Insurance Through Your Employer

Employer-sponsored health insurance is a health plan chosen and primarily paid for by your employer. These plans are also offered to or can include your dependents . Your employer chooses which plan options are available to you and splits the cost of premiums. You can also pay your premiums on a pre-tax basis, which lowers your taxable income.

Who Is Eligible For Health Insurance Marketplace

There are only a few requirements to be able to shop in the marketplace:

• You must live in the United States
• You must be a U.S. citizen, U.S. national or considered lawfully present
• You cant be incarcerated
• You cant be currently enrolled in Medicare

If you pass all four, youre OK to shop and enroll. But, when it comes to whether the health insurance marketplace is right for what you need, thats a different question.

Definition And Examples Of The Health Insurance Marketplace

The Patient Protection and Affordable Care Act , often called Obamacare, mandates affordable insurance exchanges. The goal of the provision is to create a market where individuals and small business owners can compare and purchase health care insurance plans that meet ACA price and quality standards.

Essentially, the Health Insurance Marketplace is a government-operated store. Within the Marketplace you can also learn whether you qualify for premium tax credits and for government health programs such as the Childrens Health Insurance Program and Medicaid.

The Health Insurance Marketplace is a nationwide federal health insurance exchange you can access at HealthCare.gov. However, some states have their own state-based exchanges that state residents use instead, such as Covered California .

• Alternate names: Marketplace, health insurance exchange

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Why Does Open Enrollment Exist

Before the Affordable Care Act, insurance companies could raise insurance premiums or refuse coverage to an individual based on their medical history. The Affordable Care Act made it illegal for insurance companies to deny coverage due to someones medical history or any type of pre-existing condition. To avoid a situation where people only get health insurance the month they know they need medical care, the Affordable Care Act established an Open Enrollment Period so that everyone can get health insurance once a year.

So now when someone pays their monthly insurance premium, it essentially goes into a large pot . And this gives insurance companies the ability to put that money towards medical care whenever a consumer needs it.

A Health Insurance Broker Or Agent

A health insurance broker or agent is a trained professional who can help you navigate the wide range of insurance options and enroll in the best health insurance plan for you. An agent may work for a single health insurance company while a broker will represent several companies at once. You dont pay any fees when working with agents or brokers, as theyre paid on commission for selling you a plan.

To find a broker or agent, you can use the federal governments Find Local Help tool to set up in-person, phone or email appointments. You can also enter your phone number or email address to be contacted by an agent or broker to talk about plan choices. Agents and brokers must be licensed in their states to sell health insurance and are often required to act in the best interest of the customer.

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How Long Must An Employer Provide Health Insurance After Termination

There is no particular time frame when an employer must keep your health insurance coverage after a job termination. This decision is up to the company.

Some employers cancel health insurance on the day of termination. Others wait until the end of the month or a few months so that you can have extra time to seek new employment.

That being said, most employers are required to provide you access to its employer health insurance plan for at least 18 months after termination through COBRA . COBRA requires that private employers with at least 20 employees offer COBRA benefits to former employees, except those fired for gross misconduct. Many states also have mini-COBRA laws for small businesses.

Note that youll pay the full price of health insurance during this COBRA period, with no subsidies provided from your employer, so expect to pay costly premiums, adds Kronk.

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How Do I Get Health Insurance If I Am Retired

If you are retired but still under the age of 65 and no longer have employment health insurance due to job loss, you can apply for coverage through the healthcare Marketplace. Losing coverage will qualify you for a special enrollment period. Based on household size and income, you may qualify for a premium tax credit and lower out-of-pocket costs.

Retirees who are 65 and older will qualify for Medicare and Medicare Advantage. You can also switch to a Marketplace plan if you have retiree health coverage but wont be eligible for the tax credits and lower out-of-pocket benefits or the special enrollment period. If you turn 65 in the middle of the year, you can apply for a Marketplace plan to cover you until Medicare begins.

If you are 65 but do not qualify for premium-free Medicare, you can buy insurance through the Marketplace and receive lower costs with tax credits.

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How Does The Health Insurance Marketplace Help Individuals

When individuals shop on the Marketplace, all the available health plan options are ACA-compliant. This means they are wont be subject to medical underwriting or exclusion due to a pre-existing condition. Also, all health insurance plans will cover the ten essential health benefits without annual or lifetime benefit caps.

Financial assistance programs, like premium tax credits and cost-sharing subsidies, are also available through the Marketplace. Your monthly premiums will be reduced if you qualify for any health insurance subsidies.

You can also see if your income level qualifies you for Medicaid or the Childrens Health Insurance Program5 to save on premiums.

The Marketplace helps you quickly and easily find health insurance that fits your budget and lifestyle. No matter where you live, you can purchase insurance with comprehensive benefits, including doctor visits, hospital stays, preventive care, and prescription drugs, for an affordable cost.

Affordable Care Act Standards

Employer-based health insurance must meet ACA standards. If you have a job-based plan, you can still purchase Marketplace health coverage. However, if your employers health care plan meets ACA standards, youll have to pay the entire premium for a Marketplace plan.

The ACA requires employers to offer affordable health insurance, defined as less than 9.61% of your monthly household income. This standard doesnt apply if you enroll in a family plan, or one offered by your spouses employer. For example, if youre single and only buy job-based coverage for yourself, the lowest-cost available plan must be less than 9.83% of your income. But if youre married and enroll in family coverage, the rate can exceed that percentage.

The ACA also requires qualifying health coverage to pay at least 60% of covered health care costs. If you arent sure if your job-based health insurance meets ACA standards, ask your employer to complete the Marketplaces Employer Coverage Tool. If the employers plans dont meet ACA standards, you may qualify for premium tax credits for a Marketplace plan.

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Find Affordable Healthcare Thats Right For You

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Updated: February 2nd, 2022ByDan Grunebaum×

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Our mission is to provide information that will help everyday people make better decisions about buying and keeping their health coverage. Our editorial staff is comprised of industry professionals and experts on the ACA, private health insurance markets, and government policy. Learn more about our content.

Small Business Health Options Program Marketplace

The Small Business Health Options Program Marketplace – also known simply as SHOP – helps small businesses provide health coverage to their employees. While the SHOP Marketplace was previously only open to employers with 50 or fewer full-time equivalent employees, starting in 2016, some states may make the SHOP Marketplace available to businesses with up to 100 employees. If you have more than 50 employees and don’t know if you can use the SHOP Marketplace, contact your state Department of Insurance or the SHOP Call Center.

The SHOP Marketplace – which is also open to non-profit organizations – allows you to offer health and dental coverage that meets the needs of your business and your employees. SHOP offers flexibility, choice, and online application and account management. You can enroll in SHOP any time of year. Theres no restricted enrollment period when you can start offering a SHOP plan.

Businesses that offer health coverage through the SHOP Marketplace may be eligible for the small business health care tax credit.

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What Is A Premium Tax Credit

A “premium tax credit” is a credit you can use to lower your monthly insurance payment when you enroll in a plan through the Marketplace. Only certain people are eligible for lower premiums and lower out-of-pocket costs for Marketplace plans. To qualify for lower premiums for a Marketplace plan, your household income must be between 100% of the federal poverty level and 400% of the federal poverty level .

Congress removed the 400% of FPL limit for 2021 through 2025

From 2021 through 2025, Americans who earn over 400% of the federal poverty level don’t have to pay more than 8.5% of their household income for Obamacare health insurance. No matter how high your income is, you can get a premium tax credit to the extent the cost of the silver benchmark plan in your area exceeds 8.5% of your household income. Those with incomes under 400% of the federal poverty level are required to pay less than 8.5% of their income for health insurance, based on a sliding scale.The old pre-2021 rules are scheduled to return in 2026.

If you are offered health coverage through your employer, you can purchase a policy through the Health Care Marketplace, but you are eligible for subsidies only if your employer-provided insurance isn’t affordable based on certain criteria. If you don’t qualify for your employer’s insurance because you work part-time, you can get health coverage through the Marketplace.

What Kinds Of Health Insurance Plans Are Available On The Marketplace

There are four levels of health plans that you can buy on the Marketplace: Bronze, Silver, Gold, and Platinum. Each level pays a different portion of your health care bills.

You will also pay a portion of your health care expenses through your monthly premium, copays, deductible, and coinsurance . The amount you pay depends on your plan.

The right plan to choose will depend on many factors, which vary from one person to another.

Get more advice on how to get the right coverage

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Changing To A Marketplace Plan

If you have job-based coverage, you might be able to change to a Marketplace plan. But you probably wont qualify for a premium tax credit or other savings. As long as the job-based plan is considered affordable and meets minimum standards, you wont qualify for savings. Most job-based plans meet these standards.

Learn about changing to a Marketplace plan.

More Help Before You Apply

• Estimating your expected household income for 2022

• You can probably start with your households adjusted gross income and update it for expected changes.
• You may qualify to enroll in or change Marketplace coverage through a new Special Enrollment Period based on estimated household income. See if you may qualify.
• Learn more about estimating income, and see what to include.

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Medicare Can Negotiate Prescription Drug Prices

To address the cost of prescription drugs, the law lets Medicare annually negotiate prices with pharmaceutical companies on 10 pricey medications, starting in 2026.

Fifteen more high-cost and high-use drugs will be added the following year, another 15 in 2028, and 20 more drugs would make the list in 2029. “Currently, our drug pricing system works for corporations and middlemen, not patients,” Senate Democrats said in an Aug. 7 statement. “The new negotiation policy will ensure that patients with Medicare get the best deal possible on high-priced drugs and pay cost-sharing for those drugs based on the Medicare negotiated price.”

Some 5 to 7 million Medicare beneficiaries could see their prescription drug costs go down because of the provision, according to the White House.

It also closes a “rogue Secretary” loophole that could have allowed a future administration to refuse to try to get the best prices for medications, according to Senate Democrats, “or negotiate fewer than the maximum number of drugs.”

Prescription costs would be capped at $2,000 a year for seniors on Medicare Part D drug plans.

How Health Insurance Helps

Health insurance protects you before you get hurt or sick.

If you get hurt or sick and need to go to the doctor, health insurance protects you from paying high medical bills.

Health insurance is also called a health benefit plan. Health benefit plans cover preventative services like wellness visits, shots, and screening tests. These services help you stay healthy and avoid future health problems.

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Choosing A Health Insurance Plan

Reading the fine print is important when choosing health care plans. These questions may help:

• Can I go to any doctor, hospital, clinic, or pharmacy I choose?
• Are specialists, such as eye doctors and dentists covered?
• Does the plan cover special conditions or treatments such as pregnancy, psychiatric care, and physical therapy?
• Does the plan cover home care or nursing home care?
• Will the plan cover all medications my physician may prescribe?
• What are the deductibles? This is the amount you must pay each year before your insurance company will begin paying claims.
• Are there any co-payments? This is the amount of money you pay each time you receive medical services or a prescription.
• If there is a dispute about a bill or service, how is it handled?

Are There Different Plans Available Through The Health Insurance Marketplace

The four different categories of insurance plans available through the Marketplace are Platinum, Gold, Silver, and Bronze. All of the categories’ plans provide the same essential health benefits. The quality of care provided, or the access to doctors, doesn’t vary between plan types. The various categories differ by the types and amount of costs you’ll pay.

A Platinum plan’s premium is the highest, but you’ll have lower out-of-pocket costs, like copays for visiting the doctor and for prescription drugs. A Bronze plan’s premiums are the lowest, but you’ll have higher out-of-pocket costs. The Gold and Silver plans are in between.

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Failing To File Tax Returns Will Prevent Advance Payments In The Next Year

The IRS reminds taxpayers who received advance payments of the premium tax credit that they should file their tax return timely to ensure they can receive advance payments next year from their Marketplace.

If advance payments of the premium tax credit were paid on behalf of you or an individual in your family, and you do not file a tax return reconciling those payments, you will not be eligible for advance payments of the premium tax credit or cost-sharing reductions to help pay for your Marketplace health insurance coverage in the next year. This means you will be responsible for the full cost of your monthly premiums and all covered services. In addition, we may contact you to pay back some or all of the advance payments of the premium tax credit.

If you have a question about the information shown on your Form 1095-A, or about receiving Form 1095-A, or about a letter you received, contact your Marketplace as shown in the table below or visit HealthCare.gov/taxes.

How To Enroll And Get Answers To Your Questions

You can learn more about and apply for ACA health care coverage in several ways.

• Visit HealthCare.gov to apply for benefits through the ACA Health Insurance Marketplace or you’ll be directed to your state’s health insurance marketplace website. vary by state.

• Find a local center to apply or ask questions in person.

• Download an application form to apply by mail

Find the answers to common ACA questions about submitting documents, getting and changing coverage, your total costs for health care, tax options, and more.

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Saving On Your Health Insurance Plan

In order to apply for healthcare plans from the Marketplace, you will want to go to healthcare.gov.

You will be able to check which plans are available from there and choose one that suits your needs best.

Before you enroll in a healthcare plan, however, you should use our site to compare quotes and find the best deals.

There are a lot of health insurance plans available from insurance providers in your area, but not all of them offer great deals, great customer service, or nice member perks to add real value to their plans.

You can use our site to find out which plans are being sold at the best price and which insurance companies are offering the best rates on short term plans and private health insurance and more.

Our site will list health insurance plans for your area along with the rates for those plans. It will be very simple to find out which plans are priced the cheapest and which ones you can actually afford.

Your insurance provider will work with you to find a plan that fits the budget. Our site helps you find budget-friendly options and ensure that you know what your choices are.

These plans do come with a monthly premium that needs to be paid, but not everyone will have to pay the full premium.

There are some government subsidies available to low-income earners to help them cover the cost of the premiums.

This keeps your costs low and ensures that you can still get the plan you want and the coverage that you need.