UPDATED: OCTOBER 04, 2023 | 3 MIN READ
If you’re shopping for health insurance for yourself and your dependents, you may consider purchasing health coverage through the Health Insurance Marketplace. New to the insurance-buying process or unfamiliar with the Affordable Care Act? Here’s everything you need to know to find the right ACA plan and how to apply for Marketplace coverage at HealthCare.gov.
What is the Affordable Care Act?
Sometimes known as ACA or Obamacare, the Affordable Care Act is a comprehensive health care reform law enacted in March 2010.
The ACA has three goals:
- To make health insurance more affordable and available by providing subsidies (premium tax credits) to households with incomes between 100% and 400% of the federal poverty level (FPL).
- Expand the Medicaid program to cover everyone with income below 138% of the FPL.
- Supporting innovative medical care methods that keep healthcare costs low.
The ACA’s main purpose is to extend health-care coverage to those with income below the FPL, who don’t have health insurance through their work, or Americans excluded from health insurance plans due to pre-existing conditions. The law also requires everyone to be covered under a health plan and imposes coverage rules on health insurers.
Who is eligible for Obamacare?
As of 2021, over 11 million Americans are enrolled in coverage provided by the Health Insurance Marketplace (HIM). To be eligible for health coverage through the Marketplace, consumers must live in the United States and be U.S. citizens or nationals (or be lawfully present.) Obamacare isn’t available to those incarcerated or enrolled in Medicare coverage.
What are the different Affordable Care Act health plans?
Considering individual factors such as your budget, location, and healthcare needs is important before enrolling in an ACA plan.
ACA health insurance plans are split into four main coverage options:
- PPOs or Preferred Provider Organization Plans
- POSs or Point-Of-Service Plans
- HMOs or Health Maintenance Organization Plans
- EPOs or Exclusive Provider Organization Plans
You can use almost any doctor or healthcare facility depending on the plan type. Other plans may charge you more or limit your choices if you use out-of-network providers. Review each plan’s offerings before enrolling if a large network is important to you.
Essential health benefits
The ACA mandates that all Marketplace plans cover ten essential health benefits. Understanding these benefits is the first step toward maximizing your coverage:
- Ambulatory patient services: These ambulatory services include outpatient care, such as doctor’s visits, without hospital admission.
- Emergency services: Coverage for unexpected medical emergencies, ensuring you receive prompt care when needed.
- Hospitalization: Coverage for surgeries and overnight stays, offering peace of mind during serious medical situations.
- Pregnancy, maternity, and newborn care: Comprehensive care before and after childbirth, supporting you throughout this important journey.
- Mental health and substance use disorder services: Includes counseling, psychotherapy, and behavioral health treatment.
- Prescription drugs: Coverage for necessary medications to manage your health conditions.
- Rehabilitative and habilitative services: Services and devices to aid recovery from injuries, disabilities, or chronic conditions.
- Laboratory services: Diagnostic tests and screenings to ensure accurate healthcare decisions.
- Preventive and wellness services: Vital for staying healthy, including vaccinations and screenings for chronic diseases.
- Pediatric services: This covers oral and vision care for children, though adult dental and vision aren’t essential health benefits.
Addressing state variations and options
It’s crucial to recognize that the specific services covered within these benefit categories can vary from state to state. Therefore, the second step in maximizing your ACA benefits is understanding the requirements in your state. To do this:
- Visit your state’s ACA Marketplace website or consult a licensed insurance agent specializing in ACA plans.
- Ensure you know any additional services your state mandates, which may enhance your coverage.
Extra benefits and customization
In addition to the essential health benefits, ACA plans offer extra benefits and coverage. These include:
- Birth control coverage: Ensuring access to contraception methods.
- Breastfeeding coverage: Support for new mothers during a critical time.
- Optional dental and vision coverage: Some plans may offer these additional services.
- Medical management programs: Plans may provide specialized programs for specific needs like weight management, back pain, and diabetes.
Customization is the key to maximizing your ACA benefits. Evaluate your unique healthcare requirements and consider plans that offer the extra benefits you need. This tailored approach can help you optimize your coverage.
Understanding the costs related to ACA benefits and coverage
The cost will vary depending on the plan metal tier, location, and plan you select. To understand your costs, review your plan materials, such as the online portal, and summary of benefits. This will help you understand your plan deductible, copayments, and coinsurance for different services and procedures. It’s important to understand which items require the deductible to be met before being covered and the plan’s maximum out-of-pocket
What are the Affordable Care Act’s metal categories?
In addition to the ACA’s plan types, Obamacare health insurance coverage is presented in 4 categories. These categories indicate cost-sharing between you and your health insurer — not quality of care. The ACA’s 4 “metal” categories include Bronze, Silver, Gold, and Platinum. Catastrophic plans are also available.
Costs associated with each metal tier
Each ACA plan tier offers varying cost-sharing between health insurers and consumers. These are only averages—your actual costs will vary.
- Bronze: The insurance company pays 60%, with the remaining 40% paid by the consumer.
- Silver: Your insurer will pay 70%, while you’ll pay a 30% copay.
- Gold: Your insurance covers 80%, and you’ll pay 20%.
- Platinum: The insurance company pays 90%, and you pay a 10% copay.
Affordable Care Act metal tier pros and cons
Each metal tier offers its unique benefits and drawbacks, so it’s important to weigh the pros and cons to find the best Obamacare plan for you. For example, Bronze plans offer the lowest monthly premium, but you’ll pay the most for routine care. Learn more about each metal tier below.
- Bronze plans offer the lowest monthly premium, but your deductible can be thousands of dollars yearly, making costs high when you need routine or emergency care. They’re generally best for healthy young adults.
- Silver plans have moderate monthly premiums and out-of-pocket costs, with lower deductibles than Bronze plans. Silver plans are a good choice if you’re eligible for a premium tax credit based on your estimated household income.
- Gold plans charge high monthly premiums with low deductibles. Gold plans could be a good value if you require more care or have frequent doctor visits, as you’ll reach your deductible quickly.
- Platinum plans carry the highest premium but provide the lowest costs of care. Deductibles are very low, so your plan will start paying its share earlier than other tiers. If you use a lot of care and are willing to pay more each month, you’ll pay far less for each visit.
Each metal tier provides free preventive care; some plans offer free or discounted services before your deductible is met.
How and when to enroll in Obamacare
If you’re considering ACA health insurance coverage, here’s what you need to know about how and when to enroll via the Health Insurance Marketplace.
How to enroll
To get started, you must create a Marketplace account on Healthcare.gov. If your state runs its Marketplace, you’ll be automatically taken to its website. You’ll run through the provided enrollment checklist and estimate your income.
Once you submit your application, you’ll receive your eligibility results for potential savings. This includes tax credits to help with monthly premiums, lower coinsurance, copayments, deductibles, and free or low-cost Medicaid and Children’s Health Insurance Program (CHIP) coverage.
When to enroll
The ACA guarantees coverage for all Health Insurance Marketplace applicants as long as eligibility requirements are met. However, enrollment is limited to an annual open enrollment period that varies by state.
Individuals may also apply during a Special Enrollment Period with a qualifying life event, such as loss of health coverage, certain changes in household and residence, and more.
FAQs
What are Affordable Care Act plans?
Affordable Care Act plans are individual, and family plans from the federal government. PPOs, POSs, HMOs, and EPOs are available in Bronze, Silver, Gold, and Platinum cost-sharing tiers.
What was the Affordable Care Act ACA intended to do?
The ACA is a healthcare law intended to get affordable health insurance coverage to those who may not have been able to afford or qualify in the past due to certain health conditions.
What is the difference between ACA and Obamacare?
ACA and Obamacare are the same things. The law was nicknamed after President Obama signed it into law in March 2010.
What is an ACA Marketplace?
Also known as a health insurance exchange, a health insurance Marketplace is where American consumers can buy health insurance plans and receive income-based subsidies.
What is a pre-existing condition?
A pre-existing condition is a medical condition you have before enrolling in a new health care plan. Examples include cancer, sleep apnea, and pregnancy.
What is the difference between a Bronze, Silver, Gold, and Platinum plan?
Each ACA metal tier offers different cost-sharing percentages. For example, Bronze plans generally offer the lowest premium with the most expensive copay and deductible. In contrast, Platinum plans tend to have the highest premium with the smallest copay and deductible.
Why are ACA plans so expensive?
Many ACA premiums have increased due to the ever-rising healthcare costs in the United States.
What are the benefits of Affordable Care Act plans?
On the Marketplace, you can pick the best possible plan for you and your dependents, regardless of pre-existing conditions.
How much does it cost to buy an ACA plan?
Your actual cost will depend on which ACA plan you choose.
How does ACA affect employer-based health insurance?
The ACA requires businesses to provide Marketplace information to their employees (whether they offer insurance), a maximum 90-day waiting period for benefits, and a standard Summary of Benefits and Coverage (SBC) form that explains the plan covers and what it costs.
The ACA also established the Small Business Health Options Program (SHOP) for small businesses (1-50 full-time employees) that want to provide health and dental coverage. These plans are generally the only way to qualify for the Small Business Health Care Tax Credit to lower premiums.
Do the benefits remain the same in each state?
Generally, yes, but some state-specific variations exist.
Do all Marketplace plans cover essential health benefits?
All ACA Marketplace plans include these benefits, regardless of plan category (e.g., HMO, PPO) or metal level.
Am I required to pay deductibles and copayments for essential health benefits?
Typically, yes. However, there are exceptions. Certain preventive services are provided at no cost, and specific plans may offer no-cost coverage for select services.Do Employer Plans and Grandfathered Plans have these essential benefits?
Regarding employer-sponsored or grandfathered plans, it’s important to note that their coverage may vary compared to ACA plans. While many of these plans do include essential health benefits, it’s essential to remember that they’re not required to do so.Get help understanding Affordable Care Act (ACA) plans
Maximizing your ACA benefits and coverage involves knowing what’s available, considering your unique healthcare needs, and being aware of state-specific variations. By tailoring your coverage to your requirements, you can make the most of the healthcare options provided by the Affordable Care Act. Explore your options, ask questions, and ensure your healthcare plan aligns with your well-being.
Obamacare has helped make healthcare more accessible to millions across the country. Before you enroll in an ACA plan, reviewing your options is best to ensure you’re making the best decision for your care needs and budget. Explore your options with Marketplace and off-exchange plans by requesting free quotes today.
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