What is it?

The Individual healthcare insurance market is known by a few different names: Major Medical Insurance, The Marketplace, Affordable Care Act, Obamacare, etc. All of these are in fact the same thing: a platform that facilitates the sale of private health insurance plans operated by the United States federal government under the Patient Protection and Affordable Care Act of 2013.

Who is eligible?

People who are not on an employer group insurance plan such as those who are self-employed, small business owners or students, and/or those who are not on Medicare.

What does it cover?

All Marketplace plans cover the same 11 Essential Benefits:

  1. Preventative and wellness services, and chronic disease management
  2. Emergency services
  3. Ambulatory patient services (outpatient hospital care)
  4. Hospitalization (inpatient hospital care)
  5. Laboratory services
  6. Prescription drugs
  7. Birth control coverage
  8. Pregnancy, maternity, and newborn care, including breastfeeding coverage
  9. Pediatric services, including oral and vision care
  10. Mental health and substance abuse disorder services
  11. Rehabilitative and habilitative services and devices

These are the minimum coverage requirements for all plans; some plans may offer additional benefits such as adult dental and vision, and medical management programs for specific needs such as diabetes.

All Marketplace plans must also cover treatment for pre-existing medical conditions, and cannot reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started.  After you are enrolled, your insurance carrier cannot deny you coverage or raise your rates based only on your health.

When can you enroll?

Each year there is an Open Enrollment Period during which you can apply for a new plan or change your current coverage; the 2019 Open Enrollment Period ended on December 15th, 2018.  To apply or change your plan outside the Open Enrollment Period you must have had one or more of the following Life Changes within the past 60 days to qualify for a Special Enrollment Period:

  • Changes in household
    • Such as marriage, birth/adoption of a child, divorce, or death
  • Changes in residence
    • Such as moving to a new zip code or county, moving to the U.S. from a foreign country, or moving to/from a shelter or transitional housing
  • Loss of health insurance
    • Such as losing employer group coverage, losing eligibility for Medicaid or CHIP, or losing coverage through a family member
  • Other qualifying reasons

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