Marketplace insurance FAQs and terms

ACA Marketplace plans are health care plans that people can buy on their own, rather than through an employer or another government-run program, like Medicare or Medicaid. You might also hear names like Exchange plans and Individual & Family Plans. The health care Marketplace (also called the Exchange) is where ACA health care plans are sold.

Under the American Rescue Plan Act of 2021 (ARPA) and Inflation Reduction Act of 2022, you may be able to enroll in ACA Marketplace coverage with lower premiums — and you can see if you qualify for financial subsidies. These subsidies could be tax credits or cost-sharing reductions to help pay for your health care costs.

A pre-existing condition is a health problem you had before your health plan starts. Under current law, companies offering ACA Marketplace health plans that meet minimum essential coverage requirements can't refuse to cover you or charge you more because of a pre-existing condition.

A qualifying life event is a life-changing situation — like turning 26, moving to a new state, or having a baby — that can impact you and your health insurance. If you have a qualifying life event, you may be able to buy a new health plan during a Special Enrollment Period (SEP). Some states may offer SEPs for other qualifying reasons, like natural disaster relief or pandemic relief. 

If you sign up for an ACA Marketplace plan during Open Enrollment (Nov. 1 through Jan. 16), your individual and family marketplace health coverage will either start Jan. 1 or Feb. 1, 2024, depending on when you enroll in your plan.

• If you enroll by Dec. 15, 2023, your plan will start Jan. 1, 2024
• if you enroll after Dec. 15, 2023, your plan will start Feb. 1, 2024

If you enroll during a Special Enrollment Period, your coverage start date could vary.

• If you enroll by the 15th of the month, your coverage will start on the first day of the next month after you enroll in a plan. For example, if you enroll on Feb. 15, coverage will start March 1.
• If you enroll between the 16th and end of the month, your coverage will start on the first day of the second month after you enroll in a plan. For example, if you enroll Feb. 16, coverage will start on April 1.
• If you enroll because you had certain Qualifying Life Events, your coverage could start on the first day of the following month after you enroll. For example, if your Qualifying Life Event is due to a marriage, you could enroll Feb. 28, and coverage will start on March 1.

Keep in mind, there are exceptions to these guidelines depending on which state you enroll in, or for certain qualifying life events. A licensed insurance agent can help you determine which Qualifying Life Event you have.

All plans sold on the health care Marketplace are required to cover 10 essential health benefits. Keep in mind, these are minimum requirements. That means most Affordable Care Act (ACA) plans (like UnitedHealthcare Individual & Family Marketplace plans) may offer these and many more benefits.

No matter which Marketplace plan you choose, you’re guaranteed to have the following benefits:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Pregnancy, maternity and newborn care (including contraceptives and breastfeeding coverage)
5. Mental health and substance use disorder services (including behavioral health treatment)
6. Prescription medicine
7. Rehabilitative/habilitative services and devices
8. Laboratory services
9. Pediatric services (including oral and vision care)
10. Preventive and wellness services, and chronic disease management

All plans include a yearly wellness exam (physical) with your primary care provider. Your yearly exam is a good opportunity to check in with your doctor on how you’re feeling. It’s your chance to bring up any health concerns or questions — and get answers from your doctor.

Here are common things that may happen during your yearly exam:

• Annual flu vaccine (and a check to make sure you’re up to date on all your vaccines) 
• Cholesterol screening 
• Blood pressure screening 
• Cancer screenings for adults (like breast, colorectal, cervical, lung) 
• Standard lab work (you may have to pay for lab work)
• $0¹ contraceptives

A plan’s network is a group of facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. It’s important to see doctors within your plan’s network to make sure your visit is covered by your plan. (So you don’t have to pay more out-of-pocket.) You can check your UnitedHealthcare provider directory online within your account.

Your primary care provider (PCP) is the doctor, nurse practitioner or physician's assistant you'll see for most of your care. You can see them for things like yearly checkups, screenings, chronic conditions and everyday concerns. Plus, they can refer you to a network specialist if you need one.

Your welcome kit will let you know if your plan requires a referral before you can see a network specialist. If that’s the case, your doctor will send us a referral for the specialist you want to see before you make your appointment. This extra step helps us make sure that specialist is in our network, and that your plan will help cover the cost.

A copay (or copayment) is a fixed amount you may pay for a covered health care service, usually at the time you receive the service.

You might remember times when you went in for a doctor visit and maybe paid a $15 or $20 copay before or after your visit (copay amounts vary depending on the provider and service). That’s how copays work. With health plans that have copays (not all do), you’ll know what you have to pay ahead of time — which can help you budget your health care costs. For most plans, your copay does not apply toward your deductible.

Coinsurance is a percentage of the cost of a health care service, and it’s what you pay once you meet your deductible. A common coinsurance amount is 20%, but the cost-sharing percentages could be anything.

If your doctor visit costs $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20 out-of-pocket. Your insurance would then pay the rest of the allowed amount ($80) for covered health care services.

You might have heard terms like out-of-pocket max or limit. They mean the same thing. They each refer to the most you could pay during a 12-month coverage period for your share of the costs of covered services. Typically, deductibles, copays and coinsurance all count toward your out-of-pocket maximum. Things like your monthly premium or anything your plan doesn't cover (like out-of-network services) do not.

If you meet your out-of-pocket maximum, your plan will pay for 100% of your covered health care costs (up to the allowed amount). Let’s say you have an annual out-of-pocket maximum of $6,000. That means once you’ve paid $6,000 out-of-pocket for your covered health care, usually including deductibles, copays and coinsurance, your plan will cover any future (covered, in-network) health care services during your coverage period.