What Is the Health Insurance Marketplace? - dummies

By Lisa Yagoda, Nicole Duritz, Joan Friedman

Copyright © 2014 AARP. All rights reserved.

As part of the Affordable Care Act, every state has a Health Insurance Marketplace, also referred to as an exchange, where people looking for coverage can go online to shop for health insurance. Some states created their own Health Insurance Marketplace; where states have not done so, the federal government administers the Marketplace.

Think of the Marketplace as an online shopping mall for health insurance that makes it easier to find health plans in your state and choose one that works well for you.

The Marketplace is a new way for people to shop for health coverage. If you enroll in the Marketplace, it also determines whether you are eligible for health coverage through a public health program such as Medicaid.

Keep in mind that you don’t have to shop for insurance coverage on your state’s Marketplace website. You can still purchase coverage elsewhere — from an agent, broker, or online insurance company, for example. However, if you want help to lower your costs based on your income, the only place to do so is the Marketplace.

Every plan offered on a state’s Marketplace site is a qualified health plan, which means it has been vetted to make sure it complies with ACA requirements for benefits, costs, and so on. Note that you may use the Marketplace only until you are eligible for Medicare.

The Marketplace is primarily for people under age 65 who need insurance. Generally, if you’re 65 or over and you apply to the Marketplace, you’ll be directed to enroll in Medicare.

Here’s another key consideration: You can’t enroll in a Marketplace plan anytime you want. If you experience what’s called a qualifying life event, such as losing your job, getting divorced or married, or having a baby, you’re granted a special 60-day Marketplace enrollment period during which you can shop for a plan on the Marketplace.

Otherwise, you must wait for an open enrollment period. Open enrollment for the Marketplace lasts for about two months each year. To secure coverage for 2015, for example, the Marketplace open enrollment period is slated to start on November 15, 2014, and to end on January 15, 2015.

Interacting with your state’s Health Insurance Marketplace involves these steps:

  1. Connecting: You can go to the Health Insurance Marketplace website for your state and view the available plans. To find the Marketplace website for your state, you can start at HealthCare.gov or HealthLawAnswers.org.

    On your state’s Marketplace website, you set up an account and will learn whether you are eligible for financial help and can review each plan that offers what you need. You find out its costs — including what the premium will be if you qualify for financial help — and see what’s covered so that you can make an informed decision about which plan to purchase.

    If you don’t use a computer, you can shop the Marketplace by phone at 800-318-2596 or find someone to speak to in your local area by going to LocalHelp.HealthCare.gov and typing in your city and state or zip code.

  2. Comparing: Your state’s Marketplace lists all plans in one place and provides a Summary of Benefits and Coverage (SBC) using a standardized form that the ACA requires.

    That way, you can make side-by-side comparisons of the benefits and prices; you’re comparing apples to apples. The ACA requires that an SBC describe what’s included in a plan in simple language, so you should face very little guesswork about what’s covered.

    Every Marketplace plan is required to cover essential health benefits, including doctor visits, hospital care, emergency care, prescriptions, preventive care, and more. Differences among plans relate to what’s covered beyond those essential benefits, provider networks, and how you and the plan share expenses.

    If you want to pay a lower premium, for example, you may be looking at a higher deductible if you use your health coverage for something other than preventive services.

  3. Choosing: After you’ve reviewed your options, you can choose the health plan that works for you and sign up.

    The ACA has established for the first time financial help to pay for health insurance. Some people who buy a plan in the Marketplace get help covering the costs. Low-cost plans are also available, depending on your income. For example, a family of four earning less than $94,200 a year may be able to get financial help.