CoverME.gov allows you to shop for and enroll in Marketplace plans, which are --comprehensive health insurance plans that protect you from financial risk if you get sick or need care. These plans cover a core set of essential health benefits (see below), including many preventive services at no out of pocket cost to you. Marketplace plans on CoverME.gov cannot turn you away or charge you more for having a pre-existing condition.
There is financial help available to most people who shop for Marketplace plans on CoverME.gov.
Essential Health Benefits
All plans offered on CoverME.gov are required to cover a certain set of benefits outlined in the Affordable Care Act, known as Essential Health Benefits. The Essential Health Benefits include:
- Ambulatory patient services: This includes all outpatient services that you may receive without admission to a hospital. This could include, for instance, a checkup with your primary care provider. Details of this coverage may vary from plan to plan.
- Emergency services: This service covers emergency room visits for urgent situations or conditions.
- Hospitalizations: Insurance must cover hospitalization, including inpatient care such as surgery and overnight hospital stays. Costs will vary depending on how long someone requires hospital services.
- Maternity and newborn care: Health plans must provide coverage before and after birth. Prenatal care is considered a preventative service and is provided at no additional cost. Insurance will cover childbirth and infant care as well.
- Mental health and substance use disorder services: The ACA requires health insurance to cover mental health services, including behavioral health treatment.
- Prescription drugs: All plans must cover at least one drug listed per category in the U.S. Pharmacopeia. For some plans, an out-of-pocket cap must be met before this coverage kicks in.
- Rehabilitative and habilitative services and devices: Many plans will cover services that assist you in gaining or recovering mental and physical skills after an injury, a disability, or a chronic condition. This coverage also includes the use of medical equipment including wheelchairs, braces, and walkers.
- Laboratory Services: This coverage may differ depending on the type of service provided. Screenings covered as preventive services (such as prostate exams or pap smears) will be covered, but you may be billed for diagnostic tests ordered by a doctor to determine if you have a disease.
- Preventive and wellness services and chronic disease management: This includes many preventative services covered by your health insurance at no extra cost to you. The idea behind this coverage is to encourage individuals to see their doctor before they get sick and medical bills arise.
- Pediatric services, including some dental and vision care (included for children only): Beyond standard coverage, children under the age of 19 must be allowed basic vision and dental care. This includes twice-yearly teeth cleanings, x-rays, fillings and even yearly eye exams, which covers a pair of glasses or a set of contact lenses. Some health plans sold through CoverME.gov include pediatric dental services, but others do not. If you have a child on your plan and select a health plan that does not cover pediatric dental care, you can select a Stand-Alone Dental Plan through CoverME.gov.
Health Insurance plans offered on CoverME.gov are categorized into four metal levels: Bronze, Silver, Gold, and Platinum. Metal levels indicate how you and your insurance plan split the cost of your health care expenses. As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers, compared to what you are expected to pay in copays and deductibles. The metal level does not reflect the quality of care or service providers available through the plan.
- Bronze: The health plan generally pays 60% of total health care costs. You pay about 40%. Bronze plans have the lowest premiums and the highest levels of cost-sharing (deductibles, co-pays, etc.).
- Silver: The health plan generally pays 70% of total health care costs. You pay about 30%. People who qualify for premium tax credits may also qualify for more savings through cost-sharing reductions. These can only be applied to Silver plans.
- Gold: The health plan generally pays 80% of total health care costs. You pay about 20%. Gold plans have higher premiums and lower cost-sharing levels.
- Platinum: The health plan generally pays 90% of total health care costs. You pay about 10%. Platinum plans have the highest premiums and the lowest levels of cost-sharing.
- Catastrophic: Available to individuals under the age of 30 and those who qualify for a hardship exemption. This plan has a low monthly premium, but a very high deductible. This may be an affordable way to protect yourself from costs of a serious illness or injury if you do not qualify for financial assistance to purchase a plan with more comprehensive coverage. But you pay most routine medical expenses yourself.