ACA (Affordable Care Act) Health insurance

The Affordable Care Act (ACA) or Obamacare is a US healthcare reform law that expands and improves access to care and curbs spending through regulations and taxes. The ACA’s main focus is providing more individuals with access to affordable healthcare, improving the quality of care for individuals with low-income.

The ACA health plans limit the cost-sharing for enrolled individuals that qualify for subsidy by reducing…

  • Deductibles, coinsurance, and copayments cannot be applied to certain recommended preventive services.
  • Annual cost-sharing limits cannot exceed specified amounts. For instance, for 2018, the limits are $7,350 for an individual and $14,700 for families enrolled in individual or group market plans.

The ACA plans are sold in levels of coverage. 

These levels are sometimes referred to as “metal levels” and are sold as metal levels Bronze, Silver, Gold, and Platinum. The levels help the consumers, agents, and brokers to compare the coverage options and determine which plans best fit the consumer’s needs and budget.

All ACA policies are mandated to provide EHB’s (Essential Health Benefits)

  •  Pediatric Services
  •  Maternity and newborn care
  •  Mental health and substance use disorder services, including behavioral health treatment
  •  Prescription Drugs
  •  Preventive and wellness services and chronic disease management
  •  Rehabilitative and habilitation services and devices
  •  Laboratory services
  •  Emergency services
  •  Hospitalization
  •  Ambulatory patient services, such as doctor visits

The levels of coverage are determined by the Actuarial Value of the plan design.

Each one of the metallic plan categories covers each of the 10 Essential Health Benefit (EHB) categories differently.

The Actuarial Value calculation is expressed in percentages. Generally, the higher the Actuarial Value of the plan, the more the enrollee pays in monthly premiums, and the less he or she could pay in out-of-pocket costs.

  • Bronze Plan

60% AV – the health insurance plan pays approximately 60% of the average cost of all EHB for an average. The deductibles are usually very high in a bronze plan and it only covers yearly preventive and a sick visit.

 

  • Silver Plan

70% AV – the health insurance plan pays approximately 70% of the average cost of all EHB for an average. The deductibles are fairly high in a silver plan. However, it includes some benefits like doctor visits.

 

  • Gold Plan

80% AV – the health insurance plan pays approximately 80% of the average cost of all EHB for an average. A gold plan covers a lot more benefits before the deductibles. Apart from doctors’ visits, they cover lab work, radiology, etc.

 

  • Platinum Plan

90% AV – the health insurance plan pays approximately 90% of the average cost of all EHB for an average. The deductibles are quite low in a platinum plan.

 

Basically, the lower the deductible, the higher the cost, the better the plan!