Insurance Marketplaces: What Your State Decides

Every individual has access to a health insuranceMarketplace, also called an Exchange.

The Marketplace is where people who don't have health insurance through an employer, MedicareMedicaid, Tricare, or the VA can enroll in a comprehensive health planSmall businesses with 50 or fewer workers can buy health insurance from the Small Business Health Options Program (SHOP) Marketplace. The main way to use the Marketplace is online, but you can also access it by phone or with assistance in person.

Your health benefits and costs may differ in important ways from those of a family like yours in another state. You should compare plans on your state’s Exchange to learn what choices are available to you.

 

What's the Same in Every State?

When it comes to your health care options on the Marketplace, some things are the same in every state.

Basic coverage. The U.S. government sets basic guidelines for essential benefits. Every health plan sold in the Marketplace has to offer them. They include emergency care, pediatric care, maternity care, lab testing, and more.

Protections. There are many new protections under the law. Some include upper limits on how much you have to spend before your insurance company covers the cost of all of your care. Also, no plan can charge you more for insurance coverage based on your health or on whether you're a man or a woman.

Four levels of coverage. Every Marketplace will rank the types of plans according to the level of benefits they offer, from platinum (the most) to bronze (the least.) There's also a special plan for people under age 30 that offers catastrophic benefits.

The Decisions Your State Can Make

Aside from those basic requirements, states have a lot of control over what to include in their health coverage.

Which insurance companies get to sell on their Marketplace? States that set up their own Marketplace can choose insurance companies and can set tougher rules for coverage than the federal guidelines require.

How many insurance companies can sell? It varies. Some states may limit the number of insurance companies selling on their Marketplace. They hope it will improve the quality of the plans offered. Other states may take a different approach and allow any insurance company certified as a Qualified Health Plan to sell plans.

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Treatments that are covered. Although the law set the 10 general categories that essential health benefits must cover, it did not list all the services that fall under each category.

Each state is allowed to identify an existing plan as a benchmark for the essential health benefits. As a result, health plan benefits vary from one state to another.

For example, some states may require Marketplace plans to pay for weight loss surgery, but others may not. Some states may cover infertility treatments, but others may not. Some may offer extra coverage for health problems that are more common in that state; for example, if diabetes is prevalent there, the Marketplace may include more plans with programs that address the condition.

One plan may only cover a few drugs for your condition -- like medicine for high blood pressure -- while another plan may cover many brands.

States can also decide what complementary and alternative treatments count as essential benefits. 

Coverage for more people with low incomes. One way health reform was supposed to help more people get medical care was to expand each state's Medicaid plan. Medicaid is the free or low-cost health program for people with very low incomes.

However, states can decide whether or not to expand Medicaid. If a state doesn’t expand Medicaid, some low-income people won't be able to afford coverage. To find out whether you qualify for Medicaid, check out the HealthCare.gov.

3 Things to Know About Your State's Marketplace

Plans will vary state to state. If you're trying to help an out-of-state relative buy a plan, remember that their options will be different from yours.

Learn about your state's plan. You can find details about what’s offered in your state by going to our interactive map.

You may get a price break. Your state's Marketplace will let you know whether you can get financial help, called a subsidy or tax credit, from the government. This can lower your monthly payment for health insurance and, in some cases, lower your out-of-pocket costs. Your state Marketplace will also show whether you qualify for Medicaid.

WebMD Medical Reference Reviewed by Sarah Goodell on October 22, 2018

Sources

SOURCES:

Bastyr University: "Health Care Law Creates Openings for CAM Fields."

Community Catalyst: "The Essential Health Benefits Process: What Advocates Need to Know."

Consumer Reports: "Health Reform: 7 Things You Need to Know."

HMFA: "Gearing Up for Health Insurance Marketplaces."

Kaiser Health News. "A Guide to Health Insurance Exchanges," "Federal Government to Run Insurance Marketplaces in Half the States," "Governors Weigh Options on Health Insurance Exchanges."

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