Health Insurance Exchange (Obamacare): 11 Things to Know
1. What is the Health Insurance Exchange? | 2. What if I already have insurance? | 3. How do I find the Exchange? | 4. How do I afford it? | 5. Types of Plans | 6. Benefits offered | 7. Young adults | 8. How to enroll | 9. Are rates lower? | 10. Can I keep my doctor? | 11. Get more information
1. What is the health insurance exchange?
Through changes brought about by the Patient Protection and Affordable Care Act of 2010 (ACA), health insurance is now more easily available for millions of Americans. The Health Insurance Exchange is one of the largest components of what’s known as Obamacare. Plan and cost information is found at Healthcare.gov.
One of the biggest advantages to the ACA is that it no longer allows insurance companies to deny health insurance coverage or charge excessive fees based on your health condition or any pre-existing conditions you might have, for example, diabetes, heart failure, or asthma.
In addition, plans won’t be able to deny you coverage or charge you more due to a pregnancy or disability. This means that all Americans can now have health coverage, even though it may have been previously denied.
You can sign up for Health insurance, if you need it, through what is known as a Health Insurance Exchange.
- The Health Insurance Exchange is similar to an online shopping website.
- You’ll be able to view your options, compare and contrast the benefits, and then make the right buying decision for you and your family.
- If you currently have insurance through your employer, or your spouse's employer, you may stay with your current plan. However, if you determine that it is more affordable for you to purchase insurance through the exchange, you may do that instead.
Open enrollment starts on November 1st. December 15th is the deadline to enroll in coverage that starts January 1st. On January 15 open enrollment ends and is the last day to enroll for coverage that starts February 1st.
After this date, you can enroll in or change plans only if you qualify for a Special Enrollment Period. You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child, or if your household income drops below a certain amount.
2. What if I already have health insurance?
You probably do not need to anything. The majority of Americans have group health insurance through their employer, or are covered by government-funded programs such as Medicaid, Medicare, or the Children's Health Insurance Program (CHIP). If this is the case, you can stay with your current health insurance.
For those with group health insurance through their employers, you are welcome to compare your monthly premium with that of your employer, but you will not receive any tax credits and most likely your group plan with your employer will be a better deal. In addition, your employer will most likely not offer any premium credits towards the Marketplace insurance.
3. How do I find the health insurance exchange?
You can find your exchange in any state by starting at Healthcare.gov and selecting the state you live in. How you apply for insurance depends upon which state you live in. Every state has to offer an exchange, but there are differences depending upon which state you live in.
No matter where you reside, you’ll be able to compare your health insurance options in the Marketplace and find a health plan that meets your needs and fits your budget.
4. What if my income is limited and I cannot afford the health insurance exchange?
For families who have a limited income and shop on the healthcare exchange, the ACA will provide tax credits to help make insurance more affordable for you and your family. The Marketplace will also tell you if you qualify for free or low-cost coverage available through Medicaid or the Children's Health Insurance Program (CHIP).
There is no longer a federal penalty for not having health insurance. But those who need health insurance but do not sign up may face a penalty in some states, like California, District of Columbia (DC), New Jersey, Massachusetts, Rhode Island and Vermont.
Age 65 and older
If you are 65 years of age or older, you can sign up for Medicare Parts A (hospital insurance), Part B (medical insurance) and optional Medicare Part D (prescription drug coverage).
- You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
- You can also shop for and buy supplemental coverage that helps pay your out-of-pocket costs (like your 20% coinsurance).
You may be eligible for Medicare before age 65 if you have a disability, End-Stage Renal Disease (ESRD), or ALS (also called Lou Gehrig's disease).
5. What types of health insurance plans are available on the exchange?
There will be several types of plans with different levels of benefit and deductibles. Plan categories will be labeled as Bronze, Silver, Gold or Platinum. The plan category you choose affects the total amount you'll likely spend for essential health benefits during the year.
- Platinum plans will require the lowest level of out-of-pocket costs for members, but the monthly premium will be higher.
- The less expensive plans, such as the bronze plan, will require more out-of-pocket costs for members but have lower monthly premiums. The gold and silver plans will fall somewhere in the middle.
- The percentages the plans will spend, on average, towards your insurance are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum).
All plans are required to offer essential health benefits like preventive care (for example, mammograms and yearly physicals), prescription medications, and payment for hospital admissions.
6. What are the health benefits offered in the marketplace?
All private health insurance plans offered in the Marketplace will offer the same set of essential health benefits like doctor visits, preventive care, hospitalization, prescriptions, and more. 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)
- 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 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
Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.
7. Can young adults stay on their parents plans?
If a plan covers your children, they can be added or kept on the health insurance policy until they turn 26 years old. The adult child may be enrolled during a plan’s open enrollment period or during other special enrollment opportunities. Be sure to include the young adult on the list of people to be covered.
Children and young adults under 26 years of age can join or remain on a plan even if they:
- are married
- have a child or adopts a child
- are not living with their parents
- start or leave school
- are not financially dependent on their parents (claimed as a tax dependent by their parents)
- are eligible to enroll in their employer’s plan
- turn down an offer of job-based coverage
- qualify for employer-sponsored coverage.
Some states have different rules, so be sure to check with on your individual plan when enrolling.
- Research and educate yourself about the Health Insurance Marketplace - you can do this by reading the information here and referring to the government’s website Healthcare.gov. Healthcare.gov is broken down into easily understood sections that answer common questions.
- Gather information about your income - for example, social security numbers, pay stubs or W-2 forms for everyone that requires insurance, and current health insurance policy numbers, if any.
- Set your budget - Use the calculator on Healthcare.gov to get an estimate of costs and savings on the Marketplace health insurance.
- Understand important terms:
- Premiums - the amount you must pay for an insurance policy
- Deductibles - The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
- Out-of-pocket maximums - The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount.
- Copayments - A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
- Co-insurance - Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service.
9. Will I qualify for lower rates on monthly premiums?
Whether or not you will be able to lower your monthly premiums depends on your family size and your income. You can see the amount of savings that you might be eligible for when you begin to fill out your application in the Marketplace.
Also, get estimated prices on plans before you apply here. Lower rates are applied immediately to your monthly premium, so you can take advantage of these savings immediately.
10. Can I keep my own doctor?
Depending on the plan you choose in the Marketplace, you may be able to keep your current doctor. If staying with your current doctors is important to you, check to see if they are included in the plans network before choosing the plan. If you use a doctor who is "out of network", your costs may be higher.
Most health insurance plans offered in the Marketplace have a network of hospitals, doctors, specialists, pharmacies, and other healthcare providers. Networks include health care providers that the plan contracts with to take care of the plan’s members.
Depending on the type of policy you buy, care may be much more expensive you get it from an "out of network provider. Realize you may be able to save money on your premium if you are willing to change doctors and see only network doctors in the lower price plans.
The No Surprise Act (NSA) of 2022 federal law helps to protect patients from surprise billing and high costs. NSA helps to protect patients from surprise billing in situations where choosing an "in network" doctor or facility may not be possible, such as emergency care, out-of-network doctors at in-network facilities,
11. Where can I get more information?
- Questions? Call 1-800-318-2596, 24 hours a day, 7 days a week (except holidays). (TTY: 1-855-889-4325).
- Questions can be researched online at the Healthcare.gov website
- Local help in your community may be available. Search here.
Source: Healthcare.gov
Further information
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.