qualified health plan

What is a qualified health plan?

A qualified health plan (QHP) is a health insurance plan that meets requirements established by Obamacare, which is also known as the Affordable Care Act (ACA). Some of the QHP rules include being licensed in the state where coverage is provided, covering pre-existing conditions, following cost-sharing limits, prohibiting annual and lifetime benefit limits, and covering the ACA’s ten essential health benefits.

Qualified health plans are certified by the federal or a state-run health insurance marketplace. The certification process happens each year ahead of the marketplaces’ annual enrollment period.

Do I have to go through the health insurance marketplace to get a qualified health plan?

No, QHP plans are available off exchange, such as through a broker or directly from the health plan. However, you can only qualify for the ACA’s premium tax credits and/or cost-sharing subsidies if you buy a QHP policy through the federal or a state health insurance marketplace.

The marketplace’s premium tax credits and cost-sharing subsidies are available for some people, depending on their income.

Are all 'metal' plans qualified health plans?

Yes. All plans, regardless of the metal level, sold on the health insurance exchanges are qualified health plans. And, all QHPs must cover essential health benefits.

QHPs sold on the marketplace are categorized by metal levels. The metal levels make it easier for consumers to compare plans that have similar premiums and out of pocket costs. Plans are assigned to a metal level based on actuarial value. While all QHPs must cover essential health benefits, a lower metal level policy (e.g., bronze) pays less of average covered health care costs than a higher metal level policy (e.g., gold).

It is important to know that actuarial value applies to a given policy’s value for an overall population. It isn’t a guarantee for an individual.

Should I look for a qualified health plan if I have Medicare?

No, you should not buy a policy from a qualified health plan if you qualify for Medicare. Qualified health plans are specific to Obamacare/the ACA and apply to people who don’t have employer-provided coverage and who don’t meet eligibility requirements for Medicare or Medicaid.

Is a non-qualified health plan lower quality?

While plans that are not a “qualified health plan” haven’t gone through a marketplace certification process, it doesn’t mean they don’t provide good health insurance coverage. A primary example of a “non-qualified health plan” is an employer-sponsored policy. .Grandfathered and grandmothered health insurance plans – which pre-date the ACA and meet some, but not all ACA requirements – are also examples of non-qualified health plans.