Marketplace Healthcare: Private Insurance Options Explained

The Health Insurance Marketplace is a federal program that helps individuals and families shop for and enroll in health insurance. The program is facilitated by the U.S. government through HealthCare.gov, although some states run their own marketplaces. The Health Insurance Marketplace, also known as the exchange, provides health plan shopping and enrollment services through websites, call centers, and in-person assistance. The Marketplace is a viable option for those who do not have health insurance through their employer or Medicare. To be eligible for enrollment, individuals must be U.S. citizens or nationals, or lawfully present non-citizens in the U.S., and not be incarcerated. Enrollment for 2025 coverage begins on November 1, with plans and prices available for preview before enrollment.

Open Enrollment

The Health Insurance Marketplace is a service that helps people shop for and enrol in health insurance. The federal government operates the Health Insurance Marketplace, available at HealthCare.gov, for most states. Some states run their own marketplaces.

The Health Insurance Marketplace provides health plan shopping and enrolment services through websites, call centres, and in-person help. Small businesses can use the Small Business Health Options Program (SHOP) Marketplace to provide health insurance for their employees.

The first day of Open Enrollment is the first day you can enrol in, renew, or change health plans through the Marketplace for the coming year. Coverage can start as soon as January 1 if you enrol by December 15 and pay your first premium.

If you miss the Open Enrollment period, you can still enrol in or change Marketplace plans if you qualify for a Special Enrollment Period. A Special Enrollment Period is a time outside the yearly Open Enrollment Period when you can sign up for health insurance due to certain life events, including losing health coverage, moving, getting married, having a baby, or if your household income is below a certain amount.

Premium tax credits

The premium tax credit is a refundable credit that helps eligible individuals and families cover the premiums for their health insurance purchased through the Health Insurance Marketplace. The Health Insurance Marketplace is a federal government-operated service that helps people shop for and enrol in health insurance.

When applying for Marketplace coverage, you will find out if you qualify for the premium tax credit, which lowers your premium—the amount you pay each month for your insurance plan. The premium tax credit is based on the income estimate and household information you provide on your Marketplace application. The amount of your premium tax credit depends on the estimated household income for the year you want coverage.

If your income is between 100% and 400% of the federal poverty line, you qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan. If your income is above 400% of the federal poverty line, you may still qualify for premium tax credits.

You can use all, some, or none of your premium tax credit in advance to lower your monthly premium. If you use more advance payments of the tax credit than you qualify for, you must repay the difference when filing your federal income tax return. If you use less premium tax credit than you qualify for, you will receive the difference as a refundable credit when filing your taxes.

It is important to report income and household changes to the Marketplace as soon as possible. If your income changes, or if you add or lose members of your household, your premium tax credit will likely change too.

Medicaid and CHIP

Medicaid and the Children's Health Insurance Program (CHIP) are government-operated programs that provide free or low-cost health coverage to low-income individuals, families, children, pregnant women, seniors, and people with disabilities. While Medicaid is a federal program, CHIP is jointly funded and managed by state and federal authorities.

Medicaid is a federal program that provides health coverage for eligible individuals with low incomes, including families, children, pregnant women, seniors, and people with disabilities. Some states have expanded their Medicaid programs to cover all adults below a certain income level, while others have not. As such, the income level to qualify for Medicaid depends on the state in which one resides. Coverage and costs under Medicaid may also vary from state to state, as each state's program must follow federal guidelines but can differ in their specific implementations. Some Medicaid programs pay for care directly, while others use private insurance companies to provide coverage. Notably, former foster children are guaranteed uninterrupted Medicaid coverage until they turn 26, provided they meet certain conditions.

CHIP provides health coverage for children in families with incomes too high to qualify for Medicaid but too low to afford private coverage. CHIP is jointly funded and managed by state and federal governments, with each state working closely with its state Medicaid program. While CHIP primarily covers children, some states also extend coverage to pregnant individuals.

Individuals can apply for Medicaid and CHIP in two ways: through the Health Insurance Marketplace or directly through their state Medicaid agency. The Health Insurance Marketplace, operated by the federal government, provides health plan shopping and enrollment services through websites, call centers, and in-person assistance. It is important to note that applying through the Marketplace may also reveal eligibility for cost savings on a Marketplace plan.

Health Insurance Marketplace® eligibility

The Health Insurance Marketplace® is a service that helps people shop for and enrol in health insurance. It is operated by the federal government and is available at HealthCare.gov for most states. Some states run their own marketplaces.

The Health Insurance Marketplace® provides health plan shopping and enrolment services through websites, call centres, and in-person help. Small businesses can use the Small Business Health Options Program (SHOP) Marketplace to provide health insurance for their employees.

To be eligible to enrol in health coverage through the Marketplace, you must meet the following requirements:

• Live in the United States
• Be a U.S. citizen or national, or be a lawfully present non-citizen in the U.S. (Learn about eligible immigration statuses on their website)
• Not be incarcerated
• If you have Medicare coverage, you cannot enrol in a Marketplace health or dental plan

Additionally, you must be a U.S. "resident" for tax purposes to be eligible for Marketplace coverage. This means that if you're a U.S. resident and file taxes, you can get Marketplace coverage.

Open Enrollment happens once a year, from November 1 to January 31. It is typically the only time you can enrol in coverage unless you have a qualifying life event or meet a certain income level. Certain life-changing events, such as getting married, moving to a new coverage area, or losing job-based health coverage, qualify you for a Special Enrollment Period (SEP).

You can check your eligibility and apply for coverage on HealthCare.gov.

Private plans outside the Marketplace

Private health plans outside the Marketplace, also known as the Health Insurance Marketplace, are available from insurance companies, agents, brokers, and online health insurance sellers. These plans are typically sold outside of Open Enrollment and do not qualify for premium tax credits or other savings based on income.

In some cases, these private plans may count as qualifying health coverage if they meet the Affordable Care Act (ACA) requirement for coverage. This means that individuals will no longer pay a tax penalty for not having health insurance. However, it is important to note that the Marketplace does not list or offer these plans, and enrollment is only possible during a Special Enrollment Period.

When purchasing a private plan outside the Marketplace, individuals can request a "Summary of Benefits and Coverage" (SBC) from the insurance company. This document provides an easy-to-read summary of the costs and coverage details, allowing for a comparison between different health plans. It is important to carefully review the terms and conditions of these private plans, as they may not include all the benefits offered by Marketplace plans.

While private plans outside the Marketplace provide an alternative option for health insurance, it is recommended to explore all options, including plans offered through the Marketplace, to find the most suitable coverage for your needs.

Frequently asked questions