Understanding the Affordable Care Act
Essential Health Benefits
Under the Affordable Care Act (ACA), fully insured small group and individual health plans on and off the Exchange/Marketplace must cover essential health benefits (EHB). Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side-by-side in the Marketplace.
Essential health benefits under the Patient Protection and Affordable Care Act will include the following general categories:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services including oral and vision care
According to the Affordable Care Act, plans of all sizes that cover benefits designated as Essential Health Benefits, including self-funded plans, must cover these benefits with no annual limits or lifetime maximums.
Footnote: This is a brief overview of Essential Health Benefits required by the Affordable Care Act. You should read thoroughly and understand the benefits offered before purchasing any insurance policy.
Preventive Health Services for Adults
Most health plans must cover a set of preventive services like shots and screening tests at no cost to you. This includes Marketplace private insurance plans. Preventive care helps you stay healthy. A doctor isn’t someone to see only when you’re sick. Doctors also provide services that help keep you healthy.
Free preventive services
All Marketplace plans and many other plans must cover the following list of preventive services without charging you a co-payment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.
- Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol Misuse screening and counseling
- Aspirin use to prevent cardiovascular disease for men and women of certain ages
- Blood Pressure screening for all adults
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal Cancer screening for adults over 50
- Depression screening for adults
- Depression screening for adults
- Diabetes (Type 2) screening for adults with high blood pressure
- Diet counseling for adults at higher risk for chronic disease
- HIV screening for everyone ages 15 to 65, and other ages at increased risk
- Immunization vaccines for adults (visit www.healthcare.gov for a full list)
- Obesity screening and counseling for all adults
- Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
- Syphilis screening for all adults at higher risk
- Tobacco Use screening for all adults and cessation interventions for tobacco users
For a more detailed list visit https://www.healthcare.gov/preventive-care-adults/ or call us for additional information
Pre-65 Health Care Insurance
If you're under the age of 65 and need health insurance, there are 4 basic options available to you. We can help you determine the right choice based on your budget and needs.
On-Exchange Plans (Affordable Care Act)
The plans are administered through the Centers for Medicare and Medicaid. Many people qualify for subsidies based on qualifying factors to help with their health care costs. This is typically the first step in finding the right plan for you and we'll guide you thru the process step by step.
Off-Exchange Plans
If you don’t qualify for a subsidy you can purchase health insurance directly from a carrier. We can help you compare plans and enroll in one that best meets your needs and budget.
Short-term major medical
These type plans are a great alternative for consumers looking for major medical coverage. Short Term health insurance, sometimes called Term health insurance or Temporary health insurance, is designed to bridge gaps in your health care coverage during times of transition. These plans allow you to:
- Start your coverage fast, as soon as the next day in many cases.
- Drop your coverage without penalty.
- Choose from a range of available deductible amounts.
- Apply for another term of coverage if needed.
Hospital Indemnity Insurance
Hospital indemnity insurance is a type of plan that pays a set amount – per day, per week, per month, or per visit. In addition to a hospital per diem, a more comprehensive plan might feature payments for an ambulance trip, surgery or maternity visit, or increased payments for intense ailments such as stroke or cancer. Benefits can disburse in lump sums for short admittances or on a daily or weekly basis during longer visits.
As you can see, there are many options to choose from with different benefits and payment methods. We're here to help you through the confusion.