With certain limited exceptions, everyone must have some form of minimum essential health care coverage beginning this year. While options for purchasing individual health coverage used to be limited, with the passage of the Affordable Care Act (ACA) in 2010, uninsured individuals and small business owners not currently providing health coverage to their employees can now purchase health insurance through Health Insurance Marketplace (Marketplaces) - The American Health Benefit Marketplace for Individuals and the Small Business Health Options Program (SHOP) Marketplaces for businesses with 50 or fewer employees (small businesses).
What Is A Marketplace
Marketplaces are a “one-stop-shop” for individuals and small business owners to compare and purchase health plans. The type of Marketplace in each state varies based on decisions made on the state level. The three types of Marketplace options available are:
- State Based Marketplaces – In these Marketplaces, the state has opted to manage its own Marketplace; however, the Marketplaces must be structured to meet certain minimum standards under federal law. Likewise, plans available in the Marketplace have to meet minimum requirements of federal law; however, states can add additional requirements as well. The healthcare.gov website will direct you to your state’s Marketplace if you are unfamiliar with the website address.
- State-Federal Partnership Marketplaces – In these Marketplaces, the state and federal government partner to make the Marketplace available to consumers in the state. The state and federal government divide the responsibilities; however, consumer enrollment in health plans is through the federal Marketplace website.
- Federally Facilitated Marketplaces – In these Marketplaces, the federal government runs and manages the Marketplace for that state. Consumers compare and purchase plans through the federal Marketplace website.
To see where your state stands, visit Kaiser Family Foundation.
What Type Of Coverage Is Available In The Marketplace
Plans available in the Marketplaces are called “Qualified Health Plans” (QHPs), which means that every plan must meet minimum requirements related to marketing and network adequacy and must offer at least a minimum essential health benefits (EHB) package. There are 10 essential health benefits that must be included in every plan:
- Prescription drugs
- Preventive and wellness services and chronic disease management
- Pediatric services
- Mental health and substance & disorder services, including behavioral health treatment
- Ambulatory patient services
- Laboratory services
- Rehabilitative & habilitative services & devices
- Emergency services
- Maternity & newborn care
The comprehensiveness of coverage of these benefits is standardized into four (4) metal tiers:
- Bronze – The percentage the plan pays of the average overall cost of providing EHBs is 60%
- Silver - The percentage the plan pays of the average overall cost of providing EHBs is 70%
- Gold - The percentage the plan pays of the average overall cost of providing EHBs is 80%
- Platinum - The percentage the plan pays of the average overall cost of providing EHBs is 90%
The average consumer’s share of cost for each plan will, therefore, vary based on the “metal” tier they purchase, with platinum requiring the lowest share of cost and bronze requiring the highest share of cost. However, an individual’s own costs may be more or less depending on their use of health care services. There are, however, out of pocket limits for plans - $6350 for an individual and $12,700 for a family – for EHB benefits or services provided in network. The out of pocket limits do not have to apply to out of network services or benefits. The out-of-pocket cost limit does not include a plan’s premium cost.
Finally, while the scope of the EHBs will be the same in every plan, the quality and amount of these services can vary from plan to plan. For example, plans can limit the number of visits a patient can have, and this can vary from plan to plan.
I Am Concerned About Whether I Can Afford A Plan
If you don’t have health care coverage and are concerned about whether you can afford a plan in the Marketplace, you may be eligible for financial assistance in the form of a premium tax credit (for persons who make between 100% - 400% of the poverty level) or cost sharing subsidies (for persons who fall below 250% of poverty who purchase a silver level plan in the Marketplace). Premium tax credits are determined on a sliding scale based on income. You can visit healthcare.gov or your state’s Marketplace website to determine the level assistance that may be available to you.
If you already have what is considered to be “minimum essential coverage,” then you may not be eligible for financial assistance if you decide to purchase a health plan in the Marketplace instead.
When Can I Enroll In A Plan
Just like in the traditional employer-sponsored insurance market, consumers make a plan selection during an annual open enrollment period. For Marketplace plans effective in 2014, the open enrollment period began on October 1, 2013 and will expire on March 31, 2014. You must choose a plan by March 15, 2014 if you want coverage to begin on April 1, 2014.
For plans beginning in 2015, the proposed open enrollment will be from November 15, 2014 until January 15, 2015. There will be special enrollment periods for consumers meeting certain limited criteria or life events (i.e., birth of a child, adoption, etc.), which will allow them to enroll in Marketplace plans outside the traditional open enrollment periods.
What If I Am Confused About The Plans Offered In My Marketplace And Need Help
The ACA provides for assistance personnel to be available in every state. The type of assisters available depends on the type of Marketplace your state has adopted. All Marketplaces, regardless of type, must have Navigators and Certified Application Counselors, while some Marketplaces may have licensed Agents and Brokers or In-Person Assisters available to assist consumers.
The roles Navigators, In-Person Assisters and Certified Application Counselors play in facilitating enrollment in plans are generally the same; however, there may be different examination, certification or licensure requirements depending on the state. Everyone who holds themselves out to be one of these assistance personnel must be licensed/certified by either the state, federal government or both. You can refer to your state Marketplace website, healthcare.gov, or your state Department of Insurance to determine whether someone offering to assist you has been licensed or certified.
Other than agents and brokers, assistance personnel are not allowed to recommend a particular plan for you. Instead, they can narrow the potential landscape of plans available to you based on specific criteria you provide them, such as cost, provider networks, or prescription drug coverage.
When working with a licensed/certified assister or other enrollment counselor available through your Marketplace’s call center, it is important to communicate your family’s and your unique health care needs. One way to assist you in thinking about these issues is to use NHF’s Health Insurance Toolkit. The toolkit can help you identify your most important needs and you can share that information with your assister to help narrow plan options, such as to plans where the HTC may be in network or where your specific clotting factor product is covered by the plan.
Ultimately, it is up to you to choose a plan that meets your family’s and your financial and health care needs. It is also important to evaluate your plan during each open enrollment period, as networks and coverage may change from year to year. Evaluating your health care options takes time and consideration; however, the consequences of choosing the wrong plan for your family can be costly in the long run.
The information on this page is provided for informational purposes only and is not intended to provide advice about your eligibility for any program or any particular insurance product for you or your family. If you have questions about whether you qualify for premium tax credits or subsidies, about whether you are required to purchase a plan in the Marketplace or about specific plans or coverage in the Marketplace, you should contact a tax professional or a licensed/certified Navigator, In-Person Assister, Insurance Agent or Broker, or Application Counselor in your state or contact your Marketplace Call Center.