How the four states differ

All four states we work in use the federal Marketplace, so the Marketplace half of the picture works the same way in each. What differs is everything sitting underneath it — and that is where a neighbour’s experience stops being a guide to yours.

This guide describes what varies rather than stating the current position of any state, because those positions change, sometimes at short notice. For where a state stands today, check with the state agency or the Marketplace Call Center.

What is the same in all four

They are federally facilitated. You apply through HealthCare.gov rather than a state-run exchange. The application, the plan comparison and the premium tax credit work identically.

Guaranteed issue. No plan may ask health questions or decline you. This holds everywhere.

The same ten essential health benefits. Every Marketplace plan covers them, whichever state and whichever tier.

The same Open Enrollment window and the same special enrollment rules.

If any of the four ever moves to running its own exchange, the mechanics change materially — dates can differ, and the application moves. That is worth checking each autumn rather than assuming.

What differs

Medicaid eligibility for adults. This is the largest difference between states and the one that most affects households. Whether adults without dependent children can qualify, and at what income, is a state decision, and the four states have not all made the same one. It has also changed over time in some of them.

The practical consequence: a household near the lower end of the income range can get quite different answers on either side of a state line. Apply and let the application decide rather than assuming.

CHIP. Each state runs its own children’s programme, with its own name, thresholds, cost-sharing and renewal process.

Which carriers offer plans, and in which counties. Carrier participation is decided county by county. A carrier active across Iowa may not be present in the Nebraska county twenty minutes away.

Networks and their width. Rural network breadth varies enormously and is the practical difference people feel most. In some counties there is genuine choice of hospital; in others there is one, and the question is only whether your plan covers it.

State insurance departments. Complaints, market conduct and producer licensing are handled by each state’s own department. If you need to complain about an agent or an insurer, it goes to the department of the state you live in.

What this means when you compare

Compare within your own county, always. Not the state, and not the nearest town over the line. Everything material is set at county level.

Do not port a neighbour’s conclusion. Different household, different income, different doctors — and possibly a different county.

If you move across a state line, start again. New Medicaid rules, new CHIP programme, new carriers, new networks. There is a separate guide on moving.

If your income is towards the lower end, check Medicaid first. It costs nothing to be assessed, the assessment happens automatically in the same application, and the answer differs by state in a way that is not obvious from outside.

Where to check the current position

HealthCare.gov assesses you against your own state’s rules automatically when you complete the application.

The Marketplace Call Center — 1-800-318-2596, TTY 1-855-889-4325 — is free and open 24 hours, and will tell you where your state currently stands.

Your state Medicaid and CHIP agency is the authority on the children’s and adult Medicaid programmes.

Navigators and certified application counselors know their own state’s specifics well and are not paid by insurance companies. Find one at localhelp.healthcare.gov.

We are licensed in all four states, which mostly means we have learned where the differences bite. Ask us; it costs you nothing, and “it depends which side of the line you are on” is a real answer here rather than an evasion.