what is an affordable care act (aca) plan?
Enacted in 2010, the Affordable Care Act (ACA) expanded health insurance coverage to more than 20 million people by increasing benefits and lowering health insurance costs to make coverage affordable. more affordable. In addition, the ACA expanded access to health insurance with the creation of a federal marketplace (sometimes called an exchange and run by the state in some states).
aca plans (also known as qualified health plans) are the main health insurance plans certified by the aca health insurance market to be offered in the market. all plans here –
- provide essential health benefits
- Follow established limits on cost sharing (such as deductibles, copays, and maximum out-of-pocket amounts)
- provide coverage for people with pre-existing conditions
- eliminate lifetime and annual dollar limits on health insurance coverage
- provide 100% coverage for preventive care and cancer screening.
The 10 essential health benefits include:
- emergency services
- outpatient services
- maternity and newborn care
- mental health, behavioral health, and substance use disorder services
- prescription drugs
- rehabilitation and habilitation services
- laboratory services
- pediatric services, including oral and vision care
- preventive and wellness services and chronic disease management
aca compatible plans are also available outside the market. You can buy ACA-compliant health insurance and other types of insurance directly from the insurance company or through a private marketplace, such as eHealth. (ehealth offers consumers access to plans here in the marketplace, as well as health insurance products offered outside of the federal and state marketplaces).
In addition, non-Marketplace health insurance offerings include non-ACA compliant medical plans, which do not include all of the benefits and consumer protections of ACA plans, as well as insurance that is not regulated by ACA, such as indemnity plans and short-term insurance policies.
plan here versus plan no here: which is the best option?
Your decision whether or not to purchase CA-compliant health insurance is likely to be determined by a number of personal factors. For example, if you find yourself uninsured and waiting a short time to enroll in an ACA-compliant group health coverage, Medicare, or an ACA-compliant individual plan, you may want the protection of non-ACA-compliant health insurance. such as -term health insurance coverage.
when considering a here plan versus a non-here plan, keep in mind –
- Enrollment in the aca plan is limited to the annual open enrollment period in the fall for the next year’s coverage, unless your life circumstances make you eligible for a special enrollment period, such as the loss of other coverage, have a baby, or get married.
- if you qualify, premium subsidies are only available if you buy a plan here on the marketplace and cost-sharing reductions are only available if you choose a silver plan on the marketplace. You can get subsidy estimates on ehealth while you’re shopping for plans, so you can get an idea of how much financial support you’ll receive.
- Although the individual tax penalty has been eliminated at the federal level, if you live in an area where the state requires individual coverage, you may be penalized if you choose a plan other than here. be sure to check your state requirements.
- Often, non-ACA plans, such as short-term and indemnity plans, can be purchased at any time during the calendar year. Similarly, they are easy to cancel at any time.
what are the different types of plans here?
There are 4 main types of health insurance plans here:
- ppos – or preferred provider organization plans
- poss – or point of service plans
- hmos – or health maintenance organization plans
- epos – or exclusive provider organization plans
It’s important to consider factors like your budget, where you live, and the type of health care you need when choosing among the plans here.
ppo (preferred provider organization plans)
preferred provider organization plans, also called ppos, are one of the most popular types of plans for individuals and families. ppos allow you to visit any in-network health care provider you want without needing a referral from a primary care provider.
in-network care will be covered at a higher benefit level than any care you receive out-of-network.
You can expect ppo plans to require you to pay an annual deductible before the insurance company begins paying its share for most services. In addition, you may also have a copay (according to ehealth surveys, copays are often around $10-$30) or coinsurance that you must pay for certain health care services.
A ppo plan may be the right plan for you if:
- you want the freedom to choose almost any medical facility or provider for your needs
- want some coverage if you choose to go off the grid
- You don’t want to have to first get a referral from your primary care provider to see a specialist
- you are buying a plan here with a low monthly premium
- you want a plan here with little or no deductible
- your usual care is preventive care services
- are willing to coordinate your care through your designated primary care physician
- your preferred doctor participates within the plan’s network
- You don’t want to have to get a referral to see a specialist
- your preferred providers are in-network
- want to receive a lower monthly premium than you would normally get with an hmo or ppo plan
hmo (health maintenance organization plans)
hmo plans, or health maintenance organization, offer a wide range of health care services through a network of providers who agree to provide these services to members. You’ll likely have coverage for a wider range of preventive health care services than you would under another plan.
As of 2018, HMOS has become the most popular ACA plan among eHealth customers. according to a recent study, 53% of buyers selected an hmo plan in 2017.
You will be asked to choose a Primary Care Physician (PCP) who will take care of most of your health care needs. Your PCP should refer you to a specialist if they decide you need to see one.
Although hmo’s tend to have lower out-of-pocket costs, you may need to pay a deductible before your hmo begins to pay its share for covered health services. your copays will likely be reasonable, and for services such as doctor’s office visits, you can pay a $20 – $35 copay and the hmo will pay the rest of the eligible charge. no deductible can be applied to the doctor’s visit. Keep in mind that with an HMO, you may not be covered for non-emergency care you receive out-of-network or for services you receive without proper referral from your PCP.
an hmo plan may be the right plan for you if:
pos (point of service plans)
A point-of-service, or pos, plan has some qualities of an hmo and ppo with benefit levels depending on whether you receive care in-network or out-of-network. You can think of a pos plan as a hybrid hmo/ppo.
Similar to an hmo plan, with a pos plan you will have to designate a pcp who will make referrals to in-network specialists when needed. Services received through your PCP are generally not subject to a deductible. Preventive care services are covered at the PCP office visit copay.
Similar to a ppo plan, you can receive care from providers outside of your provider network, but your out-of-pocket costs will be higher. you may pay a higher copay, coinsurance, or deductible for out-of-network services than you would for in-network services.
a pos plan may be the right plan for you if:
epos (exclusive provider organization plans)
With an exclusive provider organization, or epo, plan, you use only health care providers (this includes doctors, specialists, and hospitals) within the plan’s network. You don’t need a referral, but if you pay the entire medical bill if you’re out of the plan’s provider network for non-emergency care, the plan hasn’t authorized coverage before you get it.
an epo plan may be the right plan for you here if:
You can start shopping for a health insurance plan that fits your budget and coverage needs at any time of the year. However, you can only enroll in an ACA-compliant plan during the annual open enrollment period, which runs from November 1 to December 15 in most states, or during a special enrollment period.
eHealth’s intuitive site and licensed health insurance agents can help you compare your health insurance plan options to find the plan that’s right for you. visit our singles & Family Health Insurance Today page to see the ACA compliant plans that are available.
how to choose a health insurance plan: health insurance plan & network types: hmos, ppos and more. health.gov. medicare centers & Medicaid services at https://www.healthcare.gov/choose-a-plan/plan-types/