For most people, the perfect health insurance plan means comprehensive coverage at a manageable cost. But with such a broad range of plans to choose from, narrowing down your options can be a challenge.
Many looking for affordable coverage end up choosing a qualified health plan (QHP). Not sure what that is? Keep reading for all you need to know about QHPs, including what they cover, costs and where to enroll.
What is a qualified health plan?
A qualified health plan is a health insurance plan that’s certified by the health insurance marketplace. All QHPs meet Affordable Care Act (ACA) requirements for health coverage and meet a standard known as minimum essential coverage.
QHPs also follow the ACA’s regulatory limits on cost-sharing. This ensures that the out-of-pocket costs you’re responsible for, like deductibles, copays and coinsurance, and out-of-pocket maximums, don’t go over a certain amount. QHPs must also cover pre-existing conditions, include essential health benefits and not limit annual or lifetime benefits.
Can off-market health care coverage qualify as a QHP?
The Affordable Care Act was enacted to make health insurance more accessible and affordable. Health plans under the ACA are available for purchase from either state or federal health insurance marketplaces. All plans sold on the marketplace are considered qualified health plans and meet ACA standards.
Not all QHPs are sold through the marketplace, though. Some are available from employers and elsewhere. They’re known as off-exchange health insurance plans, and they’re held to the same cost-sharing and health coverage standards as plans sold on the marketplace.
Some qualified health plans are eligible for payment assistance
While you can purchase QHPs off-exchange, there are specific financial benefits you can receive by using the health insurance marketplace. You may qualify for an ACA subsidy, such as premium tax credits and cost-sharing reductions. These financial assistance subsidies can help limit monthly premium payments and out-of-pocket costs. Eligibility for ACA marketplace premium tax credits and cost-sharing reductions depends on your income level, age, location, household size and the type of plan you have.
Is every type of qualified health plan eligible for financial assistance?
If you get your QHP through your employer or a private insurer, you’re not eligible for ACA financial assistance. Your plan is still accredited by the marketplace and meets ACA standards, but ACA financial assistance is only available through the health insurance marketplace.
The benefits of a QHP
A QHP offers a policy holder essential health coverage, financial protection and flexibility. Marketplace accreditation ensures that numerous standards for health coverage are met. For example:
- Certain health care services must be covered
- Cost-sharing amounts are limited
- Costs are legally required not to exceed a certain amount
Additionally, protections are in place to prevent the denial of care.
Qualified health plans are required to cover essential health services
In terms of health care, all QHPs must cover what the ACA considers the 10 essential health benefits:
- Emergency services, like ER care
- Ambulatory services, also known as outpatient services
- Hospitalization, including in-hospital surgical procedures and overnight hospital stays
- Prescription drugs
- Maternity and newborn care, which is provided for babies and parents during and immediately after birth
- Pediatric dental services
- Mental health and behavioral health treatment
- Rehabilitation services and devices
- Lab services, like X-rays, biopsies and more
- Preventive services
QHPs can make care more affordable
As mentioned, QHPs are also subject to cost-sharing rules. The ACA limits what you’re expected to spend out of pocket, making health care services more affordable – this is called an out-of-pocket (OOP) maximum limit. OOP maximums include all cost-sharing measures associated with health services received in your plan’s network. In 2025, the maximum out-of-pocket limit for a qualified health plan is $9,200 for individual coverage and $18,400 for family coverage.
QHPs allow you to choose different types of coverage
Qualified health plans sold both on and off-exchange, like those offered by HealthPartners, are categorized into four “metal levels” – bronze, silver, gold and platinum. These tiers have less to do with health care quality and more with the amount you can expect to pay for covered services.
For instance, a bronze plan will function more like a high-deductible health plan (HDHP), which means a lower monthly premium and higher cost-sharing amounts. Comparatively, a gold plan will typically have a higher monthly premium, but you’ll pay less out of pocket for services.
Non-qualified health insurance plans
Non-qualified health plans aren’t marketplace-accredited health plans. But that doesn’t mean they’re not good health insurance options – they just don’t meet ACA standards.
The right plan for you depends on your health and financial needs. For instance, some non-QHPs are lower cost with limited coverage, but for someone on a tight budget without pre-existing conditions who may not need much care, this can be a good fit.
Do you need to enroll in a QHP?
No, you don’t have to enroll in a QHP. However, since these marketplace-accredited plans set a standard for care and cost protections, it’s a good idea to lean toward one. Having health insurance itself isn’t mandatory, but injury and illness can happen at any time – it’s important to make sure you and your family are covered.
Medicare vs. qualified health plans
Medicare and qualified health plans are both sponsored by the government, but they serve different people at different stages of life. For most seniors, if you qualify for Medicare, you don’t have to worry about QHPs. In fact, you can’t have both types of coverage at the same time, and no type of Medicare plan, whether Original Medicare or Medicare Advantage, is sold on the marketplace. While it’s possible to defer Medicare to enroll in another type of coverage, including a QHP, it isn’t often recommended. This is because if you choose to delay enrolling in Medicare until after your Initial Enrollment Period (IEP), you may be subject to penalties.
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