How It Works and Who It’s For

Virginia’s Insurance Marketplace is for individuals and families who:

• Live in Virginia

• Are lawfully present in the U.S.

• Are not incarcerated

• Are not enrolled in Medicare

It serves people without access to affordable employer coverage, Medicaid, or CHIP. Nearly 9 out of 10 Marketplace customers qualify for financial assistance, such as premium tax credits and cost-sharing reductions, based on income and household size.

Open Enrollment Period in Virginia

• Open Enrollment for 2025: November 1, 2024 – January 22, 2025 (extended from January 15)

• Enroll by December 15 for coverage starting January 1

• Enroll between December 16 and January 22 for coverage starting February 1

Outside of this period, you need a qualifying life event to enroll or change plans.

Special Enrollment Period (SEP) Rules

You may qualify for a SEP if you experience a qualifying life event, such as:

• Loss of other health coverage (including Medicaid or employer coverage)

• Marriage or divorce

• Birth or adoption of a child

• Change in residence (moving into Virginia or within the state)

• Other events, including aging off a parent’s plan at age 26, change in income, or change in legal status

Most SEPs give you 60 days from the event to enroll. If you lose Medicaid, you can report the expected loss up to 60 days before and enroll up to 90 days after losing coverage.

Types of Health Insurance Plans Available

Plans are offered in four “metal” tiers:

• Platinum: Highest premiums, lowest out-of-pocket costs; best for frequent care.

• Gold: Higher premiums, lower out-of-pocket costs.

• Silver: Moderate premiums/costs; required for cost-sharing reductions.

• Bronze: Lowest premiums, highest out-of-pocket costs; best for those who rarely use care.

Catastrophic Plans: Available to those under 30 or with a hardship exemption. These plans have low premiums, high deductibles, and cover essential benefits, including three free primary care visits per year. Premium tax credits cannot be used with catastrophic plans.

Plan Types:

• HMO: Lower premiums, limited network, referrals required for specialists.

• PPO: Higher premiums, larger network, out-of-network coverage, no referrals.

• EPO: Must use network providers, no out-of-network coverage except emergencies, no referrals needed.

• POS: Combines features of HMO and PPO (less common).

Eligibility for Subsidies and Cost Assistance

• Premium Tax Credits: Ensure you pay no more than a set percentage of your household income for the benchmark Silver plan. Eligibility is based on income and household size.

• Cost-Sharing Reductions (CSR): Available for incomes up to 250% of the federal poverty level on Silver plans, reducing out-of-pocket costs.

• Medicaid/CHIP: Virginia expanded Medicaid in 2019. Medicaid is available to low-income adults, children, pregnant women, and people with disabilities. CHIP (FAMIS) covers uninsured children under 19 in families with incomes too high for Medicaid.

How to Compare and Choose a Plan in Virginia

When comparing plans, consider:

• Premiums: Monthly cost

• Deductibles/Out-of-Pocket Maximums: What you’ll pay before coverage kicks in

• Provider Networks: Ensure your doctors and hospitals are in-network

• Drug Formularies: Check if your medications are covered

• Additional Benefits: Some plans offer wellness programs, telemedicine, or mental health services

Tips:

• Self-employed: Consider high-deductible plans with HSAs for tax benefits.

• Families: Look for pediatric dental/vision, family out-of-pocket limits, and robust provider networks.

• Retirees: Marketplace coverage bridges the gap until Medicare at 65.

Top Insurance Providers on the Virginia Exchange

Ten insurers offer plans for 2025, including:

• Aetna

• Anthem HealthKeepers

• CareFirst BlueCross BlueShield

• Cigna

• Optima Health

• Kaiser Permanente

• Oscar

• Piedmont Community HealthCare

• UnitedHealthcare

• Sentara Health Plans

Availability varies by region. Medicaid Managed Care Organizations include Aetna Better Health, Anthem HealthKeepers Plus, Humana Healthy Horizons, Sentara Community Plan, and UnitedHealthcare Community Plan.

Navigating Virginia’s Online Enrollment Portal

How to Apply:

Visit Virginia’s Insurance Marketplace and create an account.

Enter household and income information to check eligibility for subsidies or programs.

Compare available plans by premiums, coverage, and network.

Select a plan and complete enrollment.Pay your first premium to activate coverage.

Where to Get Help:

• Free, in-person help is available from Navigators and Certified Application Counselors statewide. Assistance is available in multiple languages and locations.

Alternatives to the Marketplace

• Short-term health plans: Limited to four months in Virginia; not ACA-compliant, may exclude pre-existing conditions.

• Off-exchange private plans: Purchased directly from insurers; no subsidies available but include the same essential health benefits.

• Faith-based health-sharing ministries: Not insurance, lack ACA protections, but may be an option for some.

Common Mistakes to Avoid During Enrollment

• Not updating income, which can affect subsidy eligibility and lead to tax repayment.

• Missing enrollment deadlines, resulting in loss of coverage or waiting until the next Open Enrollment.

• Choosing the wrong metal tier for your needs.

• Not checking if your providers are in-network.

State-Specific Health Programs or Initiatives

• Reinsurance Program: Helps reduce premiums for people who don’t get subsidies.

• Easy Enrollment Program: Connects tax filers to Medicaid or Marketplace coverage.

• Medicaid Expansion: Virginia expanded Medicaid in 2019, increasing eligibility.

• Updated Essential Health Benefits: New requirements for certain prosthetics and nutrition coverage begin in 2025.

Virginia’s Insurance Marketplace provides a wide range of plans, strong consumer protections, and robust assistance for residents seeking affordable health coverage.