There is no single insurance path that works best for everyone. Depending on your household, employment, income, health needs, location, and eligibility, there may be several different ways to obtain coverage. Understanding how those paths differ is the first step toward comparing them effectively.
After you've decided on the best plan for your needs, you're done! The hard part is over. Now you can focus on getting back to what you do best, and leave your health insurance worries behind. You'll know what coverages you have, what you will pay, and where to go for help.
Marketplace and private health insurance are not necessarily two completely different kinds of insurance. Many Marketplace plans are offered by private insurance companies, and ACA-compliant health plans can also be purchased outside the Marketplace. The important differences are how the policy is purchased, whether financial assistance is available, which plans and networks are offered, and whether the coverage follows ACA major-medical requirements.
| What to Compare | ACA Marketplace Coverage | Private / Off-Exchange Coverage |
|---|---|---|
| Where You Purchase It | Through HealthCare.gov, a state Marketplace, or an authorized Marketplace enrollment partner. | Directly from an insurance carrier, licensed agent or broker, or another private enrollment channel. |
| Premium Tax Credits | Available to eligible applicants. Premium tax credits can reduce the monthly premium. | Not available for policies purchased outside the Marketplace. Even if the policy itself is ACA-compliant, Marketplace premium tax credits cannot be applied to it. |
| Additional Cost-Sharing Savings | Eligible consumers who select qualifying Silver plans may receive cost-sharing reductions that lower deductibles, copayments, coinsurance, and other out-of-pocket costs. | Marketplace cost-sharing reductions are not available on coverage purchased outside the Marketplace. |
| Pre-Existing Conditions | Marketplace plans cannot deny coverage, exclude treatment, or charge a higher premium because of a pre-existing medical condition. | ACA-compliant off-exchange major-medical plans generally provide the same ACA protection. Other types of private coverage may operate under different rules, so the policy type should be verified before enrolling. |
| Essential Health Benefits | Marketplace plans cover the ACA's 10 Essential Health Benefit categories, including hospitalization, emergency services, maternity care, mental health services and prescription drugs. | ACA-compliant individual major-medical plans are also subject to applicable ACA benefit requirements. Other private products may provide more limited benefits and should be reviewed carefully. |
| Provider Networks | Networks are specific to each plan and may use HMO, EPO, PPO or other structures. Marketplace Qualified Health Plans using networks are subject to network-adequacy requirements. A doctor who accepts an insurer generally may not participate in every plan offered by that insurer. | Networks also vary by policy. Some off-exchange plans may use the same network as Marketplace plans, while others may offer different regional, PPO or national network arrangements where available. Always verify the exact physician, hospital and facility network before enrolling |
| Out-of-Network Care | Depends on the plan. HMO and EPO plans may provide little or no non-emergency out-of-network coverage, while PPO-style plans may provide some coverage at a higher cost. | Also depends on the policy. Certain private plans may provide broader out-of-network benefits, while others may have equally restrictive networks. The actual policy matters more than the "private" label. |
| Prescription Drug Coverage | Prescription drugs are an Essential Health Benefit, but every medication is not necessarily covered. Each plan has its own formulary, drug tiers, preferred medications, prior-authorization rules and pharmacy network. | ACA-compliant plans also provide prescription benefits subject to their formulary. Other private coverage may offer different or more limited prescription benefits. Consumers taking regular or specialty medications should verify the exact drug, dosage and coverage tier before enrolling. |
| Plan Selection | Consumers compare the plans approved for sale through their Marketplace. Available insurance companies, networks and plan designs depend on location. | Consumers may have access to plans sold outside the Marketplace that do not appear in Marketplace search results. Availability varies considerably by carrier, state and type of coverage. |
| Enrollment Periods | Marketplace enrollment generally occurs during the annual Open Enrollment Period or after a qualifying life event that creates a Special Enrollment Period. | ACA-compliant individual major-medical coverage may also be subject to enrollment-period requirements. Other private products can have different enrollment rules and may be available at other times of the year. |
| Medical Underwriting | Marketplace major-medical plans do not use your health history to determine whether you can enroll or how much you pay because of a medical condition. | ACA-compliant off-exchange major-medical plans follow applicable ACA protections. Some non-ACA private products may use health questions, underwriting, exclusions or other eligibility requirements. |
| Out-of-Pocket Protection | Marketplace plans have annual limits on covered in-network out-of-pocket spending. Once the applicable limit is reached, the plan pays 100% of covered in-network benefits for the remainder of the plan year. | ACA-compliant major-medical policies are also subject to applicable ACA out-of-pocket limits. Limited-benefit or non-ACA products may operate differently. |
| Best Fit for Someone Who… | Wants to determine whether they qualify for premium assistance or cost-sharing savings while comparing ACA-compliant plans available in their area. | Does not qualify for Marketplace assistance, wants to investigate additional plan or network options, or wants help comparing coverage available outside the Marketplace. |
Not necessarily. Marketplace plan changes are generally permitted during Open Enrollment or when you qualify for a Special Enrollment Period. Developing an illness by itself isn't generally listed as a qualifying life event. Events such as losing other coverage, moving, getting married, having a baby, or adopting a child can qualify.
Need assistance with any of this? That's where we come in! Our certified health insurance professionals and network of assistants can help you navigate the complex options and help tailor the right plan for you and your specific health insurance needs.
Give Us A CallCoverage, pricing, eligibility, networks, benefits, and enrollment requirements vary by state, insurer, plan, and individual circumstances. Information provided by Simple Health Advising is intended for general educational purposes and should not be considered tax, legal, or medical advice.
