Accessing affordable health insurance has become easier for everyday Americans thanks to the Affordable Care Act (ACA).
A medical insurance plan that follows the regulations of the ACA can help cover healthcare costs, medical treatments, and prescription medications. With so many plans listed on the ACA health insurance marketplace, it can be difficult to make a decision. However, it’s important to choose the one that best fits your unique circumstances.
Regardless of your selection, an ACA plan offers distinct benefits that you can’t afford to go without. If you want to learn more about ACA plans, their benefits, and how to choose the right one, this guide will provide all the necessary information.
What Is ACA Insurance?
ACA insurance refers to all the health insurance plans available on the ACA marketplace at healthcare.gov and several state insurance exchanges.
To be listed on the ACA marketplace, an insurance plan must comply with all the regulations set out under the ACA.
Although most individual health insurance policies and employer-sponsored plans are now ACA-compliant, most short-term and fixed-indemnity insurance plans aren’t.
But what exactly does a health insurance plan have to offer to be ACA-compliant? An ACA health insurance plan:
- Will not institute coverage limitations
- Will provide coverage even for pre-existing conditions (see exceptions below)
- Covers ten essential health benefits (see benefits below)
The Benefits Of ACA Insurance
There are numerous benefits of ACA insurance including the following:
Priceplans To Suit All Households
ACA health insurance plans are available across different tiers, from bronze to platinum, and your unique circumstances will dictate which is best for you. The lower tiers (bronze and silver) typically have lower premiums. The higher tiers (gold and platinum) usually have greater coverage.
These tiers also contain different types of plans, such as Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO), and Point-of-Service (POS) plans.
On a PPO plan, the insurer has contracted a network of medical providers and negotiated prices with them.
You may be covered for treatments at providers outside of this network, but your out-of-pocket costs could be higher. Therefore, using the network providers whenever possible is preferable to avoid these higher costs. But, a PPO offers more flexibility than an EPO.
An EPO plan has a network of providers in place, similar to the PPO plans. However, coverage will not extend to treatments from providers outside of the network.
Coverage is available exclusively for the network designated by the insurer; hence, it is more restrictive than a PPO. But it is generally cheaper long-term than a PPO plan – a big plus for policyholders on a tight budget.
On an HMO plan, you’ll have to use the services of local medical providers designated by your insurer. Usually, you will have to live or work in that area. Also, you will have to go through a primary care physician to access other medical services (except in an emergency).
HMO plans are typically cheaper than others and offer comprehensive healthcare access but are the most restrictive.
No Limitations On Coverage
Before the ACA was passed, insurers could limit a policyholder’s coverage yearly, over the policy’s lifetime, or both. This meant the insurer could set a dollar limit on the amounts they would pay for medical costs incurred.
This coverage limitation has been eliminated since the ACA reformed health insurance laws. Take note that this only applies to ACA-compliant health insurance. Other forms of insurance may still have coverage limitations.
Coverage For Pre-Existing Conditions
Under the ACA, policyholders can’t be discriminated against regarding coverage for pre-existing medical conditions. In the past, this could lead to a denial of coverage, rejected claims, long waiting periods, higher premiums, or even cancellations of policies if it was discovered after the policy was started.
The ACA changed all that. When it was passed into law in March 2010, children (under 19) with pre-existing conditions were no longer denied coverage for treatments related to those conditions. In addition, no waiting periods or hiked rates could apply. From January 2014, adults enjoyed the same benefit.
Young adults can stay on their family’s ACA health insurance plan until age 26.
ACA Plans Cover The 10 Essential Health Benefits
ACA regulations require all health insurance plans to cover these 10 essential health benefits:
- Ambulatory services
- Emergency medical services
- Maternity and newborn medical care
- Mental health services (including substance abuse treatments)
- Prescription medications
- Lab tests
- Preventive health services (contraception, recommended vaccines, tests and screenings for dread diseases, etc.)
- Pediatric dental/vision care
- Rehabilitative and habilitative services (physical therapy after an accident or a stroke, etc.)
How ACA Differs From Other Types Of Insurance
The ACA differs from other insurance because it has safeguards to protect policyholders. It also offers unique benefits that set it apart from different types of insurance.
- While other non-ACA-compliant insurance may have limitations on coverage, ACA plans don’t.
- Whereas other types of insurance might not offer prescription drug coverage or preventive health services, all ACA plans are required to do so, along with other essential health benefits.
- Although pre-existing conditions may pose a problem with fixed indemnity plans, they are not a barrier to coverage on ACA plans.
- Low-income households have greater access to insurance through the ACA. If they meet the eligibility requirements (based on income), they can get subsidies that lower their premiums or out-of-pocket costs like deductibles, copayments, and coinsurance.
How Can You Get ACA Insurance?
It’s easy to sign up for ACA health insurance, but you must sign up during the Open Enrollment period (November 1 to January 15 every year).
Specific qualifying life events trigger a Special Enrollment Period (SEP) outside the regular Open Enrollment period, during which individuals and families can enroll in or change their health insurance plans.
The purpose of a Special Enrollment Period is to ensure that people who experience significant life changes aren’t locked out of obtaining or changing their health insurance coverage. Qualifying life events might include:
- Marriage or domestic partnership
- Birth or adoption
- Loss of other coverage
- Moving to a new area
- Change in household size
- Expiration of COBRA coverage
Besides the enrollment period requirements, you’ll also have to meet a few eligibility requirements.
Eligibility Requirements For ACA Insurance
To be eligible for health insurance on the ACA marketplace, you must be:
- A US citizen or national, or legal resident
- Living in the United States
- Not receiving Medicare and not covered by a spouse or relative’s insurance
- Not incarcerated at the time of application
You may be asked for proof of citizenship, residence, and income. You may also apply for an ACA subsidy if your income falls between 100 and 400% of the federal poverty line set for the year. However, ACA subsidies are only available for silver-tier benchmark health insurance plans.
What Does ACA Insurance Cost?
Your monthly costs depend on several factors. These include your type of plan, the metal tier the plan falls under, and how many members of your household are covered by the plan. Also, your costs will be significantly lower if you receive an ACA subsidy.
However, on average, health insurance on the ACA marketplace will cost you between $300 and $450 for an unsubsidized plan if you are young and single. The costs can be far higher if you are older or have a family to cover.
Which ACA Health Plan Should You Choose?
Your choice of ACA plan should be determined by your family responsibilities, age, income, and health status. Look at the examples below to determine which ACA health insurance plan is right for you.
- A more basic plan on the bronze or silver tier will suffice when you are single, in good health, but not earning a high income. However, consider that lower premiums often go hand in hand with higher out-of-pocket costs like coinsurance, copayments, and deductibles.
- If you are financially responsible for a spouse and/or children and your family has a variety of healthcare needs, a silver-tier health insurance plan might be right for you. Note that your total household net income will determine your subsidy eligibility.
- Are you a mature person with a higher income, and fewer financial constraints, but with higher medical needs? A more comprehensive plan on the gold or platinum tier might be the right choice. But although you’ll enjoy more coverage, you’ll pay higher premiums.
Why An Insurance Broker Can Help
You may be unsure of how your circumstances affect your medical insurance needs. Or you can’t decide on a plan that’s right for you. That’s where the services of a licensed broker are invaluable.
As trusted health insurance brokers, Enhance Health can assist you with information, advice, and the sign-up process itself. As experts in the health insurance field, including all ACA requirements, we can help you get the best insurance.
How ACA Insurance Is Regulated
Are there consequences to not having ACA-compliant health insurance? Yes, there are, especially for businesses. But how is this regulated?
The ACA requires businesses that employ 50 or more full-time staff to provide at least 95% of them with health insurance or face stiff fines.
These businesses must also report their compliance to the IRS, with an annual confirmation of benefits offered through Form 1095-C.
When the ACA was first introduced, individuals faced possible tax penalties if they did not sign up for health insurance. That federal mandate for health insurance sign-up was later scrapped.
However, five states – California, Massachusetts, New Jersey, Rhode Island, Vermont, and the District of Columbia- retained individual health insurance mandates. Failure to comply in these states (except Vermont) and D.C. incurs tax penalties.
The Impact Of ACA Insurance On The Healthcare Industry
The Affordable Care Act significantly impacted the healthcare industry.
Easier To Get Health Insurance
It made health insurance easier through access to sign-up procedures on a centralized federal marketplace and several state insurance exchanges. This meant that a greater number of U.S. citizens than ever before now had access to health insurance.
This benefited the healthcare industry because more people felt confident accessing health services. However, it also meant they could no longer charge people exorbitant fees for medical care, as more and more people were covered by insurance with negotiated prices.
Fewer Uninsured People
The ACA reduced the number of uninsured people and eliminated barriers to coverage for people with pre-existing conditions. By eliminating the limitation on coverage that was the norm across the insurance industry pre-ACA, fewer people were forced to forego much-needed medical care.
Because of this, it’s rare for anyone with a medical issue to avoid seeing a doctor. That means more patients through the doors of doctor’s rooms, clinics, and hospitals. And more business for the healthcare industry.
Guaranteed Business If On An Insurer’s Network
By joining the networks of ACA-complaint insurers, medical providers now had access to guaranteed numbers of potential clients. However, it also meant they had to streamline their fees per the insurer’s expectations. This is a good thing, though.
In volume, the increased number of potential transactions means more profits for the healthcare industry. Therefore, the ACA has positively impacted healthcare providers and recipients of those health and medical services.
The ACA has transformed health insurance, ensuring more Americans can access essential healthcare services without financial strain.
Navigating available health plans under the ACA requires careful consideration.It’s crucial to assess your unique needs, financial situation, and family dynamics when selecting a health plan to benefit fully from its coverage and protection against unexpected medical expenses.
Which ACA plan should you choose? Your unique circumstances will be the deciding factor. But we can help you.
We’re here for you if you want sign-up assistance or advice about choosing the right ACA plan. Our qualified agents are standing by to answer your questions and help you find the healthcare coverage that best suits you. Get in touch today.