Health Insurance Marketplace

THE HEALTH INSURANCE MARKETPLACE, A PRODUCT OF THE AFFORDABLE CARE ACT, ALLOWS INDIVIDUALS AND FAMILIES TO FIND COVERAGE THAT BEST FITS THEIR BUDGET AND NEEDS.

How the Marketplace Works

The Health Insurance Marketplace offers side-by-side comparisons of local plans based on price, benefits and other features. The Marketplace helps determine who is eligible for low-cost coverage based on income and family size, as well as who qualifies for free or low-cost coverage through Medicaid (SoonerCare). Most U.S. citizens and legal residents are now required by law (Affordable Care Act, 2010) to have qualifying health insurance or pay a tax penalty.

Insurance plans in the Marketplace are offered by private companies, including CommunityCare. No plan can deny coverage or charge more because of a pre-existing illness or medical condition. Health insurance plans help pay for routine health maintenance and serve to limit unexpected, high medical costs. Many preventive services are covered at no cost to the individual.

Individuals eligible for employment-based health insurance have access to coverage that exceeds the standards required by the Affordable Care Act. In most circumstances, when an employer offers coverage, individuals are not eligible for tax credits or reduced costs through the Marketplace. However, if an individual's employment-based plan is not affordable (e.g., the employee's share of the annual premium for self-only coverage is greater than 9.5 percent of his/her annual household income), he or she may be eligible for tax credits or reduced costs through Marketplace.

Adult children can remain on their parents' plans up to age 26, including those who are full-time students, disabled or not tax dependent.

Marketplace Coverage Options

Plans in the Marketplace have a similar set of core benefits, known as “essential health benefits,” but they differ on what providers are included and how the costs of the benefits are applied. To fit different needs and budgets, plans are presented in four categories: bronze, silver, gold and platinum. This allows for selection of a plan that best fits the needs of an individual or family. One plan may be a better fit than another, depending on health needs.

Bronze

  • 60 percent coverage
  • Lower monthly payments than other plans
  • Higher cost when you receive medical care

Silver

  • 70 percent coverage
  • Higher monthly payments than a Bronze plan
  • Lower cost than a Bronze plan when you receive medical care

Gold

  • 80 percent coverage
  • Higher monthly payments than a Silver plan
  • Lower cost than a Silver plan when you receive medical care

Platinum

  • 90 percent coverage
  • Higher monthly payments than other plans
  • Lower cost than other plans when you receive medical care

Open Enrollment

The 2015 Marketplace open enrollment period is closed. The 2016 open enrollment period is tentatively set for Oct. 1 through Dec. 15, 2015. Marketplace coverage for 2015 will end Dec. 31 and for 2016 can begin as early as Jan. 1. During the next open enrollment period, those who previously enrolled will need to update their information and re-enroll in a plan for 2016. Plans and benefits offered in the Marketplace change from one year to the next, making it essential to carefully review plans prior to re-enrolling in a plan or selecting a new plan.

Special Enrollment

Individuals and families with special cases, such as those with a qualifying life event, may be able to sign up outside the open enrollment periods. Special circumstances are listed at www.healthcare.gov (www.cuidadodesalud.gov).

Individuals and families who qualify for Medicaid (SoonerCare) may enroll at any time during the year. There is no enrollment period for Medicaid.

If not eligible for special enrollment or Medicaid, individuals and families may choose to wait until the next open enrollment period for the Marketplace or purchase a health insurance plan outside the Marketplace from private insurance carriers like CommunityCare. Some individuals and families may also qualify for coverage through Insure Oklahoma.

How to Enroll

There are several ways you can apply for coverage through the Marketplace:

  • Apply with a private insurance carrier like CommunityCare.
  • Apply with one-on-one assistance from a certified application counselor (CAC) or navigator (see below).
  • Apply on your own via www.healthcare.gov (www.cuidadodesalud.gov) or 1-800-318-2596.
  • Apply with an insurance broker.

During open enrollment, St. John Health System's Marketplace assistance line connects individuals with one of our CACs, who can answer questions and set up appointments for on-site enrollment assistance. CACs help minimize confusion about Marketplace options and ensure desired providers and benefits are included in the selected plan. More information will be listed on this site closer to the next open enrollment period.

Additional Information

For key information on how health insurance works and how to get the most of a plan's benefits, download the booklet linked below, provided by the Centers for Medicare & Medicaid Services:

More information about the Marketplace and St. John is available via the St. John PulseLine, 918-744-0123 or pulseline@sjmc.org.