Marketplace Insurance

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From the Ask The Planman Podcast...
EP 40: Part 1 – What is ACA?

What do you know about the affordable care act? Are you confused by terminology like co-insurance, maximum out of pocket? Do you know how your deductibles and co-pays work? How do you know if you can qualify for federal subsidies? What’s a MEC?
EP 4: Understanding Medicare w/ David Abrams

Are you turning 65 or know someone turning 65? If you think health insurance is confusing now, wait until you try to enroll in Medicare! With over almost 9 years of experience working with Medicare and senior health benefits. David Abrams, from Insurance Benefits for Seniors is here discussing the numerous options available to recipients of Medicare.
EP 1: Talking Health Insurance w/ Joe Krivelow
In today’s episode of ‘Ask the Planman, we are joined by Mr. Joe Krivelow, founder of Compass Health Consultants and a leading expert in the field of health insurance. Joe has helped thousands of customers understand and find the coverage that best fit their needs. 

Understanding Marketplace Insurance: An Introduction to Your Exchange Options


Marketplace Insurance, commonly referred to as the “health insurance marketplace,” or “exchange,” is a key component of the Affordable Care Act (ACA).

From plans designed for individuals to those catered to families, the health insurance marketplace, which is available in every state, provides essential health benefits, ranging from preventive care to maternity and newborn care.

If you’re self-employed, unemployed, or don’t receive coverage through your employer, marketplace insurance may be the solution for you. 

The marketplace simplifies your search for health coverage by gathering all plans available in your state in one place. You can compare plans based on price, benefits, and other important features before making a decision. Plans in the marketplace are presented in four categories – Bronze, Silver, Gold, and Platinum – to make comparing them easier.

Let’s take a closer look at marketplace insurance… 

frequently asked questions about marketplace insurance

The Affordable Care Act (ACA), also known as Obamacare, is a federal law passed in 2010 with the goal of making healthcare more affordable and accessible for everyone in the United States. The ACA has several key provisions, including the creation of the Health Insurance Marketplace, where individuals can shop for and compare different health insurance plans from various insurance providers, consumer protections like prohibiting  insurance companies from denying coverage to people with pre-existing conditions, and the expansion of Medicaid. The ACA has been both praised and criticized for its impact on healthcare in the US.

The Health Insurance Marketplace is a key component of the Affordable Care Act (ACA), also known as Obamacare. The ACA created the Marketplace as a way for individuals to shop for and compare different health insurance plans. So while the insurance marketplace is not exactly the same as Obamacare, it is an important part of the law.

Health Insurance Marketplace coverage caters to various individuals: those without healthcare, self-employed persons, those with job-based insurance that doesn’t cover dependents or isn’t affordable, individuals ineligible for government health programs like Medicaid or Medicare, and those looking to explore all possible options.

If your job-based plan exceeds a certain percentage of your household income, the government deems it unaffordable. Hence, you or your dependents could qualify for tax credits to lower Marketplace insurance costs. However, if you have job-based coverage, your income may disqualify you from savings, and you may not get any savings at all with a job-based coverage offer.

The Marketplace provides comprehensive coverage, including pre-existing conditions, and potential cost assistance based on income.

A Marketplace insurance exchange, or “Marketplace,” is a service run by the federal government at HealthCare.gov for most states, offering a platform to shop for and enroll in affordable health insurance. It allows consumers to compare and buy health insurance plans meeting minimum coverage standards, known as essential health benefits. Some states run their own Marketplaces, while others use the federal platform or a partnership model. Coverage, premiums, and possible subsidies for those with low to moderate income can vary by state and individual circumstances.

“Your state’s exchange” refers to the official health insurance platform under the Affordable Care Act (ACA). While each state has an exchange, its operation varies: some states manage their own, while most opted for the federal government-run model, starting in fall 2013. States often chose the federal option due to the practical challenges of running their own exchange, regardless of their stance on the ACA’s goals. Conversely, states where leaders largely opposed the ACA preferred a hands-off approach, leaving the exchange operations to the federal government.

Over time, states have transitioned between the federal platform, HealthCare.gov, and their own exchanges. Recently, Kentucky, Maine, and New Mexico established their own platforms, increasing the total state-run exchanges from 13 in 2020 to 18 in 2023. Virginia also plans to start its own exchange by fall 2023. Previously, Maine, New Mexico, Pennsylvania, and New Jersey used HealthCare.gov for enrollments, while Kentucky switched back and forth between its own exchange and the federal platform. As of 2023, here are the 18 states with state-run exchanges.

California
Covered California | ColoradoConnect for Health Colorado | ConnecticutAccess Health CT | District of ColumbiaDC Health Link | IdahoYour Health Idaho | Kentucky –  Kynect Kentucky | MaineCoverME | MarylandMaryland Health Connection | MassachusettsMassachusetts Health Connector | MinnesotaMNsure | NevadaNevada Health Link | New JerseyGet Covered NJ | New MexicobewellNM | New YorkNY State of Health | Pennsylvania – Pennie | Rhode IslandHealthSource RI | VermontVermont Health ConnectWashingtonWashington Healthplanfinder

The following states use the federally run healthcare marketplace exchange for any coverage with a 2023 effective date:

Alabama | Alaska | Arizona | Arkansas | Delaware | Florida | Georgia | Hawaii | Illinois | Indiana | Iowa | Kansas | Louisiana | Michigan | Mississippi | Missouri | Montana | Nebraska | New Hampshire | North Carolina | North Dakota | Ohio | Oklahoma | Oregon | South Carolina | South Dakota | Tennessee | Texas | Utah | Virginia | West Virginia | Wisconsin | Wyoming

Three of the 33 states using HealthCare.gov—Arkansas, Oregon, and Virginia—use a hybrid model called state-based exchange on the federal platform (SBE-FP). They use HealthCare.gov for eligibility and enrollment but manage other parts of the exchange themselves. Kentucky, Maine, and New Mexico followed this model until they transitioned to their own state-run exchanges in 2022. Virginia plans a similar shift in fall 2023.

Whether a state or federally-run health exchange is better depends on personal needs and the state’s management. State-run exchanges may offer more plan variety, local customer service, and extra enrollment periods. However, the federal Marketplace can drive competition and potentially reduce costs due to a larger participant pool. It’s important to research both types, considering factors like cost, coverage, doctor networks, and extra benefits. The best choice depends on the individual’s unique health needs.

To enroll in Marketplace Insurance:

  • Visit HealthCare.gov, or your state’s specific site if applicable.
  • Create an account with basic personal details.
  • Fill out the application about income, household size, etc. to determine eligibility for private plans, Medicaid, or CHIP.
  • Compare eligible plans based on cost, benefits, doctors, etc.
  • Consult Weinstein Wealth Insurance Solutions, choose a plan and enroll online.


Remember, enrollment is usually between November 1 and December 15, unless you qualify for a Special Enrollment Period. Those over 65 or with certain disabilities may be eligible for Medicare.

The health insurance marketplace offers four “metal” categories:

  1. Bronze: Low-cost premiums, high costs for care. Good for protection in worst-case scenarios.
  2. Silver: Moderate-cost premiums and care costs. Eligible for extra savings if you qualify for “cost-sharing reductions.”
  3. Gold: High premiums, lower care costs. Ideal if you pay more monthly to have more costs covered during treatment.
  4. Platinum: Highest premiums, lowest care costs. Suitable if you use a lot of care and can pay high premiums, knowing most other costs are covered.

All plans cover the same essential health benefits; the difference lies in how costs are shared. Catastrophic plans, paying less for health costs, are also available for young adults and some people with a hardship exemption.

Marketplace Insurance cost hinges on income, household size, age, residence, coverage level, and tobacco use. Broadly, here are some costs (as of 2022):

  • Premiums: Monthly health insurance payment. In 2020, the average national monthly premium for a benchmark plan was $388 for a 27-year-old and $1,520 for a family of four, before tax credits.
  • Out-of-Pocket Costs: Unreimbursed expenses like deductibles, coinsurance, co-payments, and costs of non-covered services.
  • Deductibles: Amount paid for covered services before your plan begins to pay. In 2020, average deductibles were $4,364 for individuals (Bronze plans) and $4,879 for families.

Costs can be lessened if you qualify for Affordable Care Act subsidies or cost-sharing reductions. Remember, prices may have changed after 2022. The cheapest plan might not be the best for you, so consider both premium and out-of-pocket costs. Consulting with an insurance expert is advisable.

Marketplace Exchanges provide subsidies or premium tax credits to eligible individuals and families to help afford health insurance.

Eligibility hinges on your income and household size. You may qualify if your income is between 100% and 400% of the Federal Poverty Level (FPL). As of 2020, this was roughly $12,760-$51,040 for an individual, and $26,200-$104,800 for a family of four.

Subsidy amount is based on the cost of the benchmark plan (second-lowest cost Silver plan in your area) and your income. The aim is to ensure you don’t spend more than a certain percentage of your income (2%-9.83% in 2021) on the benchmark plan premium. If the cost exceeds this, you receive a subsidy.

You can apply the subsidy in advance, reducing your monthly premiums, or claim it later at tax time. If your income changes, report it to avoid paying back the difference later.

Eligibility for Marketplace Insurance hinges on your household income and family size, which should be within 100% and 400% of the federal poverty level (FPL). For 2022, the FPL was $13,590 for an individual and $28,290 for a family of three. If your income is under 100% of the FPL, you might qualify for Medicaid in some states. If it’s over 400% of the FPL, you can still purchase Marketplace Insurance, but without subsidies. These income requirements may change annually based on the FPL and other factors, so checking your eligibility with your state’s Marketplace or a licensed insurance agent is advised.

The penalty for not having health insurance, also known as the individual mandate, was repealed in 2019, so there is no longer a penalty for not having health insurance. However, it is still important to have health insurance to protect yourself and your family from unexpected medical expenses.

Keeping your current doctor when enrolling in Marketplace insurance depends on if your doctor is part of your chosen plan’s network. Each plan in the Marketplace has a network of healthcare providers, and costs are typically lower if you use these in-network doctors. You can check if your doctor is in a plan’s network on the Marketplace website or by contacting your doctor’s office. If your doctor isn’t in-network, you may face higher costs or no coverage for their services. If your current doctor is important to you, choose a plan with them in its network. Otherwise, you may need to select a new doctor from your plan’s network.

If you lose your job and your health insurance, you may be eligible to enroll in Marketplace Insurance through a Special Enrollment Period. You may also be eligible for other government programs, such as Medicaid or the Children’s Health Insurance Program (CHIP), depending on your income and other factors.

Want to talk more about marketplace insurance?

Navigating the Health Insurance Marketplace can be overwhelming with so many plan options and complex terminology. It’s essential to make an informed decision that suits your unique health needs and financial circumstances. As your dedicated insurance consultant, I’m here to help you make sense of it all.

Don’t choose a plan in the dark! Let’s shine a light on your best options. By understanding your personal situation and healthcare needs, I can guide you through the intricate landscape of Marketplace Insurance, ensuring you make a choice that truly serves you and your family’s well-being.

Take advantage of my expertise to unlock the full potential of your healthcare coverage. Don’t leave your health to chance – reach out to me today! Your peace of mind is worth one conversation. Let’s make sure you choose the right plan, not just any plan. We look forward to helping you make the best possible decision! Call us today at 1-844-4WeCover.

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