Private Health Plans vs. Marketplace (ACA) Plans: How They Compare
If you buy your own health insurance, there are two main kinds of plan: Marketplace plans, also called ACA or "Obamacare" plans, and private plans sold outside the Marketplace. They work very differently, and neither one is better for everyone. Here's how they compare.
The short version
- Marketplace (ACA) plans must accept you and must cover pre-existing conditions. Your income decides whether you get help paying the premium.
- Private plans are priced on your health. If you qualify, the premium can be lower, but the plan can turn you down, leave out conditions you already have, and cover less.
How the price is set
Marketplace: your premium is based on your age, where you live, whether you use tobacco, and the plan level you pick. Your health doesn't change the price. If your income qualifies, premium help lowers what you pay.
Private: your premium is based on your health when you apply. Healthy people often pay less than they would for a full-price Marketplace plan. There is no income-based premium help.
Pre-existing conditions
This is the biggest difference between the two.
Marketplace: you can't be turned down or charged more because of your health, and your existing conditions are covered.
Private: the insurance company reviews your health history. It can decline your application, and the plan may not cover conditions you already have.
What's covered
Marketplace: every plan covers the same ten categories of essential health benefits, including maternity care, mental health care and prescriptions.
Private: benefits vary from plan to plan. Some limit or leave out things like maternity care, and some have dollar limits on what they pay. Read the plan documents so you know what is and isn't covered.
Doctors and networks
Marketplace: many plans use local networks, so routine care may only be covered near home.
Private: some plans use broad or national networks, which can help if you travel for work, like truck drivers and travel nurses.
Either way, the network depends on the specific plan. Always check that your own doctors and hospitals are included.
When you can enroll
Marketplace: during open enrollment each fall, or after a qualifying life event such as losing other coverage, getting married or having a baby.
Private: many plans let you apply any time of year.
Who each one usually fits
A Marketplace plan is usually the better fit if:
- You or someone in your family has an ongoing health condition
- You are pregnant or planning to be
- Your income qualifies you for help paying the premium
A private plan may be the better fit if:
- You are healthy
- You earn too much to get Marketplace premium help
- You need coverage outside of open enrollment
- You want a network that works in more than one state
Questions to ask before you choose
- Are my doctors, hospitals and prescriptions covered?
- What is the most I could pay in a year, including the deductible?
- What does this plan limit or not cover?
- Would I qualify for Marketplace premium help?
- When would coverage start?
Kyle compares both kinds of plan side by side on one free call and tells you plainly which one fits. If you work for yourself, see our guide to health insurance for the self-employed.
