Everything You Need to Know About the Health Insurance Marketplace

The Health Insurance Marketplace (Marketplace) is a way to find health coverage that fits your budget and meets your needs. With one application, you can see all your options and enroll. The Marketplace is sometimes known as a health insurance Exchange.

When you use the Marketplace, you'll fill out an application and find out whether you can get lower costs on your monthly premiums for private insurance plans. You'll also find out if you qualify for lower out-of-pocket costs; or free or low-cost coverage available through Medicaid or the Children's Health Insurance Program (CHIP).

Open enrollment for 2021 Marketplace insurance will be from Nov. 1, 2020, to Dec. 15, 2020. Coverage will begin Jan. 1, 2021.

Insurance plans in the Marketplace are offered by private companies, and they all cover the same core set of benefits, known as essential health benefits. No plan can turn you away or charge you more because you have a pre-existing illness or medical condition, and plans can't charge women more than men.

The Marketplace simplifies your search for health coverage by gathering the options available for your area in one place. With one application, you can compare plans based on price, benefits, quality and other features important to you before you make a choice. You can also get help online, by phone, by chat or in person.

In the Marketplace, information about prices and benefits is written in simple language. You get a clear picture of what premiums you'd pay and what benefits and protections you'd get before you enroll. Compare plans based on what's important to you, and choose the combination of price and coverage that fits your needs and budget.

What does Marketplace health insurance cover?

All private health insurance plans offered in the Marketplace offer the same set of essential health benefits.

These 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

• 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 and habilitative 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, and you will be able to compare them side by side in the Marketplace.

Am I eligible for coverage in the Marketplace?

Most people are eligible for health coverage through the Marketplace.

To be eligible for health coverage through the Marketplace, you:

• Must live in the United States

• Must be a U.S. citizen or national (or be lawfully present)

• Can't be currently incarcerated

What if I am a U.S. citizen living outside the United States?

U.S. citizens living in a foreign country for at least 330 days of a 12-month period are not required to get health insurance coverage under the health care reform law. If you're uninsured and living abroad, you don't have to pay the fee that other uninsured U.S. citizens may have to pay.

Generally, health insurance coverage in the Marketplace covers health care provided by doctors, hospitals and medical services within the United States. If you're living abroad, it's important to know this before you consider buying Marketplace insurance.

What if I am a resident of a U.S. territory?

U.S. territories can decide whether to create their own Marketplaces or expand Medicaid coverage. Residents of a U.S. territory aren't eligible to apply for health insurance using the federal or state Marketplace. Check with your territory's government offices to learn about these options.

What is the Marketplace in my state?

Some states run their own Marketplaces, some partner with the federal government to help run their Marketplaces and some let the federal government operate Marketplaces for them. You can view a map at the end of this document to see state-by-state Marketplace decisions. However, no matter where you live, you are able to use the Marketplace to apply for coverage, compare your options and enroll.

How do I apply for Marketplace coverage?

When open enrollment begins each year, you can go to the Marketplace and see the health coverage options available to you. Then you can compare plans side by side and choose a plan that meets your needs and fits your budget.

Even if 2021 open enrollment is over, you may still have options to get health coverage through the Marketplace. You may qualify for a special enrollment period that allows you to buy a private health insurance plan through the Marketplace. Or, you may qualify for Medicaid and CHIP—you can do this any time, all year, and if you qualify you can enroll immediately. If none of the options for getting covered outside of open enrollment works for you, your next chance to enroll is the 2022 open enrollment period.

Can I keep my own doctor?

That depends on the plan or network you are in. Most health insurance plans offered in the Marketplace have networks of hospitals, doctors, specialists, pharmacies and other health care 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 covered only when you get it from a network provider.

When comparing plans in the Marketplace, you will see a link to a list of providers in each plan’s network. If staying with your current doctor is important to you, check to see whether he or she is included before choosing a plan.

What if I have a pre-existing health condition?

Being sick doesn't keep you from getting coverage. An insurance company can't turn you down or charge you more because of your condition.

How much does Marketplace health insurance cost?

All insurance plans available through the Marketplace are offered by private insurance companies. They decide which plans to offer and how much each costs.

All Marketplace plans must be approved by state insurance departments and certified by the Marketplace. Prices are approved by state insurance departments as required by state law.

When you use the Marketplace to compare plans, you’ll see prices for all plans available to you. Prices show any cost savings you may be eligible for based on your income. These lower costs are available only in the Marketplace.

What range of prices and plans are available?

Some Marketplace health plans have lower monthly premiums and may charge you more out-of-pocket costs when you need care. Some are higher-premium plans that cover more of your costs when you need care. Others fall in between. All plans cover the same essential health benefits.

How can I get lower costs on Marketplace coverage?

When you use the Marketplace you may be able to get lower costs on monthly premiums or out-of-pocket costs, or get free or low-cost coverage.

You can save money in the Marketplace in three ways. All of them depend on your income and family size.

1. You may be able to lower costs on your monthly premiums when you enroll in a private health insurance plan.

2. You may qualify for lower out-of-pocket costs for copayments, coinsurance and deductibles.

3. You or your child may get free or low-cost coverage through Medicaid or CHIP.

When you fill out your Marketplace application, you'll find out how much you can save. Most people who apply will qualify for lower costs of some kind.

Will I qualify for lower costs on monthly premiums?

When you get health insurance coverage in the Marketplace, you may be able to get a premium tax credit that lowers what you pay in monthly premiums. This will depend on your household size and income. When you fill out a Marketplace application, you’ll report your household size and income. If your income falls between the amounts shown below, you’ll qualify for a premium tax credit that you can apply directly to your monthly premiums. This means you’ll pay less money to your health insurance company each month.

If your income falls within the certain ranges, you’ll generally qualify for a premium tax credit. Typically, the lower your income is within these ranges, the bigger your credit. Incomes that qualify for tax credits are higher in Alaska and Hawaii. You may also be able to get lower out-of-pocket costs, depending on your income and family size.

How do I report my income and household size?

If you want to find out whether you qualify for lower costs on Marketplace coverage, you’ll need to provide information about your household members and income.

The Marketplace application includes detailed instructions. It makes calculations using the information you provide to determine whether you’re eligible for lower costs.

When filling out your application, include:

• Yourself

• Your spouse

• Your children who live with you, even if they make enough money to file a tax return themselves

• Your unmarried partner who needs health coverage

• Anyone you include on your tax return as a dependent, even if he or she doesn’t live with you

• Anyone else under 21 who you take care of and lives with you

When filling out your application, don't include:

• Your unmarried partner who doesn’t need health coverage and is not your dependent

• Your unmarried partner’s children, if they are not your dependents

• Your parents who live with you, but file their own tax return and are not your dependents

• Other relatives who file their own tax return and are not your dependents

When you apply for lower costs in the Marketplace, you’ll need to estimate your household income. You can start by adding up the following items for (1) yourself and your spouse, if you are married and will file a joint tax return and (2) any dependents who make enough money to be required to file a tax return:

• Wages

• Salaries

• Tips

• Net income from any self-employment or business (generally the amount of money you take in from your business minus your business expenses)

• Unemployment compensation

• Social Security payments, including disability payments—but not Supplemental Security Income (SSI)

• Alimony

Other kinds of income to include when estimating your income are retirement income, investment income, pension income, rental income and other taxable income such as prizes, awards and gambling winnings.

You should not include the following when estimating your income: child support, gifts, Social Security insurance (SSI), veterans’ disability payments, workers’ compensation and proceeds from loans (such as student loans, home equity loans or bank loans).

What is modified adjusted gross income?

When you fill out the Marketplace application, a number called “modified adjusted gross income” (MAGI) will be used.

MAGI is generally your household’s adjusted gross income plus any tax-exempt Social Security (except for SSI, which is not counted), interest and foreign income you have. It’s used to determine your eligibility for lower costs on Marketplace coverage, and for Medicaid and CHIP.

You don’t have to figure out this income yourself. The math will be done for you when you apply through the Marketplace or your state agency.

For Medicaid, it also matters if you’ve had a change in household income since your last tax return. When you apply you’ll need to give your household income now and estimate the amount for the next year, taking into account changes that you know about.

What’s the difference between Marketplace plans and other private plans?

No matter how you buy your health insurance—through the Marketplace, directly from an insurance company or with the help of an agent or broker—all plans for individuals and small groups must cover the same set of essential health benefits. They include doctor visits, hospital stays, preventive services, prescription drugs, mental health and other categories of coverage.

Plans will not be able to charge you more or refuse to cover you if you have a pre-existing condition. Most plans must also offer the consumer rights and protections provided under the health care law.

Only Marketplace plans offer lower costs based on income. When you apply for Marketplace coverage, you’ll find out whether you qualify for lower costs on your premiums or out-of-pocket costs.

What if I currently have COBRA coverage?

If you have COBRA continuation health coverage, you can keep it or, in some cases, buy a Marketplace health plan instead. Your coverage and savings options depend on whether you’re changing from COBRA to a Marketplace plan during open enrollment or after your COBRA coverage ends, and whether you’re dropping your COBRA coverage before it runs out.

Outside open enrollment, your choices and savings will depend on whether your COBRA coverage is running out or you’re ending it early.

• If your COBRA coverage is ending outside open enrollment, you qualify for a special enrollment period. This means you can enroll in a private health plan through the Marketplace. You may qualify for tax credits that can lower your monthly premiums and for lower out-of-pocket costs. This will depend on your household size and income.

• If you’re ending your COBRA coverage early outside open enrollment, you will not be able to enroll in a Marketplace plan at all, with or without lower costs.

During the next open enrollment period, or when your COBRA coverage expires, you could enroll in a Marketplace plan and be eligible to get premium tax credits and lower out-of-pocket costs, depending on your income.

During the open enrollment period you can drop your COBRA coverage and get a plan through the Marketplace instead. This is true even if your COBRA coverage hasn’t run out.

When you end your COBRA coverage and apply for a Marketplace plan during open enrollment, you may qualify for tax credits that can lower your monthly premiums and for lower out-of-pocket costs. This will depend on your household size and income.

When you fill out a Marketplace application you’ll also find out whether you qualify for Medicaid and CHIP.

If you’re planning to replace your COBRA coverage, it’s important not to let your COBRA coverage end before your Marketplace plan starts. Otherwise there will be a gap in your coverage.

Can I buy a catastrophic plan?

People under 30 and some people with hardship exemptions may buy what is called a catastrophic health plan. It protects you from very high medical costs.

A catastrophic plan generally requires you to pay all of your medical costs up to a certain amount, usually several thousand dollars. Costs for essential health benefits over that are generally paid by the insurance company.

These policies usually have lower premiums than a comprehensive plan, but cover you only if you need a lot of care. They basically protect you from worst-case scenarios.

In the Marketplace, catastrophic plans cover three primary care visits per year at no cost, even before you’ve met your deductible. They also cover free preventive services.

If you buy a catastrophic plan in the Marketplace, you can’t get lower costs on your monthly premiums or lower out-of-pocket costs based on your income. Regardless of your income, you pay the standard price for the catastrophic plan.

What happens if I don’t pay my portion of the premium?

In general, your coverage obtained through the Marketplace may be terminated if you fail to pay your portion of the monthly premium. However, issuers must provide a three-consecutive-month grace period for enrollees who:

• Receive a premium tax credit;

• Have paid at least one full month's premium during the benefit year; and

• Then fail to pay their portion of the monthly premium.

If you fail to pay all outstanding premiums following the three-month grace period, the issuer must then terminate your coverage, retroactive to the last day of the first month of the grace period. For all other qualified health plan (QHP) enrollees, QHPs must grant a grace period in accordance with applicable state law.

If your coverage is terminated for non-payment of premiums, you do not qualify for a special enrollment period due to the resulting loss of minimum essential coverage. However, you may become eligible for a special enrollment period based on other circumstances. Additionally, during the annual open enrollment, you will be able to apply for a determination of eligibility, and, if determined eligible, will be permitted to select a plan in the Marketplace for 2021. In both of these cases, the enrollment would be considered a new enrollment. Thus, the issuer cannot attribute any payment from you toward the outstanding debt from the prior, terminated coverage.

What do American Indians and Alaska Natives need to know about the Marketplace?

If you're a member of a federally recognized tribe and qualify for a health insurance plan in the Marketplace, you have certain protections, such as:

• Monthly special enrollment periods

• No copayments or other cost sharing if your yearly income is below a certain level. When you fill out a Marketplace application, you'll find out whether you qualify for these lower costs.

Also, if you’re an American Indian or Alaska Native or are otherwise eligible for services from the Indian Health Service, tribal program or urban Indian health program, you have the following protections:

• Special cost and eligibility rules for Medicaid and CHIP that make it easier for you to qualify for these programs

• If you don’t have health insurance, you won’t have to pay the penalty that most other people without health insurance must pay

If you enroll in a private health insurance plan through the Marketplace, you can get (or keep getting) services from the Indian Health Service, tribal health programs or urban Indian health programs. You can also get services from any providers on the Marketplace plan.

How do I apply for health coverage?

Use Healthcare.gov to apply for health coverage, compare plans and enroll online. You can also apply over the phone or get in-person help with your application.

• Apply online. Before you begin, preview plans and prices available in your area. Price quotes shown reflect any lower costs you may qualify for based on your income and household size. Follow these steps to apply for individual or family coverage:

- Create an account. Go to the Marketplace and select your state. Provide basic information as prompted, then choose a username, password and security questions.

- Complete your application. Provide information about yourself and your family, such as income, household members and current health coverage.

- Pick a plan. View all the options you qualify for, including Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace will let you know if you qualify for lowers costs on private health coverage.

- Enroll. After you choose a plan, don't forget to enroll online and contact your insurance company to pay your first premium by the due date.

For the best online experience, visit Healthcare.gov on a desktop or laptop computer and use these tips to help you enroll in Marketplace coverage. Help is available 24/7.

• Apply by phone: Call 1-800-318-2596, 24 hours a day, seven days a week (TTY: 1-855-889-4325). A customer service representative will work with you to complete the application and enrollment process.

• Find in-person help: You can apply with the help of an assister who can sit with you and help you fill out an online or paper application. Search by city and state or ZIP code to see a list of local organizations with contact information, office hours and types of help offered, including non-English language support.

There are several other ways you can apply for coverage.

• Enroll directly through an insurance company. If your income is too high to qualify for lower costs on coverage, you can buy health coverage outside the Marketplace, directly through an insurance company. You can also use an agent or broker, or an online insurance seller. To preview plans available outside the Marketplace, you can use the Plan Finder website.

• Apply by mail: Fill out a paper application and mail it in. Once you get your eligibility notice, go online or contact the call center to pick a plan and enroll. Download the application form and instructions to begin.

• Local resources: You may be able to apply online at a local library or at a community health center in your area.

How do I get help enrolling in the Marketplace?

In all states, there are people and organizations in your community who can help you apply, enroll and answer your questions. You can visit https://localhelp.healthcare.gov to find help in your area. As your New Jersey Insurance experts, our Life & Health team is ready to answer your questions and get you the coverage you need. Contact us today for a free quote.