What is Health Insurance Marketplace?

The health insurance marketplace is also called an Exchange. It offers various insurance plans to families, individuals, and also small businesses. The ACA (Affordable Care Act) established this platform to cover millions of Americans who are uninsured.

In this article, we have focused on the health insurance marketplace, the grouping of plans, and eligibility requirements.

In fact, many US states have their own marketplaces. The federal government extends coverage to residents of other states through its health insurance marketplace, which is also called an exchange.

What exactly is Health Insurance Marketplace

In 2010, President Barack Obama signed a healthcare reform law called Affordable Care Act (ACA). Health Insurance Marketplace is an important aspect of ACA. This act is also popularly known as Obamacare.

According to the law, states should establish their own exchanges. The residents can compare the available insurance plans and choose the one that suits them most from such exchanges.

For comparison, they can use online resources or make phone calls. They can also seek help from insurance brokers. Typically, some people prefer insurance brokers as they ease their job with relevant data readily.

Many states have started their own Health Insurance Marketplaces adhering to the law. However, some states have annexed themselves with federal exchange instead of establishing their own.

Inside the exchange, private insurers compete to offer plans. Residents who do not have employer-sponsored insurance compare the plans and choose suitable ones.

Normally, the open enrolment period for these exchanges starts in November and ends in December. The coverage takes effect from the subsequent year. In case of qualifying events like childbirth, marriage, etc., consumers can enroll even outside the open enrolment periods. It is called a special enrollment period.

How are Insurance plans Grouped in Health Insurance Marketplace?

In any state-run health insurance marketplace, the insurance plans are grouped by coverage levels. They differ on payment towards health care costs and services covered. In most cases, the levels are classified as platinum plans, gold plans, silver plans, and bronze plans

Depending on the levels, the premium costs may vary. For example,

1.) Bronze plan – Consumers have to pay about 40% of the costs
2.) Silver plan – Consumers have to pay about 30% of the costs
3.) Gold plan – Consumers have to pay about 20% of the costs
4.) Platinum plan – Consumers have to pay only about 10% of the costs

You can also make use of coinsurance, copays, deductibles, etc., to pay these costs.

In general, the more plan premium, the less you pay from your pocket.

Other Classifications of Plans

Apart from metal (Platinum, Gold, etc.,) groups, the insurance plans are also organized by:

1.) Price
2.) Types of health plans such as POS, PPO, HMO, or high-deductible ones with a savings account (Health).

Every plan has its own range of medications covered, choice of health care professionals, Etc. The expenses that you have to pay also vary accordingly.

Note that, some plans may cover bariatric surgery/Vitro fertilization also. Hence, we recommend you to analyze the plans thoroughly before going for them. You can also consult brokers or any other experts to help you suggest the best ones. Meanwhile, If you prefer a particular hospital or doctor, make sure the plans have them in their networks.

Off-Exchange Plans

Instead of purchasing insurance plans from exchanges, you can directly buy from insurance companies. These plans are called off-exchange plans. However, you may not receive cost-sharing or premium subsidy benefits. These plans may also differ from those sold inside the exchanges.

Typically, ACA protections are applicable to all individual major medical plans, even if you purchase them from outside the exchanges. However, ACA regulations may not be applicable to all “Expected benefits” plans that are sold off exchanges.

Moreover, the policies sold inside the exchanges have “QHPs (qualified health plans)” certifications additionally. You may not expect these merits from off-exchange policies.

Essential Health Benefits (EHBs)

In general, the insurance policies sold at the health insurance marketplace vary by feature. However, they must adhere to EHBs (essential health benefits). In simple terms, you can call them basic requirements.

1.) Doctor visit (Ambulatory services, including outpatient care that doesn’t require patients to be admitted in hospitals)
2.) Hospitalization for patients
3.) Emergency care services
4.) Contraception, pregnancy, and maternity care services, in addition to caring for newborns and children (features may vary for different plans)
5.) Mental health care, including substance use disorder coverage
6.) Preventive care services like vacancies and cancer screenings.
7.) Prescription medications (may not include all)
8.) Pediatric services
9.) Laboratory services
10.) Habilitative and Rehabilitative services

In fact, some political opponents who oppose ACA already made proposals to eliminate EHBs. In the future, these rules may or may not vary depending on the proposals.

Who can Purchase Insurance Plans from Health Insurance Marketplace?

Any resident can buy policies sold in exchanges as far as he qualifies the following:

1.) You should live in the US
2.) You must be a US citizen. However, you can apply even if you are a non-US citizen but present legally inside the US.
3.) At the time of application, you must not be in jail.

Also, if you have Medicare coverage, you cannot apply to purchase policies inside an exchange.

How to Apply

Typically, the application process is easy. Just visit the exchange website and fill in the required details before submitting the application.

You may need the following details to complete the application:

1.) Your social security number. If your family members need coverage, note their numbers also. Legal migrants may use document numbers for this purpose.
2.) Employment and Income information (W-2 forms or pay stubs) for all who need coverage in your family, including yourself.
3.) Information on current coverages (if applicable)
4.) Information on health plans that your company offered to you and your family members, even if you have not enrolled.

Special Considerations on ACA

Since ACA’s inception, Congress has made several changes to the Affordable Care Act (ACA). For instance, it removed the penalties that should be collected from individuals, if they do not have health insurance in 2017. In fact, penalty collection is an aspect of the Tax Cuts and Jobs Act.

The Trump administration said it may take steps to revoke the Affordable Care Act (ACA) as a whole in 2019. However, the Joe Biden administration replaces the prior in 2020 and focused on strengthening ACA and Medicaid.

As a part of its focus, it began a special enrollment period for exchanges. The aim was to help individuals who lost their insurance coverage due to the pandemic crisis.

In January 2021, the new president signed orders seeking to examine the rules or policies limiting the access of Americans to health insurance. It ordered the federal agencies to inspect five key areas and decide if action is needed.

1.) Protection for individuals, suffering from pre-existing conditions
2.) Requirements on work and other limitations that hinder access to the ACA and Medicaid.
3.) Policies that lessen the effectiveness of health insurance markets, including the exchange/health insurance marketplace
4.) Policies that increase the difficulty of the individuals while enrolling in ACA and Medicaid.
5.) Policies that reduce the financial assistance or affordability for recipients or their dependents.

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