One of the primary provisions of the ACA was to overhaul the individual health insurance market. The law did away with medical underwriting, gender-based premiums, and skimpy policies with exorbitant out-of-pocket exposure, and it narrowed the premium gap between younger and older insureds. Annual and lifetime benefit maximums were eliminated for all essential health benefits.
Buying a policy in the individual market is now a realistic option for a lot more people. And the ACA’s health insurance exchanges (marketplaces) in each state make it easy to compare policies, enroll in a plan, and receive a subsidy if you’re eligible.
But they’re not the only option. Although much of the media attention on individual health insurance is often focused on the exchanges, individual health insurance policies are also available off-exchange in every state (but not in the District of Columbia), and may be a good choice for some consumers.
An off-exchange plan is just a health insurance policy that is purchased directly from the carrier or through an agent or broker, outside of the official ACA-created health insurance exchange. Enrollment data for off-exchange plans is not tracked as closely as exchange enrollment data, but the Congressional Budget Office expected 9 million people to enroll in off-exchange health insurance plans in 2016.
It’s important to note that off-exchange plans are not available in the District of Columbia. Regulators there determined that coverage would only be available through the exchange. In Vermont, off-exchange plans were not available in 2014 or 2015, but “full-cost individual direct enrollment” (ie, off-exchange) became available in Vermont in 2016.
On-exchange vs. off-exchange
The consumer protections under Obamacare apply to all individual policies, regardless of whether the coverage is sold in the exchange. In addition to the basic requirements to which all policies must now adhere, plans that are sold in the exchanges must also be certified as qualified health plans (QHPs).
QHP certification is granted by the exchanges, and can vary from one state to another. The exchanges can set QHP requirements that exceed the basic guidelines of the ACA. (Pages 33-38 of this HHS brief are helpful in understanding this.)
Although all of the plans sold in the individual market – on or off the exchange – must meet the ACA’s requirements, QHPs can be required to comply with additional standards that vary from one state to another. QHPs in all states must offer at least one Gold plan, one Silver plan and one child-only plan (for 2018, this rule will be tightened up, requiring QHP issuers to offer at least one Gold plan and one Silver plan in each area where they offer exchange coverage; they will not be allowed, for instance, to offer a Silver plan and a Gold plan in limited areas within a state, and then offer only Bronze plans in other areas of the state)
QHPs can also be sold off-exchange. Some carriers are choosing to sell their certified QHPs both on and off exchange (with all enrollees in the same pool for risk-sharing purposes) – but policies sold off-exchange do not have to be certified as QHPs.
They are still good quality plans though – the days of Swiss-cheese coverage are over, regardless of how policies are purchased. And off-exchange plans are guaranteed issue regardless of medical history, just like policies in the exchanges. The same open enrollment dates apply outside the exchange, and most of the special enrollment period rules also apply to plans purchased outside the exchange.
To enroll … or not … in an ACA exchange
The exchange is the best option for people who qualify for premium subsidies and cost-sharing subsidies, as subsidies are only available for plans purchased in the exchanges. In October 2016, HHS estimated that there were 2.5 million people with off-exchange coverage who would be eligible for subsidies if they switched to the exchange instead. Some of those people might be well aware of the subsidies in the exchange but may have opted for off-exchange plans for reasons other than cost. But it’s also likely that a good number of those folks aren’t aware of how much less they could be paying in premiums if they switched to the exchange.
It’s also important to note that if you begin the year with an income that isn’t subsidy eligible and then your income drops during the year to a level that would make you eligible for a subsidy, you would only be able to start getting a subsidy at that point if you were already enrolled in an exchange plan. If you renew your off-exchange plan, or opt for an off-exchange plan during open enrollment, you won’t be able to switch to a subsidy-eligible exchange plan until the next open enrollment, regardless of any mid-year changes in your income.
But what if you don’t qualify for a subsidy (and are fairly certain that will continue to be the case all year), or would just prefer to skip the exchange? Whatever the reason, if you want to get coverage outside of the exchange, you still have access to ACA-qualified health insurance policies.
Plan design, pricing may differ
If the same policy is sold on and off-exchange, the price will be the same. Some carriers opt to sell identical plans both inside the exchange and outside the exchange. For those plans, the premium will not vary, regardless of whether it’s purchase on-exchange or off-exchange (of course, if you qualify for a subsidy, the after-subsidy price will be lower in the exchange).
But carriers can choose to offer different plan designs or networks for their on-exchange plans and their off-exchange plans. If a carrier is offering plans outside the exchange that are different from the plans they offer inside the exchange, the pricing will be different too – although all of the carrier’s enrollees will be in a single risk-pool.
Some carriers are only offering plans outside the exchange, so you’ll need to shop off-exchange in order to see their plans. In some states, the “best” coverage is off exchange, in others, it’s on the exchange.
In some states, the cheapest plan is off-exchange, and in others it on the exchange. There’s no one answer that applies everywhere in terms of whether it’s better to get an exchange plan or an off-exchange plan.
If you want to shop off-exchange, you can purchase a policy directly from a health insurance carrier, or from an agent or broker; the price will be the same either way. Even if you know that you won’t qualify for subsidies in the exchange, you’ll want to consider exchange options as well as off-exchange plans to find the policy that best meets your needs.
Brokers who are certified to sell exchange policies should be able to provide you with both on- and off-exchange options, all in one place. Be aware that the open enrollment window for individual health insurance applies both on- and off-exchange. For 2017 coverage, the open enrollment window continues until January 31, 2017. After that, you’ll have to wait until 2018 to have coverage, unless you have a qualifying event.
If you qualify for a subsidy, stick with the exchange. But if you don’t, take your time, compare all of the options, and then apply for the policy that makes the most sense for your situation. Disregard politically motivated advice from people who have a vested interest in directing you either onto the exchange or away from it.
The ACA has improved the quality of coverage in the individual market and has also expanded the options that are available for many people, thanks to guaranteed issue coverage and subsidies. Even though the exchanges are a heavily publicized part of the ACA, the improvements from the law extend to off-exchange plans as well. Consumers can feel confident regardless of which option they choose.
Plans that aren’t major medical coverage are not regulated by the ACA
Since some types of coverage are not regulated under the ACA, a caveat is necessary here.
All major medical health insurance plans with effective dates of January 1, 2014 or later are required to be ACA-compliant. This is true whether they’re sold in the exchange or off-exchange.
These plans are sold outside the exchanges, but they’re not what we’re talking about when we say “off-exchange plans.” They are not what people think of as “real” health insurance, and they do not conform to the regulations laid out in the ACA. In general (with the exception of short-term health insurance to bridge a short gap in coverage), they’re not designed to serve as stand-alone coverage. And in most cases, relying solely on them for your health coverage will leave you not only sorely underinsured, but also facing a penalty when you file your taxes.