Qualified Health Plans (QHPs) are health insurance Health insurance (sometimes called health coverage) pays for some or all of the cost of health services you receive, like doctors’ visits and hospital stays. Programs like Medicare and Medicaid are public health insurance offered through the government. Health insurance can also be administered by private companies that offer individual policies, group health plans, and supplemental insurance. policies that meet protections and requirements set by the Affordable Care Act (ACA). They are typically not for people with Medicare. QHPs must:
- Follow federally established cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. limits
- Provide essential health benefits
QHPs are sold in federal- or state-run forums (referred to as Marketplaces or Exchanges) where you can shop for coverage online or over the phone.
Note: People shopping for insurance may also come across short-term limited duration (STLD) plans and association health plans (AHPs) as other coverage options. These plans are not required to meet the same standards as QHPs, meaning they may not provide comprehensive coverage or may exclude certain services. Additionally, STLD plans are generally unavailable for people with pre-existing conditions.
Remember, QHPs are typically not for people with Medicare. If you are already enrolled in Medicare, you do not need to change your health coverage and you do not receive coverage through the Marketplaces.
- No type of Medicare coverage is sold through the Marketplaces
- It is illegal for someone to sell you a QHP if they know you have Medicare
- In most cases, you are ineligible for cost assistance (tax credits) to help pay for your QHP
- There is no guarantee that a QHP will pay for your care if you have or are eligible for other insurance—meaning you may have little or no coverage
- You may experience gaps in coverage Gaps in coverage are services or costs that are not covered by Original Medicare, such as vision, dental, and hearing care, as well as deductibles and coinsurance. and incur Medicare late enrollment penalties when attempting to re-enroll in Medicare
If you currently have a QHP and are becoming eligible for Medicare, in most cases you should disenroll from your QHP and enroll in Medicare. However, there are a few circumstances in which you might choose to delay Medicare enrollment to stay in a QHP.
Note: There are different rules if you are enrolled in a Small Business Health Options Program (SHOP) plan.