Medicare
Individual & Family
Marketplace
Affordable Care Act
Individual & Family 101: Who Qualifies
Deborah Meyer, and
Mark Angus Meyer
Affordable Individual & Family Coverage: The Tailored Guide for Residents of Wyoming, South Dakota, and North Dakota
Written by the Meyer Family Team at Spearfish Insurance Brokerage — licensed insurance agents serving South Dakota, North Dakota, and Wyoming, rated 4.9 stars on Google, with thousands of clients served across the region.
Every week, new people walk through our door at Spearfish Insurance Brokerage asking the same underlying question: "How can I get quality health coverage at a reasonable price?"
Maybe your employer doesn't offer health insurance, or it's too expensive. Maybe you're deciding whether to retire, bridging the gap to Medicare. Maybe you're turning 26, and getting kicked off a parent's plan. Maybe you've moved, had a baby, got married, or had some other life event that left you needing coverage.
Whatever brought you here, there's a good chance you qualify for more help than you think through a Marketplace health plan.
This guide lays out what a Marketplace health plan is, when you can enroll, and how to qualify for a tax credit to reduce your monthly premium. If you'd rather skip the research and just talk to an expert, we provide application services, quoting and enrollment at no cost by calling 605.722.1965, or you can run a quote online.
A Note for Employers
We also work with business owners across the region who are wondering whether it's better to offer their employees a group health plan, or let employees shop the Marketplace and qualify for subsidies. This is a bigger decision than it looks. Call us to discuss at 605.722.1965
What Is a Marketplace Health Plan, Really?
Marketplace health plans stem from the Affordable Care Act, signed into law back in 2010, and were later adjusted under the Trump administration, which removed the penalty for not having coverage.
Despite some lingering myths, these plans are offered by the same major carriers you already know and trust here in the region, and they work very similarly to the employer coverage you may be used to.
So the question becomes, when can you join a Marketplace health plan?
Anyone can sign up during the annual Open Enrollment Period, which runs November 1st through December 15th, for coverage that starts January 1st.
Outside of this annual window, there are many situations that can qualify you to join:
- You lost coverage under another plan
- You lost employment
- You retired
- You turned 26
- You had a baby
- You got married
- You got divorced
- You moved out of your current plan's service area
Beyond those major life events, there are a number of other, less common situations that can also open the door to a Special Enrollment Period, including losing Medicaid or CHIP coverage, adopting a child or having one placed with you for foster care, a change in household income that affects your subsidy eligibility, gaining U.S. citizenship or lawful presence, release from incarceration, or being affected by a natural disaster or serious medical emergency that kept you from enrolling on time.
Call us if you're wondering if you lost coverage.
Subsidies and the Income Cliff
The biggest factor in what you'll pay for a Marketplace plan is your household income relative to the federal poverty level.
At the end of 2025, the enhanced tax credits that had been in place since 2021 expired, which means the subsidy cliff is back for 2026: if your taxable Modified Adjusted Gross Income (not gross alone) household income is at or below 400 percent of the federal poverty level, you can qualify for a substantial tax credit that significantly lowers your monthly premium. If you're even one dollar over that threshold, you get no subsidy at all. Limits by household size:
- Household of 1: $62,600
- Household of 2: $84,600
- Household of 3: $106,600
- Household of 4: $128,600
- Household of 5: $150,600
- Household of 6: $172,600
Getting Creative on Paper
If you're close to that cliff, there are legitimate ways to reduce your taxable income and land under the threshold. We are not financial or tax professionals, and any strategy below should be vetted by a CPA before you rely on it. That said, here's what we commonly see work for our clients:
For wage earners: contributing to a traditional IRA (not a Roth), deducting student loan interest, contributing to an HSA if you have a high-deductible health plan, educator expense deductions for teachers, and alimony deductions, but only for divorces finalized before 2019.
For the self-employed or business owners, there's even more flexibility: timing when you recognize income or realize expenses across tax years, maxing out a SEP IRA or solo 401(k), and in some cases, hiring your own children as W-2 employees to create a legitimate deduction. We're always happy to help you brainstorm, but the final strategy needs to be signed off by your CPA.
A Final Word on Estimating Your Income
The income you report on your marketplace application is just an estimate, it's not what ultimately matters. What matters is your actual income when you file taxes for that year.
Because of this, we generally advise erring on the high side. If you underestimate and your real income comes in higher, especially if it pushes you over the 400 percent cliff, you may have to pay back some or all of the subsidy you received. On the flip side, if you estimate high and your actual income comes in lower, you'll get that subsidy back as a credit when you file.
One exception: catastrophic plans can never be paired with a tax subsidy, regardless of income, so if you choose a catastrophic plan, that's a separate consideration entirely.
Frequently Asked Questions
My married child under 26 is on my plan and just had a baby. Do they need their own coverage?
Your child can stay on your plan regardless of marital status, up to age 26. But the new baby (your grandchild) and their spouse generally are not eligible dependents on your plan. They'll need their own coverage, often through Medicaid, CHIP, or a marketplace plan.
My spouse and I make too much combined. Can we just file separately to qualify?
No. The IRS disqualifies married filing separately from the premium tax credit entirely, with a narrow exception for documented domestic abuse or spousal abandonment, capped at three consecutive years.
We're getting divorced mid-year and on the same plan. What happens?
You'll need to split, or "allocate," the shared policy's premium and tax credit amounts between your two separate tax returns, typically 50/50 unless you agree otherwise. Note that divorce alone doesn't trigger a Special Enrollment Period unless it causes an actual loss of coverage. Your CPA can help.
I'm divorced and we have multiple kids. Who gets to claim them for our marketplace applications?
Generally, whoever claims the children as dependents on their tax return for that year is who counts them toward household size for premium tax credit purposes. The Marketplace application follows the tax return, so this is worth coordinating clearly with your ex-spouse and your CPA each year.
What if I'm getting a subsidy and then I win the lottery?
Congratulations! But yes, lottery winnings count as income. If it pushes you over the cliff, you may owe back your subsidy for the year, though that's a pretty good trade-off, all things considered.
I lost my job and was offered COBRA. Do I have to take it?
No. Being offered COBRA doesn't disqualify you from Marketplace tax credits. You're free to shop the marketplace instead, and it's often the more frugal option.
I'm self-employed. Can I deduct my premiums and get a subsidy in the same year?
Yes, though the math is genuinely complex and circular. This is a good one to work through with your CPA.
I got a raise mid-year. Do I need to report it right away?
Yes, as soon as possible. Reporting promptly helps you avoid a larger surprise, either owing back credits or missing out on credits you're entitled to, when you file your taxes.
No Wrong Door: Reach Out to Us
Wherever you think you might land, whether that's Medicaid, a subsidized marketplace plan, or a full-price marketplace plan, there's no risk in reaching out to us. We love helping people. If it turns out you qualify for Medicaid, we can help start that application too. If you submit a Marketplace application and find out you make too much for a subsidy, nothing is lost, you can still enroll in a marketplace plan, just without the subsidy.
Our services are always free to you. You pay the exact same premium whether you enroll through us or go directly to the insurance company, there's no added cost to working with a local agent who understands the specific circumstances and opportunities for people across South Dakota, North Dakota, and Wyoming.
Give us a call at 605.722.1965 or quote for yourself online
Areas We Serve
Spearfish Insurance Brokerage is based in Spearfish, South Dakota, and most active in the counties closest to home: Lawrence, Meade, Butte, Pennington, Custer, Fall River, Stanley, Hughes, Jones, and Jackson counties in South Dakota, along with Crook and Weston counties in Wyoming.
Beyond our core area, we serve thousands of clients across every county in South Dakota, North Dakota, and Wyoming. We have deep client relationships and plan knowledge across that footprint.
Call us at 605.722.1965 or visit our office in Spearfish at 125 East Colorado Boulevard
About Your Local Agents
Deborah Meyer has been a licensed insurance agent since 2001, with over 20 years of experience. She is a prominent insurance educator in the region, having served roughly 10,000 clients across South Dakota, North Dakota, and Wyoming.
Mark Meyer has been licensed for two years, bringing a corporate leadership background into the family business. He holds an MBA from the Stern School of Business at NYU and has already helped over 1,000 clients.
Kaylee Rust has been licensed for three years and delivers incredible value to Marketplace clients. We hear it all day when we answer our phones: "I'm calling for Kaylee."
Together, our team is rated 4.9 stars on Google, reflecting the trust we’ve built with clients across South Dakota, North Dakota, and Wyoming.
