Marketplace Health Insurance: How it Works

What Is The Health Insurance Marketplace?

The Health Insurance Marketplace, also known as the Exchange, helps you find health coverage that fits your needs and your budget. You can compare plans for price, benefits, and networks, in order to make the best decision for coverage for you and your family. The Health Insurance Marketplace was established by the Affordable Care Act (ACA) to help individuals access affordable health insurance. While the federal government operates the Health Insurance Marketplace in most states, some states run their own marketplaces. All Marketplace insurance plans are offered by insurance providers like Anthem.

Who Qualifies For The Health Insurance Marketplace?

To be eligible for the Health Insurance Marketplace you must:

Live in the United States.
Be a U.S. citizen or national (or be lawfully present).
Not be incarcerated.

Are Subsidies Available Through The Marketplace?

You may be eligible for free or low-cost coverage through premium tax credits, also known as health insurance subsidies. Most applicants will qualify for some kind of savings.

Premium tax credits are based on your earnings and family size (including yourself, your spouse, if married, and anyone you will claim as a tax dependent — even if they do not need coverage). Subsidies also consider the cost of health coverage in your state. If you qualify, you may be able to lower or completely eliminate your monthly premium.

How Does The Marketplace Work?

The Marketplace offers plans in four “metal” levels: Bronze, Silver, Gold, and Platinum. Metal levels differ only in how you and your insurance provider share the overall cost. Check for availability, as not all metal level plans are available in all areas.

Plan	Bronze	Silver	Gold	Platinum
What your plan pays	60%	70%	80%	90%
Your cost	40%	30%	20%	10%

What Does It Mean To Receive Coverage Through The Marketplace?

All Marketplace plans cover 10 essential health benefits:

Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Emergency services
Hospitalization (surgery and overnight stays)
Pregnancy, maternity, and newborn care
Mental health and substance use disorder services, including behavioral health treatment (includes counseling and psychotherapy)
Prescription drugs
Rehabilitative services and devices (used to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision for children

While all Marketplace plans provide the basics, you can also select plans through your insurer that include more comprehensive coverage like dental and vision insurance.

When Can I Enroll In Marketplace Insurance?

You can enroll with the Marketplace during Open Enrollment, which typically runs between November 1 and January 15 annually, but actual dates can vary by state. If you miss Open Enrollment, there is another way you may still be eligible to apply for health coverage.

A Special Enrollment Period lets you apply if you experience a life event like losing your existing healthcare coverage, getting married, or having a baby.