Qualified Health Plans (QHPs) are health insurance policies that meet protections and requirements set by the Affordable Care Act (ACA). Specifically, QHPs must:

  • Follow federally established cost-sharing limits
  • Provide essential health benefits
  • Meet the “minimum essential coverage” (MEC) requirement, also known as the individual mandate
    • If you are not enrolled in MEC, you may incur a tax penalty
    • Note: Medicare Part A also meets the MEC requirement (Part B alone does not meet MEC)

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.

It is important to know that if you are already enrolled in Medicare, you do not need to change your health coverage and will 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 premium
  • 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 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.