The Health Insurance Marketplace: A Comprehensive Guide

The Health Insurance Marketplace is a platform created by the Affordable Care Act (ACA) to provide individuals and small businesses with a range of health insurance options. The purpose of the Marketplace is to provide affordable health insurance plans to those who may have previously been unable to obtain coverage through their employer or the private market. This guide will provide you with all of the information you need to know about the Marketplace, including eligibility, enrollment, plan options, and more.

What is the Health Insurance Marketplace?

The Marketplace is an online platform that allows individuals and small businesses to shop for and purchase health insurance. It is designed to provide a centralized location where consumers can compare plans and prices, apply for financial assistance, and enroll in coverage.

The Marketplace is operated by either the federal government or state governments, depending on where you live. If your state operates its own Marketplace, you will use that website to enroll in coverage. If your state does not operate its own Marketplace, you will use the federal website, healthcare.gov.

Who is Eligible for Coverage?

Most individuals and families are eligible to purchase health insurance through the Marketplace. To be eligible, you must:

Small businesses with fewer than 50 employees are also eligible to purchase coverage through the Small Business Health Options Program (SHOP), which is part of the Marketplace.

How to Enroll in Coverage

To enroll in coverage through the Marketplace, you will need to visit either healthcare.gov or your state Marketplace website. You will need to create an account and provide basic information about yourself and your household, including your income and household size. This information will be used to determine your eligibility for financial assistance.

Once you have completed your application, you will be presented with a list of available plans and their prices. You can compare the plans based on their benefits, deductibles, copayments, and other factors. You can also see if you qualify for financial assistance to help pay for your premiums and other out-of-pocket costs.

Once you have selected a plan, you will need to complete your enrollment by providing additional information and making your first premium payment. Your coverage will not be effective until you have made your first payment.

Types of Plans Available

The Marketplace offers a range of health insurance plans from various insurers. The plans are divided into four categories:

• Bronze: These plans have the lowest premiums but the highest out-of-pocket costs. They cover 60% of your medical costs on average.
• Silver: These plans have slightly higher premiums but lower out-of-pocket costs. They cover 70% of your medical costs on average.
• Gold: These plans have even higher premiums but lower out-of-pocket costs. They cover 80% of your medical costs on average.
• Platinum: These plans have the highest premiums but the lowest out-of-pocket costs. They cover 90% of your medical costs on average.

In addition, catastrophic plans are available for individuals under age 30 or those who have a hardship exemption. These plans have low premiums but high deductibles.

Financial Assistance

The Marketplace offers financial assistance to help make health insurance more affordable for lower-income individuals and families. This assistance comes in the form of tax credits and cost-sharing reductions.

Tax credits are available to individuals and families with incomes between 100% and 400% of the federal poverty level ($12,140 to $48,560 for an individual, $25,100 to $100,400 for a family of four in 2019). The amount of the tax credit is based on your income and the cost of the second-lowest-cost silver plan in your area. You can choose to apply the tax credit to your monthly premiums or receive it as a refund when you file your taxes.

Cost-sharing reductions are available to individuals and families with incomes between 100% and 250% of the federal poverty level. These reductions lower the amount you have to pay in out-of-pocket costs like deductibles, copayments, and coinsurance. The amount of the reduction depends on your income and the plan you select.

FAQ

What is the Open Enrollment Period?

The Open Enrollment Period is the time each year when you can enroll in health insurance through the Marketplace. The 2019 Open Enrollment Period runs from November 1, 2018 to December 15, 2018. During this time, you can enroll in coverage for the following year. Outside of the Open Enrollment Period, you can only enroll in coverage if you have a qualifying life event, such as getting married or losing your job.

What happens if I don’t have health insurance?

Under the ACA, most individuals are required to have health insurance or pay a penalty. The penalty for 2018 is $695 per adult ($347.50 per child) or 2.5% of your household income, whichever is greater. The penalty is assessed when you file your taxes.

Can I keep my current doctor if I enroll in Marketplace coverage?

The availability of specific doctors and hospitals varies by plan. When shopping for plans, you can use the provider directories to see which doctors and hospitals are in each plan’s network. If you want to keep your current doctor, make sure they participate in the plan you select.

What if I have a pre-existing condition?

The ACA prohibits insurers from denying coverage or charging higher premiums to individuals with pre-existing conditions. All Marketplace plans must cover essential health benefits, such as hospitalization, prescription drugs, and mental health services, regardless of any pre-existing conditions.

What if I can’t afford the premiums?

If you can’t afford the premiums, you may qualify for financial assistance, as discussed above. If you still can’t afford the premiums, you may be eligible for a hardship exemption that would allow you to go without coverage without paying a penalty.

What if I have more questions?

You can visit healthcare.gov or your state Marketplace website for more information. You can also speak to a licensed insurance agent who can help you understand your options and enroll in coverage.