Marketplace and private health plans: the differences

The difference between a Marketplace plan and a private plan comes down to savings, coverage rules and timing. The Marketplace is the official exchange where you compare and buy individual health plans; healthcare.gov runs it in many states, and some states run their own. healthcare.gov says it is the only way to get the premium tax credit, that all Marketplace plans must cover treatment for pre-existing medical conditions, and that all cover ten essential health benefits. A private plan usually means one bought outside the Marketplace, directly from an insurer or through a licensed advisor, and it does not carry the premium tax credit. Some private plans follow the same coverage rules and enrollment windows as Marketplace plans. Others are built outside those rules, may ask about your health history before deciding whether to accept you, and can sometimes be applied for at other times. Networks and benefits vary by plan, so read the plan documents before you choose.

• Pre-existing conditions. healthcare.gov says "All Marketplace plans must cover treatment for pre-existing medical conditions."
• Covered services. healthcare.gov says all Marketplace plans cover ten essential health benefits, including emergency services, hospitalization, prescription drugs, pregnancy and newborn care, and mental health services.
• Savings. healthcare.gov says the only way to get the premium tax credit is through the Marketplace, for households that qualify.
• Timing. You enroll during Open Enrollment, or during a Special Enrollment Period after a qualifying life change.

• healthcare.gov: pre-existing conditions
• healthcare.gov: what Marketplace plans cover
• Open Enrollment for farm households

"Private plan" usually means a plan bought outside the Marketplace, directly from an insurer or through a licensed advisor. The term covers more than one kind of plan, so the questions below matter more than the label.

• Savings. A plan bought outside the Marketplace does not carry the premium tax credit.
• Rules. Some private plans follow the same coverage rules as Marketplace plans. Others are built outside those rules, and may ask about your health history before deciding whether to accept you and on what terms.
• Timing. Plans that follow Marketplace rules use the same Open Enrollment and Special Enrollment windows, even when bought outside the Marketplace. Some plans built outside those rules can be applied for at other times.
• Networks and benefits. These vary by plan. Read the plan documents for what is covered and which doctors and hospitals are in network.

• healthcare.gov: premium tax credit

Ask these of any plan, whatever it is called.

• Does this plan cover pre-existing conditions, and in what way?
• Are all ten essential health benefits covered?
• Are my doctors, my hospital and my prescriptions in it?
• Can I get the premium tax credit with it, or not?
• When can I enroll, and when does coverage start?

• What to have ready before you call

If a subsidized Marketplace plan still fits your household, healthcare.gov or your state's exchange is usually the simpler route, and you can compare and enroll there directly. This guide is written for farm households paying most or all of the premium themselves.