Health insurance · Under 65
Coverage for you and your family, before Medicare.
If you’re under 65 and buying your own health insurance, the Marketplace is where most people start. Here’s how it works, what the plan types actually mean, and when you’re allowed to enroll.
Opens HealthSherpa, where you can compare and enroll in ACA Marketplace plans.
The Marketplace
What is the Health Insurance Marketplace?
It’s the place, created under the Affordable Care Act, where individuals and families buy health coverage directly rather than through an employer.
ACA Marketplace plans cover essential health benefits, including doctor visits, hospital care, prescriptions, emergency care, maternity and newborn care, mental health services, and preventive care.
No plan can deny coverage or charge more because of a pre-existing condition, and there are no lifetime limits on covered benefits.
Depending on your income and household size, you may qualify for help lowering your premium and possibly your deductible and copays. Your eligibility is determined when you apply, and it’s one of the first things I check with you.
What actually varies between plans is the network of doctors and hospitals, how much you pay each month versus how much you pay when you use care, and which prescriptions are covered. Those three things are what we compare.
Plan types
PPO, POS, HMO, EPO: what the letters mean.
The difference between them comes down to two questions: can you go outside the network, and do you need a referral first?
- Most flexibilityPPO: Preferred Provider Organization
- You can see providers inside or outside the plan’s network, and you don’t need a referral to see a specialist. Care outside the network is still covered, though it costs you more. Usually the highest premium of the four.
- A middle pathPOS: Point of Service
- A blend: you pick a primary care doctor and generally need a referral to see a specialist, but the plan does cover some out-of-network care. Often priced between an HMO and a PPO.
- Lower premiumHMO: Health Maintenance Organization
- Care stays inside the network, and you go through a primary care doctor for referrals. Outside the network, only emergencies are covered. The trade for that is usually a lower premium.
- Lower premiumEPO: Exclusive Provider Organization
- Network-only like an HMO, but generally without the referral step. Outside the network, again, emergencies only.
Which plans are available depends on where you live.
Insurance companies offer different plans in different counties, so your local option may vary. Before choosing a plan, check that your doctors are in the plan’s network and your prescriptions are covered. These are the details people often discover too late.
When you can enroll
Your Enrollment Options
- Once a yearOpen Enrollment
- The annual period when you can buy a Marketplace plan or change your current plan for any reason. It usually runs in late fall and early winter for coverage starting the next year. Dates vary by year and by state. To have coverage starting January 1, enrolling early is important.
- When life changesSpecial Enrollment Period
- This is a set period to enroll, an opportunity to get Marketplace coverage after a qualifying life event, such as losing coverage, moving, getting married, or having a baby. Knowing the rules before you need them can help you avoid missing your enrollment window.
Special Enrollment Periods, in detail.
What is a Special Enrollment Period?
It’s a window outside Open Enrollment when you’re allowed to buy or change a Marketplace plan, opened by a specific life event. If you qualify, you generally have 60 days from the event to enroll, and in some cases a window beforehand as well.
What kinds of events open one?
Losing health coverage you already had, including through a job, a divorce, or aging off a parent’s plan. Moving to a new area with different plans available. Getting married, having a baby, or adopting. Changes in income or household that affect your eligibility. Certain other situations, including gaining citizenship or leaving incarceration.
Does quitting my plan on purpose count?
No. Voluntarily dropping coverage, or losing it for not paying your premiums, does not open a Special Enrollment Period. That’s an important distinction to get right before you cancel anything. Call me first.
Will I have to prove the event happened?
Usually, yes. The Marketplace typically asks for documentation: a letter showing when your old coverage ended, a lease or other proof of a move, a marriage or birth certificate. Keeping that paperwork handy makes the whole thing faster.
What if I miss every window?
Then Marketplace coverage generally has to wait for the next Open Enrollment. That’s the gap short-term coverage is designed for. Call me and we’ll look at what’s available to you in the meantime.
Does it cost more to enroll through you?
No. The premium is the same whether you enroll on your own or with my help. I’m paid by the carriers, so my time costs you nothing.
Bridging a gap
Short-term coverage, when you just need a bridge.
Sometimes a full Marketplace plan isn’t what the situation calls for, because the situation is measured in months.
Two people I talk to often: someone two or three months out from turning 65, and someone who retired up to a year before Medicare starts. Both need to be covered in the meantime, and neither wants to start a whole new annual plan they’ll leave almost immediately. Short-term health insurance is built for exactly that stretch.
It works differently from a Marketplace plan, and the differences matter. Short-term plans are not required to cover the essential health benefits, they can ask health questions and decline you based on the answers, and pre-existing conditions are generally not covered. They also don’t qualify you for premium help. What they give you in exchange is a plan you can start quickly, for a defined stretch of time, at a lower monthly cost.
How long they can run, and whether they’re sold at all, varies by state. That makes this a conversation rather than a checkout. Let me know the dates you need covered, and I’ll tell you what’s actually available to you.
Calling connects you with Lisa, a licensed insurance agent.
Get covered
Ready to look at real plans?
Browse what’s available where you live, or let me narrow it down with you first. Either way costs you the same.
Calling connects you with Lisa, a licensed insurance agent.
About the Health Insurance Marketplace®
Attention: This website is operated by Lisa's Insurance Agency and is not the Health Insurance Marketplace® website. In offering this website, Lisa's Insurance Agency is required to comply with all applicable federal law, including the standards established under 45 CFR 155.220(c) and (d) and standards established under 45 CFR 155.260 to protect the privacy and security of personally identifiable information. This website may not display all data on Qualified Health Plans (QHPs) being offered in your state through the Health Insurance Marketplace® website. To see all available data on QHP options in your state, go to the Health Insurance Marketplace® website at HealthCare.gov.
Dental and vision are separate
Marketplace medical plans don’t generally include adult dental or vision coverage; those are bought separately, and you don’t have to wait for an enrollment window to do it.See dental & vision plans.
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