HomeCoverWhat Is Health Insurance Marketplace Coverage

What Is Health Insurance Marketplace Coverage

Understanding The Aca Health Insurance Marketplace

New coverage option: Health Insurance Marketplace

The Health Insurance Marketplace is a key element of the Affordable Care Act, a healthcare reform signed into law by President Barack Obama in 2010, also known as Obamacare. The law instructed states to set up their own exchanges where individuals or families without employer-sponsored coverage could compare plans. Many states, however, have chosen not to establish a marketplace and have joined the federal exchange.

The Marketplace facilitates competition among private insurers in a central location where people who do not have access to employer-sponsored insurance can find a suitable plan. Individuals can compare and apply for plans via the Marketplace during the open enrollment period. Typically, this period takes place in November and December of the year prior to the year in which the coverage will take effect. Consumers can apply for a special enrollment period in the case of a qualifying event such as the birth of a child, marriage or the loss of another insurance plan.

The Marketplace categorizes plans into four tiers: bronze, silver, gold, and platinum, in the order of least to greatest coverage. The highest tier, platinum, includes plans that cover approximately 90% of health expenses, but is also the most costly. Lower-income individuals and families can qualify for extra savings on all the health insurance plans offered on the exchange through premium tax credits and cost-sharing reductions.

Obamacare Website Glitches With The Health Insurance Marketplace

The ObamaCare website launched with some glitches. Work was done to correct the problems. The official ObamaCare website for the health insurance marketplaces, healthcare.gov, has been having technical issues. Most of the feedback from the states that created their own marketplaces have shown that they are working as intended if not better. The website glitches have been increasingly problematic since Trump cut the tech support budget. The following video discusses what was going on with the health insurance marketplace glitches. Check out this article to get an idea of what is going on with the website.

What’s The Difference Between On

If you’re buying a health insurance plan in the individual market, you’ll probably hear people referring to “on-exchange” plans versus “off-exchange” plans. An “on-exchange” plan is simply one that’s purchased through the exchange. People can shop for exchange plans on their own, or they can have help from a broker or navigator .

“Off-exchange” plans, on the other hand, are purchased without going through the ACA exchange in your state. They can be purchased directly from an insurance company, or with the help of a broker. Premium subsidies and cost-sharing subsidies are not available if you buy an off-exchange plan, even if you’d otherwise be eligible. And you can’t go back and claim the premium subsidy on your tax return if you bought an off-exchange plan, whereas you can if you buy an on-exchange plan and don’t take the premium subsidy upfront.

But in many cases, the plans themselves are identical or nearly identical, on- and off-exchange. All individual major medical plans with effective dates of January 2014 or later are required to be fully compliant with the ACA, regardless of whether they’re sold in the exchange or off-exchange. That part is important: Insurance companies cannot sell non-compliant major medical health plans in the individual market, even if they sell them outside the exchange.

Some insurers choose to only offer their plans for sale on-exchange, others only offer them off-exchange, and others offer plans both on- and off-exchange .

Read Also: Does Starbucks Provide Health Insurance For Part Time Employees

Economics Of Health Insurance Exchanges: The Individual Mandate

The health insurance advocacy group America’s Health Insurance Plans was willing to accept these constraints on pricing, capping, and enrollment because of the individual mandate: The individual mandate requires that all individuals purchase health insurance. This requirement of the ACA allows insurers to spread the financial risk of newly insured people with pre-existing conditions among a larger pool of individuals.

Additionally, a study done by Pauly and Herring estimates that individuals with pre-existing conditions in the 99th percentile of financial risk represented 3.95 times the average risk . Figures from the House Committee on Energy and Commerce would indicate that approximately 1 million high-risk individuals will pursue insurance in the health benefits exchanges. Congress has estimated that 22 million people will be newly insured in the health benefits exchanges. Thus the high-risk individuals do not number in high enough quantities to increase the net risk per person from previous practice. It is thus theoretically profitable to accept the individual mandate in exchange for the requirements presented in the ACA.

How Do Consumers Buy Health Insurance Coverage

Pritchards Perspective 9/30/13

If you dont have access to coverage provided by an employer, youll need to obtain your own health insurance in the market for individuals and families. You can visit your states marketplace/exchange to see the options that are available to you and how much the monthly premiums would be. If youre not eligible for premium subsidies or cost-sharing reductions , you might want to also check with a broker to see if there are additional plans available outside the exchange in your area.

If you feel that you can confidently manage your own enrollment and health coverage, you can enroll on your own. But the services of brokers and enrollment assisters are available free of charge, and they can help you manage the process.

Depending on your income and where you live, your state may provide you with Medicaid coverage. If youre eligible, your states marketplace will direct you to the application portal for Medicaid, and there are people available in your state who can help you complete the enrollment and answer any questions you may have.

If youre eligible for Medicare and dont have supplemental coverage provided by a current or former employer, youll also likely need to seek out supplemental coverage on your own, via Medicare Advantage or Medigap plus Medicare Part D.

Recommended Reading: Does Starbucks Provide Health Insurance For Part Time Employees

More Than 8200 Sign Up For Health Plans Under Maine’s New Insurance Marketplaceyour Browser Indicates If You’ve Visited This Link

More than 8,200 Mainers have selected plans under the state’s healthinsurance that was approved last month by federal regulators. Open enrollment began this month and residents are being encouraged to use a new tool called “Plan Compare” to essentially window shop for plans on the called CoverME.


Does Texas Protect Consumers From Surprise Balance Billing

Surprise balance billing has long been a thorny issue in health care reform. After several years of working on a solution, the federal government did ultimately enact legislation to protect consumers from most instances of surprise balance billing as of 2022.

But many states had stepped up to protect their own residents who had state-regulated health coverage, and Texas was among them. Surprise balance billing occurs when a patient uses an out-of-network provider, but not by choice. It can be an emergency situation in which the closest hospital is out-of-network, or it can be a situation in which the patient goes to an in-network facility but is treated by out-of-network providers. This might be an assistant surgeon, anesthesiologist, radiologist, laboratory, durable medical equipment supplier, etc. And while the patient did their due diligence in terms of finding an in-network facility, it can be challenging or next to impossible to ensure that every provider who works with the patient will also be in the patients insurance network.

With the enactment of S.B.1264, Texas joined a growing list of states that have addressed the issue of surprise balance billing. And the new Texas legislation, which applies to medical services provided on or after January 1, 2020, is among the most comprehensive in the country, providing solid consumer protections .

Don’t Miss: Starbucks Insurance Part Time

How To Use Your States Health Insurance Marketplace To Buy Affordable Health Insurance

ObamaCares Health Insurance Marketplace, or ObamaCare Marketplace, is your States price comparison website for subsidized health insurance under the ACA. The following guide will explain the marketplace and how you, your family, and your business can compare health plans and qualify for reduced premiums and out-of-pocket costs on marketplace based coverage.


TIP: Sometimes people call the Affordable Care Act by its nickname ObamaCare, likewise sometimes people will refer to the marketplaces for insurance created under the ACA as ObamaCare Marketplaces. On our site our goal is to help you find what you are looking for and to help you understand how everything works. For this reason we use both the official names and nicknames of the ACA, Marketplace, etc.

More Help Before You Apply

What is a Health Insurance Marketplace?
  • Including the right people in your household

  • Count yourself, your spouse if you’re married, plus everyone you’ll claim as a tax dependent, including those who dont need coverage.
  • Recommended Reading: Does Starbucks Provide Health Insurance For Part Time Employees

    How To Sign Up For The Health Insurance Marketplace Website

    Here are the official directions for signing up for health insurance through healthcare.gov.

  • Set up an account. First, youll provide some basic information. Then choose a username, password, and security questions for added protection.
  • Fill out the online application. Youll provide information about you and your family, like income, household size, current health coverage information, and more. This will help the Marketplace find options that meet your needs. Important: If your household files more than one tax return, call the Marketplace Call Center at 1-800-318-2596 before you start an application. This is a very important step. Please dont skip it. Representatives can provide directions to make sure your application is processed correctly.
  • Compare your options. Youll be able to see all the options you qualify for, including private insurance plans and free and low-cost coverage through Medicaid and the Childrens Health Insurance Program . The Marketplace will tell you if you qualify for lower costs on your monthly premiums and out-of-pocket costs on deductibles, copayments, and coinsurance. Youll see details on costs and benefits to help you choose a plan thats right for you.
  • Irs Suspends Requirement To Repay Excess Advance Payments Of The 2020 Premium Tax Credit

    If you have excess advance Premium Tax Credit for 2020, you are not required to report it on your 2020 tax return or file Form 8962, Premium Tax Credit.

    If you claim a net Premium Tax Credit for 2020, you must file Form 8962.

    If you already filed and have excess advance Premium Tax Credit, you dont need to file an amended return or take any other action. The IRS will refund any excess APTC you paid on your 2020 tax return.

    1. What is the premium tax credit?

    The premium tax credit is a refundable tax credit designed to help eligible individuals and families with low or moderate income afford health insurance purchased through the Health Insurance Marketplace, also known as the Exchange. The size of your premium tax credit is based on a sliding scale. Those who have a lower income get a larger credit to help cover the cost of their insurance. When you enroll in Marketplace insurance, you can choose to have the Marketplace compute an estimated credit that is paid to your insurance company to lower what you pay for your monthly premiums . Or, you can choose to get all of the benefit of the credit when you file your tax return for the year. If you choose to have advance payments of the premium tax credit made on your behalf, you will reconcile the amount paid in advance with the actual credit you compute when you file your tax return. Either way, you will complete Form 8962, Premium Tax Credit and attach it to your tax return for the year.

  • Birth or adoption of a child
  • Also Check: Can I Go To The Er Without Health Insurance

    Exchange Enrollees Identified On Id Cards

    At the end of May 2015, the Texas state senate passed House Bill 1514, and Governor Abbott signed it into law the following month. The law became effective in September 2015, and requires insurance carriers to label policy ID cards with QHP if the plan was purchased through the exchange.

    The initial version of the House bill called for two different designations for exchange-purchased policy ID cards: QHP for plans purchased without a subsidy, and QHP-S for plans purchased with a subsidy . But the version that was ultimately signed into law dropped the S and simply calls for identifying all exchange enrollees with the QHP designation.

    Many provider organizations were in support of HB 1514, because theres a 90 day grace period for subsidized exchange enrollees who fall behind on their premiums, as opposed to the 30 day grace period for plans purchased outside the exchange and for non-subsidized exchange plans. During that time, carriers have to pay claims from the first 30 days, but can retroactively deny claims from the following 60 days and can require the provider to refund payments made during that time.

    Small Business Health Options Program Marketplace

    Medical Insurance Marketplace / Nys health insurance ...

    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.

    Read Also: Part Time Starbucks Benefits

    In A Marketplace How Many Health Plan Choices Will I Have For Each Level Of Coverage

    Your state and the federal governments decide which insurance companies can sell on the Marketplace. All companies they allow must offer at least one silver-level plan and one gold-level one. So your number of choices depends on the state and federal governments and on the insurance companies that choose to sell plans on the Marketplace in your state.

    Is It Cheaper To Buy A Health Insurance Marketplace Plan On A State Exchange The Federal Exchange Or Through A Private Exchange

    You will always pay the same price for a marketplace plan no matter where you buy it. Your premiums and any subsidies you are eligible for will be identical on the federal and state exchanges and on private sites like eHealth.Note that different people may pay different prices for their marketplace plans. Thats because premiums will vary based on your state, income, and household size. However, the price that you pay will not change from one site to another. You can be confident that you are not going to get a better price somewhere else for the same exact plan, so you can relax, and avoid hopping around to too many sources.

    Don’t Miss: Does Starbucks Provide Health Insurance For Part Time Employees

    Some Drawbacks To Consider

    Yes, marketplace insurance in 2019 is a great option for so many Americans, but its not for everyone. Everyones healthcare needs are different, and even with uniform health plans, some people will be better off looking elsewhere for health coverage. Lets begin with the extremely small window or enrollment.

    Unless youve had a qualifying life event , youll have a very narrow window to sign up for coverage. Each year, youll have a 45-day window, which isnt a lot of time when you think about it. There are millions of Americans who miss the Open Enrollment Period each year, which forces Americans to either go an entire year without health insurance or see whats available elsewhere.

    The most frustrating thing about the marketplace is the pricing. If you dont qualify for subsidized coverage, then youll be paying hundreds of dollars a month in premiums, and possibly thousands depending on the size of your family and where you live. There arent many options for you to choose from either, with some counties only having a single insurer offering plans.

    You may also end up paying for coverage you dont need. The minimum essential benefits are great for the average American, but if you think about it, there are some who end up forking over extra money for benefits they will never use. Its going to be up to you to decide whether or not the marketplace is your best option in 2019. So, make sure to explore plans both on and off the exchange.

    Health Coverage For People With Disabilities

    Streamlined Marketplace Application Drilldown Loss of Health Coverage SEP

    If you have a disability, you have three options for health coverage through the government.

    • Medicaid provides free or low-cost medical benefits to people with disabilities. Learn about eligibility and how to apply.

    • Medicare provides medical health insurance to people under 65 with certain disabilities and any age with end-stage renal disease . Learn about eligibility, how to apply and coverage.

    • Affordable Care Act Marketplace offers options to people who have a disability, dont qualify for disability benefits, and need health coverage. Learn about the .

    You May Like: Does Starbucks Provide Health Insurance For Part Time Employees

    Benefits All Healthcaregov Plans Must Have

    All health plans listed on healthcare.gov must cover Obamacareâs 10 essential benefits:

    • Outpatient care

    • Hospitalization for surgery, overnight stays, and other conditions

    • Mental health coverage and substance use disorder services

    • Rehabilitative and habilitative services

    • Pregnancy, maternity, and newborn care

    Plans on the federal marketplace must also include birth control coverage, breastfeeding coverage, and coverage for pre-existing conditions. State marketplaces may require all insurers to offer further coverage.

    Additionally, health insurance companies can only provide policies through healthcare.gov if they have a plan available for each of the four metal tiers. Individual plans are divided into the metal tiers â Bronze, Silver, Gold, and Platinum â based on the cost-sharing split between the customer and the insurance company. Having the metal tiers allows you to make an apples-to-apples comparison of benefits and costs.

    Related article: How much Obamacare costs in each state.

    Popular Articles

    explore more