The Affordable Care Act
The Patient Protection and Affordable Care Act, commonly referred to as the ACA or ‘Obamacare’, was signed into law on March 23, 2010. The ACA was passed with the goal of lowering the number of uninsured individuals through enrollment in private insurance and the expansion of public insurance coverage. It also looks to increase the quality and affordability of health insurance through the creation of individual and employer mandates, tax credits and health insurance marketplaces.
ACA Health Plans: Qualified Health Plans
The ACA imposes new regulations on health plans in the Exchanges and in the individual and small group markets (Off-Exchange). These plans are called ‘Qualified Health Plans’.
Guarantee Issue – No Pre-existing Condition Limitations
The ACA requires that qualified health plans be guarantee issue with no preexisting condition limitations. This means that health plans must permit consumers to enroll regardless of health status, age*, gender, or other factors that might predict the use of health services.
* Individuals entitled to Part A of Medicare are ineligible to enroll. However, not all individuals that are age 65 are entitled to Part A of Medicare; therefore, they may be able to enroll in an on or off-exchange health plan.
Dependent Children Up to Age 26
The ACA requires dependent coverage for children up to age 26 for all individual and group policies.
Essential Health Benefits
The ACA requires health plans offered in the individual and small group markets, both inside and outside of the Exchange, to offer a comprehensive package of items and services known an essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Minimum Value Standard - 60 Percent Actuarial Value and Metallic Plans
The ACA requires plans to cover at least 60 percent of the actuarial value of the covered benefits (‘Minimum Value’ standard) and establishes Bronze, Silver, Gold, Platinum ('Metallic') and Catastrophic Plans.
Prohibition on Annual & Lifetime Dollar Limits for Essential Health Benefits
The ACA prohibits individual and group plans from placing annual and lifetime limits on the dollar value of coverage on essential health benefits.
Open Enrollment Period (OEP) and Special Enrollment Periods (SEP)
The open enrollment period for ACA Health Plans is generally from November 1 to December 15 each year. Outside of the Open Enrollment Period, consumers can enroll in a private insurance plan through the Marketplace only if they have certain life events that give them a Special Enrollment Period. Consumers can apply for Medicaid or the Children’s Health Insurance Program (CHIP) any time and can enroll right away.
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