Home » Marketplace Individual Health Insurance vs. Private Off-Marketplace Individual Health Insurance

Marketplace Individual Health Insurance vs. Private Off-Marketplace Individual Health Insurance

Deciding on health insurance can be confusing, but at Insurance for Wholeness & Health, we can help you choose which path is right for you. Marketplace individual health plans and private off-Marketplace individual health plans can vary, so it’s best to learn the differences in plan options before making a final decision. 

Essential Health Benefits

Regardless of which health plan you choose, each plan is required to offer these 10 essential health benefits:

  • Outpatient care
  • Prescription drug coverage
  • Pediatric services, including dental and vision coverage for children
  • Preventive care
  • Laboratory services
  • Emergency services
  • Hospitalization for surgery, overnight stays and other conditions
  • Mental health coverage and substance use disorder services
  • Rehabilitative and habilitative services
  • Pregnancy, maternity and newborn care

Marketplace plans must also include birth control coverage, breastfeeding coverage and coverage for pre-existing conditions. State Marketplace plans may require the offering of further coverage as well.

What is a Marketplace Individual Health Plan?

The Health Insurance Marketplace (Marketplace), sometimes known as the Health Insurance Exchange, is one way to obtain health insurance. Marketplace individual health insurance plans are offered by Insurance for Wholeness & Health through the federal health exchange program. 

To be eligible to enroll in a federal or state plan, you must fall under the following criteria: 

  • Must live in the United States
  • Must be a U.S. citizen
  • Can’t be incarcerated

Residents of all states have access to the Marketplace and can use it if qualified. Individual states may run the Marketplace for their residents, while the federal government may run other states’ Marketplace. 

Generally speaking, there are four categories of Marketplace insurance plans: bronze, silver, gold, and platinum. The category you choose affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or prescription medications. It also affects your total out-of-pocket costs. Specific coverage can vary depending on your state’s benchmark.

All plan categories offer the same set of essential health benefits, and the categories do not reflect the quality or amount of care the plans provide.

With federal or state Marketplace plans, you may be able to qualify for cost-saving subsidies to help you obtain quality coverage at a lower out-of-pocket cost to you. Be sure to ask your Insurance for Wholeness & Health representative for more information about such subsidies. 

What is a Private Off-Marketplace Individual Health Plan?

Private off-Marketplace individual health plans meet the requirements set forth by the ACA, including the federal rules for Marketplace plans. These private plans are not offered or listed on the Marketplace. Instead, insurance companies, agents, brokers, and online health insurance sellers may offer these plans.

Those who offer private off-Marketplace individual health plans may provide additional shopping support such as specific plan recommendations based on your personal preferences. Plan designs and cost-sharing requirements may vary greatly depending on what is offered to you, and unlike Marketplace plans, private plans don’t typically provide cost-saving tax subsidies. There are also opportunities to save some money due to the flexibility in how the plans are structured.  

We’re Here to Help

Choosing a health care plan can be confusing, complex and time-consuming. But, you don’t have to make this decision alone. Let the experts at Insurance for Wholeness & Health help you make an informed decision to protect your health and your pocketbook for the upcoming year. Contact us today to get started!