4 FAQs about Marketplace Health Plans
1. All health plans must offer the same essential health benefits.
These benefits include coverage for things like:
• Doctor visits
• Prescription drugs
• Maternity and newborn care
• Preventive care
Plans can offer other benefits like vision dental or medical management programs for a specific disease or condition. As you compare plans you’ll see what benefits each plan covers.
2. Plans are put into 4 categories
These 4 categories (Bronze Silver Gold Platinum) are based on how you and the plan expect to share the costs for health care. Catastrophic plans are available if you qualify. You can’t use a premium tax credit to help pay for a Catastrophic plan.
The category you choose affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or prescriptions.
It also affects your total out-of-pocket costs – the total amount you’ll spend for the year if you need lots of care.
• Bronze covers 60% of the total average costs of care
• Silver covers 70% of the total average costs of care
• Gold covers 80% of the total average costs of care
• Platinum covers 90% of the total average costs of care
3. In general, the lower the premium the higher the out-of-pocket costs when you need care.
Premiums are usually higher for plans that pay more of the medical costs.
Categories describe how much of the total average cost of care they cover.
For example, if you have a Gold plan you’ll likely pay a higher premium but may have lower costs when you go to the doctor or use another medical service.
4. Qualifying for a Special Enrollment Period
After February 15, 2015, you can enroll in a 2015 health insurance plan only if you have a life event that qualifies you for a Special Enrollment Period.
Life events that may qualify you for a Special Enrollment Period
• Getting married
• Having a baby
• Adopting a child or placing a child for adoption or foster care
• Losing other health coverage
• Moving to a new residence
• Gaining citizenship or lawful presence in the U.S.
• Leaving incarceration
For people already enrolled in Marketplace coverage:
• Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions
Note: Voluntarily quitting a Marketplace plan mid-year doesn’t qualify you for a Special Enrollment Period.