State-by-state guide to health insurance marketplaces

The Affordable Care Act (ACA) requires every state to have a health insurance exchange or marketplace. These exchanges allow individuals and small businesses to purchase their own health insurance coverage or get financial assistance through Medicaid, CHIP, or premium tax credits.

While some states use the federal exchange, others established their own state-run health insurance exchanges. This means that depending on where you live, the exchange you’ll use to find coverage will differ.

In this blog post, you'll learn:

• What the exchanges are
• How they differ
• Which states have their own marketplaces

What are the state and federal health insurance marketplaces?

The health insurance marketplaces are where individuals and families can shop for health insurance plans and receive access to premium tax credits. Depending on where you live, you can also purchase vision or dental plans. Each state has an exchange residents must use if they want to enroll in marketplace coverage. These are either state-run marketplaces, state-federal partnerships, or the federal government’s Health Insurance Marketplace.

Some employers offer group health insurance coverage to their employees. If you don’t have employer-sponsored coverage, you can purchase an individual plan from the marketplaces. But, you don’t need to purchase health insurance coverage through the marketplaces. The federal government repealed the ACA’s individual mandate, which previously required everyone to have health insurance coverage or pay a penalty at tax time. Now, only a handful of states require you to have health insurance.

The health insurance exchanges allow you to get a qualified health plan that covers the ACA’s essential health benefits. Many people believe marketplace coverage is only for those with low incomes. However, anyone can find a plan that fits their needs. This misconception might stem from the federal subsidies available on the exchanges, such as premium tax credits. These subsidies lower your premiums and the government bases eligibility on the federal poverty level.

Now millions of Americans can get access to affordable health insurance coverage.

What's the difference between the Marketplaces and private exchanges?

The public Marketplaces aren’t the only place you can shop for health insurance. If you’re looking to purchase a policy, you can also do so through a private exchange or work with an insurance broker. With a private exchange, you get a plan from an insurance carrier directly. Individuals can also choose to go without coverage.

When can you enroll in marketplace coverage?

You can enroll in marketplace plans during open enrollment. This runs from November 1 through January 15 in states that use HealthCare.gov. States with their own exchanges can choose a different end date.

Previously, states could determine their own open enrollment period. But, a new rule in 2024 requires all state exchanges to open on November 1 and stay open through at least January 15 starting in 2025.

All Americans must enroll in marketplace coverage by December 15 if they want their coverage to start on January 1. Otherwise, your coverage will start on February 1. However, this can differ by state.

You can still get coverage outside of the open enrollment period. If you experience a qualifying life event, you can get a special enrollment period (SEP). This usually gives you 60 days from your qualifying event to sign up for or change your health insurance.

How does a state-based marketplace differ from the federal Health Insurance Marketplace?

A state-based exchange is where a state government regulates the exchange.

The state controls:

• Plan eligibility
• Enrollment
• Customer support
• Enrollment assistance
• Premium tax credit eligibility
• Marketing efforts
• Other state-specific subsidies.

States also deal directly with health insurance carriers to determine which plans they list on the marketplace. This includes approving annual rate increases or decreases.

The federal government runs HealthCare.gov and controls these functions in places without a state-run marketplace. This eases the burden on many states that don’t have the capacity or funding to run a state-based exchange.

There are also state and federal partnerships. Some states manage their own exchanges but use the federal Health Insurance Marketplace for enrollment.

Health insurance marketplaces by state

As of 2024, 19 states and D.C. have state-based marketplaces. Two states have state-based marketplaces on the federal platform. The remaining states use the federal Marketplace.

Georgia Access is Georgia’s new state-based exchange, opening in November 2024 for open enrollment.

Hawaii previously ran a state-based exchange called Hawaii Health Connector. The state has since changed to the federal Marketplace.

What health insurance plans are available on the marketplaces?

The plans available for individuals and families depend on your state. Some states will have more carriers and options than others. But, every exchange has plans that fit the different ACA metallic tiers of health coverage.

These plans range from bronze to platinum and cover different portions of your healthcare costs. Catastrophic health plans are also available for those younger than 30 or who qualify for hardship exemptions. Bronze plans have lower monthly premiums but higher deductibles than other metal levels. In contrast, platinum plans have the highest monthly premiums and lowest deductibles.

The types of health insurance available² on the marketplaces include the following:

• Exclusive provider organization (EPO)

• Health maintenance organization (HMO)
• Point of service (POS)
• Preferred provider organization (PPO)
• High deductible health plans (HDHPs)

How individual health insurance benefits employers

If you’re an employer, you may wonder how individual health insurance benefits your organization. Traditional group health insurance is expensive and complex. These plans often come with minimum participation requirements and annual rate increases that small businesses struggle to meet.

Instead, employers can provide a health reimbursement arrangement (HRA) to their employees. This allows employers to reimburse their employees tax-free for their qualifying medical expenses which can include individual health insurance premiums. This allows employees to choose the health plan that best fits their unique needs while saving organizations time and money.

The two types of HRAs that can reimburse individual health insurance premiums are:

• The qualified small employer HRA (QSEHRA): A QSEHRA is for organizations with fewer than 50 full-time equivalent employees (FTEs).
• The individual coverage HRA (ICHRA): An excellent health benefit for organizations of all sizes. Applicable large employers (ALEs) that offer an affordable allowance can use an ICHRA to satisfy the employer mandate.

When you offer an HRA, your employees will use their state or federal marketplace (or an insurance broker) to enroll in individual coverage. You’ll offer a monthly allowance to reimburse your employees for their eligible expenses, and your employees then request reimbursement for their expenses.

By administering your HRA through PeopleKeep, your employees can shop for coverage right from their PeopleKeep accounts. Plus, our in-house benefits specialists are available to help them. You can also save time on ensuring proper compliance. We’ll review your employees’ expenses for you and help you through every step of the process.

Conclusion

The state and federal health insurance marketplaces provide millions of Americans with access to affordable healthcare coverage. Depending on where you live, you’ll either use a state-run exchange or the federal exchange. No matter which one you must use in your state, the ACA guarantees standard levels of coverage.

By understanding which exchange your state uses you’ll be better prepared for open enrollment.

This blog post was originally published on July 19, 2023. It was last updated on October 9, 2024.

1. CMS Fact Sheet
2. HealthCare.gov