The Health Insurance Marketplace is a platform established by the Affordable Care Act (ACA) of 2010 to provide insurance plans for individuals, families, and small businesses. It was created to extend health insurance coverage to millions of uninsured Americans. In addition, the Marketplace (HealthCare.gov) functions as an online health insurance exchange — facilitating competition among private insurers in a central location where people can find a suitable plan. This allows individuals without access to employer-sponsored insurance and small businesses the chance to evaluate health insurance and make an informed decision about what to buy.
As written, the ACA (also known as Obamacare) instructed states to set up their own exchanges where individuals or families without employer-sponsored coverage could compare plans. Many states, however, chose not to establish a marketplace and joined the federal exchange instead.
WHO’S ELIGIBLE TO USE THE HEALTH INSURANCE MARKETPLACE?
The Marketplace was designed to provide coverage for individuals and families who were either uninsured or already buying their own health insurance. This includes self-employed people, those employed by a business that doesn’t offer health benefits, and people who retired before age 65 and are too young to be covered by Medicare.
The majority of working Americans get health coverage through an employer, which means they don’t need to use the Marketplace. That said, except for those enrolled in Medicare coverage, virtually all Americans are eligible to use it — they can choose to decline their employer’s coverage and select a plan in the Marketplace instead. However, they won’t be eligible for the same tax credits and subsidies available to uninsured individuals in most cases.
Most non-elderly Americans eligible for Medicaid can also use the Marketplace to enroll — or at least to determine their eligibility.
WHAT KIND OF INSURANCE IS AVAILABLE THROUGH THE MARKETPLACE?
The Marketplace organizes plans into four metal-themed tiers: Bronze, Silver, Gold, and Platinum. Generally speaking, Bronze plans have the lowest monthly premiums, but they also come with the highest out-of-pocket costs. That trend continues upward to Platinum plans, which typically have the highest monthly premiums and the lowest out-of-pocket costs.
All four plans are eligible for premium tax credits, which can help pay for health insurance if someone meets the income-based qualifications. Silver plans are also eligible for cost-sharing reductions, a subsidy that lowers the amount you have to pay for deductibles, copayments, and coinsurance.
Another type of plan is also available: Catastrophic. Catastrophic plans cover only essential health benefits and are only available to people under 30 (unless someone has obtained a hardship exemption). They typically have lower monthly premiums than Bronze plans, but they also have incredibly high out-of-pocket costs. They’re also not eligible for the premium tax credit — which is why, for some people, a Bronze plan with a tax credit may be the more affordable option.
All health plans offered in the Marketplace cover these essential health benefits:
- Ambulatory patient services (outpatient care without admittance to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both before and after birth)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices that help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care (adult dental and vision benefits, on the other hand, are not covered by all plans)
- Birth control coverage
- Breastfeeding coverage
WHEN CAN SOMEONE BUY COVERAGE?
Individuals can compare and apply for Marketplace plans during the open enrollment period. Typically, this period occurs in November and December, although the precise dates change from year to year. Consumers can also apply for a special enrollment period in the case of a qualifying event such as the birth of a child, marriage, or the loss of another insurance plan.
SPECIAL ENROLLMENT PERIOD GOING ON NOW
Through August 15, 2021, there is a special enrollment period through HealthCare.gov. If you don’t have health insurance, you can enroll in coverage from the Marketplace during this period.
MAKING THE RIGHT CHOICE
The Health Insurance Marketplace was designed to make health care accessible to everyone. But the process of selecting the right plan can still be daunting for those who’ve never shopped for a policy before. At Health & Benefits Partners, we’re here to make sure you can get the health insurance coverage you need. Our tools and resources will help educate your decision-making, help you compare plans and benefits, and learn about any credits or subsidies for which you might qualify.
Reach out to one of our qualified specialists today and be empowered when buying Marketplace insurance.