The Affordable Care Act (ACA) is one of the significant pieces of legislation to affect the U.S. health care system. It dramatically affects Individual Comprehensive Major Medical Plans.
Changes in ACA Benefits and Protections
The major changes in ACA Benefits and Protections include:
- After Jan. 1, 2014, no coverage can be limited or denied because of pre-existing conditions, regardless of the age of the covered individual.
- The guaranteed issue requirement is expanded to ensure that health insurance companies will offer all of their individual and group market plans to any eligible individual in a state, regardless of health status. Also, health insurance companies must offer to renew or continue in force coverage at the option of the policyholder; a provision known as guaranteed renewability.
- Annual and lifetime limits may not be imposed on the dollar value of coverage of essential health benefits.
Qualified Health Plans (QHPs) and the Five Levels of Coverage
- Must include Essential Health Benefits
- Must adhere to Cost-sharing and Out-of-pocket limits
- Must belong to one five Plan Levels of Coverage: four “metal levels” plans and catastrophic plans
Although Qualified Health Plans are standardized and share the common levels of coverage, they can vary. For example:
- Some plans may cover additional benefits
- You may have to see certain providers or use certain hospitals
- The premiums, copays, and coinsurance will be different in different plans
- The quality of care can vary
- Some plans will be structured differently, like high-deductible plans
Affordable Health Insurance Options
To help low- and moderate-income families to reduce the cost of health insurance, the federal government provides two affordability programs:
Both of them are available only through the Marketplace when you enroll in one of the metal levels of Qualified Health Plans (QHP). It is assumed that you are not eligible for other minimum essential coverage, such as affordable employer-sponsored coverage, Medicaid, CHIP, and Medicare.
Individual Comprehensive Major Medical Plans: HMO and PPO
HMO and PPO Individual Comprehensive Major Medical Plans are the most comprehensive and the most expensive types of coverage. They include both catastrophic coverage and routine medical care.
Individual Comprehensive Major Medical Plans without a deductible have the highest premium; they are HMO plans based on the copay, rather than on coinsurance.
Comprehensive Major Medical Plans with a deductible, on the other hand, have a lower premium: the higher the deductible you choose, the lower the premium. Most of the plans are PPO plans, but some of them are HMO plans. In-network deductibles are typically applied to services such as hospital and emergency care. For doctors’ visits, preventive services and screenings, the deductibles are waived, and copays are used.
Many companies also provide less expensive ‘proactive’ plans. The premium is lower because the plan network is smaller. It has several tiers (such as Preferred, Enhanced, and Standard), and your cost depends to the tier your doctor or hospital belongs to.
Individual Comprehensive Major Medical HDHP (HSA Compatible)
Comprehensive Major Medical High Deductible Health Plans (HDHP) are high deductibles plans – normally $1,500 – $5,000 per individual, and $3,000-$10,000 per family. The deductible is typically applied to ALL medical services (including drug expenses), except for preventive care. PPO’s are the most common HDHP.
It is because of the high deductible that the HDHP premium is relatively low.
Comprehensive Major Medical HDHP does not often include any additional expenses after the deductible has been met, as long as you are staying within the network (0% coinsurance).
The tax-advantaged Health Saving Account (HSA) may be used together with HDHP. HSA is a tax-free savings account (similar to a 401(k)) that is used for future medical expenses: deductibles, coinsurance, and other qualified medical expenses. HSA allows portability (it stays with you even if you change jobs), annual rollover, and tax-free investment earnings and gains.
A Comprehensive Major Medical High Deductible Plan may be a good option if you are healthy or if you have enough HSA savings to cover your medical expenses.
Let Liberty Medicare help you choose an Individual Health Plan
Liberty Medicare is here to help you learn about the Health Insurance Marketplace and assist with eligibility determination for enrollment in a Qualified Health Plan (QHP) and for insurance affordability programs, which include Medicaid, CHIP, premium tax credit, and cost-sharing reductions. We will help you to compare plans and enroll in coverage.
As an independent insurance agency, we will provide you with the benefits of objectivity in reviewing multiple plans. We’ll help you to understand the insurance industry jargon and ‘fine print.’
All of our services are offered to you at no cost. We’ll help you to compare Comprehensive Major Medical Plans in your area based on:
- Doctor access and network limitations
- Prescription drug coverage
- Extra benefits
- Plan quality
If you are considering buying an Individual Comprehensive Major Medical Plan (ACA plan), let us guide you. To see real quotes from insurance providers, fill out our Individual Health Quote form or give us a call at 877-657-7477.