The Virginian’s Definitive Guide to ACA Health Insurance: Navigating the Marketplace for 2025

Introduction: Understanding Virginia’s New Health Insurance Landscape

The Patient Protection and Affordable Care Act (ACA), enacted in 2010, fundamentally reshaped the American health insurance system by expanding access, improving quality, and increasing affordability for millions.¹

For Virginians, the framework established by the ACA has evolved into a sophisticated, state-managed system designed to meet the specific needs of the Commonwealth’s residents.

This guide provides an exhaustive analysis of this system, offering the detailed information and strategic context necessary to navigate your health coverage options with confidence.

Virginia’s Insurance Marketplace: A New Era of State Control

A pivotal development for health insurance in the Commonwealth occurred in the fall of 2023 with the launch of Virginia’s Insurance Marketplace.²

Previously, Virginians used the federal HealthCare.gov platform to enroll in ACA plans.

The transition to a state-based marketplace marks a new era of local control and customization.

The official portal for this new system is

Marketplace.Virginia.gov.³

This marketplace is not merely a new website; it represents a strategic shift by the Commonwealth to gain autonomy over its health insurance market.

It is operated by the Health Benefit Exchange (HBE), a dedicated division within the Virginia State Corporation Commission (SCC).⁵

The HBE’s mission is to increase access to affordable, reliable health coverage by tailoring the insurance shopping experience specifically for Virginians.³

State-run exchanges provide significant advantages over the federal model, including greater flexibility in setting enrollment periods, establishing locally managed customer support centers to avoid the “one-size-fits-all” federal approach, and the ability to control market-stabilizing programs.⁷

For example, Virginia’s reinsurance program, which took effect in 2023, directly lowers premiums for individuals and is more effectively managed at the state level.²

Furthermore, by operating its own exchange, Virginia can avoid certain federal fees previously levied on insurance carriers, creating the potential for lower consumer premiums over time.⁷

Perhaps most importantly, the state now owns its enrollment data, enabling it to conduct targeted outreach and better support underserved populations across the Commonwealth.⁷

The “Single Door” Advantage

A core feature of Virginia’s Insurance Marketplace is its function as a “single door” application portal.

When a Virginian completes an application at Marketplace.Virginia.gov, the system does more than just present private insurance options.

It simultaneously screens for eligibility for the Commonwealth’s public health coverage programs: Virginia Medicaid and the Family Access to Medical Insurance Security (FAMIS) program for children and pregnant individuals.⁴

This integrated approach streamlines the process, ensuring that residents are directed to the most affordable coverage for which they qualify without needing to navigate multiple agencies or websites.

This streamlined system is particularly critical in the current environment.

The end of the COVID-19 public health emergency triggered a nationwide “Medicaid unwinding,” where states resumed annual eligibility redeterminations for the first time in three years.¹⁰

This process has led to many individuals and families losing their Medicaid coverage.

The launch of Virginia’s Insurance Marketplace coincided with this period, positioning it as the primary safety net for those transitioning from public to private insurance.⁷

Loss of Medicaid is a Qualifying Life Event (QLE) that grants a Special Enrollment Period (SEP) on the marketplace, and Virginia has established an extended 90-day window for this specific group to enroll in a new plan, ensuring a pathway to continuous coverage.¹²

Section 1: Are You Eligible? A Comprehensive Checklist

Eligibility for health coverage in Virginia is layered.

The first layer determines who can use the marketplace at all.

The subsequent layers determine eligibility for specific programs, such as Medicaid, and for financial assistance to lower the cost of private plans.

1.1 Core Marketplace Eligibility

To be eligible to shop for and enroll in a Qualified Health Plan (QHP) through Virginia’s Insurance Marketplace, an individual must meet four fundamental criteria ²:

1. Be a resident of Virginia. You must reside in the Commonwealth to use its marketplace.
2. Be a U.S. citizen, U.S. national, or a lawfully present immigrant. This status must be held for the entire period for which coverage is sought.
3. Not be incarcerated. Individuals who are incarcerated, other than incarceration pending the disposition of charges, are not eligible to enroll.
4. Not be enrolled in or eligible for Medicare. If you have Medicare coverage, you cannot purchase a health or dental plan through the marketplace.

1.2 The Medicaid and FAMIS Gateway

As noted, the marketplace application serves as the screening tool for Virginia’s public insurance programs.

The system automatically assesses whether an applicant’s income and household information qualify them for low-cost or no-cost coverage.⁴

A landmark event in Virginia healthcare was the expansion of Medicaid, which took effect in January 2019.¹⁰

This expansion made coverage available to a significantly larger group of low-income adults.

The income eligibility for these programs is based on the Federal Poverty Level (FPL), which is updated annually.

For 2024, the key income thresholds are as follows ¹⁰:

• Adults (age 19-64): Eligible for Medicaid with household incomes up to 138% of the FPL. For a single individual in 2024, this is an annual income of $20,782.
• Pregnant People: Eligible for Medicaid with household incomes up to 148% FPL. They may be eligible for the FAMIS MOMS program with incomes up to 205% FPL. This coverage continues for 12 months postpartum.
• Children (under age 19): Eligible for FAMIS Plus (Medicaid for children) with household incomes up to 148% FPL. They are eligible for FAMIS (Virginia’s Children’s Health Insurance Program, or CHIP) with incomes up to 205% FPL.

If the marketplace system determines an applicant is eligible for Medicaid or FAMIS, it will direct them to complete their enrollment with the appropriate state agency.

Applications can also be initiated through other portals, such as CommonHelp, by calling the Cover Virginia Call Center at 1-855-242-8282, or by contacting a local department of social services.⁸

1.3 Eligibility for Financial Assistance (Subsidies)

For those who are not eligible for Medicaid but meet the core marketplace criteria, the next step is determining eligibility for financial assistance (subsidies) to lower the cost of private plans.

To qualify for these subsidies, an applicant must meet the core eligibility criteria and ²:

• Not be eligible for Medicaid, FAMIS, or premium-free Medicare Part A.
• Not have an offer of “affordable” health coverage through an employer that provides “minimum value.”

This last point is a critical gatekeeper for subsidies and a common source of confusion.

Employer-sponsored insurance is generally considered “affordable” under the ACA if the employee’s contribution for the lowest-cost, self-only plan is less than a certain percentage of their household income (8.39% for plan year 2024).

A recent regulatory change fixed what was known as the “family glitch,” so affordability for family members is now based on the cost of the family plan, not the self-only plan.

However, understanding this affordability test is paramount, as an offer of qualifying employer coverage to anyone in the household can render them ineligible for subsidies on the marketplace.

The marketplace functions as an automated eligibility sorter.

A consumer does not need to know in advance whether they qualify for Medicaid or a subsidized private plan.

The most effective course of action is to complete the single application at Marketplace.Virginia.gov and allow the system to determine the appropriate program and level of financial assistance based on the information provided.⁴

1.4 Guidance for Special Populations

The ACA and Virginia’s marketplace have specific provisions for certain groups:

• Veterans: Veterans who are enrolled in VA health care have met the ACA’s requirement to have health coverage. They can apply for VA care at any time. However, family members of Veterans who are not eligible for VA care can use Virginia’s Insurance Marketplace to obtain coverage.¹⁷
• Former Foster Care Youth: The Commonwealth provides specific pathways and coverage options for young adults who were formerly in the foster care system. They can apply online through CommonHelp or by contacting the Cover Virginia Call Center.⁸
• DACA Recipients: Recent court decisions have impacted the eligibility of Deferred Action for Childhood Arrivals (DACA) recipients for marketplace coverage. Individuals with this status should consult Marketplace.Virginia.gov or HealthCare.gov for the most current information on their eligibility status.¹⁸

Section 2: Enrollment Windows: When to Apply

Securing health coverage through the marketplace is a time-sensitive process.

There are specific periods during the year when individuals can enroll.

Missing these windows can mean going without coverage until the next opportunity.

2.1 The Annual Open Enrollment Period (OEP)

The Open Enrollment Period (OEP) is the primary time each year when any eligible Virginian can enroll in a new health plan or change their existing marketplace plan for the upcoming year.¹⁹

For coverage in 2025, the Open Enrollment Period in Virginia runs from November 1, 2024, to January 15, 2025.¹²

Within this period, there are two critical deadlines that determine when coverage begins:

• To have coverage start on January 1, 2025, you must enroll in and pay the first premium for a plan by December 15, 2024.²⁰
• If you enroll between December 16, 2024, and the final deadline of January 15, 2025, your coverage will begin on February 1, 2025.²

Failing to enroll by the December 15 deadline means a potential gap in coverage for the month of January, which could have significant financial consequences in the event of an unexpected medical need.

Table 1: Virginia ACA Open Enrollment Deadlines for 2025 Coverage
Enrollment Period	Deadline to Enroll	Coverage Start Date
First half of OEP	December 15, 2024	January 1, 2025
Second half of OEP	January 15, 2025	February 1, 2025

2.2 Special Enrollment Periods (SEPs): Your Key to Year-Round Coverage

Outside of the annual OEP, you can only enroll in a marketplace plan if you experience a Qualifying Life Event (QLE).

A QLE triggers a Special Enrollment Period (SEP), which is a limited window of time to purchase coverage.³

Generally, an SEP provides a 60-day window following the date of the qualifying event to enroll in a plan.¹³

For certain predictable events, such as an expected loss of coverage, you may be able to apply up to 60 days in advance.¹²

Virginia has also established a crucial, extended SEP for a specific population: Virginians who lose their Medicaid or FAMIS coverage have up to 90 days after their coverage ends to enroll in a marketplace plan.¹²

This provides an essential and generous transition period for those affected by the Medicaid unwinding.

A wide range of life changes can qualify an individual for an SEP.

These events are broadly categorized as follows:

Table 2: Qualifying Life Events (QLEs) Triggering a Special Enrollment Period in Virginia
QLE Category	Specific Qualifying Life Event Examples	Typical Enrollment Window
Loss of Health Coverage	Losing job-based health insurance (due to job loss, reduction in hours, etc.); Losing Medicaid or FAMIS coverage; Losing eligibility for Medicare; Turning 26 and aging off a parent’s plan; COBRA insurance coverage ending; Losing an individual or student health plan. 13	60 days from event (up to 90 days for Medicaid/FAMIS loss in VA)
Changes in Household	Getting married; Getting divorced or legally separated, resulting in a loss of coverage; Having a baby; Adopting a child or having a child placed for foster care; Death of a family member on the plan, resulting in a change in eligibility for remaining members. 23	60 days from event
Changes in Residence	Moving to a new ZIP code or county within Virginia; A permanent move to Virginia from another state or U.S. territory; A student moving to or from the place they attend school; A seasonal worker moving for a job; Moving to or from a shelter or other transitional housing. 23	60 days from event
Other Qualifying Events	A change in income that affects eligibility for financial assistance; Gaining U.S. citizenship or qualifying immigration status; Being released from incarceration (jail or prison); Gaining or losing status as a member of a federally recognized tribe or Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder; AmeriCorps members starting or ending their service. 13	60 days from event

Section 3: Decoding Your Plan Options: Tiers and Networks

Once eligibility and an enrollment window are established, the next step is to select a plan.

Virginia’s Insurance Marketplace offers a variety of plans from multiple insurance carriers.

These plans differ in two fundamental ways: their “metal tier,” which dictates how costs are shared, and their “network type,” which determines where you can receive care.

3.1 The “Metal Tiers”: Balancing Premiums and Out-of-Pocket Costs

All plans on the marketplace are categorized into four metal tiers—Bronze, Silver, Gold, and Platinum—plus a fifth category, Catastrophic.

These tiers indicate the average percentage of costs a plan will cover for a standard population.

It is critical to understand that the metal tier has no bearing on the quality of care or the scope of covered benefits; it is purely a measure of cost-sharing.²⁸

• Bronze: These plans have the lowest monthly premiums but the highest out-of-pocket costs when you need care. On average, a Bronze plan pays for 60% of covered medical costs, while you pay 40%. Deductibles can be very high, often thousands of dollars. These plans are a good choice for healthy individuals who primarily want protection against major, worst-case medical scenarios like a serious accident or illness.³⁰
• Silver: These plans are often considered the “benchmark” and feature moderate monthly premiums and moderate out-of-pocket costs. A Silver plan pays for approximately 70% of costs, with the member paying 30%. Deductibles are typically lower than Bronze plans. The most important feature of Silver plans is that they are the only tier eligible for Cost-Sharing Reductions (CSRs), a powerful subsidy for lower-income individuals that will be discussed in detail in the next section.²⁸
• Gold: Gold plans come with high monthly premiums but low out-of-pocket costs. The plan covers about 80% of costs, and the member pays 20%. Deductibles are generally low. A Gold plan can be a good value for individuals and families who expect to use medical services regularly and want more predictable costs when they do.³⁰
• Platinum: These plans have the highest monthly premiums and the lowest out-of-pocket costs. A Platinum plan covers, on average, 90% of medical expenses, with the member responsible for just 10%. Deductibles are very low, meaning the plan begins paying its share of costs very quickly. This tier is best suited for individuals with significant, ongoing health needs who are willing to pay a higher premium for maximum cost predictability.²⁸
• Catastrophic Plans: This is a special category available only to individuals under the age of 30 or those who have received a hardship or affordability exemption. These plans have very low premiums but feature an extremely high deductible (equal to the federal maximum out-of-pocket limit, which is $9,200 for an individual in 2025). They cover certain preventive services at no cost but provide little coverage for other care until the high deductible is met.²⁸

Choosing the right metal tier requires a careful assessment of personal health needs and financial circumstances.

A consumer who focuses only on the lowest monthly premium (Bronze) without considering the potential for thousands of dollars in out-of-pocket costs may find themselves underinsured when they need care most.

Table 3: Comparative Analysis of ACA Metal Tiers
Metal Tier	Plan Pays (Avg)	You Pay (Avg)	Typical Monthly Premium	Typical Deductible	Ideal Consumer Profile
Bronze	60%	40%	Lowest	Highest	Healthy individual seeking protection from major medical events; comfortable paying for most routine care out-of-pocket.
Silver	70%	30%	Moderate	Moderate	Individual or family with average health needs; Essential for anyone qualifying for Cost-Sharing Reductions (CSRs).
Gold	80%	20%	High	Low	Individual or family who expects regular medical care or prescriptions and prefers lower out-of-pocket costs.
Platinum	90%	10%	Highest	Lowest	Individual with significant, ongoing health needs who values predictable costs and is willing to pay a high premium.
Catastrophic	N/A	100% until deductible	Very Low	Extremely High	Person under 30 or with a hardship exemption seeking only protection from “worst-case” financial scenarios.

3.2 Understanding Plan Networks: Where You Can Get Care

The second major decision point is the plan’s network type.

The network is the group of doctors, hospitals, specialists, and pharmacies that the insurance plan has contracted with to provide care at negotiated rates.

Staying within your plan’s network results in significantly lower costs.

The most common network types in Virginia are HMOs and PPOs.³²

• HMO (Health Maintenance Organization): HMO plans generally require you to use providers within their network for all care, except in a true emergency. Many HMOs require you to select a Primary Care Physician (PCP), who acts as a “gatekeeper” for your care. To see a specialist (like a cardiologist or dermatologist), you typically need a referral from your PCP. In exchange for these restrictions, HMOs often have lower monthly premiums.³³ Examples in Virginia include plans from Anthem HealthKeepers and CareFirst BlueChoice HMO.³¹
• PPO (Preferred Provider Organization): PPO plans offer more flexibility. They have a network of “preferred” providers, and you pay the least when you use them. However, PPOs also provide coverage for out-of-network providers, though your share of the cost (coinsurance, deductible) will be much higher. You generally do not need to select a PCP and do not need referrals to see specialists. This flexibility comes at the cost of higher monthly premiums.³² An example in Virginia is the CareFirst BluePreferred PPO.³¹
• POS (Point of Service): A POS plan is a hybrid of an HMO and a PPO. Like an HMO, it may require you to have a PCP and get referrals. Like a PPO, it allows you to go out-of-network for care, but at a higher cost. These plans attempt to balance cost control with flexibility.³²
• EPO (Exclusive Provider Organization): An EPO plan is more restrictive. It only covers services from providers within its network (except in an emergency). However, unlike many HMOs, an EPO generally does not require you to have a PCP or get referrals to see specialists.³⁴

The best network type depends entirely on individual priorities.

If keeping costs low is the top priority and you are comfortable with having your care coordinated through a single doctor, an HMO may be an excellent choice.

If you have established relationships with specific doctors or want the freedom to see any specialist without a referral, the higher premium of a PPO may be a worthwhile investment.

Table 4: Comparison of Health Plan Network Types
Plan Type	PCP Required?	Referrals to Specialists Needed?	Out-of-Network Coverage?	Typical Premium Cost
HMO	Usually Yes	Usually Yes	No (except for emergencies)	Lower
PPO	No	No	Yes (at a higher cost)	Higher
POS	Usually Yes	Usually Yes	Yes (at a higher cost)	Moderate
EPO	No	No	No (except for emergencies)	Moderate

Section 4: Financial Assistance: Making Coverage Affordable

A central promise of the ACA is making health insurance affordable.

Virginia’s Insurance Marketplace is the only place where Virginians can access federal financial assistance to lower their costs.

In fact, nearly 9 out of 10 consumers on the marketplace qualify for financial help.³

This assistance comes in two primary forms: Advance Premium Tax Credits (APTCs) and Cost-Sharing Reductions (CSRs).

4.1 Advance Premium Tax Credits (APTCs)

APTCs are tax credits that can be used immediately to lower your monthly health insurance premium.⁹

Instead of waiting to claim the credit on your tax return, the marketplace allows you to have it paid directly to your insurance company each month, reducing your bill.

• How it Works: The amount of your APTC is based on your estimated household income for the coverage year and the cost of the second-lowest-cost Silver plan in your geographic area, known as the “benchmark” plan. The credit is calculated to ensure that the premium for this benchmark plan does not exceed a certain percentage of your income (from 0% to 8.5%).⁴⁰ You can apply this credit to any metal tier plan (Bronze, Silver, Gold, or Platinum), but the amount of the credit is fixed based on the benchmark Silver plan’s cost.⁹
• Eligibility: APTCs are generally available to households with incomes between 100% and 400% of the FPL. However, the American Rescue Plan Act and the Inflation Reduction Act have temporarily eliminated the 400% FPL income cap for subsidy eligibility through 2025, meaning many households with higher incomes can now qualify for assistance if the benchmark plan premium would exceed 8.5% of their income.²⁸
• The Tax Reconciliation Imperative: The “advance” in APTC is a key concept. The credit you receive each month is based on an estimate of your annual income. When you file your federal income tax return for that year, you must reconcile the total APTC received with the premium tax credit you were actually eligible for based on your final, verified income. This process is done using IRS Form 8962. If your income was higher than you estimated, you may have to repay some or all of the credit. If your income was lower, you will receive the difference as a tax refund. This system introduces an element of financial responsibility for the consumer. It is crucial to report any significant income changes (such as a new job or a raise) to Virginia’s Insurance Marketplace during the year to adjust your APTC and avoid a large, unexpected tax bill.⁹

4.2 Cost-Sharing Reductions (CSRs): The “Extra Savings” on Silver Plans

CSRs are a second, powerful form of financial assistance that directly lowers your out-of-pocket costs when you receive medical care.

They reduce the amount you have to pay for your deductible, copayments, and coinsurance.⁹

• The Silver Plan Rule: This is arguably the most important strategic point for eligible consumers: CSRs are ONLY available if you enroll in a Silver-tier plan.⁹
• Income Eligibility: CSRs are available to individuals and families with household incomes up to 250% of the FPL.² The level of assistance is tiered, with those at lower income levels receiving the most substantial reductions in their out-of-pocket costs.
• The Strategic Value of CSRs: The impact of CSRs cannot be overstated. For an eligible individual, a CSR-enhanced Silver plan can have out-of-pocket costs that are comparable to a Gold or even a Platinum plan, while maintaining a more affordable Silver-level premium. For example, a standard Silver plan might have a deductible of $5,000. For someone with an income around 150% FPL, a CSR-enhanced Silver plan could have a deductible of just a few hundred dollars. This makes the plan vastly more valuable when care is needed. A consumer who is eligible for CSRs but chooses a Bronze plan to save a small amount on the monthly premium is making a significant financial misstep, as they are forgoing thousands of dollars in potential out-of-pocket savings.²⁹ For anyone with an income under 250% FPL, the first and most important step in plan selection is to closely examine the value of a CSR-enhanced Silver plan.

4.3 How to Estimate Your Household Income for the Marketplace

The marketplace uses a figure called Modified Adjusted Gross Income (MAGI) to determine eligibility for both APTCs and CSRs.

To estimate your household’s MAGI for the upcoming coverage year, you can follow these steps ⁹:

1. Start with Adjusted Gross Income (AGI). Find your household’s AGI on your most recent federal income tax return (this is Line 11 on Form 1040).
2. Add Back Certain Income. To calculate MAGI, add the following tax-exempt income sources back to your AGI, if applicable: tax-exempt foreign income, tax-exempt interest, and non-taxable Social Security benefits. Do not include Supplemental Security Income (SSI).
3. Project for the Coverage Year. Adjust this baseline figure for any expected changes in income for the year you are seeking coverage. This includes anticipated raises, new jobs, changes in work hours, or changes in self-employment income for every member of your household whose income must be included in the calculation.

Section 5: What’s Covered: A Guide to Your Benefits

All health plans sold on Virginia’s Insurance Marketplace must provide a comprehensive set of benefits, ensuring that consumers are protected against a wide range of medical needs.

This coverage is defined by a combination of federal and state requirements.

5.1 The 10 Federally Mandated Essential Health Benefits (EHBs)

Under the ACA, all individual and small-group health plans must cover services in the following ten categories, known as the Essential Health Benefits (EHBs).

This ensures a baseline level of comprehensive coverage in every plan, regardless of the insurer or metal tier.⁴

1. Ambulatory patient services: Outpatient care you receive without being admitted to a hospital.
2. Emergency services: Care for medical emergencies, which must be covered without prior authorization, even if the hospital is out-of-network.
3. Hospitalization: Inpatient care, including semi-private rooms, and surgeries.
4. Pregnancy, maternity, and newborn care: Care provided before, during, and after birth.
5. Mental health and substance use disorder services: Including behavioral health treatment, counseling, and psychotherapy.
6. Prescription drugs: Coverage for a range of prescription medications.
7. Rehabilitative and habilitative services and devices: Services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.
8. Laboratory services: Diagnostic tests and lab work.
9. Preventive and wellness services and chronic disease management: Including a wide range of screenings, immunizations, and counseling services provided at no cost-sharing.
10. Pediatric services, including oral and vision care: All plans must offer dental and vision coverage for children. Adult dental and vision benefits are optional.

5.2 Virginia’s State-Mandated Benefits

In addition to the federal EHB floor, Virginia law mandates that individual and group health plans cover certain specific services.

These mandates provide an additional layer of consumer protection and ensure access to care for specific conditions that are priorities within the Commonwealth.

While many of these may fall under the broad EHB categories, the state mandates often provide greater specificity and guarantee of coverage.

Table 5: Selected Virginia State-Mandated Health Benefits
Benefit Category	Specific Mandated Coverage in Virginia	Citation (Code of Virginia)
Hospice Care	Coverage for hospice services for the terminally ill.	§38.2-3418.11
Cancer Treatment & Surgery	Coverage for reconstructive breast surgery following a mastectomy; coverage for participation in approved clinical trials for cancer treatment.	§38.2-3418.4, §38.2-3418.8
Mental Health Services	Coverage for biologically based mental illnesses (such as schizophrenia, bipolar disorder, major depressive disorder) on par with physical illnesses; coverage for postpartum depression screening and services.	§38.2-3412.1:01, §38.2-3414.1
Specific Conditions	Coverage for the diagnosis and treatment of lymphedema; coverage for equipment, supplies, and self-management training for diabetes; coverage for hemophilia and congenital bleeding disorders.	§38.2-3418.14, §38.2-3418.10, §38.2-3418.3
Preventive Screenings	Coverage for mammograms, Pap smears, prostate-specific antigen (PSA) testing, and colorectal cancer screenings.	§38.2-3418.1, §38.2-3418.1:2, §38.2-3418.7, §38.2-3418.7:1
Newborn & Child Care	Coverage for newborn children from the moment of birth; coverage for infant hearing screening; coverage for early intervention services for developmental delays.	§38.2-3411, §38.2-3411.4, §38.2-3418.5
Dental Anesthesia	Coverage for hospitalization and general anesthesia for dental procedures for certain patients (e.g., children under five, individuals with severe disabilities).	§38.2-3418.12

Source: ⁴⁵

Section 6: The Application and Selection Process: A Step-by-Step Guide

Navigating the application and choosing the right plan can seem daunting, but a systematic approach can simplify the process.

6.1 Gather Your Information

Before beginning the application at Marketplace.Virginia.gov, it is highly efficient to gather all necessary information for yourself and every member of your household who is applying for coverage.

This includes ⁴:

• Full names, birth dates, and home/mailing addresses.
• Social Security numbers for all applicants.
• Document information for any lawfully present immigrants (e.g., “A-Number” or I-94 Number).
• Employer and income information for every household member, even those not applying for coverage (e.g., pay stubs, W-2 forms, wage and tax statements).
• Your best estimate of the household’s total income for 2025.
• Information about any health insurance offered by an employer, including the premium cost for the lowest-cost plan.
• A list of current doctors and prescription medications for all applicants.

6.2 Using the Plan Comparison Tools

Virginia’s Insurance Marketplace provides a powerful, anonymous Plan Comparison Tool that allows you to preview available plans and get personalized cost estimates before you create an account or submit a formal application.⁴⁶

By entering your ZIP code, estimated household income, and the ages of family members, the tool will ⁴⁷:

• Estimate your eligibility for APTCs and CSRs.
• Show you the plans available in your area.
• Provide an estimated total annual cost for each plan, which includes the monthly premium minus any APTC, plus your estimated out-of-pocket costs based on a selected usage level (low, medium, or high).
• Allow you to filter plans and check if specific prescription drugs are on a plan’s formulary.

It is important to remember that this tool provides an estimate.

The final, official determination of eligibility and cost is made only after a complete application is submitted.⁴⁶

External tools, such as the KFF Health Insurance Marketplace Calculator, can also be used for preliminary estimates.⁴⁰

6.3 A Strategic Framework for Choosing Your Plan

With the tools and information at hand, follow this strategic, step-by-step framework to select the best plan:

1. Step 1: Determine Your Financial Assistance. Use the Plan Comparison Tool to get an estimate of the APTC and CSR savings you qualify for. This is the foundational step that will shape all subsequent decisions.⁹
2. Step 2: Select the Right Metal Tier. Based on your subsidy eligibility and your family’s expected health needs, choose the appropriate tier. Crucially, if your income is below 250% FPL, your analysis should begin with Silver plans to take full advantage of powerful CSR benefits.³⁰
3. Step 3: Verify the Provider Network. Once you have narrowed your options to a few plans, the next step is critical: check the provider network. Do not rely solely on the marketplace’s tool. Go directly to the insurance carrier’s website and use their official provider directory to confirm that your preferred doctors, hospitals, and specialists are in-network for the specific plan you are considering. As some consumers have found, this direct verification is the most reliable method.⁷
4. Step 4: Confirm the Prescription Drug Formulary. Similarly, use the insurer’s official drug list (formulary) for the specific plan to ensure that any necessary medications are covered and to understand the cost-sharing tier they fall into. A drug’s tier determines your copay or coinsurance amount.⁴⁶
5. Step 5: Compare Total Estimated Costs. Finally, look beyond just the monthly premium. The most important figure to compare between plans is the estimated total annual cost provided by the marketplace tool. This number combines your premium payments with your likely out-of-pocket spending, giving a much more realistic picture of what each plan will cost over the course of the year.

Section 7: Don’t Go It Alone: Your Guide to Free, Unbiased Assistance

The complexity of health insurance is well-recognized, and Virginia has established a robust network of free, expert assistance to help consumers navigate the enrollment process successfully.

The creation of this state-certified assistance network is a direct benefit of the move to a state-based exchange, as it allows for dedicated funding and local control over these vital consumer support services.⁷

7.1 Understanding Your Helpers

There are two main types of certified professionals available to provide free assistance ³:

• Navigators and Assisters: These are individuals or community-based organizations that are trained and certified by the Virginia State Corporation Commission to provide fair, accurate, and impartial information and enrollment assistance. They are funded by grants and are prohibited from receiving compensation from insurance companies. Navigators can educate you on your options, guide you through the application, and help you understand how to use your plan, but they cannot recommend one specific plan over another.¹¹
• Certified Agents and Brokers: These are state-licensed insurance professionals who are also certified by Virginia’s Insurance Marketplace. Like navigators, they can help you with the application process free of charge. Because of their professional license, they are also permitted to analyze your specific health and financial needs and provide recommendations on which plan or plans would best suit you.³

7.2 Key Official Resources

Virginians can access this free help through several official channels:

• Virginia’s Insurance Marketplace Consumer Assistance Center: For assistance over the phone, you can call 1-888-687-1501 (TTY: 711). The call center is staffed with representatives who can answer questions, update your application, and help with enrollment. Free translation services are also available.⁴
• Online “Find Local Help” Tool: The marketplace website features a searchable directory where you can enter your ZIP code to find a list of certified Navigators, Assisters, and Agents in your local community. You can arrange for free help in-person, over the phone, or via email.³
• Enroll Virginia: This is a prominent, statewide navigator organization administered by the Virginia Poverty Law Center.¹¹ Enroll Virginia operates a helpline at
  1-888-392-5132 and partners with a vast network of over 150 community health centers and legal aid societies across the Commonwealth to provide in-person and virtual assistance.¹¹ This network ensures that expert help is accessible in nearly every part of the state.

Conclusion: Empowered to Choose

Navigating the health insurance landscape can be complex, but Virginia’s state-based marketplace provides the tools and resources necessary for consumers to make informed and confident decisions.

By understanding the structure of the system, the key deadlines, and the strategic choices involved in selecting a plan, Virginians can secure coverage that meets both their health needs and their budget.

The analysis presented in this guide distills the process into several key strategic takeaways:

1. Use Marketplace.Virginia.gov as your single point of entry. It is the official and only platform to access both private plans with financial assistance and to be screened for eligibility for Virginia Medicaid and FAMIS.
2. Prioritize the December 15 deadline. To ensure there is no gap in coverage at the beginning of the year, completing enrollment by December 15 is paramount.
3. If your income is below 250% of the Federal Poverty Level, begin your search with Silver plans. The value of Cost-Sharing Reductions (CSRs) is immense and can provide Gold- or Platinum-level benefits at a Silver-level premium. This is the single most important financial strategy for eligible consumers.
4. Always verify networks and formularies directly with the insurer. Before finalizing enrollment, confirm that your preferred doctors and necessary prescriptions are covered by the specific plan you have chosen.
5. Leverage the free, certified assistance available. Whether through the state’s call center, a local Navigator from an organization like Enroll Virginia, or a certified agent, expert help is available at no cost and is an integral part of the system designed to ensure your success.

By employing this knowledge and these resources, Virginians are well-equipped to navigate the marketplace effectively and secure the health coverage that is essential for the well-being of themselves and their families.

Works cited

1. Health Insurance – Virginia State Bar, accessed August 10, 2025, https://vsb.org/soyoure18/groups/SoYouRe18/health_insurance.aspx
2. Virginia ACA Health Insurance Marketplace – Healthinsurance.org, accessed August 10, 2025, https://www.healthinsurance.org/aca-marketplace/virginia/
3. Virginia’s Insurance Marketplace | Virginia Health Benefit Exchange, accessed August 10, 2025, https://www.marketplace.virginia.gov/
4. FAQs | Virginia’s Insurance Marketplace, accessed August 10, 2025, https://www.marketplace.virginia.gov/faqs
5. Privacy Policy | Virginia’s Insurance Marketplace, accessed August 10, 2025, https://www.marketplace.virginia.gov/privacy-policy
6. About the Virginia Health Benefit Exchange (HBE), accessed August 10, 2025, https://scchbe-marketplace.virginiainteractive.org/about-us
7. Virginia’s health insurance marketplace debuts with some hiccups, but higher enrollment, accessed August 10, 2025, https://cardinalnews.org/2023/12/26/virginias-health-insurance-marketplace-debuts-with-some-hiccups-but-higher-enrollment/
8. Affordable Care Act – Virginia Department of Social Services, accessed August 10, 2025, https://www.dss.virginia.gov/benefit/healthcare_reform.cgi
9. Financial Savings | Virginia’s Insurance Marketplace, accessed August 10, 2025, https://www.marketplace.virginia.gov/financial-savings
10. Medicaid eligibility and enrollment in Virginia – Healthinsurance.org, accessed August 10, 2025, https://www.healthinsurance.org/medicaid/virginia/
11. ENROLL Virginia! – Virginia Poverty Law Center, accessed August 10, 2025, https://vplc.org/enroll-virginia/
12. Qualifying Life Events and Special Enrollment Periods – Virginia’s Insurance Marketplace, accessed August 10, 2025, https://www.marketplace.virginia.gov/sites/default/files/2025-04/VIM-024%20Qualifying%20Live%20Events%20One-Pager_FINAL%20%2810.3.23%29.pdf
13. Special Enrollment Period | Virginia’s Insurance Marketplace, accessed August 10, 2025, https://www.marketplace.virginia.gov/special-enrollment
14. Who is eligible? – Virginia’s Insurance Marketplace Help, accessed August 10, 2025, https://help.marketplace.virginia.gov/hc/en-us/articles/11972827990541-Who-is-eligible
15. Are you eligible to use the Marketplace? | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/quick-guide/eligibility/
16. Eligibility Policy | Medicaid, accessed August 10, 2025, https://www.medicaid.gov/medicaid/eligibility-policy
17. Affordable Care Act | ChooseVA, accessed August 10, 2025, https://choose.va.gov/health/affordable-care-act
18. Welcome to the Health Insurance Marketplace® | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/
19. Marketplace (ACA) Insurance Plans in Virginia – HealthSherpa, accessed August 10, 2025, https://www.healthsherpa.com/states/virginia-aca
20. Virginia Open Enrollment 2025: Health Insurance Coverage, accessed August 10, 2025, https://www.oneilandbowmandisability.com/blog/virginia-open-enrollment-2025-health-insurance-coverage/
21. When Is Open Enrollment 2024-2025? – HealthMarkets, accessed August 10, 2025, https://www.healthmarkets.com/resources/health-insurance/open-enrollment/
22. When can you get health insurance? | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/quick-guide/dates-and-deadlines/
23. Qualifying life event (QLE) – Glossary | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/glossary/qualifying-life-event/
24. Special Enrollment Period (SEP) – Glossary | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/glossary/special-enrollment-period/
25. What is a Qualifying Life Event? (QLE) – Virginia’s Insurance Marketplace Help, accessed August 10, 2025, https://help.marketplace.virginia.gov/hc/en-us/articles/11972880960269-What-is-a-Qualifying-Life-Event-QLE
26. ACA Open Enrollment and Qualifying Life Events – Carefirst BlueCross BlueShield, accessed August 10, 2025, https://individual.carefirst.com/individuals-families/health-insurance-basics/how-health-insurance-works/open-enrollment.page
27. Virginia – How does the special enrollment period work?, accessed August 10, 2025, https://special-enrollment-kpif.kp.org/en/virginia/guide/life-event
28. What Are the Four ‘Metal’ Tiers of Affordable Care Act Health Plans? – GoodRx, accessed August 10, 2025, https://www.goodrx.com/insurance/aca/aca-tiers-of-coverage
29. Health plan categories: Bronze, Silver, Gold & Platinum | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/choose-a-plan/plans-categories/
30. Health Plan Options | Virginia’s Insurance Marketplace, accessed August 10, 2025, https://www.marketplace.virginia.gov/health-plan-options
31. Individual & Family Health Insurance Plans in Virginia – Carefirst BlueCross BlueShield, accessed August 10, 2025, https://individual.carefirst.com/individuals-families/plans-coverage/medical/individual-family-medical-plans-va.page
32. Health insurance plan & network types: HMOs, PPOs, and more | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/choose-a-plan/plan-types/
33. Health insurance plan & network types – Virginia’s Insurance Marketplace Help, accessed August 10, 2025, https://help.marketplace.virginia.gov/hc/en-us/articles/11972827221901-Health-insurance-plan-network-types
34. What is the Difference Between an HMO, EPO, and PPO? – Cigna Healthcare, accessed August 10, 2025, https://www.cigna.com/knowledge-center/hmo-ppo-epo
35. HMO vs PPO: Differences, Similarities & Things to Consider …, accessed August 10, 2025, https://individual.carefirst.com/individuals-families/health-insurance-basics/how-health-insurance-works/hmo-vs-ppo.page
36. Arlington, Virginia ACA Health Insurance Plans – HealthMarkets, accessed August 10, 2025, https://www.healthmarkets.com/plans/aca-health/virginia/arlington/
37. Virginia Health Insurance Plans | Anthem, accessed August 10, 2025, https://www.anthem.com/va/individual-and-family/health-insurance
38. Preferred Provider Organization (PPO) – Virginia’s Insurance Marketplace Help, accessed August 10, 2025, https://help.marketplace.virginia.gov/hc/en-us/articles/11972833643149-Preferred-Provider-Organization-PPO
39. What’s the difference between an HMO and PPO plan? – HealthSherpa Blog, accessed August 10, 2025, https://blog.healthsherpa.com/difference-between-hmo-and-ppo/
40. Health Insurance Marketplace Calculator – KFF, accessed August 10, 2025, https://www.kff.org/interactive/subsidy-calculator/
41. Financial Assistance | CareFirst BlueCross BlueShield, accessed August 10, 2025, https://individual.carefirst.com/individuals-families/health-insurance-basics/health-insurance-costs/financial-assistance.page
42. Essential health benefits – Glossary | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/glossary/essential-health-benefits/
43. What are essential health benefits? – Healthinsurance.org, accessed August 10, 2025, https://www.healthinsurance.org/glossary/essential-health-benefits/
44. Information on Essential Health Benefits (EHB) Benchmark Plans – CMS, accessed August 10, 2025, https://www.cms.gov/marketplace/resources/data/essential-health-benefits
45. Virginia – State Required Benefits | CMS, accessed August 10, 2025, https://www.cms.gov/files/document/va-state-required-benefitspdf
46. Virginia’s Marketplace Plan Comparison Tool, accessed August 10, 2025, https://enroll.marketplace.virginia.gov/prescreener/
47. Marketplace health insurance plans and prices | HealthCare.gov, accessed August 10, 2025, https://www.healthcare.gov/apply-and-enroll/health-insurance-plans-estimator-overview/
48. Navigators – Virginia’s Insurance Marketplace, accessed August 10, 2025, https://www.marketplace.virginia.gov/navigators
49. Find Local Help – the Health Insurance Marketplace, accessed August 10, 2025, https://www.healthcare.gov/find-local-help/