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What is the Affordable Care Act (ACA)?

The Individual healthcare insurance market is known by a few different names: Major Medical Insurance, The Marketplace, Affordable Care Act, Obamacare, etc. All of these are in fact the same thing: a platform that facilitates the sale of private health insurance plans operated by the United States federal government under the Patient Protection and Affordable Care Act of 2013.

Affordable Care Act 101

Under the Affordable Care Act all medical health insurance plans must cover a list of essential health benefits that includes:

  • Ambulatory patient services
  • Emergency services
  • Maternity, pregnancy, and newborn care
  • Mental health and substance use disorder services
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventative and wellness services
  • Pediatric services

All plans must also include some additional benefits, including birth control coverage and breastfeeding coverage. Plans may provide other benefits such as dental and vision but are not required to.

The Affordable Care Act also introduced a number or rights and protections for healthcare consumers such as requiring insurance companies to cover people with pre-existing health conditions and making it illegal for insurance companies to cancel coverage for patients who become sick.

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Who is eligible for the Affordable Care Act?

People who are not on an employer group insurance plan such as those who are self-employed, small business owners or students, and/or those who are not on Medicare.

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What does the ACA cover?

All Marketplace plans cover the same 11 Essential Benefits:

  1. Preventative and wellness services, and chronic disease management
  2. Emergency services
  3. Ambulatory patient services (outpatient hospital care)
  4. Hospitalization (inpatient hospital care)
  5. Laboratory services
  6. Prescription drugs
  7. Birth control coverage
  8. Pregnancy, maternity, and newborn care, including breastfeeding coverage
  9. Pediatric services, including oral and vision care
  10. Mental health and substance abuse disorder services
  11. Rehabilitative and habilitative services and devices

These are the minimum coverage requirements for all plans; some plans may offer additional benefits such as adult dental and vision, and medical management programs for specific needs such as diabetes.

All Marketplace plans must also cover treatment for pre-existing medical conditions, and cannot reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started.  After you are enrolled, your insurance carrier cannot deny you coverage or raise your rates based only on your health.

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When can you enroll in ACA?

Each year there is an Open Enrollment Period during which you can apply for a new plan or change your current coverage; the 2019 Open Enrollment Period ended on December 15th, 2018.  To apply or change your plan outside the Open Enrollment Period you must have had one or more of the following Life Changes within the past 60 days to qualify for a Special Enrollment Period:

  • Changes in household
    • Such as marriage, birth/adoption of a child, divorce, or death
  • Changes in residence
    • Such as moving to a new zip code or county, moving to the U.S. from a foreign country, or moving to/from a shelter or transitional housing
  • Loss of health insurance
    • Such as losing employer group coverage, losing eligibility for Medicaid or CHIP, or losing coverage through a family member
  • Other qualifying reasons

Alternatives to ACA

There are two alternatives to traditional Marketplace plans: Health Sharing plans and Short-Term Major Medical plans.

Health Sharing plans are NOT insurance, strictly speaking, but do satisfy the ACA requirement. As a member of a Health Sharing plan you pay a monthly “contribution” instead of a premium. When you see your doctor, they will send the bill to the Health Sharing company who then pays the bill using money from a pool of every member’s contributions.

Short-Term Major Medical plans are designed to last no more than 90 consecutive days. They are helpful for providing coverage while someone is in between jobs, until someone becomes eligible for Medicare, or if someone missed the chance to enroll in an ACA plan. Some plans can be “stacked” to provide coverage longer than 90 days.

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