An “off exchange plan” refers to a health insurance policy that is not available for purchase within a federal or state exchange. An exchange is a government-run marketplace of health insurance plans. Both off and on-exchange health plans in the individual and small group markets must satisfy Essential Health Benefits coverage requirements and utilize one of the metal plan designs for medical out-of-pocket costs.
It is possible for the same plan offered by the same carrier to have some differences. Plans participating on an exchange may have additional regulations regarding how they are configured that may result in some differences between the on-exchange and off-exchange versions. For example, an exchange could require plans to provide pediatric vision benefits directly through the plan as opposed to a stand-alone policy working in conjunction with the main medical plan. However, both on-exchange and off-exchange plans in the individual and small group markets must provide all the mandatory Essential Health Benefits. Moreover both on-exchange and off-exchange plans in the individual and small group markets may only vary premium rates based on four factors: family size (individual or family), geographic rating area, age (up to a 3:1 ratio for adults) and tobacco use (up to a 1.5:1 ratio).
For people with lower incomes who qualify for a decreased cost-sharing, there are special Cost-Sharing Reduction (CSR) versions of Silver Plans only available on an exchange. Cost sharing reductions as well as premium subsidies can only be obtained by eligible low-income individuals enrolling through an insurance exchange.
No. Some insurers have chosen not to offer health insurance on an exchange. Aetna and United Healthcare, for example, are not participating in several exchanges. Depending on the state there may by many or few health plans sold off exchange. HealthPocket is committed to displaying both on exchange and off exchange plans so consumers can make the most informed choice given their personal circumstances.
Additionally, every category of health insurance product is not available on an exchange. For example, large group health insurance and short-term health insurance (otherwise known as temporary medical insurance) are not currently offered on exchanges. Short-term health insurance is not required to comply with the Affordable Care Act’s coverage requirements. In particular short-term insurance may deny coverage to consumers based on medical history, pre-existing conditions, or health status.
If the same plan is offered off exchange and on exchange than the premium should be the same for a particular applicant. However, lower income applicants may qualify for premium subsidies and those subsidies can only be obtained within an exchange. Additionally, since all off-exchange plans will not be available on exchange there may be regions where the lowest cost plan for individuals ineligible for subsidies is available off exchange only.
Off exchange health insurance plans can be purchased directly from the insurance company, from a broker or agent, or from a private exchange that is not run by the government. HealthPocket’s health insurance comparison tool provides links to entities that can enroll you within a qualified health plan.