A qualified health plan is a plan that has been certified for sale on a health insurance marketplace. The certification is a floor, not a grade. To carry the label, a plan has to cover the categories of essential health benefits, stay within set limits on cost sharing, and accept anyone who applies — it cannot turn you down or charge you more because of a pre-existing condition.

That floor is the whole of what the label guarantees. It says nothing about who you can see with the plan. Certification does not rate the network, and two plans on the same metal tier, at nearly the same premium, can have entirely different hospital lists and entirely different drug lists. The tier describes how costs are split between you and the insurer. It does not describe who is in the plan.

So the comparison that matters starts after the tier. Check the network for the doctors and the hospital you actually use, check the drug list for what you actually take, and treat the certification as the reason those two plans are comparable at all rather than as a verdict on either one.

The practical reason the label matters is money. The premium tax credit attaches only to a qualified health plan bought through the marketplace. The same insurer may sell you a similar policy directly, and that purchase is not eligible for the credit. The discount does not follow you off the exchange.

In New York: four things change the shape of this.

Plans are certified county by county. The county you put on the application builds the menu you are shown. An insurer certified where you live may not be certified one county over, which is why a plan a relative recommends can simply fail to appear for you, and why the address is the first thing to get right on the application.

The season is longer here. Open enrollment runs November 1 to January 31, wider than the federal window, with December 15 the cutoff for coverage that starts January 1.

Three programs below the marketplace are not qualified health plans at all — Medicaid, the Essential Plan and Child Health Plus. They are not certified, not sold by metal tier, and they have no enrollment season: you apply in any month of the year. The Essential Plan is $0 a month at or below 200% of the federal poverty level, with no deductible. The same marketplace application sorts you, so this is never a choice between two forms. It is one form and an answer.

Short-term limited-duration insurance is prohibited in New York. In other states it is sold as the cheap alternative to a certified plan, without the benefit floor and without the pre-existing-condition protection. It cannot be sold here at all, so an unusually cheap offer that is not a qualified health plan is worth a hard look at what it actually is.

Also called: QHP, marketplace plan, exchange plan. Full guide: The New York health insurance marketplace.

More in Glossary of health coverage and billing terms

  • Spend-down (excess income) — The monthly amount of medical expense you must incur before Medicaid covers the rest of the month, when your income is over the limit.
  • Pooled income trust — A trust run by a nonprofit that holds your excess monthly income so Medicaid disregards it, while still paying your rent and bills.
  • Fair hearing — The state's review of a decision about your Medicaid, with two different deadlines that people routinely confuse.

This page explains how the system works. It is not medical advice. More.