Health Insurance Marketplaces 101

• Use the Marketplace if you do not have coverage through your job, Medicare, Medicaid or the Children’s Health Insurance Program (CHIP). 
• If you get insurance from your employer, you can buy through the Marketplace, but you’ll likely pay full price unless your employer’s insurance isn’t affordable or doesn’t meet certain standards.  
• You must live in the U.S. as a citizen or be in the U.S. legally. This fall, for the first time, Deferred Action for Childhood Arrivals (DACA) recipients will be eligible for coverage and premium subsidies through the Marketplace. Enrolling in the Marketplace is not considered a public charge benefit and will not affect an individual’s application for citizenship or immigration status. Please note Colorado and Washington have special programs for low-income individuals who don't currently qualify for federal premium tax credits to apply for subsidized coverage regardless of immigration status.
• You may not be in prison. Once you are granted parole, you will have the opportunity to purchase health coverage on the exchange or enroll in Medicaid. In  11 states, qualifying individuals may be eligible for Medicaid between one and three months prior to parole.

• You'll get comprehensive health insurance covering essential health benefits like hospitalization, prescription drugs, preventive care, and more – with no exclusions for pre-existing health conditions. 
• You can compare costs and coverage between different health insurance plans. 
• You can see your premium, deductibles and out-of-pocket costs before you decide to enroll. 
• Even if in the past you have not found a plan that worked for you, the 2022 Inflation Reduction Act expanded financial assistance to help people afford quality coverage. About 80% of people will be able to find a plan that costs $10 or less. 
• Shopping through the Marketplace ensures that the plans you see meet ACA standards for coverage and financial protection. By contrast, insurance companies and brokers who sell plans outside of the Marketplace may not show you all of your options and may receive extra money to sell you non-standard plans, regardless of whether they are appropriate for you.

• There are four categories of plans – Bronze, Silver, Gold and Platinum. They balance coverage and out-of-pocket costs.Generally, plans with lower monthly premiums will require you to pay more for out-of-pocket for care and will include narrower networks of providers. This video provides a brief explanation about the trade-offs between different plans and this website provides additional information to help you shop.
• Marketplace catastrophic plans have low premiums and very high deductibles. They cover the same essential health benefits as other Marketplace plans, but you cannot receive financial support for them, and they are only available to people under 30 or with a hardship exemption.

All health plans offered on the Marketplace must cover a comprehensive set of benefits, including physician visits, hospital stays and prescriptions. Plans must also treat everyone fairly; discrimination based on pre-existing conditions is prohibited. Preventive services must be covered for free by all plans as long as they are being delivered by a doctor or provider that is in-network.

• Anyone can enroll through the Marketplace during open enrollment. In 2024, open enrollment runs from November 1 to January 15, 2025. A few states (including California, Massachusetts, New Jersey, New York, Rhode Island and Washington DC) have extended the deadline for open enrollment beyond January 15. Check with your state marketplace to learn more.
• You might qualify to enroll outside of open enrollment because of a “qualifying life event” that allows you to access a Special Enrollment Period. Find out if you are eligible here.
• Individuals with lower incomes (less than $38,730 a year for a family of 3) can also enroll at any time through a special enrollment period in most states. 
• Individuals who recently lost Medicaid coverage can enroll at any time through November 30, 2024.

• A lot has changed this year, so you should double check if your plan is still the best fit for you. Your plan may have changed their doctors and hospitals as well as the medications that are covered.  
• Costs may be very different compared to last year.  You should check if you have better options to maximize your access to financial support.
• New plans might have been added that may work better for your needs. You should log in and compare these plans to your current plan.
• If you are satisfied that your current plan is still the best choice, you can allow your plan to automatically renew.

• Information is available on the website www.HealthCare.Gov where you can also find resources, videos, and checklists and live web chat available 24/7 in English and Spanish.  
• Consumers can call (1-800-318-2596) 24 hours a day, 7 days a week and reach customer service representatives that are trained to help you complete your application. 
• The call center is available in English and Spanish and has a language line to assist callers in over 150 additional languages.
• There is also web-support for non-English speakers. Para español, visite www.CuidadoDeSalud.gov. You can also select other languages and find help on this site.

• For local help, you can work with a Navigator, a Certified Application Counselor (sometimes called an assister) or an Insurance Broker.  
• Navigators and Application Counselors are trained to provide impartial education about the Marketplace, help applicants determine whether they qualify for subsidies or Medicaid, and assist them in the enrollment process. They cannot recommend one plan over another, and your choice does not impact how they are paid.  
  • Input your zip code into this independent site for help finding a local Application Counselor.
• Insurance Brokers are insurance professionals who are certified by the Marketplaces to provide enrollment assistance. Unlike Navigators and Application Counselors, they can recommend a plan. Their services are generally free to the consumers. Some, but not all, brokers receive a commission from the health plans for whom they sell products. 
• You should only access an Insurance Broker through your Marketplace – to ensure they are licensed and trained. This link allows you to request help from a Marketplace-registered Broker. 
• If you are using a Broker, here are a few questions to consider asking:
  • Do you represent all plans on the Marketplace? Ideally, a broker should represent all plans in your area, so you know they are looking at all your options.
  • How are you compensated? If brokers make more commission from one plan than another, it might inappropriately influence their recommendation.  
  • Why are you recommending this plan for my family?

The Marketplace lets you compare based on your priorities. You should consider the trade-off between monthly premiums and the costs you will have to pay from your own pocket when you receive care.  Also look to see if the doctors and places you go to get care are included in the plans you are considering. Finally, it is important to check if your medications are covered and how much you will have to pay for them. For additional help, see our checklists for lung disease patients and tobacco users.

• This calculator can help you determine if you may be eligible for financial help. About 80% of people who will be able to find a plan with premiums of $10 or less. 
• Help may come in two forms. You may be eligible for: 
  • A premium subsidy to help offset the cost of your monthly premiums. The premium subsidy can be used with any of the Platinum-Gold-Silver-Bronze plans.
  • For income-eligible people, cost sharing reductions (CSR) lower the amount you pay when you receive care. All people eligible for CSR support are also eligible for premium subsidies but not vice versa. Unlike the premium subsidies, CSRs can only be used with a qualified Silver plan.
• Subsidies do not apply to catastrophic plans or any plan purchased outside the Marketplace.
• Your state Marketplace will check your income to confirm your eligibility.

• Potentially yes. Thanks to a recent change in  federal rules, if your offer of employer-sponsored insurance is considered "unaffordable" based on the premium for family coverage, your spouse and kids may be eligible for Marketplace coverage with premium subsidies and/or cost-sharing reductions. The Marketplace considers your coverage unaffordable if the cost of coverage for a family premium under your employer plan is more than 9.12 percent of your household income.
• Keep in mind that your children may be eligible for your state’s Children’s Health Insurance Program (CHIP), depending on your income and the eligibility rules of your state. You can learn whether your children are eligible for CHIP by entering your information into your Marketplace’s application form. 
• Once you know what your family is eligible for, compare the premiums and out-of-pocket costs for your plan options. It may be that buying two different plans &mndash; the employer plan for one spouse, and a Marketplace plan for the other spouse and/or your children — with two premiums and two deductibles, would cost your family more than paying the family premium for the employer plan and having just one family deductible to meet. You can work with a local assister for help navigating your options.

• Many forms of coverage are widely advertised and sold off the Marketplace, promising cheaper alternatives to Marketplace plans. These products (collectively referred to as "junk" plans) may not cover the services and treatments you need, and may leave you exposed to high out-of-pocket costs for care. Junk plans are not sold on the Marketplace. Check our facts about junk plans and start your insurance search at HealthCare.gov.

• If you select a plan by December 15 your coverage will begin January 1, 2025. If you select a plan between December 15 and January 15, your coverage will begin February 1, 2025. It is important to note that your coverage will only begin once you have made your first payment, which you will pay directly to the insurance company. 

• If you believe you are still eligible for Medicaid, follow up with your Medicaid program and return your renewal form as soon as possible if you haven’t already. You may still be within the 90-day reconsideration period to restore coverage.
• If you lost coverage because you no longer qualify for Medicaid, you may qualify for a health plan through the Marketplace. You can enroll at any time through November 30, 2024, due to a special enrollment period, to avoid any gaps in coverage. You will also be able to enroll or re-enroll in Marketplace coverage during the general open enrollment period that begins November 1, 2024. 
• In some states Medicaid might send you a letter letting you know that your information has been sent to the Marketplace. You can follow the link they provided.