Looks like a combo of contributions to HSA and Simple IRA would reduce household income enough to be below 400% FPL. Since the working spouse has a decent amount of self employment income, some can be deferred into the Simple IRA. It takes some talking to help client see that their money can be used in their favor instead of taking a calculated risk of coverage with no pre-ex for someone with some conditions that could lead to more serious issues. In my book a higher risk in going STM or CSM. They have to be willing to take the money they would have spent on insurance and put it away for future use. Others here have convinced clients to use HSA's to make tax deductible contributions to go below FPL limits. Thanks for the idea!