Affordable Care Act 101
How the Affordable Care Act (ACA) Benefits You
The Affordable Care Act (ACA), passed by Congress in 2010, and beginning in 2014, drives every factor in choosing your own health insurance plan. This page summarizes the many benefits and rules.
Essential Health Benefits
The Affordable Care Act mandates that all ACA-compliant health insurance plans must cover 10 "Essential Health Benefits." Those essential health benefits are:
Ambulatory Services
Medical services performed without admission to a hospital.
Emergency Services
Medical services requiring immediate action, performed in the ER.
Hospitalization
Medical services performed in a hospital based setting.
Prescription Drugs
Prescriptions administered in hospital, and also picked up at a pharmacy
Mental Health, Substance Abuse
Inpatient and outpatient medical care offered by mental health professionals.
Maternity and Newborn Care
Pre-natal, delivery and post-natal medical care, including complications.
Rehabilitative Services + Devices
Services such as physical therapy, occupational and speech therapy.
Laboratory Services
Medical tests to aid in diagnosis, treatment, and prevention of disease.
Preventative / Wellness Services and Chronic Disease Management
Preventative medical testing and services such as annual exams, mammograms, physicals, colonoscopies, well-baby/child visits.
Pediatric Services for those under age 19, including Dental and Vision
A full host of medical services for children. Also some basic dental and vision services like exams.
Two Important Guarantees the ACA Offers You
Most of the old health insurance horror stories you hear revolve around exorbitant costs paid for medical care, or insurers denying coverage. See below for guarantees the Affordable Care Act affords to all insureds covered by ACA compliant plans.
Maximum Out of Pocket Costs and No Lifetime Benefit Maximums
As you begin to use medical services and pay copays, deductible and coinsurance according to the details of your health insurance plan, you wonder when the costs will stop!
The Affordable Care Act mandates the health insurer only allows you to pay out of pocket medical costs up to an “out of pocket maximum” for the calendar year.
Health insurers can set the out of pocket maximum in their plan designs, but only up to $9,200 for a covered individual, or $18,400 for a family (more than one person covered).
If you were to meet the out of pocket maximum during the plan year the health insurer is required to pay 100% of the cost for the remainder of the year.
The ACA also guarantees that there can be no cap on the amount of medical expense costs an insurer may have to pay for your care, both in one plan year, and also over the policy lifetime. In short, there is no lifetime benefit maximum limit.
All People Can Get Health Insurance, No Matter Their Health or Coverage History
The Affordable Care Act requires health insurance issuers to offer all of their Affordable Care Act compliant plans (individual and family plans available through the Marketplace and directly through insurers, and also employer-sponsored health insurance) to any applicant living in the state where the insurer offers products.
The ACA also requires health insurance issuers to accept any individual who applies for those policies, as long as the applicant agrees to the terms and conditions of the policy, including the payment of premium costs. In other words, the health insurance policies are “guaranteed issue.” You cannot be turned down by the insurer because of your medical conditions, In fact, there are no health questions asked in the enrollment process.
The Affordable Care Act requires health insurance providers to offer to renew or continue in force coverage at the option of the policyholder. In other words, the health insurance policies are “guaranteed renewable” each plan year.
The Affordable Care Act prohibits health insurance issuers from limiting or excluding coverage related to pre-existing health conditions, regardless of the age of the covered individual. Generally, a pre-existing condition is any health condition or illness that was present before the coverage effective date, regardless of whether medical advice or treatment was actually received or recommended.
Put another way, there are no more pre-existing conditions that health insurance companies can refuse to cover! All medical services are guaranteed to start your first day of coverage.
Federal Subsidies: Advanced Premium Tax Credits and Cost-Sharing Reductions
One of the biggest benefits of the Affordable Care Act that benefits many (but not all) individuals and families are two subsidies offered through the Marketplace that assists in controlling the costs of medical care:
Advanced Premium Tax Credits (APTCs) help lower the cost of the monthly premiums we pay to insurers for health insurance. The tax credits are instant, subtracted from the health insurer’s premium rates, and you pay the lower remaining premium cost.
Cost Sharing Reductions (CSRs) help lower out of pocket medical costs we pay to doctors, hospitals and pharmacists with lower copays and deductibles on silver metallic level plans. If you are eligible for CSRs you can choose Silver level benefit plans where the copays, deductible and out of pocket maximums have been reduced, to limit the medical costs you have to pay.
Chip Millard is a member of Healthcare.gov's "Champions Circle."
A distinction awarded to health insurance agents and brokers who go above and beyond to increase access to health insurance (helping local people understand their benefits and costs options, and helping them enroll) in their communities.
You Can Enroll in Health Insurance at Any First of the Month
Because only the annual enrollment period (AEP) is publicized many people mistakenly you can only enroll in your own health insurance plan at the beginning of each year. Not true! Read below to understand the two enrollment periods.
Annual Enrollment Period (AEP)
During the fourth quarter of each calendar year anyone, for any reason, can choose their own individual or family health insurance plan for the upcoming plan year.
The Annual Enrollment Period or “AEP” in which anyone can choose their own health insurance plan always begins on November 1st, then runs until December 15th….and any coverage chosen in this AEP begins on January 1 of the following year.
No matter what your current coverage is, or even if you do not have health insurance, you can choose any health insurance plan design from any available health insurer and the coverage will begin January 1.
Special Enrollment Periods
(SEP)
But as we know, life does not happen so conveniently that all of our life changes happen only on January 1! The Affordable Care Act takes this into account and offers Special Enrollment Periods or “SEPs” to allow you to choose health insurance on a first of the month within the year to accommodate a life change.
Here are the SEPs we see most often:
1. Losing employer-sponsored health insurance: The most often utilized SEP…losing your employer offered health insurance because you left the employer, were fired, laid off, furloughed, or moved to part-time hours. We can enroll you in a health insurance plan you choose the first of the month after your employer-sponsored coverage ends (which is usually the end of a month).
2. Turning age 26 and losing health insurance as your parents’ dependent. When you turn 26 you can no longer remain on a parent’s employer based or individually chosen coverage. This SEP allows you to choose your own plan.
3. Losing your health insurance based on a separation agreement or finalized divorce. When either of these two decrees are issued and you lose your coverage as a dependent, you can enroll in a new plan you choose.
4. Having a baby or adopting a child. This is the one SEP where we can begin coverage other than the first of the month…rather the start date is the date of the baby’s birth or the adoption date.
5. Moving. If you move to a new county, new state or move back from abroad, you can choose a plan and enroll for coverage beginning the first of the next month.
6. Losing student coverage. If you graduate and lose access to health insurance offered by a college or university, you can choose a new health insurance plan to begin the next first of the month.
And many others, including getting married, losing Medicaid eligibility, the death of a family member, becoming a U.S. citizen, leaving incarceration, and unique SEPs announced after major events such as a hurricane.
We Work With All Affordable Care Act Compliant Health Insurers in North Carolina, Including…
Free Personalized Quote and Information
Complete the form below and Chip will send you an email with recommended quotes of insurance to compare to your COBRA health coverage. All in a conversational, “plain speak” explanation of the details Chip is known for (see our reviews on the home page). You can review the information, then follow up with your questions via email, phone call, text, Zoom, or in person.
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