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The Health Insurance Marketplace

The new health care law gives some people with cancer, cancer survivors, and their families, as well as others who need to buy health insurance on their own, a choice to shop for a plan on a website called www.healthcare.gov. This website connects you with the health insurance marketplace (also called a health insurance exchange) for your state. In these state marketplaces, people can compare health plans by the amount of coverage they offer and price. All plans sold in the marketplaces cover essential health care and cannot deny coverage to people with pre-existing conditions like cancer.

What is a marketplace?

Since October 2013, each state has had an online health insurance marketplace that allows people looking for coverage to shop for plans and compare them by benefits, quality, and price. The health care law requires that information about prices and what a plan covers be written in simple terms that are easy to understand, so there’s no guessing about costs. People can get a clear picture of what they’re paying for and what they’re getting before making a choice.

Am I eligible for the marketplace?

If you are under 65 and don’t have access to health coverage through your employer* or Medicare, you can buy a health plan through the insurance marketplace in your state. If you like your work health plan and want to keep it, you don’t need to buy insurance through the marketplace. If you or a family member loses a job or health insurance benefits, the marketplaces give you options that may be more affordable to you.

*People with health care through their job whose monthly premiums are too high compared to their income may be eligible for financial help in affording a plan sold on their state’s marketplace.

Will it cover everything I need for cancer treatment/follow-up?

The health care law allows more people with cancer and cancer survivors to get the health care they need by requiring all health plans sold in the marketplaces to cover essential benefits. These include coverage for cancer screening, treatment, and follow-up care. The marketplaces offer a variety of plans, and eligible people are able to choose one that works best for them.

By law, insurance plans offered through the marketplaces cannot deny coverage to anyone because of pre-existing conditions like cancer. And all insurance plans must provide basic benefits that cover things like doctor’s visits, hospitalizations, preventive care, and prescriptions. While each plan offers a similar set of benefits, what you pay varies.

Will I be able to afford a plan?

Plan categories or groups

Each marketplace puts the health plans into 5 groups, labeled platinum, gold, silver, bronze, or catastrophic. Plans in these groups differ based on how you and the plan share the costs of your care. The groups have nothing to do with the amount or quality of care you get.

For instance, bronze plans are the cheapest, but they pay on average only 60% of the cost of a medical service like a doctor’s visit or surgery. This means you must pay as much as 40% of the cost. Silver, gold, and platinum plans cost more, but you pay less of the cost of care. Catastrophic coverage plans generally pay less than 60% of the total cost of care – and only after you have paid all the costs of your care up to a certain amount. They’re available only to people who are under 30 years old or have a hardship exemption.

Finding out if you can get help paying for a plan

The marketplace will help people figure out if they qualify for help paying for health insurance or if their income makes them eligible for state programs such as Medicaid. Most people who make up to $45,960 per year and families of 4 with a combined income of up to $94,200 per year should be able to get financial help to buy a health plan through the marketplace. Depending on your income, you may also qualify for financial help to limit your out-of-pocket costs for medical services. Tax credits can be taken in advance to reduce monthly premiums or as a refund at tax time. For details on whether you qualify and for how much, visit www.healthcare.gov.

Under the health care law, states have the option to give everyone below a certain income level access to health coverage through Medicaid. Several states have done so, but not all. In states that have not broadened access to Medicaid coverage, many low-income people will not qualify for Medicaid. Some of the poorest of these people also won’t qualify for help paying for insurance in the marketplace, either.

Terms you need to know

When deciding which plan is right for you, it’s important to not only look at the benefits offered, but also the total amount you will have to pay, including:

  • Monthly premium: the monthly amount you pay the insurer for health coverage or the amount of your monthly bill.
  • Annual deductible: the amount you pay in a calendar year before the plan pays.
  • Co-pays: a flat dollar amount you pay for a covered service, each time that you use the service.
  • Co-insurance: the percentage of the cost of the total service you must pay.

How/when do I sign up?

The next open enrollment period is expected to be November 15, 2014 through February 15, 2015. You can enroll through www.healthcare.gov/marketplace, or find your state marketplace by calling this toll-free number 1-800-318-2596.

People may also qualify for special enrollment periods outside of open enrollment if they experience certain events, such as marriage, divorce, or the birth of a child.

Where can I get help?

Information is available online through www.healthcare.gov and www.getcoveredamerica.org. You can also learn more through a toll-free call center at 1-800-318-2596 or TTY: 1-855-889-4325 – both of which are available 24 hours a day, 7 days a week. Callers can get information in multiple languages.

You can use the website, https://localhelp.healthcare.gov, to find people in your community who can help you apply, enroll, or give you answers to any questions you might have.

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

Last Medical Review: 06/30/2014
Last Revised: 09/29/2014