Health Insurance Exchanges
The Affordable Care Act (ACA) created guidelines for a new kind of marketplace for health insurance. Learn more about public exchanges and how Innovation Health supports them.
Exchanges at a Glance
What are public exchanges?
Public exchanges (also referred to as “marketplaces”) are online markets where consumers and small businesses can go to shop for health insurance. On these sites, they can compare the plans available to them and then purchase online.
Understand the basics about exchanges:
Who creates and maintains the exchanges?
- Each state has the option to create and operate its own exchange.
- If the state opts not to offer an exchange, a federal exchange will be available.
- Outside of the public exchanges, private exchanges may also exist. These are not required by the ACA and do not include access to government subsidies.
Who can shop on an exchange?
On October 1, 2013, the federal and state-based public exchanges, for those states that chose to participate, became available for small employers and individuals shopping for health insurance.
Do exchanges help address the cost of health insurance?
For individuals who meet certain criteria, two elements can help make health insurance affordable for them:
Premium tax credits
Individuals and families may qualify for a “premium tax credit” that lowers your monthly premium when you enroll through a public exchange. The amount of the premium tax credit depends on your estimated household income.
In addition to a premium tax credit, your income may qualify you to save on the out-of-pocket costs you pay whenever you get health care, like deductibles and copayments. But you get these additional savings only if you enroll in a Silver plan through a public exchange.
Use this quick tool to see if your 2017 income estimate falls in the range for cost-sharing reductions
What kind of plans will be available on an exchange?
To participate on an exchange, health plans need to meet specific criteria.
Essential health benefits
The ACA requires that the following services are included in any benefits package sold on or off exchange to individuals and small group employees. These include:
- Ambulatory services
- Emergency services
- Rehabilitative/habilitative services and devices
- Laboratory services
- Preventive/wellness services/chronic disease management
- Maternity/newborn care
- Mental/behavioral health/substance abuse treatment
- Prescription drugs
- Pediatric services (including dental and vision care)
Qualified health plans must have networks that meet certain requirements, including the size of the network and how it is created. The network also needs to include essential community providers, who typically provide care to patients with low incomes.
Qualified health plan
The ACA requires that all health plans offered through an exchange meet certain requirements. These include:
- Being certified by the state exchange for criteria such as the size of the network, how the plan is marketed, and the how the plan helps improve the member’s health
- Providing a minimum essential health benefits package
- Following established limits on cost-sharing (like deductibles, copayments and out of pocket maximums)
- Offering at least one silver and one gold plan
- Charging the same premium both on and off exchange
- Both on and off exchange, health insurance plans for individuals and small group markets are assigned a metallic level. The level is based on the how much of the total health care cost the plan pays, versus what the member will pay out-of-pocket
|Plan type||% of essential benefit costs covered by plan in a typical year*|
*However, the plan may pay a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
For more information about exchanges, including the solution that is available in your state, please visit www.HealthCare.gov.