QUESTION

My employer’s workplace wellness program increases premiums for employees who don’t participate and/or can’t meet certain targets for healthy behavior. Can I leave my employer-sponsored plan and get marketplace coverage?

Individuals with coverage | Coverage for Employees of a Large Employer
ANSWER

It depends on how much your costs go up based on any premium increases you face due to the wellness program. If your premiums with the wellness penalty would be 9.86 percent of your income or more in 2019 (9.56 percent in 2018), or if your cost-sharing increases enough to lower the value of your plan below the minimum value standard (60 percent of average costs of covered services), then you may be eligible for premium tax credits. 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). (26 C.F.R. § 1.36B-2(c)(4); 26 C.F.R. § 1.36B-6(a)(c)(2).

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