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Eligibility & Benefits

To be eligible for health coverage through the Marketplace, you: 1) must live in the United States; 2) must be a U.S. citizen or national (or be lawfully present), and, 3) cannot be currently incarcerated.

Depending on family size and income, one may be eligible to receive an advance tax credit that can be applied toward monthly premium amounts to help meet these monthly obligations. There is also an opportunity to qualify for lower out-of-pocket costs, again dependent upon family size and income level. Additionally, there is still the possibility to qualify for a Medicaid or CHIP program, thus further reducing the potential out-of-pocket costs associated with health care coverage*.

The Qualified Health Plans (QHP's) offered through the Health Insurance Marketplace must meet 10 Essential Health Benefits (EHB) established in the ACA. The 10 EHB are:

  1. Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  2. Emergency services
  3. Hospitalization (such as surgery)
  4. Maternity and newborn care (care before and after your baby is born)
  5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services

Source: https://www.healthcare.gov/what-does-marketplace-health-insurance-cover

Last Updated: 9/30/2013