Overview of the Health Insurance Marketplaces
Essential Health Benefits
Enrolling in the Health Insurance Marketplaces
When to Enroll
Key Marketplace Terms
The Affordable Care Act (ACA) of 2010 established the Health Insurance Marketplaces (also referred to as the “Marketplace” or the “Exchanges”) to increase access to private health insurance. Individuals that do not have affordable health insurance through their employment can now enroll themselves as well as their families in plans on the Marketplaces. Each state has its own Marketplace which can be run by the state government, federal government, or a partnership between the two. All state Marketplaces can be accessed through HealthCare.gov; CuidadoDeSalud.gov is also available for Spanish-speaking consumers.
The ACA requires that health insurance plans (offered both on and off the Marketplaces) cover ten essential health benefits (EHBs). Cost-sharing may still apply, except for preventative care services.
The following are the ten EHBs: ambulatory services, emergency care, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral treatment), prescription drugs, rehabilitative and habilitative services, laboratory services, preventative care and chronic disease management, and pediatric care.
Health insurance plans on the Marketplaces are classified into metal tiers according to their actuarial value – or the percentage of an enrollee’s total health cost that is covered by the insurer. In general, consumers will have a lower monthly premium and higher out-of-pocket expenses when enrolled in plans with a low actuarial value and vice versa. Below are the metal tiers and their corresponding actuarial values.
- Catastrophic – Less than 60% actuarial value
- Bronze - 60% actuarial value
- Silver - 70% actuarial value
- Gold - 80% actuarial value
- Platinum - 90% actuarial value
Catastrophic plans are only available to consumers under the age of 30 or consumers that qualify for a “hardship exemption,” where health insurance is considered unaffordable for their situation. Three primary care visits are covered as well as preventative care; all other services are subject to cost-sharing until the consumer has spent an amount equal to the annual limit.
See Kaiser Family Foundation’s brief “What the Actuarial Values in the Affordable Care Act Mean” for more information about metal tiers and actuarial value.
Technical details about qualifying for a hardship exemption can be found on the CMS factsheet “Tips for Assisters: Hardship Exemptions and Catastrophic Coverage.”
HealthCare.gov posts a list of available catastrophic plans on its “Catastrophic Plan Information” webpage
All state marketplaces can be accessed through HealthCare.gov. After selecting the state of residence, enrollees will need to provide the following information: zip code, age, estimated annual income, household size, and whether or not they smoke. Enrollees can then see which plans are available in their area as well as review coverage details and costs.
Once the enrollee has selected a plan, additional documentation may be needed to submit an application. The “Marketplace Application Checklist” from HealthCare.gov provides details about what is needed.
Open Enrollment is the annual period when individuals and families can enroll in a private health insurance plan or switch health plans. Most people can only enroll during this time, unless a “life event” qualifies them for a Special Enrollment Period (SEP). This is designed to prevent people from enrolling in plans only when they are sick and subsequently dropping their health insurance when healthy.
The Open Enrollment for 2018 is from November 1, 2017 to December 15, 2017. Plans sold during open enrollment start January 1, 2018. View the "Getting ready to apply 2018 coverage" webpage for more information.
The Special Enrollment Period (SEP) is the time outside the yearly Open Enrollment Period when individuals and families can sign up for health insurance if they have experienced a qualifying life event. Qualifying life events include: losing health coverage, moving, getting married, having a baby, or adopting a child. Individuals generally have 60 days after the qualifying event to enroll in a plan.
HealthCare.gov’s webpage “See if you can get or change 2017 health coverage” has more information about SEP qualifying events and how to apply.
Medicaid and CHIP Enrollment
Qualifying individuals can enroll in Medicaid or the Children’s Health Insurance Program (CHIP) any time throughout the year. Consumers can either enroll directly through the state Medicaid agency or on the Marketplace. If it appears that anyone in the household qualifies for Medicaid or CHIP on the Marketplace application, the information is sent to the appropriate state Medicaid agency who will contact the consumer about enrollment.
Originally, the ACA planned to have all states expand their Medicaid programs to cover individuals up to 138% of the federal poverty level; however, the Supreme Court ruled that it was a voluntary decision that could be made by each state. States that do expand their Medicaid programs receive additional federal funds.
Kaiser Family Foundation’s “Status of State Action on Medicaid Expansion Decision” can be referenced to determine if Medicaid has been expanded in a consumer’s state of residence.
In expansion states, consumers can qualify for Medicaid coverage if the household income is below 138% of the federal poverty level. Eligibility determinants may include income, household size, disability, family status, or other factors. Eligibility rules differ between states. Because the ACA intended for all states to expand their Medicaid programs, Marketplace subsidies are not available for households making below 100% of the federal poverty level, even if the consumer does not qualify for Medicaid in his/her state. This is often referred to as the “coverage gap.”
Healthcare.gov’s webpage “Medicaid & CHIP Coverage” provides contact information for state Medicaid agencies and a tool to determine if the consumer qualifies for Medicaid or CHIP based on income in his/her state.
Assister programs are available across the United States to help enrollees navigate the Health Insurance Marketplaces and make their enrollment decisions. Healthcare.gov’s Local Help Tool provides a list of available assisters by zip code.
For information on consumer assistance resources, visit https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance.html
Agents and Brokers
Many insurance agents can also help with Marketplace enrollment. A list of health insurance agents can also be found by using the Local Help Tool.
Answers to common questions are available on the Healthcare.gov website. In addition, the Marketplace Call Center is available to answer questions and assist with applying for coverage over the phone 24 hours a day, 7 days a week (Phone: 1-800-318-2596, TTY: 1-855-889-4325).
The National Disability Navigator Resource Collaborative (NDNRC) aims to support to navigators and other enrollment specialists as they assist consumers with enrollment in the Health Insurance Marketplaces. The NDNRC develops materials with a consumer friendly approach to help disability advocates and consumers with disabilities that are enrolling in a health insurance plan.
- State Resource Guide
- Disability Guide for Marketplace Enrollment
- NDNRC Training Slides (Presented at the National I&R Support Center technical assistance webinar on 2/6/2014)
Shopping for health insurance can be complex for individuals with disabilities. Health care needs and desired covered benefits will likely vary for many consumers. NDNRC publishes Population Specific Fact Sheets to address many of these questions.
Medicare is not part of the Health Insurance Marketplace. If a consumer is enrolled in Medicare, whether through a traditional Medicare or a Medicare Advantage plan, he/she is already covered by health insurance.
For newly eligible Medicare beneficiaries that are already enrolled in a plan on the Health Insurance Marketplaces, the Marketplace plan can be ended without penalty. Beneficiaries can also opt to keep their Marketplace plan once their Medicare coverage begins; however, they are no longer eligible for Health Insurance Marketplaces’ premium tax subsidies or cost-sharing reductions.
State Health Insurance Assistance Programs (SHIPs) offer enrollment assistance to older adults that are eligible for Medicare as well as to their families and caregivers. SHIP resources can help consumers compare their plan choices, advise consumers about financial assistance programs, detail Medicare eligibility criteria, and outline what services are covered by Medicare, among other things. To receive local assistance, the SHIP website provides contact information for state SHIP resources. A central toll-free number (877-839-2675) as well as an email inbox (firstname.lastname@example.org) can also be used to receive assistance.
Premium tax credits, or subsidies, help lower the monthly premium amount of a plan on the Health Insurance Marketplaces. Households with an estimated income falling between 100% and 400% of the federal poverty level (FPL) are eligible for subsidies. The amount of savings is based on the premium of the benchmark plan available in the enrollee’s area (silver plan with the second lowest premium amount).
The Modified Adjusted Gross Income (MAGI) is used to determine income eligibility for subsidies as well as eligibility for CHIP and some Medicaid population groups – all except for the elderly, blind, and disabled. MAGI is a household’s adjusted gross income, untaxed foreign income, non-taxable social security benefit, and tax exempt interest; however, MAGI does not include supplemental security income (SSI). The “What to Include as Income” article on Healthcare.gov provides more information about whether certain types of income are included and how a consumer can estimate their MAGI.
People that qualify for cost-sharing reductions (CSR) receive assistance with their out-of-pocket expenses. Cost-sharing reductions can only be applied to a silver plan. Households with an estimated income between 100% and 250% FPL are eligible for cost-sharing reductions.
Healthcare.gov's Saving Money Tool shows qualifying income levels for subsidies, cost-sharing reductions, and Medicaid in each state.
The total cost of health insurance includes both monthly premiums as well as out-of-pocket costs. Monthly premiums for each plan are listed on the Marketplaces. To estimate out-of-pocket expenses, the plan’s deductible, copayments and coinsurance, and out-of-pocket maximum have to be considered. This information can be found on the Marketplace for each plan.
In some health plans, beneficiaries can only see certain provides and other plans allow beneficiaries to see out of network providers at a higher cost. Noting the type of health plan, whether desired clinicians are in or out of the plan’s network, and the added cost for seeing a provider that is outside a plan’s network are considerations when selecting a health plan.
When shopping plans on Healthcare.gov, the site indicates whether your provider, medical facility, and prescription drugs are covered in the plans available in your area. It also calculates the estimated yearly medical expenses under each plan.
Copayment: A set dollar amount for covered services (e.g. $20 per general physician visit).
Cost Sharing: Portion of charges for a health care service that the consumer is responsible for paying.
Cost Sharing Reduction (CSR): A discount that lowers the amount a consumer has to pay for deductibles, copayments, and coinsurance. Qualifying consumers must enroll in a silver plan to receive the extra savings.
Coinsurance: A percentage of the allowed cost for covered services (e.g. 20% of the allowed cost for a specialist visit).
Deductible: A set dollar amount that enrollees must pay before their plan starts to cover the health care service (e.g. $200 drug deductible before drug coverage begins).
Health Maintenance Organization (HMO): A type of health insurance plan that typically limits beneficiaries to certain providers that are in contract with the HMO or work for the HMO. Generally, providers that are not in contract with the HMO (out-of-network) are not covered, except for emergency care.
Health Savings Account (HSA): A savings account that allows consumers to set aside money on a pre-tax basis to pay for qualified medical expenses. HSA funds can be carried over from year to year, and maintained if the consumer leaves the workforce or finds new employment.
Health Insurance Marketplace: Platform that individuals, families, and small business can use to learn about their health insurance options, compare plans, and select and enroll in a health plan.
High Deductible Health Plan: Plans that usually have a lower monthly premium, but the enrollee has to pay for more for health care services before the insurance plan starts to contribute.
Modified Adjusted Gross Income (MAGI): a household’s adjusted gross income in addition to untaxed foreign income, non-taxable social security benefit, and tax exempt interest.
Out-of-Pocket Costs: Amount the consumer pays for covered services, not including the amount paid for monthly premiums.
Out-of-Pocket Maximum: Total amount of costs the consumer has to pay for covered services each year.
Premium: Amount paid to the health insurance plan each month to receive coverage. This does not include additional cost-sharing that may apply to covered services.
Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers (i.e. hospitals and physicians) to create a network. Beneficiaries typically pay less if in-network providers are used; an additional cost is incurred for providers that are out-of-network.
Point of Service Plan (POS): A type of health plan that contracts with medical providers (i.e. hospitals and physicians) to create a network. Beneficiaries pay less if in-network providers are used. POS plans also require that beneficiaries get a referral from a primary care doctor in order to see a specialist.
Subsidy: A tax credit used to lower the cost of monthly premiums. The amount of the tax credit for qualifying consumers is based on the estimated annual income and other household information. Subsidies are more formally known as a “premium tax credit.”
Healthcare.gov’s Glossary includes additional terms and information.
- Understanding Health Insurance by Kaiser Family Foundation
- Health Reform FAQ by Kaiser Family Foundation
- Information for Assisters and Outreach Partners by the Centers for Medicare & Medicaid Services (CMS)
- From Coverage to Care by the U.S. Department of Health & Human Services (HHS)
- Navigator Resource Guide by the Robert Wood Johnson Foundation
- Enroll America