Health Care Reform — Health Insurance Marketplace

The Health Insurance Marketplace helps uninsured people find health coverage. When you fill out the Marketplace application online the website will tell you if you qualify for:

• Private health insurance plans. The site will tell you whether you qualify for lower costs based on your household size and income. Plans cover essential health benefits, pre-existing conditions, and preventive care. If you do not qualify for lower costs, you can still use the Marketplace to buy insurance at the standard price.
• Medicaid and the Children’s Health Insurance Program (CHIP). These programs provide coverage to millions of families with limited income. If it looks like you qualify, the exchange will share information with your state agency and they’ll contact you. Many but not all states have expanded Medicaid to cover more people.

If you are eligible for job-based insurance, you can consider switching to a Marketplace plan, but you will not qualify for lower costs based on your income unless the job-based insurance is unaffordable or does not meet minimum requirements. You also may lose any contribution your employer makes to your premiums.

What is Covered?

All private health insurance plans offered in the Marketplace offer the same set of essential health benefits. The essential health benefits include at least the following items and services.

• Ambulatory patient services (outpatient care you get without being admitted to a hospital).
• Emergency services.
• Hospitalization (such as surgery).
• Maternity and newborn care (care before and after your baby is born).
• Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy).
• Prescription drugs.
• Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills).
• Laboratory services.
• Preventive and wellness services and chronic disease management.
• Pediatric services, including oral and vision care.

Essential health benefits are minimum requirements for all Marketplace plans. Specific services covered in each broad benefit category can vary based on your state’s requirements. Plans may offer additional benefits that are not included in essential health benefits, such as dental and vision coverage.

Benefits are generally the same in each state. However, some states require insurers to cover additional services and procedures. When you compare plans in the Marketplace, you will be able to see the specific benefits each plan offers.

How to Apply for Marketplace Coverage

Open Enrollment

An open enrollment period is a yearly time when you can enroll in a health insurance plan. The open enrollment period is generally November 1 through December 15. Some states have longer open enrollment periods that start sooner and/or end later.

Outside the open enrollment period, you can only enroll in or change a Marketplace plan if you have a life event that qualifies you for a Special Enrollment Period. You may qualify for special enrollment if you or anyone in your household in the past 60 days:

• Got married.
• Had a baby, adopted a child, or placed a child for foster care.
• Got divorced or legally separated and lost health insurance.
• Died.
• Moved to a new ZIP code or county.
• Lost qualifying health coverage (including through your job or a family member).
• Lost eligibility for Medicaid or CHIP.

Note: There is no limited enrollment period for Medicaid or CHIP. If you qualify, coverage can begin immediately.

Apply Online

Most states do not have their own Marketplace. Individuals in those states can use HealthCare.gov to apply for and enroll in health coverage online. If you live in a state that operates its own Marketplace, you will go to your state’s Marketplace website to apply and enroll. See the following chart.

Other Ways to Apply

• Find and contact an agent, broker, or assister to help you. Some offer help in languages other than English and in-person assistance.
• Apply through the website of an approved enrollment partner, such as an insurance company or online health insurance seller.
• Contact the Marketplace Call Center at 1-800-318-2596 (TTY 1-855-889-4325) to enroll by phone.
• Print an application obtained online at HealthCare.gov and mail it to the Marketplace. You will get eligibility results in the mail within two weeks.

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