Health Insurance Marketplace Basics


young-man-on-cell-phone-looking-at-health-insurance-online Health Insurance Marketplaces, often called Exchanges, are a key component of the Affordable Care Act. But, as entirely new entities, they can be rather confusing. Here we introduce the basics of Marketplaces, what is covered through ACA-compliant plans, how to understand the metal plans, and the specifics of the marketplace in Colorado.

What are marketplaces?

Health insurance Marketplaces are online resources where individuals, families, and small employers can compare private health insurance plans and purchase health coverage. Akin to other online shopping sites, applicants will see comparisons in price and coverage across different insurance companies and plans. They will be able to compare prices, plan specifics, and networks (as well as a great deal more) to make sure you’re getting the plan that best fits your and your family’s needs.

In addition to comparing companies and plans, individuals and families will be able to see if they are eligible for premium tax credits and other cost assistance in the Marketplaces. Plans can also be purchased from Rocky Mountain Health Plans (and other carriers) either directly or through a broker. However, for those eligible for premium tax credits or cost-sharing assistance, these options are only available for plans purchased through the Marketplaces.

What is covered?

Beginning January 1, 2014, new health plans sold to individuals, families and small employer groups, whether purchased through Connect for Health Colorado or directly from a health insurance carrier, must cover a minimum set of benefits called essential health benefits. Essential health benefits include coverage for:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and rehabilitative services and devices
  • Laboratory services
  • Preventive and wellness services, including chronic disease management
  • Pediatric services, including oral and vision care

What do Metal Levels mean?

The metal levels help consumers compare plans. All health plans in the Marketplaces get a metal designation based on the level of cost-sharing. Cost-sharing refers to the costs that members share when they get medical care, such as a deductible and co-insurance. Since all plans will offer the same basic benefits, assigning each plan a metal level helps consumers more easily compare plans from different companies. The metal levels offer an apples-to-apples comparison of plans with very similar coverage. The plans are broken down as follows:

§  Bronze level –The plan must cover 60% of expected costs for an average member on this plan.
§  Silver level – The plan must cover 70% of expected costs for an average member on this plan.
§  Gold level –The plan must cover 80% of expected costs for an average member on this plan.
§  Platinum level – The plan must cover 90% of expected costs for an average member on this plan.

Platinum is the highest level of coverage. The premiums for Bronze and Silver plans are lower than Gold and Platinum Plans. With lower premiums, there are typically higher deductibles and higher out-of-pocket costs for care. The Bronze and Silver plans might be good choices for individuals and families who want lower premiums. The Gold or Platinum levels might be a good choice for those who want more coverage. In addition, there are high deductible catastrophic plans.

What are catastrophic plans?

Catastrophic plans provide the required essential health benefits at a much higher deductible but with a lower premium. The Catastrophic plans are only available to people under age 30 and those who meet certain criteria. Catastrophic plans are also not eligible for premium tax credits.

More Information on Colorado’s Marketplace

Colorado’s Marketplace is called Connect for Health Colorado ( Colorado is one of only 16 states that set up its own Marketplace. If you are considering applying through the marketplace, be sure to have not only health histories for the family readily available, but income information (for premium tax credit purposes) and a general knowledge of how much coverage you and your family wants. Having this information before starting the application will make the process go much more quickly.

Consumers in Colorado may apply for coverage and premium tax credits through the Connect for Health Colorado website for 2014 coverage and tax credits. If you have any questions, we encourage you browse our Healthcare Reform site, get in touch with us or contact your broker or healthcare provider.