Virginia Marketplace Basics
Start with the fundamentals of individual and family health insurance in Virginia.
What is Virginia's Insurance Marketplace?
Virginia's Insurance Marketplace is Virginia's official health insurance Marketplace for individuals and families. Eligible Virginians can compare qualified health plans and apply for financial assistance that may reduce premiums and other healthcare costs.
Who can enroll in Marketplace health insurance?
Eligibility depends on factors including Virginia residency, citizenship or qualifying immigration status and other applicable Marketplace requirements. Eligibility for financial assistance has additional requirements.
Can self-employed people use Virginia's Marketplace?
Yes. Self-employed individuals and business owners who need individual or family health insurance can use Virginia's Insurance Marketplace to explore available coverage and determine whether they qualify for financial assistance.
Can a licensed insurance broker help me enroll?
Yes. Virginia-certified licensed insurance agents can assist consumers with comparing plans and completing Marketplace enrollment. Holloway Benefits Group can help you review premiums, provider networks, prescriptions and plan benefits.
HBG can help you compare available Virginia Marketplace coverage and understand the differences between your options.
Open Enrollment & Special Enrollment
Open Enrollment isn't your only opportunity to obtain coverage. Certain life events may allow enrollment during the year.
When is 2027 Open Enrollment in Virginia?
Virginia's 2027 Open Enrollment period runs from November 1, 2026 through January 29, 2027.
What is a Special Enrollment Period?
A Special Enrollment Period, often called an SEP, can allow eligible consumers to enroll in or change Marketplace coverage outside the annual Open Enrollment period following certain qualifying life events.
What life events may qualify for Special Enrollment?
Examples can include loss of qualifying health coverage, marriage, divorce, pregnancy, birth or adoption, certain moves, loss of Medicaid, a dependent aging out of coverage at age 26, and certain other changes in eligibility.
Eligibility depends on the particular event and applicable Marketplace rules. Documentation may be required.
I am losing employer health insurance. When should I apply?
Loss of qualifying job-based health coverage can create a Special Enrollment Period. In many situations, eligible consumers have an enrollment window before and after the loss of coverage.
Starting the process before your existing coverage ends can help reduce the risk of a gap in health insurance.
I'm turning 26 and losing coverage through my parent. Can I enroll?
A dependent aging out of qualifying health coverage at age 26 can qualify for a Special Enrollment Period. Review your Marketplace options before the existing coverage terminates so you can plan for the transition.
Will I need proof of my qualifying life event?
Possibly. Depending on the Special Enrollment Period, Virginia's Marketplace may request documentation of the qualifying event and, in certain circumstances, proof of prior qualifying coverage.
Financial Assistance
Marketplace financial assistance can affect both your monthly premium and what you pay when you receive medical care.
What is an Advance Premium Tax Credit (APTC)?
An Advance Premium Tax Credit is federal financial assistance that eligible consumers can apply toward their monthly Marketplace health insurance premium.
Eligibility and the amount available depend on factors such as projected household income, household size and other applicable eligibility rules.
What income does the Marketplace use?
Marketplace financial assistance generally uses expected household income for the coverage year and Modified Adjusted Gross Income rules. This means the Marketplace is not simply looking at the previous year's income.
What happens if my income changes during the year?
Update Virginia's Insurance Marketplace when applicable household or income information changes. Changes in projected income can affect the financial assistance for which your household qualifies.
Could I have to repay some of my premium tax credit?
Potentially. Advance Premium Tax Credits are reconciled through the federal income-tax process. If the advance credit paid on your behalf differs from the amount for which you ultimately qualify, that difference is handled under applicable federal tax rules.
What are Cost-Sharing Reductions (CSR)?
Cost-Sharing Reductions can lower eligible consumers' deductibles, copayments, coinsurance and maximum out-of-pocket costs. To receive CSR benefits, an eligible consumer must select an applicable Silver Marketplace plan.
A low-premium plan isn't automatically the least expensive plan for your family. Deductibles, copays, prescriptions, provider networks and maximum out-of-pocket exposure matter too.
Virginia Premium Savings
Virginia Premium Savings is a new state-funded program for 2027 designed to lower monthly Marketplace premiums for eligible Virginians. It can supplement available federal Advance Premium Tax Credits.
Bronze, Silver or Gold — What's the Difference?
Marketplace metal levels don't represent the quality of the insurance company or the quality of medical care. They indicate how costs are generally shared between the member and the health plan.
Bronze plans generally have lower monthly premiums but higher costs when you receive healthcare. They may appeal to people who primarily want protection from larger unexpected medical expenses.
Silver plans generally balance monthly premiums and out-of-pocket costs. If you qualify for Cost-Sharing Reductions, you must select an eligible Silver plan to receive those additional savings.
Gold plans generally have higher monthly premiums but lower cost-sharing when you receive covered healthcare. They can be worth comparing when you expect significant medical use.
Your monthly premium is only one part of the cost. Depending on your doctors, prescriptions and expected healthcare use, a plan with a higher premium may produce lower total healthcare spending.
HMO, PPO, EPO & POS Explained
Two plans with similar premiums and deductibles can have very different provider-network rules. Always verify the exact plan network before enrolling.
Health Maintenance Organization plans generally focus on in-network care and typically provide limited or no coverage for non-emergency out-of-network care. Referral requirements vary by plan.
Preferred Provider Organization plans generally allow members to use both in-network and out-of-network providers, although out-of-network care typically costs more.
Exclusive Provider Organization plans generally require members to use the plan's network for covered non-emergency care.
Point of Service plans generally cost less when using network providers and may require primary-care referrals for specialist services.
A carrier name alone isn't enough. Different plans from the same insurance company can use different networks. Verify your doctors and hospitals against the exact plan.
Health plans maintain lists of covered medications and assign drugs to different cost-sharing tiers. Check your actual prescriptions when comparing plans.
Know What You're Actually Paying
Understanding a few basic insurance terms makes comparing health plans considerably easier.
What is a health insurance premium?
Your premium is the amount charged for keeping your health insurance coverage in force. Marketplace financial assistance may reduce the portion of the monthly premium you pay.
What is a deductible?
A deductible is an amount you may need to pay for covered healthcare services before your plan begins paying for certain benefits. Not every benefit necessarily requires the deductible to be met first, so review the specific plan's Summary of Benefits and Coverage.
What is a copay?
A copayment is a fixed amount you pay for a covered service under the terms of your plan — for example, a specified amount for an office visit or prescription.
What is coinsurance?
Coinsurance is a percentage of the allowed cost of a covered healthcare service that you're responsible for paying under the terms of your health plan.
What is the maximum out-of-pocket?
The maximum out-of-pocket is the most you generally pay during a plan year for covered in-network services that count toward the limit. After reaching the limit, the health plan generally pays 100% of covered in-network benefits for the remainder of the plan year. Premiums and certain other expenses do not count toward the maximum.
Does every service have to meet the deductible first?
Not necessarily. Some plans provide certain services with a copay or other cost-sharing before the deductible is met. The specific benefit structure varies by plan, so review the Summary of Benefits and Coverage.
What are Essential Health Benefits?
ACA Marketplace plans cover essential health benefit categories, including outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance-use services, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive and wellness services, and pediatric services.
Are preventive services covered before I meet my deductible?
ACA-compliant health plans generally cover specified preventive services without cost sharing when applicable requirements are met, including use of appropriate in-network providers. Coverage rules can vary by the particular preventive service and circumstances.
Before enrolling, HBG can help you compare the exact provider network and prescription coverage associated with the plans you're considering.
Employer Coverage & COBRA
Can I use the Marketplace if my employer offers health insurance?
You may be able to purchase Marketplace coverage, but access to qualifying employer-sponsored coverage can affect eligibility for Marketplace financial assistance. The employer plan and your household circumstances need to be evaluated.
Can my spouse use Marketplace coverage while I stay on my employer plan?
Families do not necessarily have to use the same source of health coverage. However, an offer of employer coverage can affect a spouse's or dependent's eligibility for Marketplace financial assistance. Eligibility depends on the employer coverage offered and applicable affordability and coverage rules.
Should I choose COBRA or Marketplace coverage after leaving a job?
The better fit depends on your circumstances. COBRA may allow you to temporarily continue the same employer plan, while Marketplace coverage may provide different premiums, networks, deductibles and potential financial assistance.
Compare both options before making a decision, particularly if you have ongoing treatment, prescriptions or providers you want to continue using.
Medicaid & FAMIS
Can some family members have Medicaid or FAMIS while others have Marketplace coverage?
Yes. Eligibility is determined for individual household members, so one family can have members enrolled in different health coverage programs depending on each person's eligibility.
Can my children qualify for FAMIS while the parents use Marketplace coverage?
Potentially. Children's eligibility for Medicaid or FAMIS can differ from the parents' eligibility. This means a household can have children enrolled through Medicaid or FAMIS while one or both parents obtain coverage through Virginia's Insurance Marketplace.
What happens if I lose Medicaid?
Loss of qualifying Medicaid coverage can create a Special Enrollment Period through Virginia's Insurance Marketplace. Review your options promptly so you can reduce the risk of a gap in coverage.
What if I become eligible for Medicaid or FAMIS while I have Marketplace coverage?
If you become enrolled in Medicaid or FAMIS coverage that qualifies as minimum essential coverage, eligibility for Marketplace financial assistance can change. Update your Marketplace application promptly so your eligibility and financial assistance can be handled correctly.
After You Select a Plan
Is selecting a plan the final step?
No. You generally must pay your first premium to the insurance company by its deadline for coverage to become effective. Follow the carrier's payment instructions after enrollment.
When will I receive my insurance card?
Insurance identification cards are issued by the insurance carrier, not Virginia's Insurance Marketplace. Timing varies by carrier. After completing enrollment and paying any required first premium, set up your carrier account and review your plan materials.
Should I report income or household changes after I enroll?
Yes. Changes in income, household size, address and access to other health coverage can affect Marketplace eligibility and financial assistance. Update applicable changes with Virginia's Insurance Marketplace promptly.
Can I change Marketplace plans whenever I want?
Generally, plan changes are made during Open Enrollment or when you're eligible for an applicable Special Enrollment Period. Simply wanting a different plan during the year does not necessarily create an opportunity to change coverage.
What if my doctor says they don't accept my insurance?
Confirm the provider's participation in your exact plan network with the insurance carrier. A doctor's office may accept some plans from an insurance company but not every network or product offered by that carrier.
What if one of my prescriptions isn't covered?
Review the plan's current formulary and contact the insurance carrier regarding coverage, alternatives, prior authorization, step therapy or applicable exception and appeal procedures. Your prescribing provider may also need to participate in that process.
Before Your HBG Coverage Review
Having a few pieces of information ready can make comparing coverage considerably easier.
Household members, dates of birth and relevant tax-household information.
Your best estimate of applicable household income for the coverage year.
Primary care providers and specialists you'd like to continue seeing.
Names and dosages of medications you want checked against plan formularies.
Preferred hospitals, medical groups and health systems.
Information about employer, Marketplace, COBRA or other existing health coverage.