ACA Qualified
Health Insurance Plans
The world of Obamacare is full of helpful and yet confusing acronyms — sort of like the details of the reform itself. There’s ACA, QHP, CHIP, MEC — and the list goes on. However, there’s no reason why you can’t easily understand how the Affordable Care Act (ACA) can work for you and your family’s health.
Since its inception, the Affordable Health Care Act focused on lowering health care costs and providing better medical care for Americans as a whole. So far, the ACA is responsible for a reduction in the rise in health care costs every year. It also increases the number of medical benefits that are “essential” in qualified plans, while reducing the overall ranks of the uninsured.
The world of Obamacare is full of helpful and yet confusing acronyms — sort of like the details of the reform itself. There’s ACA, QHP, CHIP, MEC — and the list goes on. However, there’s no reason why you can’t easily understand how the Affordable Care Act (ACA) can work for you and your family’s health.
What Is a Qualified Health Plan?
It’s very simple — QHP stands for “Qualified Health Plan,” and these are ACA compliant health insurance plans that are certified by the Health Insurance Marketplace as ones that provide the “minimum essential coverage” (MEC). Besides these requirements, QHPs must:
- Follow established limits on cost-sharing (deductibles, co-payments, and out-of-pocket maximum amounts)
- Offer the same set of core benefits, including preventative services, prescription drugs, hospitalization, and more
About 88% of the over 10 million people who already have ACA compliant health insurance receive a federal subsidy for using Qualified Health Plans. These comprehensive plans are broken down into four specific tiers, to help consumers make easy comparisons between cost and coverage.
Bronze
A Bronze QHP must cover 60% of the expected costs for the individual. As such, it’s the plan with the lowest monthly premiums but the highest out-of-pocket costs. It has a very high deductible. If you don’t plan on using many medical services — in other words, you’re young and in relatively good health — the Bronze plan is a smart way to make sure you don’t get taxed for being uninsured under Obamacare.
Silver
These are the most common types of plans and many of the ACA subsidies are based on the cost of a Silver plan. While it’s true that premiums on the lowest-cost Silver plans on health insurance exchanges are up an average 35%, many individuals also qualify for the ACA subsidies, which can help offset costs.
88% of individuals who use the health marketplace already qualify for a tax credit to buy ACA plans so this is good news. On a Silver QHP, individuals pay moderate premiums and moderate out-of-pocket costs. The deductibles are, of course, lower than the Bronze plans.
Gold
Gold QHPs have high monthly premiums but also feature lower out-of-pocket costs. The deductibles are low, and their cost is sometimes far more than a Silver plan. However, this depends on your county and state of residence. While the upfront cost is high, the amount you have to shell out when you receive care is relatively low. So, if you have multiple medical conditions, this might be the right option for you.
Platinum
As the name suggests, Platinum plans are the very top-of-the-line QHPs available under the Affordable Care Act. These plans work hard for those who expect to use the full range of medical care services and frequently. The high monthly premiums keep your out-of-pocket costs very low, along with low deductibles. Again, if you qualify for subsidies, this may make a Platinum, or even a Gold QHP, a more cost-effective solution for your healthcare.
What Do Qualified Health Plans Cover?
ACA Qualified Health Plans all have a standard set of services and medical provisions they must cover, known as Essential Health Benefits (EHB). This is an ACA requirement that QHPs must meet. All plans have these 10 provisions:
- Ambulatory outpatient services
- Emergency services
- Hospitalization, including surgeries and overnight stays
- Pregnancy, maternity, and newborn care (including birth control and breastfeeding)
- Mental health and substance use disorder care (including behavioral health treatments, counseling, and psychotherapy)
- Prescription Medication
- Rehabilitative services
- Lab services
- Preventive
- Pediatric services including oral and vision
These are the details on the services and provisions of ACA compliant health insurance plans. However, QHPs are also known as such for the other aspect of health insurance: costs. Besides meeting coverage for essential benefits, which you can think of as a baseline, QHPs must also meet maximum (or “upper” ceiling) limits on deductibles, out-of-pocket costs, and copays.
Out-of-Pocket Costs
Every QHP is based on cost-sharing between insurers and individuals. Out-of-pocket expenses are your portion of what you’re responsible for paying when you receive healthcare. However, these are not to be confused with monthly health insurance premiums. These can be in the form of copay, coinsurance, or deductibles.
Bronze QHPs with low monthly premiums are also the ones with the highest out-of-pocket costs because the idea is that if you’re opting to reduce the amount you pay each month, you’re saying that you have the capacity to pay out of pocket to a greater degree. Perhaps that’s because you’re not anticipating using healthcare services very frequently, so shelling out a greater amount once or twice is financially feasible for you.
Deductibles
Health insurance deductibles are the amount of money you must first pay before the insurance company starts paying its share of costs. For example, a QHP with a $2,000 deductible means that you would have to pay for $2,000 worth of healthcare provisions before your insurance kicks in and pays its share.
Copayment - Coinsurance
Copays are based on the health care service. For example, a doctor’s visit might have a $25 copay while an emergency room visit may have a $250 copay. Copays are usually in lieu of the deductible for certain medical services.
Coinsurance is the amount you must pay in addition to your deductible in order to reach your Out of Pocket. Now it’s important to note that these out-of-pocket expenses have maximums. Recent changes made to ACA means that some insurers could offer non-compliant health plans that do not cover all 10 essential benefits, such as maternity and mental health.
Open Enrollment Periods
Every year, the health markets open for enrollment from November 1st through December 15th. Dates can vary by year and even by state. There is also a Special Enrollment Period where individuals who qualify by means of a major, life-changing event. Events include loss of job, the arrival of a new baby, or marriage. Individual applicants qualify to keep their plans intact but they can make changes and additions even after official open enrollment has closed down.
What are the benefits of enrolling in a qualified health plan?
ACA Qualified Health Insurance Plans offer a multitude of advantages that make them an essential choice for individuals and families seeking comprehensive healthcare coverage. Let’s explore some of the key benefits of opting for ACA Qualified Health Insurance Plans:
- Comprehensive Coverage: ACA Qualified Health Insurance Plans provide extensive coverage for essential health benefits mandated by the Affordable Care Act (ACA). These benefits typically include services such as hospitalization, prescription drugs, preventive care, maternity care, mental health services, and more. By opting for ACA Qualified Health Insurance Plans, individuals can rest assured knowing that they have access to a wide range of medical services to meet their healthcare needs.
- Pre-existing Condition Coverage: One of the most significant benefits of ACA Qualified Health Insurance Plans is the inclusion of coverage for pre-existing conditions. Under the ACA, insurance companies are prohibited from denying coverage or charging higher premiums based on an individual’s health status or pre-existing medical conditions. This ensures that individuals with prior health issues can access affordable healthcare coverage without fear of discrimination or denial of coverage.
- Financial Assistance: ACA Qualified Health Insurance Plans offer financial assistance to eligible individuals, making coverage more affordable for those with lower incomes. Premium subsidies are available to help reduce the cost of monthly premiums, while cost-sharing reductions can lower out-of-pocket expenses such as deductibles, copayments, and coinsurance. These subsidies and reductions help ensure that healthcare coverage remains accessible and affordable for individuals and families across a wide range of income levels.
- Access to Preventive Care: ACA Qualified Health Insurance Plans emphasize preventive care and wellness services, encouraging individuals to maintain optimal health and well-being. These plans typically cover preventive services such as routine check-ups, screenings, vaccinations, and counseling services at little to no cost to the insured. By promoting preventive care, ACA Qualified Health Insurance Plans aim to prevent and detect health issues early, leading to better health outcomes and reduced healthcare costs over time.
- Protection Against Lifetime Limits and Annual Caps: ACA Qualified Health Insurance Plans provide protection against lifetime limits and annual caps on essential health benefits. Prior to the ACA, many insurance plans imposed lifetime limits on coverage, leaving individuals vulnerable to financial hardship in the event of catastrophic illness or injury. ACA Qualified Health Insurance Plans prohibit lifetime limits and set annual caps on out-of-pocket expenses, providing greater financial security and peace of mind for insured individuals and families.
In summary, ACA-qualified health Insurance Plans offer comprehensive coverage, protection against pre-existing conditions, financial assistance, access to preventive care, and safeguards against lifetime limits and annual caps. By choosing ACA-qualified health Insurance Plans, individuals and families can secure quality healthcare coverage that prioritizes their health and well-being, ensuring peace of mind and financial security for the future.