The Affordable Care Act, commonly known as Obamacare, established marketplaces where uninsured Americans can shop for individual health insurance coverage. There are different marketplaces that people can use depending on where they live. In many states, shoppers use the federal Health Insurance Marketplace. Some states, however, have their own state-run marketplaces for residents. Learn what type your state uses and how to access it.
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What Is the Health Insurance Marketplace?
The Health Insurance Marketplaces are shopping and enrollment services for individual health insurance plans. Most states utilize the federal Health Insurance Marketplace, while some states operate their own. The marketplace you can use to shop for coverage depends on where you live.
The Health Insurance Marketplace at Healthcare.gov is the federal government’s health insurance shopping service. Americans in 33 states use the federal marketplace to shop for insurance, and nearly 10.3 million people enrolled in their 2022 coverage through the service.
The Healthcare.gov platform allows shoppers to browse a list of health insurance plans available in their area. They can compare the services each plan covers and view estimated premiums and out-of-pocket costs. Shoppers can enroll at any time during Open Enrollment, which runs from November 1 to Jan. 15 in most states, or outside of this period if they are eligible for a Special Enrollment Period.
Shoppers who prefer not to sign up online can access the federal marketplace by calling 1-800-318-2596 (TTY: 1-855-889-4325).
The Affordable Care Act offered states the option to run their own marketplaces rather than using the federal platform. More than 4.2 million people across 17 states and Washington, D.C. enrolled in their 2022 coverage through their state’s marketplace.
States may choose to run their own marketplaces for many reasons, including customizing the service to meet their residents’ needs and having more control over advertising and consumer assistance. For example, states with their own health insurance exchanges can extend the Open Enrollment Period window or create an integrated system that allows residents to apply for marketplace plans and state assistance programs at the same time.
With this flexibility, state-based marketplaces can work a bit differently from state to state. However, all state marketplaces allow residents to compare available plans and enroll in health insurance coverage.
How Metal Tiers Work Within the Marketplace
Both federal and state marketplaces categorize health plans into four metal tiers: Bronze, Silver, Gold, and Platinum. These metal tiers refer to the plan’s cost, not the quality of coverage. For instance, Bronze plans tend to have the lowest monthly premiums but high deductibles, so they might be a good choice for people with few care needs.
On the other end, Platinum plans tend to have the highest premiums, but their low deductibles can make them appealing to people with ongoing medical needs. Silver and Gold plans fall somewhere in between. However, Silver plans have an added bonus of being eligible for federal subsidies and tax credits.
State Marketplaces For Health Insurance
Please verify that all the states in the table have state marketplaces and link to them. List out the name of each state’s marketplace. For those that have mandatory health insurance, put an asterisk next to the state’s name.
All other states
Who Should Use State-Based Exchanges?
State-based exchanges, like their federal counterpart, are designed to help uninsured Americans get health insurance coverage, or those looking to change their insurance plan. You might choose to shop your state’s exchange if you do not have health insurance through your employer, parent, or spouse. Keep in mind that if you live in a state that uses a state-based exchange, you cannot shop on the federal marketplace.
Being uninsured is not a requirement to use the Marketplaces, so those who are not satisfied with their current coverage could also choose to shop their state-based exchange. Some general eligibility rules for using the marketplaces include:
- Being a resident of the state
- Being a U.S. citizen or lawfully present immigrant
- Not currently serving time in jail or prison
- Not currently receiving Medicare
States With Mandatory Health Insurance
The federal mandate to either have health insurance or pay a tax penalty was effectively repealed in 2018. However, 5 states with health insurance exchanges, as well as Washington, D.C., have passed their own laws mandating residents maintain health coverage.
Some states have adopted rules similar to the old federal mandate, requiring residents to either maintain qualifying health insurance coverage from a job, marketplace, or another source, or pay a tax penalty. As of 2022, these states are:
How to Shop for Health Insurance in State Exchanges
State-based exchanges offer a way for residents to shop for health insurance on their own or with the guidance of a licensed agent. Consider your preferred type of plan network, expected health needs, and health insurance budget, then browse the exchange to find a plan that meets your requirements.
1. Decide on the Network Type You Need
Each marketplace plan has a provider network. This is a list of healthcare providers and healthcare facilities that have agreed to accept the plan. There are different types of provider networks, and the type you choose may affect how you access care and how much that care costs. These are the most common network options:
- Preferred Provider Organization (PPO): Members can get care from any provider, but they pay less if they see an in-network or “preferred” provider.
- Health Maintenance Organization (HMO): Coverage is typically limited to in-network providers except in emergencies. Members also typically need referrals for specialist care from a designated primary care physician.
- Exclusive Provider Organization (EPO): Like HMOs, plan members are required to get non-emergency care from providers in the network. However, unlike HMOs, EPO networks may be larger and members may not need a designated primary care physician.
- Point of Service (POS): Like PPOs, plan members pay less if they see in-network providers but can choose to seek out-of-network care. However, unlike PPOs, most POS plans require members to get referrals for specialist care.
2. Evaluate Your Current and Future Health Needs
Before shopping for a plan, consider your typical health needs and estimate how much medical care you’ll likely use in the coming year. Evaluating your anticipated health needs can help you narrow down which benefits you want your plan to cover, as well as which plan tier to choose.
Marketplace plans are required to cover a set of 10 essential health benefits, but the specific services each plan includes may vary. Make a list of services you’d like your plan to cover. Consider any ongoing, predictable health expenses, such as prescriptions or doctor visits, as well as future health needs, such as planned surgeries.
3. Factor in Your Health Budget
Take a look at your budget and decide how much you could afford to spend on health insurance costs per month or year. Consider your budget for the basic components of every health insurance plan: monthly premiums, annual deductibles, and cost-sharing requirements.
A plan’s monthly premium is the cost to keep the insurance active. Premiums vary, but the average benchmark premium for a 2023 marketplace plan for one person is $456. Ensure your preferred plan’s monthly premium fits your budget, and remember that plans with lower premiums tend to have higher deductibles.
The annual deductible is the amount of money plan members spend out of pocket on covered healthcare services before the plan starts paying. For example, if your annual deductible is $500, you must pay the first $500 of your health care expenses before your insurance begins paying for covered costs. As noted earlier, typically lower premium plans have higher deductibles, while higher premium plans have lower deductibles. Keep in mind that copayments do not count towards deductible amounts.
Copayments, or copays, are flat fees that plan members pay for each visit to the doctor or every time they fill a prescription. The copay amount can differ based on the type of care sought. For example, a plan might charge a $15 copay for a visit to a general practitioner and a $45 copay for a visit to an urgent care clinic. In addition to copays, cost-sharing also comes in the form of coinsurance, which is expressed in percentages that indicate how much of the covered costs you would be responsible for paying. For example, if a plan has a 20% coinsurance, that means you would be responsible for paying 20% of the final bill and your insurance would cover the remaining 80%.
Checking these out-of-pocket costs for services you expect to use is critical in ensuring it fits your budget. Also consider your preferred plan’s out-of-pocket maximum, which is the most you would be expected to pay for covered services each year. In 2023, the maximum out-of-pocket cost for marketplace plans is $9,100 for an individual.
4. Look at Your State’s Exchange Options and Get Quotes
People living in states with health insurance exchanges can visit their marketplace to browse available insurance plans. Residents in states without their own health insurance exchanges will use the federal marketplace.
Each state-based exchange works differently, but shoppers generally start by entering their ZIP code, age, household size, and total annual household income. Then, they can view a list of plans available in their area, including estimated premiums. From there, you can choose to look at the details about each plan’s network type, costs, and covered health services.
However, you do not need to shop for health insurance plans in the marketplace entirely on your own. Shoppers can call their state’s marketplace service phone number or work with a licensed health insurance agent or broker.
5. Make Your Selection and Enroll
After choosing a plan, complete the marketplace application or allow your health insurance agent to complete it on your behalf. Online and phone applications can take about 45 minutes to complete, so set aside adequate time to fill out the forms and answer the questions. Be prepared to provide information about each member of your household that will be on the plan, including their Social Security numbers, birth dates, and employer and income information.
Once you enroll, watch your mailbox for a welcome packet and ID card from the insurer, or download the electronic health insurance card if applicable. Your insurer will provide you with information about your plan’s benefits and network, as well as when the coverage starts. Generally, enrolling by December 15th means coverage starts on January 1st of the following year.