State Exchange Health Insurance Marketplace Overview and Enrollment

The State Exchange Health Insurance Marketplace is a platform where individuals and families can shop for and enroll in health insurance plans. It's a vital resource for those who don't have access to employer-sponsored coverage.

The marketplace is open to anyone who lives in the United States, regardless of income or health status. You can enroll in a plan during the annual open enrollment period, which typically runs from November to December, or during a special enrollment period if you experience a qualifying life event, such as losing your job or getting married.

To enroll in a plan, you'll need to create an account on the marketplace website or call the customer service number. You'll then be guided through a series of questions to determine your eligibility for subsidies and select a plan that meets your needs and budget.

State exchange health insurance plans are sold via state health insurance exchanges, which provide the infrastructure, website, and customer support for individuals and small businesses to purchase these plans.

More than 21.4 million people enrolled in Marketplace plans throughout the country during the open enrollment period for 2024 coverage.

Each state has just one official Marketplace, operated either by the state, the federal government, or both, where consumers can purchase ACA-compliant individual/family health insurance plans.

In most states, HealthCare.gov serves as the enrollment platform and runs the customer service call center, but some states run their own platforms.

States that offer their own health insurance exchanges can determine which insurers can offer state-based plans via their exchanges, and some states give priority to insurers whose plans offer benefits that align with the state's overall health needs.

To qualify for state exchange plans, you must not have access to affordable health insurance through an employer and not be covered by Medicare or Medicaid. You must also live within the state where the exchange is offered and meet certain income requirements, which can vary by state.

You can enroll in marketplace plans during open enrollment, which runs from November 1 through January 15 in states that use HealthCare.gov. States with their own exchanges can choose a different end date.

To enroll, you'll need to provide several key pieces of documentation and information, including proof of identity and citizenship, social security number, income verification, and current health insurance information. This ensures that all correspondence reaches you and helps determine your eligibility for subsidies.

Here are the income requirements to qualify for state exchange plans:

If you experience a qualifying life event, you can get a special enrollment period (SEP) to sign up for or change your health insurance. This usually gives you 60 days from your qualifying event.

To qualify for state exchange plans, you must not have access to affordable health insurance through an employer and not be covered by Medicare or Medicaid.

You must also live within the state where the exchange is offered and meet certain income requirements, which can vary by state.

Most Americans under age 65 get their coverage from an employer, so they don't need to use the Marketplace unless their employer's coverage wouldn't be considered affordable and/or wouldn't provide minimum value.

Virtually all Americans are eligible to use the health insurance Marketplace as long as they're lawfully present in the U.S., with the exception of people who are enrolled in Medicare coverage.

Starting November 1, 2024, DACA recipients can use the Marketplace and qualify for income-based subsidies, a change that wasn't in place in previous years.

The Marketplaces were designed to provide coverage for individuals and families who were either uninsured or already buying their own health insurance, including self-employed people and those employed by small businesses without health benefits.

To be eligible for the health insurance Marketplaces, you must meet certain criteria. The good news is that virtually all Americans are eligible, with the exception of those enrolled in Medicare coverage.

You must be lawfully present in the U.S. to use the Marketplace. Starting November 1, 2024, DACA recipients can use the Marketplace and qualify for income-based subsidies.

The Marketplaces were designed to provide coverage for individuals and families who are uninsured or already buying their own health insurance. This includes self-employed individuals, those employed by small businesses without health benefits, and people who have retired before age 65 and are too young for Medicare.

You can choose to decline your employer's coverage and select a plan in the Marketplace instead, but you won't be eligible for financial assistance unless your employer's coverage wouldn't be considered affordable and/or wouldn't provide minimum value.

Most Americans under age 65 who are eligible for Medicaid can use the Marketplace to enroll in Medicaid or determine their eligibility.

You can check the eligibility requirements for your state using the table below:

To qualify for a state exchange plan, you must live within the state where the exchange is offered and meet certain income requirements, which can vary by state.

You'll need to provide several key pieces of documentation and information to enroll, including proof of identity and citizenship, social security numbers, income verification, and current health insurance information.

These documents and information can be found in recent pay stubs, tax returns, or W-2 forms, as well as valid government-issued IDs and proof of U.S. citizenship or lawful presence.

You'll be asked to enter some personal information to determine whether you qualify for a federally supported state-based health insurance plan, and you can also go to Healthcare.gov, which will redirect you to your state's marketplace.

If you qualify, you'll be presented with the health insurance plans you qualify for, divided into four categories: Bronze, Silver, Gold, and Platinum, which represent how you and the insurer will divide medical costs.

Here's a breakdown of the four categories:

You'll be able to review the health insurance plans and what specific coverage options they offer before selecting one, and most marketplaces provide additional phone support in case you need extra assistance understanding the various options.

The health insurance marketplaces are where individuals and families can shop for health insurance plans and receive access to premium tax credits.

You can choose from a variety of private health insurance companies that offer different qualified health plans. All qualified plans offered for sale in the Marketplace must be ACA-compliant, meeting standards established and enforced by the federal and state governments.

The health insurance marketplaces are categorized into different levels—Bronze, Silver, Gold, and Platinum—which indicate the percentage of healthcare costs the plan covers relative to what you pay out-of-pocket.

Here's a breakdown of the different levels:

Most Americans under age 65 get their coverage from an employer, which means they don't need to use the Marketplace. However, anyone can find a plan that fits their needs, regardless of income level.

The health insurance marketplaces allow you to get a qualified health plan that covers the ACA's essential health benefits.

If you earn between 100 percent and 400 percent of the federal poverty level, you qualify for federally supported state-based health insurance, which means your monthly premiums for your state-based health insurance plan will be lower depending on how much subsidy you qualify for.

Federal subsidies on state-based health insurance, also referred to as "tax credits", are automatically added to your tax refund, but they're applied at the beginning of the tax period to lower the premiums on your state-based plan based on your estimated income for the year.

Be careful about guessing your income when applying for health insurance, as estimating too low can lead to owing money once tax season comes around.

Lower premium plans, like Bronze, typically have higher out-of-pocket costs at the point of service, such as higher deductibles and copays.

Higher premium plans, like Platinum, generally offer lower out-of-pocket costs.

You can choose from various health insurance plans on the marketplace, including HMOs, POS, PPO, and HDHPs. These plans are designed to meet the essential health benefits as defined by the ACA.

Each plan has a different level of coverage, indicated by the metal level: Bronze, Silver, Gold, and Platinum. The metal level shows what percentage of healthcare costs the plan covers relative to what you pay out-of-pocket.

Bronze plans have lower monthly premiums but higher deductibles, while Platinum plans have the highest monthly premiums and lowest deductibles. Catastrophic health plans are also available for those younger than 30 or who qualify for hardship exemptions.

You can find plans that fit your needs by checking the marketplace in your state. Some states have more carriers and options than others, so it's essential to explore your options.

Here are the types of health insurance available on the marketplaces:

You can enroll in a plan through the marketplace if you're lawfully present in the U.S. or a DACA recipient, as long as you're not enrolled in Medicare coverage. Most Americans under age 65 get their coverage from an employer, but you can choose to decline your employer's coverage and select a plan in the marketplace instead.

More than 16.3 million people have coverage through the ACA's exchanges, a record-high enrollment driven by subsidy enhancements.

This number is based on enrollment data from the end of open enrollment for 2023 coverage, which ended on January 15, 2023, in most states.

The majority of exchange enrollees have coverage in the individual market, with fewer than 200,000 people enrolled in small business exchange plans nationwide in 2017.

Some states have made their 2021 Small Business Exchange (SBE) Qualified Health Plan (QHP) Public Use Files (PUFs) available for download, including California, Colorado, and Massachusetts.

Here is a list of states that have made their 2021 SBE QHP PUFs available:

More than 16.3 million people had coverage through the ACA's exchanges at the end of open enrollment for 2023 coverage.

The American Rescue Plan and the Inflation Reduction Act played a significant role in driving this record-high enrollment.

Fewer than 200,000 people were enrolled in small business exchange plans nationwide in 2017, a relatively small number compared to the overall enrollment in individual market plans.

The majority of ACA exchange enrollees have coverage in the individual market, not through small business plans.

This suggests that the individual market is the primary source of ACA coverage for most people.

The 2022 SBE QHP PUF Datasets are a treasure trove of information, with data current as of July 29, 2022.

You can access the 2022-SBE-QHP-PUF-Data-Dictionary (ZIP) to explore the datasets further.

The datasets cover 14 states, including California, Colorado, Connecticut, District of Columbia, Idaho, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, and Oregon.

Here's a breakdown of the states covered:

Each state has its own dataset, which can be accessed by downloading the corresponding ZIP file.