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How Do You Qualify For Marketplace Insurance?

How Do You Qualify For Marketplace Insurance? | Very Good Coverage

How do you qualify for marketplace insurance? You must be a U.S. citizen who is not incarcerated, and who is not already covered by medicare.

Roughly 1 out of every 10 Americans living in the U.S. do not have health insurance. Many hourly, part-time, and contract jobs do not provide health insurance for employees. This forces many families to fork over a huge part of their paycheck for expensive, private insurance with high premiums.

Marketplace insurance is available to all Americans and U.S. residents regardless of income level. You can qualify for marketplace insurance if you are not incarcerated and not covered by Medicare. If you get a new job that offers health insurance, you will not qualify for marketplace insurance.

Anyone can qualify for marketplace insurance as long as their workplace does not provide them with insurance and they are not on Medicaid. There are no income limits that can disqualify someone from receiving marketplace insurance. For individuals who are at or below the poverty line, they are eligible to receive subsidies to make their care more affordable.

Sources include, GoodRx, Health Insurance Marketplace, and the U.S. Department of Health and Human Services.

What is Marketplace Insurance?

The term “marketplace insurance” is shorthand for the Health Insurance Marketplace. It is an enrolling service created by the 2010 Affordable Care Act that allows families and individuals to price shop for affordable health insurance.

Unlike Medicare or Medicaid, marketplace insurance is not a coverage plan. It is an insurance enrollment service that is managed on the federal or state level. Under the Affordable Care Act, marketplace insurance offers additional protections to people who have pre-existing conditions. It is also mandated by law that marketplace insurance plans must cover preventative care.

How to Qualify for Marketplace Insurance

There are 3 qualifications to be eligible for marketplace insurance:

  1. You must live in the U.S. as a citizen or legal resident.
  2. You must not be incarcerated.
  3. You must not be covered by Medicare, Medicaid, or another insurance plan.

Marketplace insurance is also available to anyone who is a green card holder, a refugee, an asylum seeker, a lawful temporary resident, a member of a federally recognized tribe, protected under DACA or TPS, or who has a student or worker visa.

Applicants must live in the U.S. or American Samoa at the time of application. If you leave the U.S. or its territories, you will no longer qualify for marketplace insurance.

Marketplace insurance is available to parolees and individuals who have been granted compassionate release or a deferred sentence. If you or a family member is incarcerated, you will not qualify for marketplace insurance. Individuals are allowed to enroll in marketplace insurance after their release. If you are convicted of a crime, you have 30 days to notify marketplace of your status and terminate your coverage.

How Do I Apply for Marketplace Insurance?

If you qualify for marketplace insurance, you simply must fill out an application to see if you qualify for subsidies, lower premiums, or CHIP (Children’s Health Insurance Program). Each state runs its own health insurance marketplace, so you will need to find your state’s program.

After you have applied for marketplace insurance and it is deemed that you qualify, you must enroll in your plan during the designated enrollment period.

If the enrollment period has already passed, you may qualify for a Special Enrollment Period under certain circumstances:

  • You or someone in your household has gotten married in the last 60 days.
  • You or someone in your household has had a baby, adopted a child, or has had a foster child placed in their home.
  • If you or someone in your household has legally separated or divorced and lost their health insurance as a result.
  • If you or someone in your household has changed residencies by moving to the U.S., moving to a different county for any reason, moved to or from transitional housing, or is a seasonal worker and has moved to or from your current workplace.
  • If the family member whose insurance plan you were on has died.
  • If you or a family member lost job-based health insurance due to losing employment.
  • If you aged out of your parents’ insurance plan in the last 60 days.
  • Becoming a U.S. citizen, acquiring a green card, or coming to the U.S. to seek asylum.
  • If you or a member of your household was released from incarceration in the last 60 days.

What Happens After I Enroll in Marketplace Insurance?

After you qualify for and enroll in marketplace insurance, you must pay your first premium for your coverage to start. The first premium must be paid directly to the insurance company, which will vary depending on your plan. Because marketplace insurance is a shopping and enrolling service, you cannot pay your premium directly to the Health Insurance Marketplace.

After you have enrolled and paid your first premium, your health insurance company will mail you a health insurance card. If you have dependents, a spouse, or other family members on your plan, you will receive additional insurance cards for them to carry. An insurance card is your proof of insurance and must be presented when you get medical care and pick up prescriptions.

How To Get Care With Marketplace Insurance

As long as your monthly premiums are paid on time and you continue to qualify for marketplace insurance, you will retain coverage. Marketplace insurance covers:

  • Filling prescriptions
  • Seeing your Primary Care Physician
  • Emergency room care
  • Seeing a specialist with a referral

Not all providers will be covered by marketplace insurance. To find an in-network provider, you will need to visit your insurance plan’s website and access their directory of approved providers.

If your marketplace insurance denies coverage for a visit, prescription, or procedure, you have the right to appeal the decision. During this process, the decision is reviewed by an objective third party to determine whether or not you should have been covered.

How is Marketplace Insurance Different From Medicare or Medicaid?

Marketplace insurance is distinct from Medicare and Medicaid. The purpose behind the Affordable Care Act and marketplace insurance is to close the gap in coverage. There are many families and individuals who make too much to qualify for Medicaid coverage, but are unable to afford private insurance or receive insurance benefits through employment.

What is Medicare?

Medicare is a federally run program that provides health insurance for people over the age of 65, as well as anyone who has a certain type of disability. Everyone who pays taxes pays into Medicare to create a trust fund to cover the cost of care for older adults. There are no income limits on Medicare; to qualify for Medicare you or your family member has to be over the age of 65 or have a certain qualifying disability. Individuals on Medicare pay small monthly premiums for additional coverage and are responsible for paying a small deductible for hospital care.

What is Medicaid?

Medicaid is an assistance program that is available to individuals and families under a certain income level, regardless of age. Anyone covered under Medicaid pays a small copay for medical services, but the cost of most visits and procedures are paid for by the program. Medicaid is administered on a state-by-state basis, so coverage and income limits will depend on where you live.

Marketplace Insurance vs. Medicare and Medicaid

Marketplace insurance was created by the Affordable Care Act to help people who needed insurance assistance and did not qualify for Medicare or Medicaid.

If you are eligible for coverage under Medicare or Medicaid, you will not be able to qualify for marketplace insurance. It is actually against the law for someone to sell you marketplace insurance if you already have an existing policy. Even if you only have Medicare Part A or Part B, you cannot qualify for marketplace insurance.

In special circumstances, individuals may qualify for marketplace insurance coverage until they are able to enroll in Medicare. For example, if you or a family member turns 65 after the Medicare enrollment deadline has already passed, you are eligible for a Special Enrollment Period. This allows you to enroll in marketplace healthcare until you can enroll in Medicare. Once your Medicare coverage begins, you must terminate your marketplace insurance coverage.


Greg McKnight

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