QUESTION

If I buy an individual health plan outside the health insurance marketplace, is my coverage going to be the same as it would be inside the marketplace?

Individuals with no coverage | Coverage Outside the Marketplace
ANSWER

Not necessarily. There are some health plans sold outside the health insurance marketplace that are required to provide the same basic set of benefits as plans sold inside the marketplace, are not allowed to exclude coverage of a pre-existing condition, and are also required to provide a minimum level of financial protection to their consumers. Specifically, these plans must cover at least 60 percent of what the average person would spend on covered benefits and there is a cap on the maximum amount you will pay out of pocket ($7,900 for an individual and $15,800 for a family in 2019).

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. While plans sold through the health insurance marketplace must be certified by the marketplace as meeting minimum coverage and quality standards, plans sold outside the marketplace need not be certified.

Contact your state’s Department of Insurance for a list of reputable brokers who can direct you to these plans, which are sold outside the marketplace, but are still required to provide the same protections as plans sold inside the marketplace.

There may be other coverage options available outside of the marketplace that are not required to provide the Affordable Care Act’s protections as described above. 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 coverage limitations, particularly for pre-existing health conditions or for basic medical care. (45 C.F.R. § 147; 26 U.S.C. § 36B; 45 C.F.R. § 156.130; 81 Fed. Reg. 94058, Dec. 22, 2016).

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