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Want to buy health insurance but confused about where to start? You’ve probably heard the terms thrown around: exchange, marketplace and Healthcare.gov (oh my!). You’ve also probably seen advertisements from private marketplaces that claim to offer a better experience than a government-run exchange. But what are the differences between these marketplaces and how do you know where to go?
A few quick things to start:
Still have questions? Keep reading for our answers.
A health insurance exchange or marketplace is where you can buy health insurance during the open enrollment period or a special enrollment period. You may also be able to sign up for public health insurance, like Medicaid, through the exchange or marketplace.
Marketplaces were set up by the Affordable Care Act (ACA), also known as Obamacare. The most common and well-known exchanges are run by either the states or the federal government. The federal health exchange, Healthcare.gov, and the state exchanges allow you to see some of the health insurance plans available in your state, compare policies and submit an application.
There are also private health insurance exchanges designed to provide more support during the shopping process and make specific recommendations based on your preferences. Private health insurance exchanges may also allow you to purchase “off-exchange” plans, which cover the same essential benefits as on-exchange plans, but may provide you with additional plan options. Additionally, both on- and off-exchange plans can only base their premium on four factors: whether it’s an individual or family plan, the area you live in, your age and whether you use tobacco.
Government exchanges can enforce additional rules for on-exchange plans (for example, the requirement that insurance companies who participate in the exchange offer a plan at every metal tier). Insurance companies don’t have to follow these rules for off-exchange plans, allowing them more flexibility. They may only offer a single plan at the Gold level, or example, or decide not to cover services the state requires but not all customers need (e.g., pediatric dental coverage).
It’s important to note, however, that premium tax credits and other subsidies do not apply to off-exchange plans. To use these government subsidies, you must purchase an ‘on-exchange’ or marketplace health insurance plan.
Healthcare.gov is the health insurance marketplace operated by the federal government. It launched in 2013 and first served the 2014 open enrollment period. Americans in the 28 states that rely on the federal exchange will use Healthcare.gov to shop for, compare and apply for private health insurance policies. You can also use the site to see if you qualify for public health insurance plans like Medicaid or CHIP.
If a state elects not to create their own health insurance marketplace, their citizens will default to using Healthcare.gov. In states with their own health insurance marketplaces, Healthcare.gov will redirect citizens to the appropriate state marketplace.
All plans on Healthcare.gov must provide ten essential benefits. Depending on your state, plans may need to cover additional services in order to be sold on the marketplace. Additionally, health insurance companies providing plans on Healthcare.gov must have a plan available for each of the four metal tiers. The metal tiers – bronze, silver, gold and platinum – help shoppers understand the cost-sharing split between them and the insurance company and compare plans apples-to-apples.
In order to qualify for a government premium subsidy, you must purchase a health insurance policy that has been approved for a government marketplace such as Healthcare.gov. However, this doesn’t mean you need to shop for the policy on Healthcare.gov – as we’ll get to later, private marketplaces can show you marketplace plans as well.
Creating a Healthcare.gov login in is relatively straightforward:
Have trouble making an account? You can call the Marketplace Call Center at 1-800-318-2596.
Currently, 12 states, including the District of Columbia have built their own marketplaces for individuals and families: California, Colorado, Connecticut, District of Columbia, Idaho, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont and Washington. The remaining 11 states run a hybrid exchange. You can learn more about the marketplaces in these states here.
In general, state marketplaces work the same way as the federal health insurance exchange. The big difference is the state, not the federal government, is in charge of all aspects of the health insurance exchange.
This also means the state has more control over the health insurance policies available on their exchange. States who build their own marketplaces can place additional rules on health insurance policies, requiring them to cover additional services, for example. States can also set different quality and pricing guidelines for policies.
States may also set different qualifying events for Special Enrollment Periods. For example, New York State allows women to qualify for a Special Enrollment Period when they get pregnant, while the federal government only counts the birth of a child as a qualifying event.
Besides the federal and state health insurance marketplaces, there are also private health insurance exchanges, such as PolicyGenius.
Private health insurance exchanges can still show you all the plans available on your federal or state marketplace. If you qualify for a premium subsidy, you can still use it even if you shop through a private health insurance exchange.
Private exchanges can also show you “off-exchange” health insurance plans. Off-exchange health insurance plans are not available on any federal or state marketplace. However, off-exchange plans still adhere to the same federal rules as on-exchange plans, such as covering the ten essential benefits. Like on-exchange plans, off-exchange plans can only base your premium on four factors: whether it’s an individual or family plan, the area you live in, your age, and whether you use tobacco.
How are off-exchange plans different? Primarily, they allow health insurers to structure their plans in different ways and potentially save the customer money. For example, state and federal exchanges require participating insurers provide a plan at every metal tier. However, an insurer may only want to offer a single Gold tier plan. With off-exchange plans, they can do that.
Private health insurance exchanges like PolicyGenius can also provide different shopping support for customers. At PolicyGenius, for example, we have designed our private health insurance marketplace to help customers find the right plan for their budget by balancing their different needs. Shopping for health insurance is all about compromise – you may decide you’re willing to pay more every month in order to get a lower deductible, for example. PolicyGenius is designed to help you navigate those compromises.
Enrolling in a health insurance plan is relatively straightforward. To enroll, you need to pick either a private marketplace or your government-run option. (You can also enroll in health insurance through your employer if they provide health insurance benefits.)
If you’re planning on shopping on one of the marketplaces, make sure that you’re shopping during Open Enrollment (or that you qualify for a Special Enrollment Period). Here are the dates for open enrollment 2018:
If you want to search on a state or federal marketplace, you typically need to make an account on the appropriate marketplace site and fill out a short application before you can view plans. Once you can view plans, you can enroll straight on the site.
You can also shop on a private exchange like PolicyGenius. As we mentioned above, private exchanges may be able to show you additional options. These additional options, often off-exchange plans, may be better suited for your needs and budget. When you find a plan through PolicyGenius, you’ll fill out a short online application, then complete the process with a quick phone call with a licensed agent. The agent will verify your identity, check on your eligibility for a premium subsidy and answer any additional questions you have about your plan.
No matter where you shop for health insurance, after you’ve filled out the application and officially enrolled, you will receive your membership materials, including your member ID card, and your first bill directly from the health insurance company. Pay that bill and your coverage will go into effect on the specified effective date.