QUESTION

Will covered benefits under all Marketplace plans be the same? How can I compare?

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

In general, Marketplace health plans are required to cover the 10 categories of essential health benefits. However, insurers in many states will have flexibility to modify coverage for some of the specific services within each category. Any modifications must be approved by the Marketplace before plans can be offered. Also, your cost-sharing for various services is likely to vary from plan to plan. All health insurance Marketplace health plans must provide consumers with a Summary of Benefits and Coverage (SBC). This is a brief, understandable description of what a plan covers and how it works. The SBC will also be posted for each plan on the Marketplace website. The SBC will make it easier for you to compare differences in health plan benefits and cost-sharing.

Plans might differ in other ways, too. For example, the network of health providers might be different from plan to plan.

Insurers in the federal Marketplace, HealthCare.gov, and some state-run Marketplaces are required to offer standardized plans. For these plans, the covered benefits will have the same fixed deductible, out-of-pocket costs and cost-sharing amounts for certain services within a metal tier. In particular, certain services—such as primary care, generic drugs, and some specialty care services for plans sold on HealthCare.gov—may be covered without you needing to meet your deductible. (45 C.F.R. §§ 147.200(a)(2)(i)(G), 156.110, 156.115, 156.200, 156.230; Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2024, 88 Fed. Reg. 25740 (Apr. 27, 2023).)

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