Learn about the Health Insurance Marketplace

What is the Health Insurance Marketplace?

The Health Insurance Marketplace, also referred to as the Healthcare Marketplace or the Exchange, is a platform where individuals and families can shop for and enroll in affordable health insurance. The Marketplace lets you browse through health plans from various insurers, all in one place. This helps individuals and families make informed choices about the coverage that suits their needs best.  You can compare plans based on their monthly premium, deductible, out-of-pocket costs, and care provider networks. All Marketplace health insurance plans — whether offered through a state-run or federal exchange — must meet the ACA's standards for accessibility and quality of coverage.

How does the Health Insurance Marketplace work?

The Marketplace is a one-stop shop for insurance enrollment and health plan savings. Through the Marketplace, you can evaluate important features of a variety of health insurance plans. Health insurance plans on the Marketplace are categorized into four distinct levels, making it easy to compare coverage by costs and find an affordable plan. These “metal” levels include Bronze, Silver, Gold, and Platinum plans.

Metal level plans each cover the same essential benefits,  including, but not limited to: preventive care, emergency services and hospitalization, maternity and newborn care, mental health services, and prescription drugs. However, the metal levels differ in how you and your insurer share the overall cost of care. Be sure to check for availability, because not all metal level plans are available in all areas.

When selecting a Marketplace health insurance plan, consider how often you anticipate using your benefits and the trade-offs between the monthly premium and potential out-of-pocket costs.

• Bronze plans have the lowest monthly premium, but the deductible and out-of-pocket costs are the highest compared to the other metal levels. Bronze plans are typically best suited for individuals who are healthy — they may only visit their doctor for their annual physical and are comfortable paying more out-of-pocket for unexpected care if that means paying less monthly.
  
  
• Silver plans have a moderate monthly premium and out-of-pocket costs, providing more balanced cost-sharing for those who might seek care more often. Silver plans are the only metal level on the Marketplace that offer cost-sharing reductions to those who qualify, which can lower out-of-pocket costs for care.
  
  
• Gold plans can offer more protection for individuals and families who expect frequent doctor visits and prescription expenses. The monthly premium for a Gold plan is higher, but the out-of-pocket costs for care are lower than Bronze or Silver plans.
  
  
• Platinum plans offer the highest level of coverage, making them a good option for those with ongoing medical care needs. Platinum plans have the highest monthly premium, but the lowest out-of-pocket costs of any Marketplace plan. Wellpoint offers Bronze, Silver, and Gold metal level plans on the Marketplace.

How much does marketplace health insurance cost?

The cost of Marketplace health insurance varies based on the plan you select and any financial help you may be eligible for. Several specific coverage-related expenses contribute to your overall cost of care, including:

• Monthly Premium: The payment to your insurer each month to keep your coverage active.
• Deductible: The amount you need to pay out-of-pocket for care before your plan starts to pay its share of the costs.
• Maximum Out-of-Pocket Limit: The maximum you'll spend on healthcare in a plan year. After reaching this limit, your insurer pays 100% of eligible healthcare expenses for the rest of the plan year.
• Copay: A fixed amount you pay a care provider for each visit.
• Coinsurance: The percentage of costs you pay for care after you've met your deductible.

A key part of the ACA is the availability of financial help in the form of health insurance subsidies. Subsidies can make coverage more affordable for an estimated 9 out of 10 eligible individuals and families nationwide.¹ Eligibility for these subsidies depends on your income, household size (which includes yourself, your spouse or domestic partner, and anyone you claim as a dependent on your taxes), and the cost of healthcare in your area.

There are two types of ACA subsidies:

• Advanced Premium Tax Credits, which can help lower or eliminate your monthly premium.
• Cost-Sharing Reductions (CSRs), which are special savings that can help lower out-of-pocket costs for care, including your deductible, copays, coinsurance, and out-of-pocket maximum. CSRs are only available to eligible individuals enrolled in a Silver plan.

It is possible to qualify for both advanced premium tax credits and CSRs at the same time.

Who can get a plan through the marketplace?

To qualify for Marketplace health insurance, you must live in the United States and be a U.S. citizen, U.S. national, or a lawfully present non-citizen. In addition to these residency requirements, applicants for coverage through the ACA cannot be: 

• Currently incarcerated (in jail or prison)
  
• Enrolled in public health coverage through Medicaid, Medicare, or the Children's Health Insurance Program (CHIP)

The Marketplace is intended for individuals and families who do not receive health benefits through their jobs—including part-time workers, self-employed individuals, contractors, small business owners, and early retirees who are not yet eligible for Medicare. Marketplace health insurance may also be an affordable option for someone who is unemployed and needs to fill a gap in coverage until they find a new job that provides health coverage. It is also a valuable coverage option for low-to-moderate-income families who qualify for ACA subsidies that help make health insurance more affordable.

When can I buy insurance through the marketplace?

The annual ACA Open Enrollment Period is your primary opportunity to enroll in Marketplace health insurance for the upcoming year. If you’re currently enrolled in an ACA plan, it’s your chance to review your existing coverage and choose to either renew or change your insurance plan. Open Enrollment generally begins November 1 and ends January 15, but specific dates can vary by state.

Outside the Open Enrollment Period, you may be able to purchase a Marketplace plan during a Special Enrollment Period (SEP). An SEP allows you to get coverage if you experience a qualifying life event — such as losing other health coverage, moving, getting married or divorced, having a baby, or adopting a child.

Reference

1. Centers for Medicare & Medicaid Services: Health Insurance Marketplaces 2024 Open Enrollment Report (2024): https://www.cms.gov/files/document/health-insurance-exchanges-2024-open-enrollment-report-final.pdf