Coverage Outside the Marketplace

The Affordable Care Act created health insurance Marketplaces that exist in each state. These Marketplaces enable consumers to shop for and compare health plans, and access premium tax credits and cost-sharing reductions to make health insurance more affordable. However, coverage is also available outside of the Marketplaces.

Some health plans sold outside the health insurance Marketplace are required to provide the same basic set of benefits as plans sold inside the Marketplace, are not allowed to exclude coverage of pre-existing conditions, and are required to provide a minimum level of financial protection to enrollees. However, it is important to note that you may only obtain premium tax credits and cost-sharing reductions if you purchase a plan through the health insurance Marketplace. There is no income limit on eligibility for premium tax credits, so most people will do better to buy coverage through the health insurance Marketplace.

Depending on where you live, there may be other coverage options available outside of the Marketplace that are not required to comply with the Affordable Care Act’s consumer protections. These include plans that are not traditional health insurance products, including short-term, limited duration insurance; association health plans; health care sharing ministries; and farm bureau plans. If an insurer or entity cannot provide a Summary of Benefits and Coverage that indicates the coverage is minimum essential coverage, be aware that the plan may have significant coverage limitations, particularly for pre-existing health conditions and even for basic medical care.

If you decide to forgo Marketplace coverage and premium tax credits, proceed with caution when evaluating options outside of the Marketplace, as there have frequently been cases of fraudulent activity and deceptive practices. Note that using a general search engine to find health insurance online may lead you to sites and sales representatives that steer you towards non-ACA-compliant products. In order to evaluate your options outside of the Marketplace, contact your state’s department of insurance for a list of reputable brokers who can assist you in assessing your options. Always insist on getting plan documents to review prior to buying a plan, particularly when purchasing a plan outside of the Marketplace.

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