Navigator Guide FAQs of the Week: What Does My Marketplace Plan Cover?

Enrolling in coverage on the marketplace requires consumers to compare different health plans and decide which one best fits their needs for the upcoming year. To avoid unwelcome surprises, it’s crucial that consumers have an accurate understanding of what plans will and will not cover before making a final selection. Luckily, resources are available to assist individuals and families in making an informed decision, including CHIR’s recently updated Navigator Resource Guide. This week, we highlight FAQs about marketplace plans’ coverage standards.

I heard marketplace plans have to cover certain health benefits referred to as essential. What are essential health benefits?

All qualified health plans offered in the marketplace (as well as non-grandfathered individual plans sold outside the marketplace) will cover essential health benefits. Categories of essential health benefits include:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care

The precise details of what is covered within these categories may vary somewhat from plan to plan.

I notice marketplace plans are labeled “bronze,” “silver,” “gold,” and “platinum.” What does that mean?

Plans in the marketplace are separated into categories — bronze, silver, gold, or platinum — based on the amount of cost-sharing they require. Cost-sharing refers to out-of-pocket costs like deductibles, co-pays and coinsurance under a health plan. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out-of-pocket limit on cost-sharing. The exception is for preventive health services, which health plans must cover entirely.

In the marketplace, bronze plans will generally have the highest deductibles and other cost-sharing. Silver plans will require somewhat lower cost-sharing, but this may not always be the case. If you are deciding between a bronze and silver plan, you will want to determine what the cost-sharing amounts are for the services you would use under each plan. Gold plans will have even lower cost-sharing. Platinum plans will have the lowest deductibles, co-pays and other cost-sharing. In general, plans with lower cost-sharing will have higher premiums, and vice versa. Keep in mind, however, that if you qualify for cost-sharing reductions, you must enroll in a silver plan to obtain cost-sharing reductions that lower your out-of-pocket costs.

Will my marketplace plan cover dental benefits?

Some marketplace health plans offer coverage of dental benefits and others do not. In addition, all marketplaces offer separate, stand-alone dental plans for children and often for adults, as well. Consumers who wish to have dental coverage should examine whether the plans they are comparing include coverage for dental benefits. Those who purchase a stand-alone dental plan should be aware that a separate plan means separate premiums, deductibles, co-pays, and a separate limit on total out-of-pocket costs.

What is a Catastrophic Health Plan?

A “Catastrophic Plan” is a qualified health plan offered through the marketplace that covers essential health benefits and requires the highest level of cost-sharing allowable for essential health benefits. In 2022, under a “catastrophic policy,” the annual deductible for covered services is $8,700 for an individual. After you have satisfied the deductible, the plan will pay 100 percent for covered essential health benefit services for the remainder of the year. “Catastrophic policies” may also be sold by insurers outside of the health insurance marketplace. Not everybody will be allowed to buy Catastrophic Plans. They are only for adults up to age 30, although adults of any age can buy a Catastrophic Plan if they receive an affordability exemption (either marketplace coverage or employer-sponsored coverage is determined unaffordable) or they receive a hardship exemption from the marketplace.

In most states, the deadline to sign up for coverage that begins January 1 is December 15. Check back next week for more tips on choosing a health plan, and in the meantime, find over 300 FAQs and other resources on our Navigator Resource Guide.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.