The Affordable Care Act

The Affordable Care Act was passed in 2010 with the goal of making affordable health insurance accessible to all Americans. Also commonly referred to as Obamacare, the Act created new requirements for both Americans and their insurers.

All Americans were required to obtain health insurance to protect their health and insulate their finances against potentially devastating medical emergencies. Insurers were commanded to eliminate policies that disqualified or discriminated against applicants and enrollees on the basis of preexisting conditions. The ACA also implemented a set of minimum standards that all health insurance plans must comply with to count as qualifying coverage. This effectively phased out non-compliant plans, ensuring universal minimum coverage for insured families.

Equally importantly, the Affordable Health Care Act led to the establishment of consolidated online marketplaces. These “portals” were designed to allow families in need of insurance to see all of their options and easily make informed decisions.

ACA Marketplace Health Insurance Plans

By law, ACA marketplace health insurance plans must include services considered Essential Health Benefits (EHB) in ten categories. Plans must also cover birth control and breastfeeding support. They may include additional benefits at their discretion. Obamacare’s ten mandatory EHB coverage categories are:

  • Ambulatory Patient Services.
  • Emergency care.
  • Hospital care.
  • Maternity care and newborn care.
  • Behavioral health care, including mental health and substance use/abuse treatment services.
  • Prescription medications.
  • Rehabilitation and habilitation products and services.
  • Laboratory and testing services.
  • Preventive care, wellness services and chronic disease management services.
  • Pediatric care, including oral, dental and vision services.

Affordable Health Care Act plans are divided into four levels: bronze, silver, gold and platinum. The levels are based on plans’ Actuarial Values (AVs). AVs are the percentage of total healthcare costs, on average, that a plan pays. For instance, a plan that covers 60 percent of enrollees’ total costs and leaves policy holders to pay the remaining 40 percent is classified as a Bronze plan.

Marketplace health insurance plans that cover 70 percent of costs are Silver plans and those that pay for 80 percent of costs are Gold plans. In some cases, plans will pay 90 percent or more of enrollees’ costs. These plans are referred to as Platinum plans. Alternatively, some enrollees will qualify for inexpensive but minimally protective non-metal-level “Catastrophic-only” plans.

The Health Insurance Marketplace

Many Americans continue to enroll in Obamacare-compliant health insurance via their employers. Individuals and families for whom this is not an option or is not affordable, can purchase qualifying plans through an approved healthcare marketplace. Each state has the option to run its own marketplace. States that choose not to host their own can instead participate in the nationally-run marketplace for health insurance.

To use a marketplace, enrollees must create accounts using standard personal identifying information such as their names, addresses and Social Security Numbers. During the Obamacare enrollment process, applicants can also expect to supply information on their:

  • Employment.
  • Household compositions.
  • Incomes.
  • Ages.
  • Ethnicity (e.g. Native American Tribal membership of ancestry).
  • Other health insurance options.

Recent updates to the system have streamlined the account creation and enrollment processes, making the national marketplace more convenient to use. Once applicants have entered all the necessary information, they will be able to review the marketplace health insurance options for which they qualify.

Related Article: Medicaid Eligibility

Enrollees can compare plans by services covered, cost, value and other factors to determine which plans best meet their needs. In some cases, applicants exploring their options will find that they qualify for federal support programs, such as Medicare or Medicaid, or that their employers’ plans are the most effective options. In that event, applicants will be directed toward those options, as appropriate.

Obamacare Enrollment Windows

Americans can apply for Obamacare during annual enrollment windows near the end of each year. Additional temporary enrollment windows open throughout the year when families experience qualifying “life events.” For the purposes of Obamacare enrollment, a qualifying life event includes:

  • Losing health care coverage for any reason, such as leaving a job, aging out of coverage under a parents’ plan or ceasing to meet eligibility criteria for state and federal assistance plans such as CHIP or Medicaid.
  • Changes to household composition such as marrying, divorcing, birthing or adopting a child or a death.
  • Changing residences. Applicants’ eligibility for former plans may be affected when they move from one home to another, or if they must leave home temporarily or indefinitely.
  • Other causes. Changes to citizenship, income, incarceration status or public service can all change enrollees’ needs and their eligibility for supports and subsidies.

Enrollees typically have 60 days from the date of the qualifying event to apply for Obamacare. Applicants who miss this window must generally wait until the next open enrollment period to secure insurance.

Obamacare Income Limits and Eligibility

Applicants eligibility for Affordable Care Act plans, supports and subsidies is determined by several factors. Chief among those factors are enrollees’ access to other types of plans, personal and family characteristics and income levels. Obamacare income limits exist on a sliding scale that takes into account family size, household income and area of residence.

For example, a single individual living in Delaware earning $16,753 or less per year who attempted to purchase marketplace health insurance would be directed to apply for Medicaid by the enrollment system. If the same applicant made between $16,754 and $48,560, he or she would qualify for a discounted health insurance plan. With an income above $48,560, that applicant would have a choice between purchasing an individual plan through the healthcare marketplace or through an alternate option, such as employer health insurance coverage. An equivalent individual living in a different state or a larger family in the same state would be subject to different income limits on a similar scale.

Enrollees may also qualify for subsidies if they are members of historically disadvantaged populations, such as Native Americans or Native Alaskans.

Recent Changes to Obamacare

As presidential administrations change, new laws continue to be passed impacting and altering the scope and operation of the Affordable Care Act. Most recently, in December of 2017, Obamacare was significantly altered by the repeal of the individual mandate. As a result of that change, beginning in 2019, Americans will not be penalized for failing or choosing not to carry health insurance. This change is expected to have long-term ramifications for marketplace health insurance plan premiums and subsidies. It will not, however, impact the availability of plans or change how authorized marketplaces operate.

Related Article: Medicaid Related Program

It might also interest you: