Major Medical Insurance
PPACA Compliant Plans
Individual and Family on Federally Facilitated Marketplace
For below 65
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 This part of the Act was rescinded.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 to low and middle level income 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.
- It is optional to take offered APTC for direct payment to the insurance carrier. If eligible, it can be claimed as Premium Tax Credit and accounted on Federal Tax Return using IRS Form 8962 for that year.
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, the affordability of deductibles and Out-of-Pocket Maximums gets out of reach. Insurance companies have guaranteed flow of premiums, but out-of-reach claims by the beneficiaries.
- 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.
Terminology and Common Conditions of Enrollment
It is significant for a buyer to understand certain common terms and conditions of ACA plans and make assessment of suitable plans for yourself by opening Healthcare.gov. Follow links below for guidance:
- Browse here for Common Conditions of Enrollment in Major Medical ACA Plans.
- You may download its copy here.
Help Yourself for Pricing and Enrollment
ACA plans are designed to reach out to middle and lower income level segments of society with mission that health insurance gets affordable by governmental subsidies of premiums. These subsidies are related to age and income levels for individual and families. It is significant to work out financials of these medical insurance plans for coverage. To get assessment of pricing, and even self-enrollment, follow these steps:
- Click here to open customized link. You will be interacting with Heathcare.gov in the background through this interface to get quotes and may enroll yourself if you choose to.
- Enter basic information.
- See price quotes developing on the screen.
- Scroll down and apply filters for your choices.
- Decide on the plan that you want to purchase.
- Select the plan and help yourself to follow the screens to sign up. Or else, contact us, and we will be happy to help you enroll for the plan.
- Save link of your account that you establish to access later. If your situation changes, you can help yourself to update your account page.
- While configuring your health insurance cost, you may like to add supplemental Hospital Insurance to offset deductible and out-of-pocket costs.
Selection of Plan for Enrollment by Our Assistance
PPACA plan tends to get complicated to make best of its features. If you have helped yourself to select a plan that you want to enroll in and need help, please contact us. We will be pleased to assist you to enroll and maintain any changes that may happen. The carrier we help you select to sign up pays our commission fees. There is no cost to you to take our assistance. We recommend that at the minimum you purchase a supplemental Hospital Insurance to offset hospitalization costs.
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.
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