From the LRRC Case Files - Week 9


Yitzchak Kupersmith is a freelance graphic designer with seven children and an income of $50k a year. Because of his income and family size, he was eligible to enroll in health insurance through NJ FamilyCare. Recently, however, he accepted a job as manager of a graphics department for a media company with an annual salary of $70k. Because of his new income, NJ FamilyCare terminated his and his wife's health insurance policies. Without insurance, Yitzchak had two options. He could either purchase the insurance plan offered by his employer or buy an insurance plan through the Health Insurance Marketplace. His employer offered three insurance options: a single plan that would cover just Yitzchak for $50 a month, a couple plan that would cover him and his wife for $600 a month, and a family plan for $1,100 a month. While the plan offered by his employer was reasonable and cheap to cover just him, the plan that included his spouse was expensive, offered lousy coverage, and was not accepted by the OB/GYN that his wife used.

Conversely, the insurance plan offered on the Marketplace was accepted by his wife's OB/GYN, yet at $490 a month, it was also expensive. However, because of his family size, Yitzchak was told that his wife would be eligible for government assistance in paying the premiums, bringing the monthly cost down to $280. This seemed like a good option. However, when Yitzchak completed the application, he was informed that they would receive no government subsidies, because his employer offered affordable insurance. This made no sense to him, as his employer's couple plan was prohibitively expensive and was not even an option in their situation.

Question: How does insurance offered by an employer affect one's ability to receive financial assistance through the Marketplace?

Answer: This is a confusing and upsetting topic for many. During Open Enrollment, the LRRC receives over 50 inquiries a day from people seeking clarity on this topic.

A little background: Under the Affordable Care Act, everyone must buy health insurance. However, many people have trouble paying for their medical expenses, so the government stepped in to assist. Depending on a person's income, the government will assist with paying the premiums and/or 'out of pocket' expenses, which include copays and deductibles.

Now here comes the upsetting rule: If one spouse's employer offers health insurance that is considered affordable based upon the Affordable Care Act's rules, then the entire family is not eligible for financial assistance. Although Yitzchak has no interest in enrolling his wife in his employer's plan, as long as that plan is considered affordable, neither he nor anyone in his family is eligible to receive financial assistance.

What is considered an affordable plan? An employer plan is considered affordable as long as the least expensive single employee plan costs less than 9.69% of the employee's total household income. This is a real problem for Yitzchak and his wife. The couple plan offered by his employer is prohibitively expensive and is not accepted by his wife's OB/GYN. Nevertheless, as long as the single plan offered by Yitzchak's employer is considered affordable, the entire family is not eligible for financial assistance. What should Yitzchak do? Until the laws change, he really has no option other than to pay full price for the Marketplace plan.

Tip: Open Enrollment is much shorter than usual this year. Normally lasting 3 months, this year Open Enrollment will span a mere 45 days - from November 1st until December 15th. After this date, it is virtually impossible to buy insurance or change plans - even through a private broker.

Fact: Open Enrollment is one of the busiest times of the year for the LRRC.

Total number of encounters during last Open Enrollment: 7,865

Total number of clients assisted with submitting applications for health insurance: 2,340

To get a sense of how many people that is, consider this fact. The total combined number of people enrolled in 2017 by the ten organizations that spent the most amount of money on outreach last year was only 314.

Top Tips from Mrs. Matitia - Case Manager

Number of encounters in the past month: 261

Key Skills:

  • In-depth knowledge of NJ FamilyCare
  • Comprehensive understanding of the Marketplace application process and private insurance plan rules and benefits

Need help purchasing health insurance for the coming year? In prior years, when someone contacted the LRRC requesting help with purchasing insurance, we would book them a one-hour appointment to meet with a case worker. This process, however, turned out to be inefficient. Often, several minutes into the appointment, it would become clear that the client was actually eligible for NJ FamilyCare or was missing a vital piece of documentation. Because hundreds of people were requesting our assistance every day, this created a crushing backlog of rescheduled appointments.

After experimenting with several models, we came up with what we believe to be the most efficient system. Every caller is scheduled a 15-minute phone appointment with a case worker. During this appointment, the case worker determines the client's eligibility and tells the client what information and documentation they will need for their next appointment. If the client is deemed eligible for a Marketplace plan at the end of the 15-minute appointment, they will be scheduled for a full hour-long in-person appointment to complete a Marketplace application, look over the various insurance options available and sign up for a healthcare plan.

This year, we are launching a new initiative to help people save time and skip the line. We created a short online form you can fill out that will tell our caseworkers everything they need to know regarding your eligibility. This form can be accessed on the homepage of our website,, or directly at Anyone who completes this form will, if eligible, be automatically scheduled for a full hour-long appointment to sign up for health insurance without needing the initial 15-minute phone appointment.