Qualified Health Plan
Qualified Health Plans (QHPs) meet the protections and requirements set by the Affordable Care Act.
What are qualified plans?
♦ All plans sold at the Health Insurance Marketplace must be certified as a Qualified Health Plan.
♦ All Qualified Health Plans provide Essential Health Benefits
Qualified Health Plans are required to spend at least 80% of revenues on healthcare and not on excessive advertising and bonuses.
Qualified Health Plans have limits on cost sharing expenses like deductibles, copayments, and out-of-pocket maximums.
• In 2025, the most an individual will have to pay for in-network covered medical care is $9,200 and $18,400 for a family. This is referred to as out-of-pocket maximum.
Many plans will have lower limits but the trend is clearly toward the maximum the law will permit. This has many people worried they have to buy insurance they cannot afford to use.
♦ All Qualified Health Plans offer the same core set of benefits, including preventive services, mental health and substance abuse services, emergency services, prescription drugs and hospitalization.
• Some plans include benefits beyond the core set.
♦ All qualified plans must also guarantee the same consumer protections.
Qualified Health Plans are categorized into four tiers based upon how much they are expected to pay for coverage healthcare expenses. The levels are referred to as metal levels.
• Bronze: pays 60%
• Silver: pays 70%
• Gold: pays 80%
• Platinum: pays 90%
Bronze plans will have the lowest premium but you will have the most potential healthcare costs. Platinum plans will have the highest premium but you will have the least potential healthcare costs.
Short-term Health Insurance
These are a form of skimpy health insurance intended for short periods of time.
These plans work best of people who are healthy and never suffer an accident.
These types of plans are NOT qualified.
• They are often described as "consumer beware" plans.
Who certifies a qualified health plan?
The Marketplace will certify a plan as a Qualified Health Plan.
The Affordable Care Act allows some leeway from state to state for setting the requirements for QHP certification.
Depending upon how your state setup their marketplace the plans offered could very possibly include some additional benefits not required by the Affordable Care Act, such as vision care for children.
This can be a good reason to purchase a plan through the Marketplace even if you do not qualified for a premium tax credit.
Insurance companies can choose to sell the same QHP off the exchanges. They are not required to do so but they can if they want.
♦ It is important to understand that plans sold off the exchanges do not have to be certified as QHP.
Plans purchased off the exchanges may be or may not be a QHP. If they are not QHP certified this does not mean they are bad.
♦ Plans sold off the exchanges still must meet minimum requirements established by the Affordable Care Act. They might not include all the same benefits that a QHP plan has.
♦ Plans sold off the exchanges may have a different network of providers, in many cases a more expanded network of providers than the plans offered through the Marketplace.
You should take the time to read the various plan benefit documents to see which plan fits your needs.
♦ You may find a plan off the exchange at a price you can better afford than one on the exchange. The difference may simply be that it provides a few less benefits. If those benefits are not so important to you, then such a plan may be a better fit for you.
Where to find insurance ?
HealthCare.gov serves as the Marketplace for the majority of the United States. 18 states including the District of Columbia maintain their own online exchanges.
If you live in state that chose to setup their own marketplace, you would purchase insurance through your state’s marketplace. Everyone else would be able to purchase insurance through Healthcare.gov.
Various marketplace contact information — websites & phone numbers can be found here ... Marketplace.
How marketplaces are setup
It is really not all that important what path your state chose. If your state was a bit more progressive you might have a chance to receive a few extra perks.
• People in the do nothing states unfortunately tend to get the least assistance with signing up for insurance.
The premium tax credit is really what matters. And it is tied to market conditions in your state not how your state's shopping site is setup.
State-based marketplace
States running a state-based marketplace are responsible for performing all marketplace functions.
If you live in one of these states you apply for coverage through the marketplace website created by your state.
Federally-supported state-based marketplace
States with this type of marketplace are considered to have a state-based marketplace.
The state is responsible for performing all marketplace functions, except that the state will rely on the federally-facilitated marketplace's computer system rather than setup their own.
If you live in one of these states you apply for coverage through Healthcare.gov.
State-partnership marketplace
States entering into a partnership marketplace may administer in-person consumer assistance functions and the U.S. Department of Health & Human Services (HHS) will perform the remaining marketplace functions.
If you live in one of these states you apply for coverage through Healthcare.gov.
Federally-facilitated marketplace
In a federally-facilitated marketplace, HHS performs all marketplace functions.
If you live in one of these states you apply for coverage through Healthcare.gov.
Keep in mind, you can only use the premium tax credit to purchase a plan from the Marketplace handling your state.
