Marketplace and Non-Marketplace Plans – Which Is Right for You?


The federal government set up an online insurance marketplace called healthcare.gov. This website was launched in 2013 as part of the Affordable Care Act (ACA). Unless the state creates its own marketplace, citizens will default to using the federal exchange. These marketplaces are the most used by consumers searching for health insurance, but this is not the only option for them. It’s time to answer the leading question: which is right for you? Going through the health insurance marketplace or outside of it?

What Is The Marketplace?

The Marketplace allows you to compare and apply for private health insurance policies. Did you know that health insurance companies can only provide policies through healthcare.gov if they have a plan available for each of the four metal tiers? Individual plans are separated into metal tiers – Bronze, Silver, Gold, and Platinum. These metal tiers allow for people to make a fair comparison between all of these benefits and costs. All health plans offered on the marketplace must include these 10 benefit coverages:

  • Outpatient care (officially called ambulatory patient services)
  • Prescription drug coverage
  • Pediatric services, including dental and vision coverage for children
  • Preventive care
  • Laboratory services
  • Emergency services
  • Hospitalization for surgery, overnight stays, and other conditions
  • Mental health coverage and substance use disorder services
  • Rehabilitative and habilitative services
  • Pregnancy, maternity, and newborn care

In addition to this, plans on the federal marketplace must also include birth control coverage, breastfeeding coverage, and coverage for pre-existing conditions. It’s important to note that state marketplaces, depending on which state, may require all insurers to offer further coverage.

Why Look Outside the Marketplace?

The government marketplace requires that all participating insurers provide a plan in each of the four metal tiers. However, an insurer may only want to provide a single plan and they can do this by looking outside the marketplace. Did you know that outside the marketplace plans also have to offer coverages for the ten essential benefits? When you go with outside of the marketplace you get four major choices:

  • Choice of a different carrier
  • Choice of a different network
  • Choice of different drug coverage
  • Different plan coverage

Non-marketplace plans, which don’t follow these rules, can be structured differently and can potentially offer a lower price on similar coverage. As a reminder, this will all depend on which state you are looking for coverage.