The health insurance marketplace, also popularly called health exchanges, is an organization in the USA in which individuals can buy health insurance. Established by the ACA (Patient Protection and Affordable Care Act), it helps individuals find health coverage that suits their needs and budget.
The ACA insurance marketplace is a good option if your employer or you can’t get an employer-sponsored health insurance plan. It helps you choose from a range of organized and government-regulated healthcare plans provided by insurance taking part in the exchange. The health insurance marketplace is made available for all families, individuals, and small businesses.
Often called Obamacare, ACA health marketplace plans offer comprehensive coverage. They are the only type of plan with premium tax credits that lower health insurance costs if the individual qualifies.
What are the Types?
The Affordable Care Act (ACA) established the marketplace, which enables people to compare health plans provided by private health insurers. The marketplace is a good way for individuals to locate the health plans available in their state. Below are the two types of insurance marketplaces.
The federal; this is directed and monitored by the federal government at healthcare.gov. Many states make use of the federal marketplace to provide health plans to the people who live there.
State-run: Almost all states in the USA have their state-run marketplaces. The website layout may be quite different, but every state offers details about the plans they offer. And allow you to provide your household income data to know if you are eligible for a subsidy. You just have to enter your household income, Zip code, and family size. And the marketplace will allow you to compare the plans offered in your location. It will also provide the cost estimates for every plan offered.
Who can Qualify for the ACA Health Insurance Marketplace?
When it comes to the ACA plans, there are no strict eligibility requirements, unlike Medicare and Medicaid. To qualify for the plans, you must be a citizen or resident of the U.S.A. and not incarcerated.
How does Marketplace Insurance Work?
On the health insurance marketplace, individuals can locate plans that offer benefits similar to those in employer-sponsored insurance. They cover comprehensive benefits such as doctor visits, medicine, emergencies, and mental health care.
However, the main difference is that the marketplace shows you how much each plan costs by putting them into metal tiers. So, you can tell if a plan has high premiums (the amount you pay every month) or high out-of-pocket costs (what you pay when you use the services). There are four types of metal tiers: platinum, gold, silver, and bronze plans.
The metal tiers in the health insurance marketplace will only show you how much you’ll pay each month and out of pocket. They don’t tell you the coverage, like whether you need to stay in-network or need a referral to see a specialist. For that information, you will have to check the plan’s “benefit design.”
Bronze and silver plans cost less for premiums but make you pay more when you need care. Gold and platinum plans cost more in premiums, but you pay less for care. According to our research, on average, a 40-year-old person pays up to $469 a month for marketplace health insurance.
What is covered by the ACA Marketplace plans?
The ACA required the marketplace health plans to cover at least the 10 important health benefits. They include:
- Ambulatory/outpatient care
- Emergency care
- Hospitalizations
- Mental health and substance use services
- Pediatric services
- Pregnancy, maternity, and newborn care
- Prescription drugs
- Prevention and wellness services
- Rehab and habilitative services
- Laboratory services
Additionally, the plans can cover breastfeeding and birth control services. Although not compulsory, some insurers also offer dental and vision services. They also provide medical management programs for certain health issues such as back pain and diabetes.
What Health Plans Does the Marketplace offer?
The marketplace Health insurance companies offer different types of plans: HMO, EPO, PPO, and POS. These might sound familiar since employer benefits packages offer these types of plans.
- HMO (Health Maintenance Organization): HMOs have strict networks. They only cover in-network care, apart from emergencies. An HMO also requires referrals from your primary doctor to see specialists. They’re usually cheaper than other types of plans.
- EPO (Exclusive Provider Organization): EPOs are like HMOs. but you won’t need a referral to see a specialist. You still have to stay within the network for care coverage.
- PPO (Preferred Provider Organization): PPOs offer the easiest plans. You can see any doctor, but out-of-network care can be quite a bit more expensive than in-network. You don’t need referrals to see specialists. These plans are more expensive than HMOs and EPOs.
- POS (Point of Service): POS plans are a mix of HMO and PPO features. They cover out-of-network care just like the PPOs but require a primary care doctor and referrals for specialists just like HMOs. POS plans are not that common and might not be available in your location.
When can I Purchase Health Insurance through the Marketplace?
The health plans via the marketplace can be purchased during the annual enrollment period. And this falls on Nov 1 to Jan 15 in most states. Keep in mind that some states may have slightly different dates for the open enrollment period.
You can easily purchase the coverage in any month of the year if you already qualify for a unique enrollment period. You will need to have qualifying life events that spark the unique enrollment period of 60 days during any month of the year.
These include getting married, having or adopting a child, getting separated or divorced, moving to a new state, the death of a dependent or spouse, income changes, losing Medicaid eligibility, or aging out of your guardian’s health insurance.
