requirements and file a tax return with Form 8962, Premium Tax Credit (PTC). The IRS provides an "Am I Eligible to Claim the Premium Tax Credit" interview tool to help determine eligibility. The requirements for the Marketplace and the health plans offered are administered by the Department of Health and Human Services (HHS). Generally, you purchase health insurance at the Marketplace during an open enrollment period. After an open enrollment period is over, individuals who experience certain life events may qualify for a special enrollment period to buy a health plan through a Marketplace.
For the 2021 and 2022 tax years, the American Rescue Plan Act of 2021 (ARPA) temporarily expanded eligibility for the premium tax credit by eliminating the rule that a taxpayer with a household income above 400% of the federal poverty line cannot qualify for a premium tax credit. For 2021, if you or your spouse (if filing a joint return) received or were approved to receive unemployment compensation for any week in 2021, your household income is considered to be within these limits. For 2025, the federal poverty level is projected to be $15,060 for a single adult or $31,200 for a family of four.
In addition, to be eligible for the premium tax credits, individuals must not be eligible for public coverage—including Medicaid, the Children's Health Insurance Program, Medicare, or military coverage—and must not have access to health insurance through an employer. If your income is below 100% of the FPL, you typically will not qualify for premium tax credits under Marketplace plans.
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Frequently asked questions
If you are a U.S. "resident" for tax purposes, you are eligible to get Marketplace coverage.
If you live in a U.S. territory, you cannot get health coverage through the Marketplace unless you also qualify as a resident in any of the 50 states or Washington, D.C.
If your circumstances change, you should report this to the Marketplace. Changes may include alterations to your household income or family size. Changes in circumstances may affect your eligibility for advance payments of the premium tax credit.
Each state's Marketplace has its own enrolment instructions. You can visit Healthcare.gov to find your state Health Insurance Marketplace and learn more about eligibility and enrolment.
