Patient Protection Affordable Care Act [PPACA] compliant plans for Individual and Family

This Act, also often referred to as ‘Obamacare’ came into being in March 2012. These plans are put out through Federal and State Exchanges, call Marketplaces, and may be offered off-exchange by the insurance companies. The basic premises of this Act are:

• It is for all ages below 65, covers all citizens and legally resident person except those incarcerated.
• All preexisting conditions are covered.
• There is no penalty for not buying ACA compliant plan since Jan 1, 2019. This part of the Act was rescinded.
• The Act aims to make the ACA plans accessible through Marketplace/Exchanges for low to middle income level families by subsidizing premiums through mechanism of offering Advance Premium Tax Credit (APTC) and Cost Share Reductions. These two mechanisms have eligibility criteria related to: i) size of the family, and ii) estimated income falling in range of 100% to 400% of Federal Poverty Line (FPL). If your income is below 138% of FPL, and your state has expanded Medicaid coverage, you qualify for Medicaid based only on your income.
• If the income level falls between 138% to 250% of the Federal Poverty Line (FPL), there may be further reduction of your share of coinsurance with the insurance company, called Cost Share Reduction.
• Since Year 2022, further concessions have been made under American Rescue Plan for upper ceiling levels of income.

Basic Benefits of ACA Compliant Plans

Plans to be offered by the Issuer (insurance company) must be a licensed as Qualified Health Plans.  (QHP). A Qualified Health Plan must offer ten benefits as follows:

• Offer health insurance plans that cover benefits in at least ten categories, called Essential Health Benefits (EHB), which must carry no maximum dollar limits. These ten categories of EHBs items and services are required on all individual and small group plans starting in 2014.These 10 categories are: 1) Outpatient care; 2) Emergency care; 3) Hospitalization; 4) Maternity and newborn care; 5) Mental Health Services and addiction treatments; 6) Prescription Drugs; 7) Rehabilitative services and devices, 8) Laboratory Services, 9) Preventive services, 10) Pediatric services. 
• Most of the preventive services are to be rendered free to the consumer.

Financials of ACA Plans

ACA plans have been under criticism ever since the Act came into being due to following factors:

•  To the lower income group of people who may get maximum benefit of APTC subsidy for premiums, but the affordability of deductibles and Out-of-Pocket Maximums are out of reach.
• For groups of people who are in income levels beyond 400% FPL, the premiums have gotten progressively out-of-reach, especially for above 40 age group.
• To negotiate with Out-of-Pocket Maximum in case of hospitalization, medical supplemental hospital indemnities have emerged in the market, which provide relief in financials related to hospitalizations.

 

Steps to Follow to Select a Plan and Sign Up

Click here and enter basic information to see the plans offered by UnitedHealthcare® On-Exchange [Healthcare.gov]  or Off-Exchange and help yourself to sign up to purchase. Follow the screens to answer simple questions, and you will see a recommended plan for you. You may however browse over all plans offered by UnitedHealthcare® and select one to sign up. Recommended selection criteria for a plan

• You may skip giving answers to initial screens to get to see all plans under tab All plans to see what plan you want.
• Depending upon your income and size of your family, plans being offered by UnitedHealthcare® will be pulled up from Marketplace of Healthcare.gov.
• Since the ‘Deductible’ prevails for the year before insurance picks up to share costs with you, look for plan(s) where you can put up with ‘least deductible’ since premium increases as deductible reduces. This is the amount that your health plan wants you to pay per year upfront before the coinsurance share from the carrier is picked up.
• Filter the plans for Silver and Gold which will show plans for reasonable deductible. Gold and Platinum plans have least deductibles.
• You may click on tab All plans and use slider Max deductible to filter out plans.

Selection of a Primary Care Physician

• Click here to search for physicians and tentative select 2 – 3 physicians.
• Call offices of physicians and verify that the tentative plan(s) you selected are active and the physician is accepting new patients.
• Make note of the contact information of the physician you have selected to input in your application for enrollment.

Selection and Enrollment in Plan

• Click here to revert back to enrollment in the plan.
• Follow the step through screens and enter information about the level of healthcare you expect during the year, the Primary Care Physician, the Prescription medications you take. This will show up on the plans that are displayed before you.
• You see the premiums, the subsidy of Advance Premium Tax Credit (APTC) you get based on your estimated income of you and your family for the enrolling year. Select the plan you want to enroll in.
• Click on the button Plan details to download this PDF file and save it for future reference. Browse over the benefits and details of the plan.
• Click on the button Enroll now, and follow the screens to enroll in the plan. You will get an email for enrollment.
• Save your login credentials of enrollment. You’d need to login to update your income and special events or changes in your life that may affect your insurance status.

Follow up after enrollment

• Click here to enroll in Galileo.  This is UnitedHealthcare® Virtual First Plan. This is your amazing virtual access to doctors through text or video, 24/7. It covers primary, urgent, and chronic care. You can get prescriptions, lab test, and specialist referrals. Best of all, there are no copays, deductibles, or surprise bills.
• Make sure you stick to In-Network providers to lower your costs for ‘Doctor visits’ and ‘Prescription drugs’.
• Be ready to file your tax return sometime in March of next year. If you have not received an IRS Form 1095-A from Healthcare.gov to show the partial premiums paid to carrier on your behalf, you can download this form from HealthCare.gov using your login credentials you saved on HealthCare.gov via enrollment with UnitedHealthcare®.
• Give this IRS Form 1075-A to your tax preparer to reconcile your Premium Tax Credit payment on IRS Form 8962 as part of your tax return.

What is window of timeframe for enrollment?

• The Open Enrollment Period for Individual and Family plans starts November 1^st and ends January 15^th the following year.
• December 15^th is the last day to enroll for the plan to commence on Jan 1^st the following year.
• After January 15^th, a Special Enrollment Period starts. This category of enrollment is attributable to changes in life, changes in household, changes in residence, loss of health insurance and any such pressing event. Look for such defined events here.

 

Alternatives to Individual ACA Plans

Here are some other options available to you as alternatives to ACA major medical plans to consider:

• If you are in a situation that ACA compliant major medical plan is too expensive, look for alternatives of Short Term Medical plan(s) and TriTerm Medical Plans. There is an array of these plans available from 1 to 36 months with range of deductibles and Out-of-Pocket Maximums. Browse over these plans under menu items.
• A typical Short-Term Medical or TriTerm Medical plan when combined with supplemental plan of Hospital Insurance (for below age 65) can offset out-of-pocket costs due to hospitalization. See an illustrative example here.