On-Marketplace, off-Marketplace—what’s the difference?

The health insurance Marketplace is an online tool individuals and businesses can use to shop, compare, and buy health insurance plans. Created by the Affordable Care Act (ACA), Marketplaces began operation on Jan. 1, 2014. They offer a choice of different health plans and provide detailed information to help people better understand their options.

Marketplaces may be operated either by a government agency (such as the Department of Health and Human Services) or a nonprofit organization. Each state was required to set up its own Marketplaces for the individual and small business markets. For states that didn’t create their own Marketplaces, the federal government did it for them—Wisconsin, for example, has a Federally Facilitated Marketplace.

Health insurance Marketplaces don’t replace traditional means of obtaining coverage—such as through an employer or from a private insurance company. Instead, the Marketplaces coexist with other means as an option that simplifies the buying process and helps promote competition.

So, what’s the difference?

Your insurance agent can show you a variety of health plans. Marketplaces do that too, by listing health plan options available in a given ZIP code. They display information in a standard format to help buyers compare insurance companies and plan benefits.

Your agent can help you enroll in a health plan or you can enroll with an insurance company directly. On the Marketplace, you can enroll online, in person, by phone, or by mail.

Plans and enrollment options are pretty similar whether you choose to buy from the Marketplace, an insurer, or an agent.

The big difference is that when you buy on the Marketplace, you could get help paying for the premium. You may be eligible for individual premium tax credits, cost-sharing reductions, and coverage exemptions. These money-saving opportunities are the biggest advantage when enrolling in an on-Marketplace health plan.

Qualified health plans

Under the ACA, every health plan sold on the Marketplace must be certified as a “qualifying health plan” and meet a set of minimum standards. For example, each plan must provide coverage for 10 “essential health benefits” as determined by the Department of Health and Human Services.

Most off-Marketplace plans must meet these standards, too. There are exceptions for short-term health plans and certain employer-funded group health plans.

Generally speaking, these benefits are based on the typical employer plan and include preventive and wellness services, chronic disease management, maternity and newborn care, pediatric services, emergency services, laboratory services, rehabilitative services, and more.

Make sure you’re covered

Whether you buy your health plan on or off the Marketplace, the main thing is to make sure you’re covered to prevent financial disaster. An accident or serious illness can wipe out your bank account very quickly. Make sure you get signed up during Open Enrollment, which runs from Nov. 1 until Dec. 15! You can check out WPS plans on our individual health plan product page. You can’t buy until Open Enrollment, but you can sign up for a reminder so you can get a jump on your shopping once it starts.

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6 thoughts on “On-Marketplace, off-Marketplace—what’s the difference?

  • I’m a 64 yr old female. I tried to get Medicaid but could not. According to them. I get ss. And drive a school bus. About 20 hrs a week. I get to sign up for medicare in Jan 2921. But won’t get that til April. Would like a plan that covers medical,dental,vision,hearing and prescriptions.

  • Yes I am on social security and I am Medicare parts A and B I got both of them 11/ 1 2006 But I have special enrollment. Can they help me pay the cost. Thanks Julie or can Medicare take out my social security since I am disabled sincerely Julie remitz

    • Hello, Julie. Thanks for your question. We have sales representatives dedicated to answering Medicare-related questions. You can call 1-800-236-1448 to discuss your Special Enrollment Period options.

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