Obamacare vs. Off-Exchange Health Insurance Plans
What is Obamacare?
Obamacare is a law, which is more formally known as the Patient Protection and Affordable Care Act (PPACA), or for short, the Affordable Care Act (ACA). The law has had many impacts on the healthcare industry, but its main purpose was to increase the number of people who have health insurance coverage.
The law has increased the number of people with health insurance, by making coverage more affordable, through two main ways:
- States have the option to expand Medicaid for lower income people. Medicaid is a free or low cost health insurance program administered at the State level.
- Subsidy (tax credit) made available to decrease the cost of health insurance plans available in the market. The subsidy amount is calculated based on income on a sliding scale.
What are Obamacare Health Insurance Plans?
Obamacare health insurance plans are plans which are eligible for reduced costs with a subsidy tax credit. Obamacare plans are only offered through the federal government exchange marketplace healthcare.gov or some States have their own exchange marketplace website. Although plans are only offered through the exchange marketplaces, the federal government allows certified brokers, agents, and web brokers to help you enroll in an Obamacare plan and apply for a subsidy.
What are Off-Exchange Health Insurance Plans?
Off-Exchange health insurance plans are plans which are available outside of the federal government exchange marketplaces. Off-Exchange plans existed before Obamacare. For example, if someone did not have access to a health insurance plan through work, they may have purchased an Off-Exchange plan offered on the Individual Market.
You can enroll in an Off-Exchange plan through a broker, agent, web broker, or by contacting the insurance company directly.
What’s the difference between Obamacare plans and Off-Exchange plans?
The main difference between Obamacare plans and Off-Exchange plans is that only Obamacare plans are eligible for a subsidy tax credit to reduce costs.
Otherwise there are not many other differences between Obamacare plans and Off-Exchange plans. Plan design, coverage, and rates are similar and both sets of plans must adhere to federal government regulations. In fact, there are many plans which are available as both Obamacare plans and as Off-Exchange plans.
Can a plan be both an Obamacare and Off-Exchange plan?
Yes, a plan can be available as both an Obamacare and an Off-Exchange plan.
On the other hand, some plans are only offered as Obamacare plans while other plans are only offered as Off-Exchange plans.
Do plans which are both Obamacare and Off-Exchange plans cost the same price?
Yes, by law a plan which is offered as both an Obamacare plan and an Off-Exchange plan must be sold at the same price. In addition, broker, agents, and web brokers are required to sell plans at the same market price. However, keep in mind that only Obamacare plans are eligible for a subsidy to reduce the monthly premium price.
Who is eligible for Obamacare and Off-Exchange plans?
Technically everyone is eligible for Obamacare plans and Off-Exchange plans. The real question is - who is eligible for a subsidy tax credit? - which can only be used to reduce the costs of Obamacare plans. Note that even if you are not eligible for a subsidy tax credit, you are still allowed to purchase an Obamacare plan at the full price.
What is the Obamacare Subsidy (Tax Credit)?
The Obamacare subsidy is really a tax credit, and it is formally known as the Advanced Premium Tax Credit (APTC). Typically people receive a tax credit at the end of the year when filing taxes, but this tax credit can be received “in advance”, during the year, to reduce the monthly premium costs of an Obamacare health insurance plan.
You must complete an official federal government application to learn your subsidy amount. Everyone’s amount will be different. The calculation for the subsidy amount can be quite complicated. It is based on several different factors, but household income is the main factor. We recommend using our tool to estimate your subsidy amount.
Who is eligible to receive an Obamacare Subsidy (Tax Credit)
To be eligible for a subsidy to reduce the monthly premium costs of Obamacare plans, you must meet the following requirements.
- Income requirements based on household size and household income. As examples, earn less than $48,240 for an individual and less than $98,400 for a family of four
- Not eligible for other federal government sponsored insurance, such as Medicare or Medicaid
- Do not have access to a health insurance plan from your employer which meet federal government coverage and affordability requirements
- File taxes or be claimed as a spouse or dependent on taxes. Married couples are required to file taxes jointly.
- Not be incarcerated
- Be legally present in the United States
Why should I consider Off-Exchange plans?
Off-Exchange plans may provide you with additional options compared to available Obamacare plans. If you are not eligible for a subsidy, or only eligible for a small subsidy amount, Off-Exchange plans may still be an affordable option for you.
A second reason for considering Off-Exchange plans is that your favorite doctor may only accept a plan which is available as an Off-Exchange plan. We recommend researching provider networks when considering health insurance plans. We provide links to official provider directories, or doctor lookups, on Health Plan Radar.
In addition, some health insurance companies have been leaving the Obamacare plan market, but they may still offer Off-Exchange plans. Your preferred insurance company may still offer plans on the Off-Exchange market.
How do I choose an Obamacare plan or Off-Exchange plan which is best for me and my family?
There are several health insurance concepts you should understand before choosing a plan that’s best for you, including premium price, out-of-pocket costs, deductibles, and plan metal levels. Visit our choosing a plan FAQ page to learn more.
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