Shopping the Health Insurance Marketplace: What You Need to Know

Shopping for medical insurance can be a daunting task. Johanna Lawrence, a certified application counselor with the Phelps Health EnrollU Department, answers commonly asked questions about the Health Insurance Marketplace, to guide you in selecting coverage best suited to your specific needs.

What is the Health Insurance Marketplace?

The Health Insurance Marketplace is a service that helps people shop for, compare and enroll in health insurance. The federal government operates the Marketplace, available at healthcare.gov.

The Marketplace is the only place where you can get premium tax credits to help you pay for your insurance premiums. It’s a wonderful tool for our community to be able to get affordable care.

Do I qualify for insurance through the Health Insurance Marketplace?

You can use the Health Insurance Marketplace if you meet the following criteria:

• You are an individual or family buying insurance on your own.
• You do not have access to affordable coverage through your job or a spouse’s job.

If you use the Marketplace to buy coverage, you may qualify for financial help. When you fill out an application, you will find out if you can get tax credits to lower your monthly premiums and out-of-pocket healthcare costs. These tax credits are available to people with income at a certain level.

Can I enroll in the Health Insurance Marketplace with a pre-existing condition?

Yes, all Marketplace plans must cover treatment for pre-existing medical conditions that would normally be covered under the plan.

• No insurance plan can reject you, charge you more or refuse to pay for essential health benefits for any condition you had before your coverage started.
• Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.

Exception: Grandfathered plans don’t have to cover pre-existing conditions or preventive care. If you have a grandfathered plan and want pre-existing conditions covered, you have two options:

• You can switch to a Marketplace plan that will cover pre-existing conditions during open enrollment.
• You can buy a Marketplace plan outside open enrollment when your grandfathered plan year ends, and you’ll qualify for a Special Enrollment Period.

What plans does the Marketplace offer?

The Marketplace offers a wide variety of health insurance plans, and within Phelps County, we have two insurance companies that participate in the Marketplace, Ambetter and Anthem. (These two are the most common not only in Phelps County, but also in our service area.) All Marketplace plans have to follow minimal essential coverage guidelines. These plans all offer preventive care, immunizations and more.

Plans are categorized based on cost sharing (Bronze, Silver and Gold.) Bronze plans will have higher out-of-pocket expenses, and Gold plans will be lower. If your income falls within 138% and 250% of the federal poverty level (FPL), you may be eligible for extra savings called cost-sharing reductions if you enroll in a Silver plan. This benefit helps reduce your out-of-pocket expenses.

When is open enrollment for the Marketplace? And when would my coverage begin?

Open enrollment for the Missouri Health Insurance Marketplace is November 1 – January 15. However, if you are wanting coverage to start January 1, you need to enroll by December 15. If you enroll after December 15 (but before January 15), your coverage will begin February 1.

How do I sign up for the Health Insurance Marketplace?

Individuals can sign up for the Marketplace online or over the phone. To sign up online, visit healthcare.gov. You’ll need the following information handy: your email address, Social Security number, income information and a list of your current medical providers and prescriptions (to verify they are in-network with the plan you choose.) The other option would be to call the Marketplace at (800) 318-2596. Their staff can assist you and enroll you over the phone.

Can EnrollU help me sign up?

Absolutely. Our team can walk you through the process, whether you sign up online or over the phone. Call (573) 458-3676 to set up an appointment. You do not have to be a Phelps Health patient to receive assistance with EnrollU. We provide this free service to the community.

If I already have coverage through the Marketplace, do I need to reapply each year? Can I change plans during open enrollment?

Your Marketplace coverage can roll over from year to year. If your specific plan is offered again the following year, you have the option to re-enroll. So, you don't necessarily have to reapply every year. However, it is best practice to go online during open enrollment and review your application every year. Ensure that your income information is the same and that you are still happy with your current plan. Finally, make sure there are no better options available for you. Marketplace plans change every year. Your current plan may be best for you this year, but there may be a plan available next year that better suits you and your family’s needs.

How do premium tax credits work?

Premium tax credits are just like they sound; they are a tax credit from the federal government to help you pay your health insurance premiums. You can choose to receive them in one of two ways. If you elect to receive them in advance, the government will pay your insurance company directly each month. Or, you can choose to receive the tax credits when you file your taxes at the end of the year. In our experience, most people choose the monthly route, but the decision is up to each individual.

In years past, your household income had to fall between 100% and 400% of the FPL to receive premium tax credits. With the expansion of Medicaid in Missouri, however, the lower end increased to 138%. So, if your household income is less than 138% of the FPL, you would likely qualify for Medicaid, making you ineligible for premium tax credits. The government also temporarily removed the 400% cutoff for this subsidy. Due to the American Rescue Plan, if your household income is over the 400% limit, you may still be eligible to receive tax credits. This is great news, because it opens the door for a lot of people who may be just on the far end of receiving that tax credit to now have that benefit available to them. This was originally only planned to apply to tax years 2021 and 2022, but Congress has now extended this relief through 2025.

Recently, the Department of the Treasury revised the so-called family glitch within the Marketplace. Previously, it stated that if your individual plan through your employer costs less than 9.61% of your household's income, it was considered affordable.

However, this guideline didn't consider those with families or offer a different percentage for family plans. This requirement put a lot of people in a bad spot, where their individual plan was affordable, but it wasn’t affordable to add a spouse and children to the plan. And they were no longer eligible for tax credits because they had an offer of “affordable” coverage. This glitch has recently been fixed to now include the family as well.

For example: If a family's cost of coverage is less than 9.12% of their household income, it would be considered affordable and therefore, they wouldn't be eligible for the tax credits. But if the cost exceeds that, then a family is able to get premium tax credits through the Marketplace. We often see this with school teachers in our area. Teachers may have extremely low-priced individual plans, but it's incredibly expensive to insure their families. With this change taking effect in 2023, their family may now be eligible for these tax credits.

What is a special enrollment period (SEP) and who qualifies for this?

A special enrollment period is any time outside of open enrollment or general enrollment where you are eligible to sign up for or make changes to your Marketplace coverage. SEPs are triggered by life events or changes in your household. You may qualify for an SEP if you or anyone in your household:

• Has moved into a different service location
• Lost insurance coverage
• Got married
• Had a baby, adopted a child or placed a child for foster care
• Got divorced or legally separated and lost health insurance (Note: Divorce or separation without losing coverage does not qualify you for an SEP.)
• Passed away

Note that when you apply, you must confirm that the information on the application is true, including the facts that qualify you for an SEP. You may be required to submit documents that confirm your eligibility to enroll based on the life event that you experience.