In the early 2010s, the landscape of health insurance changed entirely in the United States. The Obama Administration moved to democratize health insurance for all American citizens. Before this time, it was estimated that nearly one in six Americans was uninsured. The process of getting non-employer-sponsored plans was more expensive and complicated than it is today, so the Health Insurance Marketplace was born.
Everyone can buy health insurance from the Marketplace, but there are income requirements to qualify for a tax credit.
All Marketplace plans are ACA-compliant, which guarantees certain consumer rights with your health coverage.
Dental coverage is often separate from health coverage plans, and vision is always separate except in the cases of coverage for children.
Open enrollment for Marketplace plans goes until January 15, 2023 and coverage begins as early as January 1, 2023.
What is Marketplace health insurance?
Marketplace health insurance is a method to get health insurance without an employer.
You may hear non-employer-sponsored plans referred to as any of the following:
Private medical insurance;
Marketplace insurance (Health Insurance Marketplace);
Affordable Care Act (ACA) insurance.
Reasons to buy Marketplace insurance
You can get private insurance outside the health insurance Marketplace by buying directly from an insurance plan or working with an insurance broker. While Marketplace plans are usually a more economic option, there are reasons to buy outside the Marketplace, especially if you need specialist care. There is no income requirement to qualify for insurance through the Marketplace, but if your household income is too high, you won’t qualify for a special tax credit.
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Here are some reasons you might consider buying Marketplace insurance:
- You are self-employed;
- You are opting to not elect employer-sponsored health plan coverage;
- You are unemployed.
To qualify for marketplace insurance, you must be:
- Not on Medicare;
- Living in the United States;
- A United States citizen;
- Not incarcerated.
Marketplace plans can be for individuals or families. The premium tax credit is based on an income sliding scale, and you’ll need to visit healthcare.gov to see if you qualify.
Where to buy Marketplace insurance
To buy Marketplace insurance, you’ll need to start by making an account at Healthcare.gov. Make sure you verify if your state has its own Marketplace option.
The Marketplace offers five plan types, including:
The catastrophic plan has a very low monthly premium, but a high cost of healthcare and is best considered as “emergency-only” coverage. This plan has a high deductible, but it does cover 3 preventative visits a year outside your yearly deductible. In contrast, the platinum plans have a high monthly premium, but lower deductibles and medical costs when receiving care.
There is also a range of network plan types (PPO, HMO, EPO, and POS). These types of plans dictate the way your insurance determines what providers and facilities are in-network or out-of-network. The wider the network, usually the higher the premium, because you have more care options available.
Elements of Marketplace plans
Marketplace plans have the benefit of offering private plans that are also ACA-compliant, the same way that employer-sponsored health plans must be. This means there are consumer protections put in place to ensure that the plan is fair and regulated for consumers. A few of these regulations include allowing individuals to be on a parent’s plan until age 26, and coverage of essential health benefits.
Marketplace health plans must cover:
- Hospital care;
- Preventative care;
- Emergency care;
- Mental health care;
- Rehabilitation care;
- Pregnancy care.
Dental and vision
You won’t be able to buy a dental plan without opting for health insurance. Some plans include dental care, but in other cases, you’ll need to seek dental coverage separately. Dental coverage must be offered for all insured children, but their parents have a choice whether they choose to elect this benefit. Dental coverage can’t be changed or removed outside open enrollment.
Vision care is not offered through the Marketplace, though some plans will include it. If vision care (glasses, contact lenses, vision exams, or eye surgery) is important to you, then you’ll need to speak with an insurance broker to ensure you get proper coverage. However, similar to dental care, vision coverage must be offered to all individuals younger than 18 years of age.
A “pre-existing” condition is a health condition that you had prior to the first day of your insurance coverage start date. By law, all Marketplace plans must cover treatment for existing medical conditions.
Pregnancy and contraception
Pregnancy is covered beginning the day your health plan starts. Marketplace plans also offer coverage for birth control and contraceptive methods and counseling. All plans have to cover pregnancy without charging co-payment or coinsurance for in-network providers, which applies even before you meet your deductible. Additionally, all plans must cover breast pumps and lactation support after pregnancy.
Don’t miss open enrollment for 2023
Similar to employer-sponsored health insurance, Marketplace plans have an open enrollment period. Individuals can not enroll in a Marketplace plan outside this period unless they experience a qualifying life event.
Life events may include:
- Moving to another zip code;
- Leaving incarceration;
- Job loss;
- Having a child;
- Getting divorced;
- Becoming a citizen;
- Family member death resulting in loss of coverage.
Don’t forget to shop the market for a private plan by January 15th, 2023. Plan coverage starts January 1st, 2023 at the earliest.
- Healthcare.gov. Get Coverage.
- U.S. Department of Health & Human Services. What is the Health Insurance Marketplace?
- National Academies Press (US). Changing Patterns of Health Insurance and Health-Care Delivery.