All Marketplace plans must cover Essential Health Benefits
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  1. 5 Things You Should Know About The New Health Insurance Marketplace
  2. All Marketplace plans must cover Essential Health Benefits
  3. If you can afford it, you will need minimum essential coverage
  4. Important Dates to Know

All Marketplace plans must cover Essential Health Benefits

2. All Marketplace plans must cover Essential Health Benefits

Regardless of whether you choose a Bronze, Silver, Gold or Platinum plan, certain essential health benefits must be covered and your copayments and coinsurance for them count towards your deductible. These services include:

  • Addiction treatment
  • Ambulatory patient services
  • Care for newborns and children
  • Chronic disease treatment (such as diabetes and asthma)
  • Emergency services
  • Hospitalization
  • Laboratory services
  • Maternity care
  • Mental health services
  • Occupational and physical therapy
  • Prescription drugs
  • Preventive and wellness services (such as vaccines and cancer screenings)
  • Speech-language therapy

Tip: These are minimum requirements. Many plans have additional benefits, so it’s important to look at the summary of benefits for any plan that you are considering to make sure it fits your budget and needs.

3. You might qualify for lower monthly premiums and out-of-pocket expenses

Many people will qualify for new federal subsidies that can help lower health costs, both the premiums and the care itself. When you get coverage through the Marketplace, you may be eligible for:

  • Cost-Sharing Reductions, which help lower out-of-pockets costs such as deductibles, co-pays and coinsurance; and
  • Advanced Premium Tax Credits, which reduce the amount you pay each month for your insurance premium.

Both subsidies are available only to qualified individuals who are:

  • Ineligible for public coverage (Medicaid, Medicare and Children’s Health Insurance Plan)
  • Unable to get qualified health insurance through an employer

Any savings are based on your family size and income. The Kaiser Family Foundation Calculator is a useful online tools that lets you enter your income level, family size, and ages of family members to get an estimate of your eligibility for subsidies, and what your insurance premiums might cost you.

In order to take advantage of Cost-Sharing Reductions, you must purchase a Silver plan on the Marketplace and your modified adjusted gross income (MAGI) must fall below these maximums:

Family Size Income
1 Up to $28,725
2 Up to $38,775
3 Up to $48,825
4 Up to $58,875
5 Up to $68,925
6 Up to $78,975
7 Up to $89,025
8 Up to $99,075

Tip: Your modified adjusted gross income is your household’s adjust gross income plus any tax-exempt Social Security, interest and foreign income.

Advanced Premium Tax Credits are sent directly from the government to your health insurer and are applied to your premium each month. You must apply for this subsidy on the Health Insurance Marketplace. Unlike the Cost-Sharing Reduction, you do not have to buy the Silver plan; however, you still must meet certain income requirements, based on family size:

Family Size Income Range
1 $11,490 to $45,960
2 $15,510 to $62,040
3 $19,530 to $78,120
4 $23,550 to $94,200
5 $27,570 to $110,280
6 $31,590 to $126,360
7 $35,610 to $142,440
8 $39,630 to $158,520

Tip: The amount of tax credit you receive depends on your income; you will pay more for your premiums if your income is near the top of the range and less if your income falls closer to the bottom. If your income falls below the range for your family size, you may qualify for coverage under your state’s Medicaid program.

If you can afford it, you will need minimum essential coverage

  1. 5 Things You Should Know About The New Health Insurance Marketplace
  2. All Marketplace plans must cover Essential Health Benefits
  3. If you can afford it, you will need minimum essential coverage
  4. Important Dates to Know
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