The Health Insurance Marketplace
The Health Insurance Marketplace (also called the Exchange) is a platform where individuals and small businesses can shop for and purchase health insurance. It serves as the central mechanism for delivering ACA coverage and subsidies.
Marketplace Structure
Federal vs. State Exchanges
| Type | Description | States |
|---|
| State-Based Marketplace (SBM) | State runs own exchange | ~18 states |
| Federally-Facilitated Marketplace (FFM) | Federal government operates | ~32 states |
| State-Based on Federal Platform | State uses HealthCare.gov | Several states |
HealthCare.gov
| Feature | Details |
|---|
| Website | HealthCare.gov |
| Coverage | Most states |
| Languages | Multiple language support |
| Assistance | Navigators, brokers, assisters |
Key Point: Whether a state runs its own exchange or uses the federal platform, the same ACA rules and protections apply. Subsidies are available in all marketplaces.
Qualified Health Plans (QHPs)
QHP Requirements
| Requirement | Description |
|---|
| EHBs | Must cover all 10 essential health benefits |
| Cost-sharing limits | 2025 OOP max: $9,200 individual/$18,400 family |
| Provider networks | Must have adequate network |
| Quality standards | Meet certification requirements |
| Standardization | Follow metal tier framework |
Certification Process
| Step | Description |
|---|
| Application | Insurers apply to participate |
| Review | State/federal review of plan |
| Certification | Plan approved as QHP |
| Monitoring | Ongoing compliance required |
Metal Tiers
Understanding Actuarial Value
| Metal Tier | Actuarial Value | Plan Pays | You Pay |
|---|
| Bronze | 60% | 60% | 40% |
| Silver | 70% | 70% | 30% |
| Gold | 80% | 80% | 20% |
| Platinum | 90% | 90% | 10% |
| Catastrophic | <60% | Varies | Varies |
Metal Tier Comparison
| Feature | Bronze | Silver | Gold | Platinum |
|---|
| Premium | Lowest | Low-moderate | Moderate | Highest |
| Deductible | Highest | High | Moderate | Lowest |
| Copays | Highest | High | Moderate | Lowest |
| Best for | Healthy, low usage | Average usage, subsidy eligible | Higher usage | Highest usage |
2025 Enrollment by Metal Tier
| Tier | Approximate % |
|---|
| Bronze | ~30% |
| Silver | ~55% |
| Gold | ~14% |
| Platinum | ~1% |
Exam Tip: Silver plans are most popular because they're the only tier eligible for cost-sharing reductions (CSRs), which can boost actuarial value to 73%, 87%, or 94% for lower-income enrollees.
Catastrophic Plans
Catastrophic Plan Features
| Feature | Details |
|---|
| Eligibility | Under 30 OR hardship/affordability exemption |
| Coverage | 3 primary care visits before deductible |
| Preventive care | Covered at 100% |
| Deductible | High (matches OOP maximum) |
| Premium | Very low |
| Subsidies | NOT eligible for premium tax credits |
Who Qualifies
| Category | Requirement |
|---|
| Age-based | Under 30 years old |
| Hardship exemption | Financial or personal hardship |
| Affordability exemption | Lowest bronze plan >8.39% of income |
Open Enrollment Period
2025 Open Enrollment
| Date | Event |
|---|
| November 1 | Open enrollment begins |
| December 15 | Deadline for January 1 coverage |
| January 15 | Open enrollment ends (most states) |
State Variations
| State | Extended Deadline |
|---|
| California | January 31 |
| New York | January 31 |
| DC | January 31 |
| Others | May vary |
Special Enrollment Periods (SEPs)
Qualifying Life Events
| Event | SEP Length |
|---|
| Loss of coverage | 60 days |
| Marriage | 60 days |
| Birth/adoption | 60 days |
| Move to new coverage area | 60 days |
| Divorce | 60 days |
| Death of family member | 60 days |
| Income change (Medicaid) | 60 days |
SEP Verification
| Requirement | Details |
|---|
| Documentation | May be required to prove event |
| Timing | Must enroll within 60 days |
| Coverage start | Usually 1st of month following enrollment |
| Pre-enrollment SEP | Some events allow coverage before enrollment |
Key Point: SEPs provide a limited window to enroll outside of open enrollment. The qualifying event must have occurred within 60 days, and documentation may be required.
Marketplace Assistance
Types of Help Available
| Helper | Description |
|---|
| Navigator | Trained, impartial enrollment assisters |
| Certified Application Counselor | Community organization staff |
| Insurance broker/agent | Licensed professionals (may earn commission) |
| In-person assistance | Face-to-face help |
| Phone assistance | Call center support |
Free Assistance
| Service | Cost |
|---|
| Navigators | Free |
| Call center | Free |
| HealthCare.gov | Free |
| Certified counselors | Free |
Exam Tip: Navigators and Certified Application Counselors provide free, impartial help. They cannot recommend specific plans but can explain options. Brokers/agents may earn commissions but costs are built into premiums (no extra charge to consumer).