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.
Mental Health, Substance Abuse
Inpatient and outpatient medical care offered by mental health professionals.
Emergency Services
Medical services requiring immediate action, performed in ER.
Prescription Drugs
Prescriptions administered in hospital, and also picked up at a pharmacy.
Hospitalization
Medical services performed in a hospital based setting.
Rehabilitative Services + Devices
Services such as physical therapy, occupational and speech therapy.
Maternity and Newborn Care
Pre-natal, delivery and post-natal medical care, including complications.
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 and well-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 (not true dental and vision insurance).
Two Important Guarantees the ACA Offers You
Because only the annual enrollment period 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.
Maximum Out of Pocket Costs and No Lifetime Maximums on Benefits
No matter the way each medical service is covered on each plan design (copays, deductibles and coinsurance) the Maximum Out of Pocket Costs cap on medical expenses an insured person can pay out of their own pocket for medical expenses is limited to $8,150 for a covered individual, and $16,300 for a family (more than one person covered).
That means even in a “worst case scenario” situation of your having a lot of medical services in one year, you know the cost you have to pay stops at a certain amount, and the insurer is required to pay the rest.
The ACA also guarantees that there can be no cap on the amount of medical expense costs an insurer may have to pay, both in one plan year, and also over the policy lifetime. In short, there is no lifetime maximum limit on benefits.
The Affordable Care Act Guarantees That All People Can Get Health Insurance, No Matter Their Health History or Coverage History
The Affordable Care Act requires health insurance issuers to offer all of their individual market and group market plans to any applicant living in the state where the insurer offers products. It 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.”
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:
Tax Credits (APTCs) help lower the cost of the monthly premiums we pay to insurers for health insurance
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.
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.
Free Personalized Quote and Info
We encourage you to review the next page “Health Insurance with Tax Credits” to learn more about choosing your own health insurance plan. But if you are ready now to ask for help complete the form below and Chip will send you an email with more information and recommended quotes of insurance specific to you (including detailed ideas of premium costs and benefits). You can review the information, then follow up with your questions via email, phone call, text, or Zoom / Facetime.
Note: Privacy is something we take seriously, and keeping the information you shared private is of utmost importance to us. We do not share any information with third parties. The minimum of information is shared with an insurance company to put together a detailed free quote and illustration for you.