Understanding individual & family coverage

mother playing with young daughter indoors

Individual and family plans are available to anyone age 18 and older who does not receive coverage through their employer but makes too much annually to be eligible for government assistance through Medicaid.

What is the difference between healthcare.gov, the marketplace, Obamacare, ACA, and the exchange? 

While it can be confusing to hear all of these various names, they are all referring to the same type of health insurance plan that is available to individuals over the age of 18 who do not qualify for Medicaid or employer coverage:

  • Healthcare.gov: the website where individuals can shop for a health insurance plan that the federal government operates as part of the Affordable Care Act
  • Health Insurance Marketplace® or marketplace: The Health Insurance Marketplace or marketplace is the platform that provides health plan shopping and enrollment services through websites, call centers, and in-person help. The federal government manages the Health Insurance Marketplace at healthcare.gov, while some states have their own marketplaces for their residents.
  • Affordable Care Act or ACA: The ACA was a law passed in 2010 under President Obama that was designed to reduce the cost of health insurance coverage for people who qualify for it. The law includes premium tax credits and cost-sharing reductions to help lower expenses for lower-income individuals and families.
  • Obamacare: A nickname given to the Affordable Care Act as this was passed during the presidency of Barak Obama in 2010.
  • The Exchange:  Another name for the Health Insurance Marketplace®

 

Enrollment periods

Open enrollment occurs from Nov. 1 through Jan. 15. During this time, anyone can enroll in an individual and family plan. In addition, you can buy a plan outside of this open enrollment period if you have a qualifying event, such as marriage or moving to a new home. Learn more about enrollment periods.


What is the difference between a Marketplace or Exchange Plan and a Direct or off-exchange plan? 

A Marketplace plan, or exchange plan, is a plan offered on healthcare.gov. These plans offer financial subsidies and tax credits, so to apply, you will need to enter your annual income to find out if you qualify for any of these assistance programs. These plans can also be purchased with the assistance of a licensed insurance agent but are the only plans to offer financial assistance to those who qualify.

A direct, or off-exchange plan, is a health insurance policy purchased directly from an insurer, such as WellFirst Health, or through an agent or broker, outside of the marketplace. These plans do not offer any financial subsidies or tax credits, but some may offer additional benefits you cannot receive on a Marketplace plan.  

Metal tiers

All Individual & family plans are divided into metal categories. These categories show how you and your plan share costs. No matter which category your plan falls in, the quality of care does not change.


Should you buy your plan through the marketplace or directly from the health plan?

Use our flow chart to help determine if you need to shop on or off-exchange for your individual and family coverage. View the marketplace flyer.

Do I qualify for financial assistance for paying for my health insurance? 

Depending on your income and personal situation, you may be eligible for various discounts and subsidies, too. Using the Health Insurance Marketplace Calculator, you can determine if you qualify. Visit our individual & family plans page to find out if you are eligible.

What is covered by an ACA plan? 

All individual and family plans must cover ten categories of services under the Affordable Care Act (ACA). These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, etc. Learn more about what ACA plans are required to cover

How do I enroll? 

You can enroll in a plan, both online or in-person, with a licensed health insurance agent.