Everything Virginia residents need to know about ACA marketplace plans, metal levels, premium tax credits, and enrollment. Navigate the Affordable Care Act with confidence.
The Affordable Care Act (ACA) marketplace is where Virginia residents can shop for and purchase health insurance. Virginia operates a state-based marketplace through the Virginia State Corporation Commission, offering Qualified Health Plans (QHPs) that meet ACA standards.
Key features of Virginia's marketplace:
You can only enroll during Open Enrollment (November 1 - January 30) or during a Special Enrollment Period after a qualifying life event. Missing the deadline means waiting until next year unless you qualify for an exception.
ACA plans are organized into metal levels based on actuarial value - the percentage of covered medical expenses the plan pays on average.
The plan pays 60% of covered costs on average; you pay 40%.
The plan pays 70% of covered costs on average; you pay 30%.
The plan pays 80% of covered costs on average; you pay 20%.
The plan pays 90% of covered costs on average; you pay 10%.
Available only to people under 30 or those with a hardship exemption.
If your income is 100-250% of the Federal Poverty Level, you must choose a Silver plan to get Cost-Sharing Reductions that lower your deductibles and out-of-pocket costs.
All ACA marketplace plans must cover these 10 Essential Health Benefits:
| Benefit Category | What's Covered |
|---|---|
| Ambulatory Patient Services | Outpatient care without admission to a hospital |
| Emergency Services | Emergency room visits and emergency medical transportation |
| Hospitalization | Inpatient care including surgery and overnight stays |
| Maternity and Newborn Care | Pregnancy, childbirth, and newborn care |
| Mental Health & Substance Use | Mental health treatment and substance abuse treatment |
| Prescription Drugs | Prescription medications (formulary varies by plan) |
| Rehabilitative Services | Physical therapy, occupational therapy, speech therapy |
| Laboratory Services | Blood tests, urinalysis, and other lab work |
| Preventive Services | Annual physicals, vaccines, screenings at 100% coverage |
| Pediatric Services | Children's medical, dental, and vision care |
ACA plans cannot put dollar limits on essential health benefits during your lifetime or in any plan year, providing protection against catastrophic medical costs.
The ACA provides two types of financial assistance to help make health insurance affordable.
Help lower your monthly premium costs. Available for households with income between 100-400% of the Federal Poverty Level.
Lower your deductibles, copayments, and out-of-pocket maximums. Available for households with income between 100-250% of the Federal Poverty Level.
| Income Level (% FPL) | Premium Tax Credit | Cost-Sharing Reduction |
|---|---|---|
| 100-150% | Yes | Yes (significant reductions) |
| 150-200% | Yes | Yes (moderate reductions) |
| 200-250% | Yes | Yes (modest reductions) |
| 250-400% | Yes | No |
| Above 400% | No (extended through 2025) | No |
You cannot receive premium tax credits if you have access to affordable employer coverage or other Minimum Essential Coverage. Income limits are based on Modified Adjusted Gross Income (MAGI).
November 1, 2025 - January 30, 2026
Qualifying life events that allow enrollment outside Open Enrollment:
If you lose job-based coverage, you have options:
Special Enrollment Periods are typically 60 days from the qualifying event. Document your qualifying event as you'll need to provide proof when enrolling.
Virginia expanded Medicaid under the ACA, providing coverage for more low-income adults and families.
If you qualify for Medicaid or FAMIS, you cannot receive premium tax credits or cost-sharing reductions in the marketplace. However, Medicaid provides comprehensive coverage at little to no cost.
Virginia's Medicaid expansion has provided healthcare coverage to hundreds of thousands of previously uninsured adults, improving access to care and financial security.
To enroll in Virginia's ACA marketplace, you must meet these basic requirements:
For premium tax credits and cost-sharing reductions, your tax household includes:
Modified Adjusted Gross Income includes:
MAGI does NOT include:
Be accurate with income estimates - significant changes may require paying back advanced premium tax credits. Report life changes within 30 days to avoid issues at tax time.
Choose Bronze if you:
Choose Silver if you:
Choose Gold or Platinum if you:
ACA decisions are complex and affect your healthcare and finances. Consider working with a certified Virginia Health Benefit Exchange agent who can review your specific situation at no cost to you.
Now that you understand ACA marketplace basics, here's what to do next:
Our certified Virginia Health Benefit Exchange agents are here to help you navigate the marketplace and find the best plan for your needs and budget.