Here’s an overview of the Health Insurance Marketplace, sometimes known as the health insurance "exchange."

The Marketplace helps people without health coverage find and enroll in a plan. 

If you don’t have coverage through a job, Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or another source, the Marketplace helps you find and enroll in a plan that fits your budget and meets your needs.

You can apply online, by phone, or with a paper application. When you apply we’ll tell you if you qualify for:

  • A health insurance plan with savings based on your income. Most people who apply qualify for premium tax credits that lower the costs of coverage. Some also qualify for savings on deductibles, copayments, and other costs. All plans cover: 
    • Essential health benefits

All private health insurance plans offered in the Marketplace offer the same set of essential health benefits. These are services all plans must cover. The essential health benefits include at least the following items and services:

 
  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (such as surgery)
  • Pregnancy, maternity, and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices 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 care. 

Note: All Marketplace plans must offer pediatric dental and vision care for children 18 and under. But this isn't true for adults. You're not required to have them, but be sure to shop around if you want them. 

 
    • Pre-existing conditions

Essential health benefits for pre-existing medical conditions are covered under all Marketplace plans.

      • No insurer can reject you, charge you more, or refuse to pay for essential health benefits for any medical condition you had before your coverage started.
      • This includes pregnancy. If you get pregnant and then enroll in a Marketplace plan during Open Enrollment or with a Special Enrollment Period, care for your pregnancy and childbirth is covered when your new plan begins.

    • Preventive Care

All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.

This applies only when these services are delivered by a network provider.

      • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
      • Alcohol Misuse screening and counseling
      • Aspirin use to prevent cardiovascular disease for men and women of certain ages
      • Blood Pressure screening for all adults
      • Cholesterol screening for adults of certain ages or at higher risk
      • Colorectal Cancer screening for adults over 50
      • Depression screening for adults
      • Diabetes (Type 2) screening for adults with high blood pressure
      • Diet counseling for adults at higher risk for chronic disease
      • Hepatitis C screening for adults at increased risk, and one time for everyone born 1945 – 1965
      • HIV screening for everyone ages 15 to 65, and other ages at increased risk
      • Immunization vaccines for adults — doses, recommended ages, and recommended populations vary:Lung cancer screening for adults 55 - 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years. Lung cancer screening for adults 55 - 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years 
          • Hepatitis A
          • Hepatitis B
          • Herpes Zoster
          • Human Papillomavirus
          • Influenza (Flu Shot)
          • Measles, Mumps, Rubella
          • Meningococcal
          • Pneumococcal
          • Tetanus, Diphtheria, Pertussis
          • Varicella
      • Lung cancer screening for adults 55 - 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years

      • Obesity screening and counseling for all adults

      • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk

      • Syphilis screening for all adults at higher risk

      • Tobacco Use screening for all adults and cessation interventions for tobacco users

Qualifying coverage, fees and exemptions

  • You’re considered covered if you have any job-based plan, any plan you bought yourself, Medicare, Medicaid, CHIP, and many other kinds of coverage.
  • Most people must have qualifying health coverage or pay a fee. If you don’t have coverage in 2015, you’ll pay a penalty of either 2% of your income, or $325 per adult ($162.50 per child) —whichever is higher.
  • Some people qualify for a health coverage exemption. If you do, you don’t have to pay the fee.

Contact us

To learn more how Benefit Advisors can help you and your family, contact awhull@benefit-advisors.com