Individuals & Family Plans
Minimum Requirements for Coverage:
​To obtain coverage through the Health Insurance Marketplace, you must:
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Be a U.S. citizen or a lawfully present immigrant.
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Reside in the United States.
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Not be currently incarcerated.
How Premium Costs are Calculated
Your premium costs may vary based on several factors:​
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Individual vs. Family Coverage: Family plans usually cost more.
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Location: Your region may affect pricing due to local regulations and living costs.
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Tobacco Use: Tobacco users generally pay higher premiums.
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Age: Older individuals might have higher premiums.
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Plan Category: Marketplace plans (Bronze, Silver, Gold, Platinum) offer different premium and deductible combinations.
Penalty for Not Having Health Insurance
​​If you don’t have health insurance, you may face a fee:
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Flat Fee: Charged per adult and dependent, with a family cap.
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Percentage Fee: A percentage of your household income, capped at the national average for bronze plan premiums.
Qualifying for an Exemption
Qualifying for an Exemption: You may be exempt from penalties under certain conditions, such as:
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Short-term coverage gaps (under 3 months).
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Income below the tax filing threshold.
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Membership in a federally recognized tribe or religious group with objections to insurance.
Small Business
What is the SHOP Marketplace?
The Small Business Health Options Program (SHOP) is designed to help small businesses with 50 or fewer full-time employees provide health and dental insurance. It offers flexible and convenient online management for business owners.
Eligibility for SHOP
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To use SHOP, you must:
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Have 50 or fewer full-time workers
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Offer health coverage to all full-time employees.
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Meet your state’s minimum participation requirements (usually 70%).
Tax Credits
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Small businesses may qualify for tax credits up to 50% of premium costs (35% for tax-exempt employers) if:
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You have fewer than 25 full-time employees.
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The average salary is $50,000 or less per employee.
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You cover at least half of the premium costs.
Plan Categories
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SHOP plans come in four categories—Bronze, Silver, Gold, and Platinum—differing in cost-sharing:
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Bronze: Employer covers 60%.
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Silver: Employer covers 70%.
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Gold: Employer covers 80%.
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Platinum: Employer covers 90%
Employee Choice
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Depending on your state, you can offer one or multiple plans for your employees to choose from.​
Pre-Existing Conditions
What if I have a pre-existing condition?
Insurance companies cannot deny coverage, refuse payment, or charge you more due to a pre-existing condition. All Marketplace plans, Medicaid, and CHIP cover essential health benefits for pre-existing conditions, regardless of gender. Only grandfathered plans are exempt from this rule.
Pregnancy or Adoption
Pregnancy and adoption are considered pre-existing conditions, qualifying you for a Special Enrollment Period. Coverage begins as soon as your plan starts or on the date of birth/adoption, within 60 days.
Grandfathered Plans
Grandfathered plans are not required to cover pre-existing conditions. However, after the coverage year ends, you can opt for a Marketplace plan during a Special Enrollment Period.
