QUESTION

What health plans are offered through the Marketplace?

Individuals with no coverage | Comparing Plans: Benefits and Costs |
ANSWER

All health plans offered through the Marketplace must meet the requirements of “qualified health plans.” This means they will cover essential health benefits, limit the amount of cost-sharing (such as deductibles and co-pays) for covered benefits and satisfy all other consumer protections required under the Affordable Care Act.

Health plans may vary somewhat in the benefits they cover. Health plans also will vary based on the level of cost-sharing required. Plans will be labeled bronze, silver, gold, and platinum to indicate the overall amount of cost-sharing they require. Bronze plans will have the highest deductibles and other cost-sharing, while platinum plans will have the lowest. Individuals who qualify for cost-sharing reduction subsidies can have deductibles and other cost-sharing reduced if they enroll in a silver-level plan.

Health plans also vary in the networks of hospitals and other health care providers they offer. Some plans will require you to get all non-emergency care in-network, while others will provide some coverage when you receive out-of-network care.

Insurers in the federal Marketplace, HealthCare.gov, and some state-run Marketplaces offer “standardized plans” (called “Easy Pricing Plans” on HealthCare.gov). Standardized plans at each metal level will have standardized benefits with the same fixed deductible, out-of-pocket costs, and cost-sharing amounts. The purpose of these plans is to simplify the consumer shopping experience since consumers will know that certain features like the deductible and cost-sharing amounts under such plans will be the same within a metal tier. Standardized plans also cover some important services before the deductible. For example, federal standardized plans provide pre-deductible coverage of primary care, generic drugs, and some specialty services. (Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2024, 88 Fed. Reg. 25740 (Apr. 27, 2023) ; 45 C.F.R. Part 156; 45 C.F.R. §§ 156.130, 156.140, 156.230.)

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