Whether you need healthcare coverage or already have healthcare coverage, the Affordable Care Act offers new rights and protections that make coverage fairer and easier to understand:
- Creates the Health Insurance Marketplace, , a new way for individuals, families, and small businesses to get health coverage
- Requires insurance companies to cover people with pre-existing health conditions
- Helps you understand the coverage you’re getting
- Holds insurance companies accountable for rate increases
- Protects your choice of doctors
- Covers young adults under 26
- Provides free preventive care
- Makes it illegal for health insurance companies to arbitrarily cancel your health insurance just because you get sick
- Ends lifetime and yearly dollar limits on coverage of essential health benefits
Some rights and protections apply to plans in the healthcare marketplace, other individual insurance, employer-based plans, and/or all healthcare coverage.
Eligibility for healthcare coverage through the Healthcare Marketplace in based upon income and the number of people in your family.
Those enrolling in the Healthcare Marketplace have 4 different plan options: Bronze, Silver, Gold and Platinum, each with a set of essential health benefits.
According to the Affordable Care Act guidelines, the following essential health benefits must be covered in each of these plans:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (such as surgery)
- 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
Some plans may offer additional coverage.
The percentage of premium, co-pay and coinsurance costs you pay, and that are covered by the plan will vary. You may also be eligible for premium tax credits that can greatly lower these health insurance costs.
You’re considered covered if you have Medicare, Medicaid, CHIP, any job-based plan, any plan you bought yourself, COBRA, retiree coverage, TRICARE, VA health coverage, or some other kinds of health coverage.
Although Open Enrollment ended March 31, 2014, you can still buy a Healthcare Marketplace health plan if you qualify for a special enrollment period, and/or other coverage options. Additionally, you can apply for Medicaid and CHIP (The Children’s Health Insurance Program which provides free or low-cost health coverage for more than 7 million children up to age 19) anytime. Open Enrollment for 2015 coverage starts November 15, 2014.
You can also buy a plan outside the Healthcare Marketplace and still be considered covered. If you buy outside of the Marketplace, you will not be eligible for premium tax credits or lower out-of-pocket costs based on your income.
If you’re eligible for, or have job-based insurance, you can consider switching to a Healthcare Marketplace plan. But you may not be eligible for premium tax credits or lower out-of-pocket costs based on your income unless the job-based insurance falls short of Affordable Care Act affordability or essential health benefit coverage guidelines.
According to the Affordable Care Act, you cannot be denied healthcare coverage or charged more for healthcare coverage if you or someone in your family has a pre-existing condition, or if you are ill at the time you apply for coverage (even if you’ve been denied or refused coverage due to a pre-existing condition in the past). Likewise, once you have insurance, you cannot be refused coverage for treatments of any pre-existing conditions. These same rules apply for Medicaid and the Children’s Health Insurance Program (CHIP). The only exception to the pre-existing coverage rule is for grandfathered individual health insurance plans—those purchased on your own, not through an employer—which do not have to cover pre-existing conditions.
Most people must have healthcare coverage in 2014 or pay a penalty (on their 2015 income taxes).
Dental coverage is included in some Healthcare Marketplace plans. Stand-alone dental plans may be available if you are covered by a private healthcare plan purchased through the Healthcare Marketplace.
The Healthcare.gov website is one of several ways uninsured or underinsured people can apply for healthcare coverage. Individuals and families who feel they need or desire expert guidance through this process are encourage to call the insurance professionals here at the McDaniel Hazley Group at 816-531-7500.