Information About the Health Insurance Marketplace/Exchange

What is the Health Insurance Marketplace?

The Health Insurance Marketplace is also known as the Health Insurance Exchange (or HIE). The Marketplace was created by the Affordable Care Act as a way for people to buy health insurance. The Marketplace is like Travelocity or Orbitz, except you can buy health insurance rather than book travel and hotels.

How Does the Marketplace Work?

The Marketplace gives you a menu of different insurance plans. You can compare the different plans, side-by-side, to see what they cover and how much they cost. Everything is laid out for you so that you can figure out which insurance is best for you and your family.

To help you decide which insurance to buy, the Marketplace groups insurance plans into four different categories. The different categories are based on how much your premiums are (how much you pay for your insurance each month), and how much you have to pay out-of-pocket (how much you have to pay for a service like a blood test or doctor’s appointment).

The Four Categories of Insurance

Bronze
  • The lowest monthly premiums
  • The highest out-of-pocket costs (you will have to pay more when you get medical care)
Silver
  • Low monthly premiums
  • Higher out-of-pocket costs
Gold
  • Higher monthly premiums
  • Lower out-of-pocket costs
Platinum
  • The highest monthly premiums
  • The lowest out-of-pocket costs (insurance plans will pay more of the costs when you get medical care)

In general, the lower the monthly premium, the higher the out-of-pocket costs when you need care; and the higher the monthly premium, the lower the out-of-pocket costs when you need care.

If you expect a lot of doctor’s visits or need regular prescription medication, you may want to get an insurance policy in the gold or platinum categories.

If you do not think you’ll need a lot of doctor’s visits or prescription medication, you may want to get a plan in the bronze or silver categories. However, if you get in a serious accident or have an unexpected health problem, bronze and silver plans will require you to pay more of the costs.

When Can I Use the Marketplace?

Most people can use the Marketplace to buy insurance during the open enrollment period. The open enrollment period is usually from November to February. You cannot use the Marketplace to buy insurance any other time of the year.

There are a few exceptions to this. You can buy insurance through the Marketplace even after the Open Enrollment Period is finished if:

How Can I Find the Marketplace?

Each state has its own Marketplace. Most states have a different name for the Marketplace. For example, in California the Marketplace is called Covered California.

The Marketplace is either run by your state or by the federal government. If your state runs its own Marketplace, you will use your state’s Marketplace website.

To find the Marketplace in your state, go to: https://www.healthcare.gov/get-coverage/

Who Can Use the Marketplace?

Anyone can use the Marketplace to find out about health insurance. You can use the Marketplace even if you already have insurance. The only requirements to get insurance through the Marketplace are:

Do I Have to Buy My Insurance Through the Marketplace?

You do not have to buy your health insurance through the Marketplace. You can still get your insurance through your job, or buy your insurance through an insurance agent.

What Does Marketplace Health Insurance Cover?

All insurance plans in the Marketplace must offer the same essential health benefits. There are ten essential health benefits:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Laboratory services
  5. Maternity and newborn care
  6. Mental health and substance use disorder services including behavioral health treatment
  7. Pediatric services including oral and vision care
  8. Prescription drugs
  9. Preventive and wellness services
  10. Rehabilitative and habilitative services and devices

Plans must cover the essential health benefits to be part of the Marketplace. However, plans can offer more coverage. The Marketplace will let you compare the plans, side-by-side, so that you can see exactly what each offers.

What if I Need Help Paying for My Insurance?

If you have moderate to low income, the Marketplace could help you pay for your insurance. When you use the Marketplace, it will tell you if you qualify for help.

There are three ways the Marketplace can help you pay for insurance:

  1. Lower monthly premiums
    If your income is less than 400% of the Federal Poverty Level ($46,680 per year for a single person and $95,400 per year for a family of four in 2014), you could qualify for a tax credit called the Advance Premium Tax Credit.
  2. Usually, you use tax credits to lower the amount of taxes you have to pay. The Advance Premium Tax Credit is different. Instead of using the Advance Premium Tax Credit to lower your taxes, you can use it to lower your monthly premium. This means that you do not have to pay as much for your insurance.

    The amount of credit you get depends on your income. The lower your income, the higher the credit (and the less you have to pay for your insurance). To learn more about the Advance Premium Tax Credit, go to: https://www.healthcare.gov/will-i-qualify-to-save-on-monthly-premiums/

  3. Lower out-of-pocket costs
    If your income is less than 250% of the Federal Poverty Level ($29,175 per year for a single person and $59,625 per year for a family of four in 2014), you could qualify for lower out-of-pocket costs. This means that you would pay less for deductibles, coinsurance, and co-payments. However, these savings will only apply if you choose a Silver plan from the Marketplace.
  4. To learn more about lowering your out-of-pocket costs, go to: https://www.healthcare.gov/will-i-qualify-to-save-on-out-of-pocket-costs/

  5. Medicaid and the Children’s Health Insurance Program (CHIP)
    When you apply for insurance through the Marketplace, it will tell you whether you qualify for Medicaid or the Children’s Health Insurance Program (CHIP). CHIP is a health plan administered by the states. CHIP is for children in families who can’t afford private insurance, but with incomes too high to qualify for Medicaid.
  6. Some states are making it easier to qualify for Medicaid. This is called Medicaid expansion. So you may qualify for Medicaid even if you have been turned down in the past.

What if I Need Help Using the Marketplace?

People called “navigators” will help you learn how to use the Marketplace. The navigators will be from your community and will be available in-person. The navigators are completely unbiased. They will be able to answer your questions and help you choose a plan that is right for you. In some states, navigators are called “assistors.”

You can also call the phone number for the federal government’s Marketplace: 1-800-318-2596.

Or, you can ask questions online by going to: https://www.healthcare.gov/contact-us/#

What if I am Native American or Alaska Native?

If you are Native American or an Alaska Native, you have certain benefits and protections:

Members of federally recognized tribes or Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders have additional benefits:

For more information about benefits and protections for American Indians and Alaska Natives, go to: https://www.healthcare.gov/american-indians-alaska-natives/

Where can I Use the Marketplace if I Own a Small Business?

Beginning in 2015, small business owners can buy health insurance for their employees through the Small Business Health Options Program (SHOP). SHOP will be like a Marketplace for small business owners. To use SHOP, you must have 50 or fewer full-time equivalent employees.

To learn more about the SHOP Marketplace, go to: https://www.healthcare.gov/what-is-the-shop-marketplace/

Where Can I Find More Information?

Learn more about the Health Insurance Marketplace:
https://www.healthcare.gov/families/

Information about how to choose a plan within the Marketplace:
https://www.healthcare.gov/how-do-i-choose-marketplace-insurance

Information on how to pay for insurance from the Marketplace:
https://www.healthcare.gov/how-can-i-save-money-on-marketplace-coverage

To find a Navigator or Assistor Program in your state, go to: https://localhelp.healthcare.gov/

HealthCare.gov has an interactive section of its website where you can ask questions about the Marketplace via phone or online. You can even sign up for updates by email or text:
https://www.healthcare.gov/contact-us/