State Marketplaces (Also known as Exchanges)
The Affordable Care Act (or ACA) requires every state to have its own marketplace, also known as an exchange, where you can compare insurance options, get help assessing your individual needs, request financial assistance in paying for health insurance and enroll in insurance coverage.
Some states are running their own marketplaces. In those that aren’t, the federal government is operating the marketplace. Many states have given special names to their marketplaces (such as Covered California and Get Covered Illinois). Each marketplace operates a website that allows you to look at different plan options.Find your state’s marketplace here. They also have toll-free numbers you can call to ask questions, as well as professional assistors (sometimes called navigators) who can help you understand your plan options and the financial assistance available to you.
How do I know if I am eligible for additional financial support to help pay for a plan in the marketplace/exchange?
For people who do not have insurance through their employer or are not employed, the Affordable Care Act (or ACA) established insurance marketplaces (also called exchanges) where you can compare among multiple health plans and buy coverage for yourself and your family. Financial help is available to make coverage affordable for people with lower incomes.
When you apply for coverage through your state’s marketplace, you will learn if you are eligible for financial assistance. You will also find out whether you qualify for Medicaid. To get an idea of your eligibility for subsidies and an estimate of how much health insurance will cost you, use the Kaiser Family Foundation subsidy calculator.
See what options are available where you live.
Most people can shop for coverage in the marketplace in their state. To be eligible, you must be a citizen of the United States or have been lawfully present in the United States for five years. You must not currently be incarcerated.
Not everybody who is eligible to purchase coverage in the marketplace will be eligible for subsidies, however. To qualify for subsidies you will have to meet additional income and eligibility requirements. To find out if you qualify for a subsidy, use the Kaiser Family Foundation subsidy calculator.
You can receive financial subsidies if you are eligible, no matter what state you live in.
How does health insurance purchased from a marketplace compare with that provided through other sources, like an employer?
Plans sold through the health insurance marketplaces set up as part of the Affordable Care Act (or ACA) must provide a minimum set of health benefits, which are called Essential Health Benefits. These include benefits you may find especially helpful for your HIV care, like prescription drugs, doctor visits, hospital care and mental health care as well as certain preventative services, including HIV tests.
Many insurance plans offered by employers include similar benefits, but employers are not required to provide them, so some don’t. However, in other cases employer coverage is just as generous or more generous than Marketplace plans with lower cost-sharing. You will need to check your plan to see if the benefits you need are included.
For a summary of the Essential Health Benefits set by the Affordable Care Act, click here.
If you are buying coverage on your own, you need to buy it in the state where you live. Some plans offer coverage statewide; others only cover people within a local geographic service area. If you move within a state, you will need to determine if you are moving out of your health plan’s service area. If you move and need to change your insurance, you are allowed to change insurance plans outside of the open enrollment period.
What is the difference between the bronze, silver, gold and platinum plans offered in the marketplace?
For people who do not have insurance through their employers or are not employed, the Affordable Care Act (or ACA) establishes new insurance marketplaces (also called exchanges) where you can compare multiple health plans and buy coverage for yourself and your family or qualify for government coverage (usually called Medicaid).
All health plans sold in the marketplace must meet minimum standards and offer the same set of core benefits, called essential health benefits. When you compare plan options, there will be different tiers or levels of coverage: bronze, silver, gold and platinum. These metal tiers determine how much of your health expenses your insurance company will pay and how much you will pay. In other words, the difference in plans mostly has to do with how much you will pay per month and what your copayment or cost sharing will be with your insurance company for every doctor visit and each prescription medication you take. For example, the bronze plan has the cheapest premiums (monthly payments), but also tends to have the highest deductibles, meaning you will have to pay more yourself before your insurance coverage kicks in. With a platinum plan, on the other hand, you will pay more money each month in premiums, but you will have a very low or zero deductible, and hence not have to pay as much out-of-pocket towards your health care costs.
When considering which type of plan to buy, think about how much you use medical care. If you go to the doctor fairly often, you might consider paying more money in premiums each month because it means you would then pay less when accessing health services.
Financial help is available to make coverage affordable for people with lower incomes. This can include tax credits (subsidies) to lower the cost of the premium if your income is between 100 percent ($12,060 a year for a single person) and 400 percent of the federal poverty level (about $48,240 a year for a single person), and may also include assistance with cost sharing or copayments. Cost sharing assistance is only available through silver plans.
If your income is between 100 percent of the federal poverty level ($12,060 a year for a single person) and 250 percent ($30,150 a year for a single person) of the federal poverty level you may qualify for a special type of silver plan with lower deductibles and copays. Sometimes called cost sharing reduction (CSR) silver plans, these plans have the same premiums as other silver plans, but they have lower copays and deductibles.
There is also a limit on out-of-pocket spending for insurance plans that sets a maximum amount a person has to pay for health care each year when deductibles and cost sharing are all taken into account but it excludes premiums. For 2018, this amount is $7,350 for individual coverage and $14,700 for a family policy. Lower out-of-pocket maximums will be offered in special silver plans for lower income people who qualify for cost sharing reductions.
It depends. If staying with your current doctor is important to you, check to see if s/he is included in a health plan’s network before choosing a marketplace plan. Most health plans offered in the marketplace have networks of hospitals, doctors, specialists, pharmacies and other healthcare providers. Depending on the type of policy you buy, care may be covered only when you get it from a network provider. Each plan sold in the marketplace must provide a link on the marketplace website to its health provider directory so you can find out if your doctor is included. If staying with your doctor is important to you, you should also check directly with her/him to confirm that s/he is in the network of the plan you are considering.
An out-of-pocket limit for insurance plans sold in the health insurance marketplace sets a maximum amount a person has to pay on health care each year when all cost sharingis taken into account. Premiums do not have to be included in this limit.
For 2018, this amount is $7,350 for individual coverage and $14,700 for a family policy. Lower out-of-pocket maximums are offered in special silver plans for lower income people who qualify for cost sharing reductions.
Health plans in the marketplace must include a link to their prescription drug formularywith other online information about the plan. The formulary is a list of prescription drugs the plan will cover. If you are unable to find your drug on the formulary but your doctor says it’s medically necessary for you to take that specific drug, your health plan must have a procedure in place to ensure that you have access to it. Check with your doctor or plan if this is the case.
If you are living with HIV, you may want to select a plan that includes your current HIV medical provider and covers the specific drugs on your HIV treatment regimen. You’ll have to compare the specific plan offerings in your area in terms of premium cost, cost sharing, which providers or hospitals are included in their network and other plan features. While insurers have flexibility to limit which medications they cover in each drug class, (so it is important to make sure the medicine you use is covered), most health plans generally provide the basics of HIV care.