What is the Healthcare Marketplace?
The healthcare Marketplace is a platform that offers insurance from a collection of providers to individuals, families, and small businesses. Americans can shop the best insurance options without the possibility of being denied coverage.
The Marketplace was created in 2013 under the Affordable Care Act (also known as Obamacare) – an act that aimed to make healthcare more accessible to all.
To list policies on the Marketplace, insurance agencies must pass a strict series of requirements. Specifically, plans must cover certain essential benefits, and be available to all, regardless of an enrollee’s pre-existing conditions.
All insurers located in the Marketplace are required to cover essential health benefits, including general check-ups, vaccines, prenatal care, and more.
The ACA mandated insurers cannot deny coverage based on pre-existing medical conditions, current health, previous insurance claims, gender, or occupation. Policies were to cover care and medication for any medical issue, whether it was pre-existing or not.
To analyze what kind of insurance policy you qualify for, the Marketplace still takes income, age, tobacco use, family size, and location into consideration.
The Open Enrollment Period is a limited length of time when Marketplaces are open. This runs annually in most states between November 1 and December 15. If you live in a state that runs its own Marketplace, you may have a different enrollment period.
Who Shops on the Marketplace?
The healthcare Marketplace is open to all U.S. citizens living in the United States.
Most often, the Marketplace is used by individuals and families who don’t receive health insurance coverage through their employers. It is also the preferred choice for those self-employed or unemployed.
Even if your employer provides coverage, it is still possible to shop in the Marketplace, but you will pay full price.
Essential Health Benefits
All healthcare plans on the Marketplace must cover ten essential health benefits:
- Ambulatory patient services (outpatient)
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Pediatric services (oral and vision)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Rehabilitative and habilitative services and devices.
When Can I Buy a Plan on the Marketplace?
You can purchase health insurance from the Marketplace during the Open Enrollment Period, November 1 to December 15 in most states. A Special Enrollment Period is available for 60 days to people who have had a significant life change such as moving state, getting married, or having a baby.
How Does the Marketplace Work?
The healthcare Marketplace takes information about you, such as your tax records, current income, and existing health insurance information. It puts the information together to create a list of insurance policies that are affordable and meet your needs.
This allows you to pick from a set of insurance options that will cover you and your family, rather than sorting through many unhelpful options that don’t match your needs.
The Marketplace seeks to match people without insurance with the best health insurance at an affordable price. The goal of the program is to make sure that no American goes uninsured. Health insurance costs can often be prohibitive, even for people with full-time jobs, and the Affordable Care Act was designed to lessen the gap between what people need from their health insurance and what they can afford.
What Kind of Health Insurance Plans Are Available?
The healthcare Marketplace offers four tiers of insurance coverage. These qualified health plans all offer the same basic coverage, known as the essential healthcare benefits.
These four tiers are Bronze, Silver, Gold, and Platinum. Each tier offers better benefits and less cost-sharing, depending on how much money you are willing to pay for your insurance.
The Bronze plan is the lowest available tier, which offers a 40% out-of-pocket cost on medical expenses. The Silver tier offers 30% out-of-pocket costs for non-covered items, Gold provides 20%, and Platinum, the highest tier, only makes you pay 10% of out-of-pocket on items that aren’t covered by your insurance policy.
Bronze and Silver plans are considered to be the most affordable of the tiers; this is based on the Affordable Care Act’s definition of affordable, which is 8% of an individual or family’s income.
Comparing Health plans
When browsing health plans on the Marketplace, there is a selection of options available from health insurance companies, each offering healthcare plans within the four metallic tiers.
Even once you have selected a metallic tier, there will still be a range of plans available with different premiums and out-of-pocket costs for deductibles, copayments, and coinsurance.
|PLAN LEVEL||THE PLAN PAYS||YOU PAY|
Understanding Out-of-Pocket Costs
Premium: The amount you pay for the coverage each month.
Deductible: The amount to be paid for services before your insurance provider starts to pay. A $1,000 deductible would mean you need to pay 100% of your healthcare expenses until this figure reaches $1,000.
Copayment: A fixed amount paid for certain services. For example. $30 copayment for each doctor’s office visit.
Coinsurance: The share of healthcare service costs you must pay, typically a fixed percentage. This starts after you’ve met your deductible.
Out-of-Pocket Maximum: The most you will pay during a policy period (excluding premiums) before your plan starts to pay 100%.
|Silver Plan “A”||Silver Plan “B”|
|Coinsurance||20% after deductible||30% after deductible|
How Much Will Your Plan Cost?
Because there are various insurance providers on the Marketplace, the cost of a plan varies from insurer to insurer.
The monthly premium for your healthcare plan will also be based on several other factors such as age, whether or not you smoke, where you live, and the number of people on the plan.
The federal limit for annual out-of-pocket expenses (excluding monthly premiums) is $6,850 for individuals and $13,700 for families.
Where to Apply for Health Coverage
For the majority of states, HealthCare.gov is used to apply and enroll in health coverage. However, states with their own exchange have separate websites for individuals, families, and small businesses to enroll. These include:
- District of Columbia
- New York
- Rhode Island
Benefits of the Health Insurance Marketplace
The healthcare Marketplace has given Americans the ability to shop for affordable health insurance policies without being worried about being denied coverage. This has helped millions of uninsured Americans to get covered and protect themselves and their family.
The competition in the Marketplace gives more options at better prices and has everything needed in one place. For people with low incomes or for those who own small businesses, additional subsidies and tax breaks are offered so that insurance is affordable.
The Marketplace can be used to apply for CHIP and Medicaid as well, and if Medicare already covers you, you don’t need to enroll in the open Marketplace.
Your Health Insurance Options
The healthcare marketplace offers four tiers of insurance coverage. These qualified health plans all offer the same basic level of coverage, known as the essential healthcare benefits. These are the minimum health care standards that insurance policies are required to have in order to participate in the healthcare marketplace.
The four tiers of insurance are Bronze, Silver, Gold, and Platinum. Each tier offers better benefits and less cost-sharing, depending on how much money you are willing to pay for your insurance. The Bronze plan is the lowest available tier, which offers a 40% out of pocket cost on medical expenses. The Silver tier offers 30% out of pocket costs for non-covered items, Gold offers 20%, and Platinum, the highest tier, only makes you pay 10% of out of pocket on items that aren’t covered by your insurance policy.
The higher-end insurance policies may have a 40% excise tax levied on them. The Bronze and Silver plans are considered to be the most affordable of the tiers; this is based on the Affordable Care Act’s definition of affordable, which is 8% of an individual or family’s income.
Can I Buy a Plan in the Marketplace If I Don’t Have a Green Card?
If you are not a U.S. citizen or U.S. national, you cannot buy a plan on the health insurance Marketplace.
How Long After I Enroll in a Plan Will Coverage Take Effect?
In most states, if you enroll in a health insurance plan during the Open Enrollment Period (November 1 to December 15), your new health coverage will begin on January 1.
When Can I Enroll in Medicaid Through the Marketplace?
It is possible to enroll in Medicaid or CHIP at any time during the year.
Do I Have to Prove Eligibility for a Special Enrollment Period?
Yes. The federal Marketplace requires documentation that supports your special enrollment application before you can enroll. This is required for significant life events such as loss of coverage, a permanent move to a different state, marriage, and having a baby.
Once you apply for the Special Enrollment Period, you will have 30 days to provide documentation. Only when this has been verified will you be able to complete enrollment in a healthcare plan.