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Health Insurance Marketplace
Health Insurance Marketplace
The Health Insurance Marketplace (Marketplace) is a federally operated insurance marketplace where individuals and families can purchase and compare health plans. The Marketplace is primarily accessed at www.healthcare.gov or by telephone at 800-318-2596.
An individual health plan may be purchased for you and your family during the annual open enrollment period with the Marketplace.
For information on how to purchase a health plan outside of the Marketplace, please refer to Shopping for a Health Plan.
When purchasing health coverage through the Marketplace, it’s beneficial to understand the following:
- Advance Premium Tax Credits
- Cost-Sharing Reductions
- Marketplace participation
What You Should Know
Advance Premium Tax Credits (APTC)
An APTC is a federal tax credit that is used to lower the monthly cost of a Marketplace health plan. Eligibility for an APTC is available for those with a household income between 100 percent to 400 percent of the federal poverty level. The federal poverty level is adjusted annually. The Marketplace will determine your eligibility for an APTC.
If you are eligible and use a Marketplace APTC to lower your monthly premium payment, you will have to “reconcile” the credit when you file your federal taxes. For additional information and a step-by-step guide to reconciling your APTC, visit www.healthcare.gov.
Cost-Sharing Reductions (CSR)
CSRs allow you to save money when you receive health care services. A health plan with a CSR lowers the amount you have to pay for out-of-pocket costs like:
- Out-of-pocket maximum
To qualify for a CSR, you must purchase a silver level health plan on the Marketplace and have a household income between 100 percent to 250 percent of the federal poverty level. The federal poverty level is adjusted annually.
Not all health insurers choose to participate in the federal Marketplace. Prior to selling plans on the Marketplace, an insurer's qualified health plan and rates must be certified by DIFS and the federal government.
Types of Qualified Health Plans (QHP) on the Marketplace
A Qualified Health Plan (QHP) is a health plan that's certified by the Health Insurance Marketplace and DIFS. QHPs provide essential health benefits, follow established limits on cost-sharing (like deductibles, co-payments, and out-of-pocket maximum amounts), and meet other requirements under the ACA.
QHPs are divided into five metal levels. Each metal level represents how the cost for health care services are split between you and the health plan.
The five metal levels are: platinum, gold, silver, bronze, and expanded bronze. Insurers selling health plans on the Marketplace are not required to offer plans in every metal level or in all counties.
- Platinum Level - These plans must cover 90 percent of expected health care costs and you are financially responsible for the remaining 10 percent.
- Gold Level - These plans must cover 80 percent of expected health care costs and you are financially responsible for the remaining 20 percent.
- Silver Level - These plans must cover 70 percent of expected health care costs and you are financially responsible for the remaining 30 percent.
- Bronze Level - These plans must cover 60 percent of expected health care costs and you are financially responsible for the remaining 40 percent.
- Expanded Bronze Level - These plans must cover between 56% and 62% of expected health care costs.
- If an expanded bronze plan covers and pays for at least one major service, other than preventive services, before the deductible, or meets the requirements to be a high deductible health plan, it must cover between 56% and 65% of expected health care costs.
Catastrophic Health Plans
In addition to the metal level plans described, catastrophic health plans are also available on the Marketplace. However, these plans are only available to those under age 30 or of any age who have received certain hardship exemptions through the Marketplace. Eligibility for a hardship exemption can be obtained through www.healthcare.gov.
Catastrophic plans purchased through the Marketplace generally:
- Have lower premiums and higher deductibles.
- Cover three annual primary care visits prior to the deductible being met.
- Cover preventive services at no cost.
- Are not eligible for federal tax credits.