How to Navigate the Health Insurance Marketplace

The Health Insurance Marketplace is one of the provisions of the Affordable Care Act (ACA), passed in 2010. The Marketplace, as it’s called informally, was established in 2013, enabling individuals to shop for health insurance in much the same way they currently shop online for airline tickets or hotel rooms. It provides information on insurance options, including eligibility for public coverage programs, as well as tax credits and premium assistance to help make insurance more affordable. The Marketplace ensures that people living with disabilities have access to high quality, comprehensive, and affordable care that meets their individual needs and enables them to live as independently as possible.

Other provisions of the ACA that benefit people living with disabilities include:

No penalties for pre-existing conditions. Insurance plans aren’t allowed to deny or exclude coverage to anyone based on a pre-existing condition, including a disability.

  • Lifetime and annual caps on benefits are prohibited.
  • Expansion of Medicaid. The ACA mandated expansion of state Medicaid programs for all Americans under 65 with incomes up to approximately $15,000. However, the Supreme Court decision in 2012 made state expansion optional. For information on Medicaid eligibility in your state, please visit medicaid.gov.

Expansion of home- and community-based services offered through state Medicaid programs, making it easier for people with disabilities to live at home, rather than being forced to receive services in an institutional setting.

Understanding the Marketplace

The Health Insurance Marketplace can help if you don't have coverage now, or if you have it but want to look at other options. With one Marketplace application, you can shop around for lower-cost plans based on your income, compare your coverage options side-by-side, and enroll.

For some people, the coverage options provided through the Marketplace may be a better choice than the plans currently offered through their employer. The Marketplace will also offer the uninsured choices they may not have been privy to in the past.

Where can I access the Marketplace?

Based on where you live, the Marketplace in your state will be accessible through a website operated by either the federal or state governments. HealthCare.gov will direct you to the Marketplace in your state. It's the best place to get started.

Here's how the Marketplace works:

Those interested in learning more about buying private insurance can go online and compare health insurance options. From there, you can select a plan that meets your needs and budget and enroll in coverage.

The Marketplace sites will ask you basic questions about your income, your family, and where you live, and will provide an overview of the insurance options (both private and public) for which you qualify. Ultimately, you will have to make decisions based on your own needs, the needs of your family, and your budget.

Tips to consider prior to enrollment

Be prepared with basic information

You'll need to have some basic information to get started with the enrollment process – whether you choose to enroll online or by phone. You’ll need to provide your social security number and where you live. You'll also need income information for all of the members of your family who need coverage from pay stubs, W-2 forms, and tax statement.

This information will help you determine if you're eligible for private insurance through the Marketplace, a public health coverage program (such as Medicaid), and/or for financial assistance from the government to help pay for coverage.

Budget, budget, budget

When you log on to the Marketplace, you'll be presented with plans from a number of different insurers. These plans will be organized by price, benefits, and other features.

Plans will be presented in four categories – bronze, silver, gold, and platinum – to make comparing them easier. Platinum plans will pay the highest percentage of your medical costs but will also have the highest premiums. Bronze plans will cost you less each month but will require you to pay a higher percentage of your medical costs out-of-pocket when you receive care. Knowing what you can afford to pay – both for monthly premiums, as well as out-of-pocket costs – will help you make the best decisions.

Research available plans and ask questions

While all plans in the Marketplace are required to offer a set of "Essential Health Benefits," it's important to keep in mind that specific plan benefits may be different in each state. And even within the same state, there can be small differences between plans.

This can make choosing a plan intimidating – especially for people living with a spinal cord injury who often require a significant amount of rehabilitative services, medications, therapies, and equipment. It's important that you know which services you will have access to under each plan, and this may not be obvious online.

The good news is health insurance marketplaces are staffed with people who should be able to answer very specific questions about what a certain plan does and doesn't cover. You can reach out to these staffers in real time via online chat, or by phone. HealthCare.gov offers a hotline, as well as an online chat option, to help you answer any questions you might have.

Medicare and the Marketplace

Medicare isn't part of the Marketplace, so, if you are already covered by Medicare, no action is needed. You'll still have the same benefits and security you have now, and you won't have to make any changes. (Note: The Marketplace does not offer Medicare supplement (Medigap) insurance or Part D prescription drug plans.)

Resources

If you are looking for more information on the Affordable Care Act or have a specific question, our Information Specialists are available Monday through Friday from 9:00 am to 8:00 pm ET at 800-539-7309

Additionally, the Reeve Foundation maintains fact sheets on the ACA . Check out our repository of fact sheets on hundreds of topics ranging from state resources to secondary complications of paralysis.

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.