Marketplace Coverage Options

Starting this fall, there will be a new way for individuals, families, and small businesses to buy health insurance: the Health Insurance Marketplace (also called an Exchange). The Marketplace is designed to help people find health insurance that fits their budget, with less hassle. Every health insurance plan in the new Marketplace will offer comprehensive coverage, and consumers can compare all their insurance options based on price, benefits, quality, and other features.

In addition, individuals with incomes between 100 and 400 percent of the federal poverty level (FPL) may be eligible for federal premium tax credits to help pay for private health insurance through the Marketplace.  Individuals with incomes between 100 and 250 percent of the federal poverty level may also be eligible for additional cost-sharing reductions to help lower their out-of-pocket expenses (e.g., co-pays and deductibles).

People who obtain insurance through non-grandfathered plans inside or outside Health Insurance Marketplaces or through a Medicaid Alternative Benefit Plan will be ensured coverage of essential health benefits, including items and services within at least the following ten categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services (including oral and vision care). Within these ten categories, the specific benefits to be covered will vary by state.

The Affordable Care Act includes a number of private health insurance market reforms:

• Guaranteed availability of coverage, which prevents insurers from denying coverage to individuals based on pre-existing conditions
• Fair health insurance premiums, which prohibit discriminatory premium rates by preventing insurers from charging more for individuals based on pre-existing conditions
• Prohibition of pre-existing condition exclusions or other discrimination based on health status
• Prohibitions against imposing annual dollar limits on essential health benefits
• Dependent coverage extension (up to age 26)
• Coverage of specified preventive health services without cost sharing

Most reforms will be effective on January 1, 2014, although some provisions have been effective since 2010.  Learn more about the status of ACA implementation at the HealthCare.gov timeline.