In the past, consumers in need of health insurance would have to obtain quotes from multiple companies and compare the best coverage options on their own time. Now, there is one place with all of the information needed to make informed decisions regarding healthcare coverage: the Health Insurance Marketplace.
What Is the Health Insurance Marketplace?
The Health Insurance Marketplace is a convenient insurance exchange, both in person and online, providing United States residents a place to shop, compare plans, and purchase the coverage that best suits their individual needs. It was created as part of the Affordable Care Act (ACA) in 2010 so that all U.S. consumers could purchase affordable healthcare coverage regardless of income status or pre-existing conditions.
Who Is Eligible To Use the Health Insurance Marketplace?
Generally, every American can obtain health insurance through the Health Insurance Marketplace unless they are enrolled in Medicare. The purpose of the Insurance Marketplace is to provide uninsured consumers with a place to purchase health insurance. Uninsured consumers include those who work for employers that do not offer health insurance as a benefit option, those who are self-employed or freelance, and early retirees who are not yet eligible for Medicare.
Most Americans working full time can find health insurance through an employer-sponsored policy, which tends to be significantly less costly than purchasing an individual health insurance plan. This is because employer-sponsored health plans are at least partially subsidized by the employer, helping to make coverage much more affordable to employees. If you have health insurance through your employer, it may be best to remain on that policy instead of searching for coverage in the Health Insurance Marketplace.
The Marketplace is offered more for individuals and families who do not have access to employer-sponsored health insurance. To purchase a plan from the Health Insurance Marketplace, individuals must meet specific criteria, such as maintaining residency in the U.S., being a current U.S. citizen or national, and not being incarcerated.
What Types of Plans Are Offered?
The Health Insurance Marketplace offers 5 levels of plans, each with specific benefits and costs. It is important to note that all plans provide free preventative care.
Those looking for affordable health insurance options regardless of coverage should look into the bronze plan. It has lower premiums, higher out-of-pocket costs, and high deductibles compared to other levels. Individuals and families who do not often visit a doctor may benefit from this plan as they would save money on lower premiums over time.
As a step up from the bronze plan, the silver plan has higher premiums with fewer out-of-pocket costs, though there is still a deductible that must be met before the plan kicks in. This is also the plan that must be selected for those who qualify for cost-sharing reductions (CSR), a helpful discount if the covered person requires frequent medical attention.
The gold plan has even higher premiums in exchange for fewer out-of-pocket costs. Often, this option has a lower deductible, which is an excellent value for someone who seeks medical care regularly. A lower deductible means the policyholder can expect their insurance to kick in sooner to help over otherwise expensive health costs, which could offset even the higher recurring premiums.
The platinum plan is the highest coverage option available with the highest monthly cost. This plan is designed for those who seek frequent medical attention and can afford higher monthly premiums in exchange for lower out-of-pocket costs.
Only those under 30 years old or those who qualify for an exemption based on hardship or affordability are eligible for a catastrophic plan. The catastrophic plan is usually the lowest priced option, but is excluded from tax credit help so it may not actually be the best financial option. In 2020, the deductible for this plan was over $8,000.
Health Insurance Marketplace Requirements
Many states have their own Marketplace, but the majority of states use the Federal Marketplace website. Regardless of which Insurance Marketplace your state utilizes, all the plans offered must meet crucial coverage requirements. At a minimum, all plans must cover:
- Ambulatory patient services
- Emergency services
- Laboratory services
- Prescription drugs
- Preventive and wellness services and chronic disease management
- Rehabilitative and habilitative services and devices
- Mental health and substance use disorder services, such as behavioral health counseling
- Birth control coverage
- Pregnancy, maternity, and newborn care
- Breastfeeding coverage, such as lactation specialists, counseling, and equipment
- Pediatric services, including oral and vision care
How to Choose a Plan From the Health Insurance Marketplace
Several factors should be considered when deciding which plan is best for you and your family. Frequency of care is one such factor. Consider how often medical care is needed based on your own health history as well as planned healthcare needs, such as if you have surgical procedures scheduled.
If you estimate that you will need a lot of doctor’s visits, hospital stays, or medical procedures, then gold or platinum plans may be the best options to ensure your insurance can help cover those costly services. If you have minimal healthcare needs, then consider bronze or silver plans so that you can save on recurring premiums since you are unlikely to need services where you would need to meet any high deductibles.
You should also consider long-term affordability. Except in specific circumstances, you cannot change your healthcare coverage except during the annual enrollment period at the end of each year. For this reason, it is essential to ensure that you can comfortably afford the recurring premium costs to maintain coverage. In addition, make sure the plan’s out-of-pocket costs and deductibles fit your needs not just now, but also a year from now.
There should be a balance between how much coverage you need and what fits within your budget.
How to Enroll in a Plan From the Health Insurance Marketplace
Except in specific circumstances, you can only enroll in a plan during the open enrollment period each fall. If you miss the open enrollment period, you may be eligible for a special enrollment period where enrollment or changes can be completed. Special enrollment periods are triggered by qualifying life events, such as losing employer-sponsored coverage, moving, marriage, having a baby, adoption, or if your income falls below a certain number. If you do not have a qualifying life event, you may need to wait until the next open enrollment period to enroll.
Open Enrollment 2023
The next open enrollment period will be November 1, 2022, until January 15, 2023. Individuals and families who currently have Insurance Marketplace coverage will need to re-enroll during open enrollment.