Individuals and small employers are eligible to purchase coverage on either state or federal exchanges, and must decide whether employees are better served in an Exchange with potential government subsidies or with affordable, valuable, employer-provided health coverage.
Essential Health Benefit Coverage
The Health Insurance Marketplace will also provide coverage for Essential Health Benefits, which must include ambulatory patient services, emergency care, maternity and newborn care, hospitalization, mental health and substance abuse services, prescription drugs, laboratory services, rehabilitative and habilitative services, preventive and wellness services, chronic disease management, and pediatric, dental, and vision care.
Metal Tier System
The Health Insurance Marketplace is organized into four levels of coverage, described as Platinum, Gold, Silver, and Bronze. Each has its own corresponding cost level: Platinum provides 90% coverage, while each tier drops coverage by 10% (down to 60% for Bronze coverage).
Health Insurance Marketplace plans vary by plan coverage level, geographic location, participant age, and tobacco use.
The federal government has suggested an administration fee: 3.5% of the premium, for anyone who purchases from a government-run Health Insurance Marketplace. State-run Marketplaces determine their own charge rates.
Additionally, households and individuals earning between 100% and 400% of the Federal Poverty Level may be eligible for federal premium tax credits and cost-sharing subsidies.
Private Exchanges are not able to offer federal premium and cost-sharing subsidies because, they are created by private insurance carriers, consulting firms, and business associations. However, they are able to provide more personalized customer service for employers. Remember each Private Exchange is unique and will offer different carrier and plan options.