Health Insurance Marketplace

Are you planning on getting Health Insurance? This article covers the basics of the Health Insurance Marketplace.

A Lot of times we have heard the phrase “Health Insurance” or come across the word “Marketplace”.

Health insurance is usually covered by employers or organizations you work for. If you have a low income or your spouse or parents don’t cover your Insurance, Health Insurance Marketplace is your best bet.

Health insurance in the US:

Healthcare in the United States is a complex bureaucracy. In the US most of the insurance companies are owned by the government and private companies. Most hospitals and health care units are owned by profit and non-profit organizations.

In the US most people are offered health care insurance by their employers. Organizations offer medical insurances to all their employees along with their salaries. There are also programs held by the government to cover different dynamics of society.

Getting healthcare insurance is not easy as one has to keep in mind the whole process and there are some more complicated processes. It is very important to pick up the insurance that matches your income and expenses.

The Patient Protection and Affordable Care Act is a federal statute signed into law by President Obama, which made it mandatory for every citizen to have health insurance or be penalized. The Act subsidies for low-income families, by taxing healthcare providers and high-income families, were designed to lower health care costs while providing better healthcare for Americans.

The Affordable Care Act allowed parents to and their children up to the age of 26 to their policies, in a bid to have younger healthy people paying premiums. It also allowed poorer people to get treatment for chronic illnesses instead of using the emergency room.

What is a Health Insurance Marketplace?

The health insurance marketplace helps you find the best coverage for all your healthcare needs. You can compare plans in the market and find the one that best suits you. Every health plan in the market almost covers all of the basic benefits.

Health Insurance Marketplace lets you explore the market where individuals and families can:

  1. Compare health care plans for coverage and affordability.
  2. Get all your questions answered about health care.
  3. Find out tax plans and if you are eligible for private insurance or health care programs.
  4. Find out if your family is eligible for the Children’s Health Insurance Program(CHIP).

The marketplace was created as a part of the Affordable Care Act(ACA) of  2010. It is also known as ObamaCare. Health Insurance Marketplace is available on the government’s official website and phone numbers. 17 states including Washington D.C have their own exchanges as well.

Eligibility Criteria

You can buy a plan on the health insurance marketplace if your health care is not covered by your spouse, employers, parents, or anyone else. You can apply for any plan if your income is low but Every person in the U.S must have minimum health coverage or pay a fee.

To be eligible to use the Health Insurance Marketplace, you:

  1. Must be a US citizen.
  2. Must Live in the United States.
  3. Can’t be incarcerated.

If you are Under age 30, you may be eligible to buy a plan with low monthly premiums.

Benefits of Health Insurance Marketplace

The ACA brought several important benefits to health insurance plans. Routine checkups, screening, and preventive care are covered 100%. Health Insurance companies can never deny you coverage if you have a pre-existing condition.

Pre-existing Conditions:

Condition or an illness that a person has before he signs up for the health insurance plan.

Other benefits of using Health Insurance Marketplace are:

  • Hospitalization
  • Maternity and child care
  • Mental Health-related services
  • Substance use disorder
  • Physical Therapy
  • Breastfeeding Coverage
  • Prescription medicines
  • Preventive care
  • Laboratory Services
  • Ambulance Services
  • Emergency Services
  • Dental Care
  • Family Planning Coverage

Preventive services include:

  • Blood pressure screening
  • Diabetes screening(Type 2)
  • Alcohol misuse and substance screening
  • HIV screening
  • Diet control and counseling
  • Vaccinations
  • Mammograms
  • Obesity Screening
  • Cancer Screening
  • Cholesterol Screening

If you lose your current existing health insurance because of losing a job, getting divorced, getting married, having a baby, or moving to a different state or zip code then you can qualify for a special enrollment period.

If none of these qualifying events happened with you then you have to shop for, apply for and buy any health insurance plan during an open enrollment period, which is usually in autumn.

CHIP:

Children’s Health Insurance Program(CHIP) provides healthcare to children who are in need of and are eligible for this program. This program is also incorporated in the Health Insurance Marketplace.

The CHIP state program is individual for every state. Many companies offer insurance programs for children in their Marketplace. While choosing an insurance plan for yourself and your family you can go through the details.

Like Medicaid, CHIP is administered by the states but is jointly funded by the federal government and states. The Federal matching rate for state CHIP programs is typically about 15 percentage points higher than the Medicaid matching rate for that state (i.e., a state with a 50% Medicaid FMAP has an “enhanced” CHIP matching rate of 65%). Every state administers its own CHIP program with broad guidance from CMS.

Medicaid:

Medicaid is a program started by the US government to provide healthcare packages and facilities to its citizens. This program is eligible for everyone including low-income adults, children, pregnant women, elderly people, and people with any kind of disability. This program is mainly administered by states and their government. Funding for this program is provided by both state and federal governments.

When you enroll yourself for health insurance at the health insurance marketplace. You can also check your eligibility for Medicaid, CHIP, and medicare. If you are eligible for these programs and you qualify for them you can apply to them from the official healthcare.gov website.

You have to apply through your state. Data is then collected and the state decides if you qualify for coverage or not. These programs do not provide direct healthcare or cash. It covers the cost of your hospital visits, emergency situations related to health care, long-term hospital stays, etc.

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Your eligibility is determined by income in relation to the FPL. The FPL is used to determine whether a family or individual’s income allows them to qualify for federal benefits. In general, if an individual’s income is less than 100% to 200% of the FPL, and they are either disabled, a child, pregnant, or elderly, there will be a program available for them. If their income is less than 138% of the FPL, then there may be a program available for them.

Getting Started:

Many people are confused about where to get started while buying an insurance plan. If you are one of them this section is for you.

To get started visit HealthCare.gov or call on Health Insurance Marketplace’s Phone Number. The website has all the information that you need to get started. It has all the plans on it which you can compare. You can also check your eligibility and your deductibles.

You have to enroll yourself in any of the plans. You can also enroll for saving and if you are considered eligible for the Tax credit you can find out how much you can save. If you qualify for savings you must have to buy your insurance plan from Health Insurance Marketplace.

Marketplace insurance plans

When you browse through the website you will find different insurance companies that you can choose from. These companies offer their healthcare plans in four tiers or levels. These levels indicate the percentage in which the company is offering to pay towards your health care services.

Companies that you see are dependent on your zip code. They are a mix of private and government-owned.

The four plans which the database offers you to choose from are: Bronze, Silver, Gold, Platinum.

Plan Level Company Pays You Pay
Bronze 60% 40%
Silver 70% 30%
Gold 80% 20%
Platinum 90% 10%

Bronze:

This is the first and most basic level. This plan covers almost 60% of your healthcare

needs. You will have to pay 40% of the amount yourself. This plan has the lowest

monthly premiums.

Silver:

This is the second plan that Health Insurance Marketplace Offers. According to this plan, 70% of your healthcare will be covered by your insurance company and you will have to pay almost 30%. This plan has a better percentage than the bronze one but its monthly premiums are slightly higher.

Gold:

This plan comes in third on the list. It is considered as one of the elite plans. In this tier, 80% of the insurance will be covered by the company or government and you will just have to pay the rest 20%.

Platinum:

This is the most elite plan and most people opt for this one when they choose their health care insurance. This plan covers almost all of your costs. The company will pay 90% of the bill and you just have to pay the rest 10%.

Your deductibles also vary from company to company. That is why every company offers you all their plans on a single website so you can compare which one is better for you. These options affect both your premiums and out-of-pocket costs for deductibles, copayments, and coinsurance. Health Insurance Marketplace allows various private insurance companies to offer plans, a Marketplace Insurance plan from one company may cost more or less than the same plan offered by a different company.

For example, a Silver plan from one company may cost you more upfront for your monthly deductible, but your out-of-pocket expenses will be much lower. Similarly, a Silver plan from another insurer could cost less each month, but you’ll pay more for healthcare expenses because of the higher deductible, copayment, and coinsurance amounts.

Copays, Deductibles, and Coinsurance

Copays:

Copay is the fee that you pay to a doctor/hospital on each visit. For example, if you are experiencing pain in your body and want it checked out. You will visit your doctor or the nearest hospital. You will have to pay a certain amount on your visit. This amount is called a copayment. It covers a part of your insurance. The percentage that you have to pay yourself is included in that.

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This also differs from plan to plan and from company to company. In some plans, your copays are also covered and some companies offer a small number of copays and deductibles.

Deductibles:

This is the amount you pay each year before buying this year’s insurance plan. Some of these deductibles are paid to share the services that are covered with the insurance. Deductibles are different for different insurances i.e family or individual. The amount you owe for covered services before health insurance kicks in.

If you consider yourself a healthy individual and you don’t think you will need higher costly amounts for your medical care then you should always choose a plan with higher deductibles and low premiums.

On the contrary, if you have a serious medical condition or you have a big family then the idea would be somehow different. You should choose a plan with a lower deductible and higher premium. This will help you by paying a great percentage of your medical costs.

Coinsurance:

Coinsurance is the amount that you have to pay after your deductibles are paid. That is the amount that is left after you have paid your deductibles and copays and your insurer has also paid their part. The amount will take your insurance up to 100%.

Any charges that are not covered by your insurance plan have to be paid by you and they are called coinsurance. For example, if your coinsurance is 20 percent, you pay 20 percent of the cost of your covered medical bills. Your health insurance plan will pay the other 80 percent. If you meet your annual deductible in June and need an MRI in July, it is covered by coinsurance. If the covered charges for an MRI are $2,000 and your coinsurance is 20 percent, you need to pay $400 ($2,000 x 20%). Your insurance company or health plan pays the other $1,600. The higher your coinsurance percentage, the higher your share of the cost is.

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You have to keep all these things in mind while comparing your plans in the Health Insurance Marketplace. All these factors play an important role in your healthcare insurance. You should always choose a plan that best suits you keeping your income in mind. Expenses and savings need to be kept in mind as well. These factors also make you eligible for savings and tax reductions.

Health Insurance Marketplace in different states:

Many states offer Health insurance. Some work with the federal government and some have their own private organizations for insurance purposes.

You can choose a health insurance marketplace if you live in these states:

  • California
  • Colorado
  • Connecticut
  • District of Columbia
  • Idaho
  • Kentucky
  • Maine
  • Maryland
  • Massachusetts
  • Minnesota
  • Nevada
  • New Jersey
  • New Mexico
  • New York
  • Pennsylvania
  • Rhode Island
  • Vermont
  • Washington

Every state has its own website and you can also enroll yourself on HealthCare.gov. Rules and regulations for every state are different. When you browse through the website you have to put in your zip code and then you will be shown companies and offers according to that. You can also call the Health insurance marketplace telephone number and they will guide you accordingly.

Here we will talk about just one state’s healthcare plans so you can have a basic idea about all others as well.

Health Insurance Marketplace Maine:

The Maine Health Insurance Marketplace helps people to purchase an affordable and efficient insurance plan for themselves and their families. Almost 85% of the population of Maine uses these plans to help them financially with their Healthcare needs.

Maine usually runs with the federal government so residents can enroll on the official website. Last year Maine made this institution a state-based organization and took all the administrative controls to work independently. They still use the official website for enrollments so the users didn’t notice the change.

There are three main insurance companies that are offering different plans for Maine residents. These three companies are:

  • Anthem
  • Harvard Pilgrim HMO
  • Community Health Options

These companies offer state-wide area coverage so anyone in Main can select plans and services from them.

There are many bodies in the federal and state legislature that can offer Health Insurance Resources. Maine Bureau of Insurance enrolls and regulates health insurance companies that regulate their operations in Maine. They are the main body that carries out functions like registrations, taking complaints, and answering questions.

Enrollment for Health Insurance Marketplace in Maine:

Till 2020 Maine was operating under the federal government and they were enrolling their citizens on the official website. But, after 2020 the government took control into their hands, and now enrollment is being done on a different website.

Citizens can now visit coverme.gov to “window shop” their insurance plans. They can compare and see what plan suits them best.

They can call this telephone number as well: 866-636-0355.

Health Insurance Marketplace FAQS:

Can I Refuse Health Insurance From My Employer and Get Obamacare?

Yes, of course, many people find they can get better service while using health insurance from the marketplace instead of what their organization is offering. The Affordable care act(ACA) ensures that all Americans are eligible for insurance plans. However, for qualifying for subsidies and tax reduction there are some conditions.

You can only qualify for health insurance from the marketplace only if the insurance your employer is offering you does not meet “minimum value standards” that the government has set. Or the second reason can be that the cheapest plan through your employer costs more than a certain percentage of your household income. Even without the subsidy, though, a Marketplace plan may offer a more affordable deal than your employer-based insurance, so comparison-shopping never hurts.

What Is the Income Limit for Marketplace Insurance?

There is no limit for Marketplace insurance. Anyone can purchase it.  In 2021, you can qualify for subsidies if you pay more than 8.5% of your household income toward health insurance premiums. At this rate, you can specifically qualify for the Silver Plan.

What is Open Enrollment?

Open enrollment is that time of the year in which enrollments are open for citizens to purchase a healthcare plan for themselves. The enrollment period differs from state to state. Most commonly the open enrollment is in autumn. You can enroll now on HealthCare.gov but before processing gathers this information to make the process faster:

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  1. Your name and Date of birth.
  2. Household Information
  3. Home Address and Mailing Address
  4. Social Security Numbers
  5. Immigrant Information (if Applicable)
  6. Income information
  7. Employer Information
  8. Tax Information

What Are State Healthcare Exchanges?

State healthcare exchanges, or state healthcare marketplaces, are sites where people and small businesses can compare and purchase health insurance options. Though offered by private insurers, these policies follow the coverage guidelines and criteria set forth in the Affordable Care Act. In 17 states and the District of Columbia, residents seeking such policies go through these state exchanges. Americans in other states purchase health insurance through the federal government’s marketplace.

Health Insurance Marketplace phone number

You can find all information about the health insurance marketplace on the official website but there are some other ways to contact the administration as well. Health Insurance Marketplace Phone Number is one of them.

The official number that can be dialed from anywhere in the US is: Call 1-800-318-2596

You can also contact your health insurance company and can get any details from them.

Conclusion

Health Insurance Marketplace is the only place that enables US citizens to compare and shop for the best insurance plans. Many companies are registered with the federal government and are operating as non-profit organizations to help people.

You can apply on an official website or call on phone numbers and get yourself enrolled into the system. Then you can choose any plan that best suits you and your family. There are many support centers that guide you throughout the process. You can calculate keeping in mind the coinsurance, deductibles, and copays.

If you have a big family you can choose your insurance plan accordingly.  After filling out the application you can also see if you are eligible for Medicaid, CHIP, or cost-sharing tax reductions.

Some catastrophic plans and other cost reduction plans are also offered so you can check whether you’re eligible for that or not. These things will help you choose a plan that will help you and will not be so tight on your pocket.

To find additional information regarding the Health Insurance Marketplace and extra savings, as well as state-specific information and how to apply in your state:

Visit HealthCare.gov

Call 1-800-318-2596

Sandra Johnson

Sandra Johnson

Sandra Johnson was a few years out of school and took a job as a life insurance agent in California, selling coverage door-to-door for Prudential. The experience taught her about the technical components of insurance and its benefits for individuals and society, as well as the misunderstandings people often have about insurance. She has over ten years’ experience in the insurance industry, having worked as both a Broker and Underwriter, assisting clients across a broad range of industries. At Insurance Noon, Sarah diligently gathers all the required information and curates up pieces to provide meaningful insurance solutions. Her personal value proposition is to demonstrate a genuine interest in always adding value for clients.Her determined approach to guiding clients has turned her into a platinum adviser to multiple insurers.

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