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The American healthcare system is governed by a unique set of legislation that’s primary objective is to ensure that all Americans have access to basic healthcare services through insurance coverage. 

These healthcare reform laws have put in place a wide range of subsidies and insurance plans targeting families and individuals on different spectrums of salary scales. One such insurance plan is a Qualified Health Plan (QHP), a health care plan that offers essential healthcare benefits to families and individuals.

What is a Qualified Health Plan?

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Qualified Health Plans (QHPs) were introduced by the Affordable Care Act (ACA) with the primary goal of ensuring that families and individuals don’t miss out on essential healthcare services because of their financial income or ineligibility for other federal healthcare plans such as Medicare. 

As a consumer protection regulation, the standards set by QHPs were verified by the Health Insurance Marketplace. Only qualified healthcare designs from private and public health insurance providers were approved and certified. The submitted designs were also verified based on the pricing of basic healthcare benefits.

By shopping for healthcare plans in marketplaces such as AHiX, individuals and families can get suitable insurance coverage that meets their needs. Generally, Qualified Health Plans were made to ensure health insurance plans provided the following core benefits:

  • Preventative care
  • Mental health care
  • Outpatient services
  • Emergency care
  • Laboratory services
  • Out-of-pocket purchase of prescription drugs
  • Doctor visits
  • Rehabilitation treatment and care

Qualified Health Plans also provide maternity care to reduce maternal and child mortality rates, especially among individuals and families who live below the federal poverty line. Such mothers and families may find it difficult to pay the high premiums charged by insurance companies.

Under ACA, these services are the minimum essential services that should be covered as they are necessary for comprehensive healthcare. One of the fundamental changes introduced under QHPs is the establishment of cost-sharing guidelines and regulations for these healthcare services that many Americans can’t afford due to high insurance premiums. 

The inclusion of co-payment options in insurance plans is also mandatory under QHPs. Under these new standards, individuals who meet the requirements of Qualified Health Plans can also receive federal health care subsidies to purchase insurance plans.

Categorization of Qualified Health Plans

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Qualified Health Plans are categorized into groups based on the coverage provided by the plan.


Suitable for young or older individuals who are in prime health condition, the Bronze QHP covers up to 60% of a patient’s medical cost. Individuals with this plan pay significantly lower premiums. 

However, it’s also important to note that individuals under the Bronze QHP usually pay very high out-of-pocket payments for services that health insurers are mandated to cost-share under the ObamaCare healthcare plan. Individuals under this plan pay the highest amount of deductibles across all four categories of QHPs.


Under the Silver QHP, insurers are required to pay up to 70% of the actuarial value of medical services. 

The Silver tier is widely popular among Americans. This tier accommodates individuals who can afford moderate monthly premiums, which make up a majority of the population. Therefore, the Silver QHP is considered an industry standard. This QHP tier is also popular because of the favorable government subsidies and tax credits that favor moderate payments for out-of-pocket costs.


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Individuals who purchase the Gold QHP get up to 80% of their expected medical costs paid by their insurers. This plan is suitable for individuals with several medical problems that may require a huge financial outlay, as well as out-of-pocket payments. 

The Gold QHP offers low deductibles and a high upfront cost. If you purchase this plan, you stand to benefit from largely reduced out-of-pocket payments. This plan is cost-effective for individuals who qualify for government subsidies and tax credits, too.


The Platinum QHP is suitable for individuals who are looking for a plan that will allow them frequent access to comprehensive health care services. The Platinum tier is the most cost-effective plan for individuals who qualify for government subsidies. Individuals who purchase this plan pay a high upfront cost and high monthly premiums. However, they also enjoy low out-of-pocket payments and reduced deductibles. This plan covers up to 90% of the average value of the medical services.

Catastrophic Coverage

While QHPs are classified into four metallic tiers, there is a fifth category that is tailored to meet the healthcare needs of Americans who cannot afford any of these four plans. The catastrophic coverage plan comes with basic minimum health benefits only. Unlike in the case of the four categories listed above, the insurer’s network coverage can be limited. 

This category was created to make exceptions for Americans in extremely difficult financial situations and some people who are below 30 years of age. However, this plan comes with exceptionally high monthly premiums and deductibles. Individuals who purchase this plan also have to contend with high out-of-pocket payments.

From Qualified Health Plan to Medicare

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When shopping for a suitable QHP tier that matches your healthcare needs, it’s important to know that any Qualified Health Plan is unavailable for individuals who already have Medicare. If you already meet the eligibility criteria for Medicare while on a QHP plan, you are legally obligated to disenroll from QHP before opting for Medicare coverage. 

A 14-day notice should be sent to your Marketplace official in your local area or at the federal level before opting out of your QHP and enrolling for Medicare. It’s always recommended to ask your marketplace official for guidance if you are unsure about the steps to take.

In some cases, individuals may be exempted from enrolling when switching from a QHP to Medicare within a certain time under special circumstances. Patients who need kidney transplants or dialysis for end-stage kidney disease can opt to defer enrolling for Medicare. Such an exemption also applies to individuals who are unable to raise Medicare premiums.

Signing Up for a Qualified Health Plan

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Signing up for a QHP takes place annually when state and federal healthcare Marketplaces open on November 1st and close on December 15th. The General Enrollment Period (GEP) may differ across states. However, individuals with special circumstances may also contact their federal or state healthcare market’s representative for enrollment consideration outside the stipulated period.

The purchase of a Qualified Health Plan can be made online on federal or private healthcare marketplaces. You can also contact Marketplace agents to facilitate the purchase if you need extra assistance. You should always complete the process within the stipulated time to avoid incurring penalties.

Qualified Health Plans May Be for You

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Qualified Health Plans (QHPs) were introduced as health insurance industry standards to ensure Americans have access to essential healthcare services, no matter their financial status. 

Individuals enrolled under any other four categories of a QHP can access services, such as maternity care, prescription drugs, and preventative care at a subsidized cost. If you plan on purchasing a Qualified Health Plan from a marketplace, always keep track of time to avoid late penalties and lack of coverage when you need it most.