Open enrollment for the healthcare marketplace officially opens on Saturday, November 1, but as health insurance policies continue to change, people are wondering if enrolling in the federal government program is even worth it. To learn more about the changes in the insurance industry and to discover what people need to know about the healthcare marketplace open enrollment, Woman’s World recently talked to several experts. To discover what they had to say, read on.
What is the healthcare marketplace?
The healthcare marketplace is an online program run by the federal government that allows people and small businesses to find the health insurance that works best for them.
“Healthcare insurance marketplaces were born as a consequence of the Affordable Care Act (ACA).,” explains Karim Hachem, the CEO of Suade Health. “Before this law was put in place, people purchasing coverage directly from private carriers were subject to pre-existing condition limitations, waiting period and other adverse contractual limitations that made their ability to get the care they need either impossible or incredibly expensive.” The ACA changed that. “Today, plans on the marketplace cannot exclude you from coverage for any of your pre-existing conditions, nor can they discriminate and charge you more in premiums for any pre-existing conditions you may have. The only factors that can be considered are age, geographic location, tobacco use and family size—that’s it!”
In 2024 alone, 24.2 million Americans enrolled in the healthcare marketplace—nearly twice as many as in 2020, according to the nonprofit organization KFF. Whitney Stidom, vice president of consumer engagement at eHealth, explains, “Individual health insurance plans [in the marketplace] cover benefits similar to what a plan provided through an employer would cover, including the 10 essential health benefits.”
“That includes preventive care, primary and specialty care, ambulatory and emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder, preventive services and more,” she continues. “Marketplace plans will continue to be the most affordable option for many Americans who don’t get insurance through an employer. But it is important to understand how federal subsidies are changing this year and to have a plan to effectively compare insurance options this fall.”
What is in the healthcare marketplace?
Within the healthcare marketplace, several different types of options are available to Americans.
“It is not unlike what employer-sponsored group benefit plans would offer the average employee. You will typically have an assortment of HMO (Health Maintenance Organization), EPO (Exclusive Provider Organization) and PPO (Preferred Provider Organization) plans. Depending on your income, the state will offer a federal subsidy toward the monthly premiums of these plans. In some cases, some people make too much money every year, and they will not be eligible for any credits, but they can still apply for any plan of their choosing,” Hachem says. “Typically, if you make less than the poverty level, you will qualify for Medicaid. As far as plan, inclusions, limitations and exclusions, you will find out they are typically similar to what an employer-sponsored plan would offer.”
“That said, we typically find that state-issued marketplace insurance plans will have narrower provider networks, out of area/out of state exclusions and will not be subject to ERISA (Employee Retirement Income Security Act of 1974)—a federal law that offers additional protections for those that have coverage via an employer,” he continues. “Depending on the metal color of the plan, Bronze, Silver, Gold or Platinum, you will either end up paying more in monthly premiums for lower copays and deductibles, or vice versa.” For that reason, he says, “I always advise people in the market for a state marketplace plan to consider their personal and family usage throughout the year before picking a plan: How many specialist visits do we anticipate? Any surgeries? Don’t just look at the monthly premiums.”
What changes are coming to the healthcare marketplace?
According to Stidom, “People shopping for Affordable Care Act plans during the upcoming enrollment season should brace themselves for significant cost increases, as out-of-pocket premiums are expected to increase an average of 75%.”
Some of these changes are because of President Donald Trump’s One Big Beautiful Bill Act, which Stidom says “tightens the rules around health insurance subsidies for people who buy health coverage for themselves or their families under the Affordable Care Act (ACA). Currently, people earning up to 400% of the federal poverty level (about $62,000 annually for an individual) may qualify for federal subsidies (called advanced premium tax credits) that effectively lower their monthly health insurance premiums.”
“How much subsidy people get depends on their estimated income for the current year. If a person earns more income during the year than they expected, they might owe more taxes at year’s end if they received more subsidy dollars than they were entitled to. Previously, there was a cap on how much of that surplus assistance people would be required to pay back to the government. The Big Beautiful Bill changes that. Beginning in 2026, people will be required to pay back all the excess subsidy assistance they received. ”
Is the healthcare marketplace still worth it?
Due to the fact that people will be expected to pay back the money received in 2026, Americans are wondering if enrolling in the healthcare marketplace is a good idea. However, according to Stidom, it is—in the long run it is still the cheapest option.
“Even though the federal subsidies are currently slated to return to working in the same way they originally did, ACA plans remain the most affordable option for many Americans looking for an individual or family plan,” she explains. “Having health insurance can provide peace of mind that you’ll be able to afford and get the care you need, especially if something catastrophic happens.”
How to enroll in the healthcare marketplace
“To apply for coverage and subsidies, people will need to provide basic information (name, date of birth, gender, social security number, address, estimated income),” says Stidom. “Many people will purchase individual health insurance during open enrollment, which runs from November 1 to January 15. It is also possible to purchase an individual plan during a special enrollment period after a qualifying life event, such as a loss of current coverage or a change in marital status.”
Stidom also shared some advice for those looking to purchase a plan, saying, “For the more than 24 million Americans who get health insurance through Affordable Care Act Marketplace plans, it can pay to shop around. In fact, people who compare shop ACA plans can potentially save an average of over $2,000 per year on their premiums—all while keeping comparable benefit levels.”
