ACA Health Insurance
What is the Affordable Care Act?
The Affordable Care Act, also known as Obamacare, is a law that was created to make health insurance more affordable and available for everyone. It ensures that all health plans cover important services like doctor visits, emergency care, and prescription drugs.
Who can get health insurance through ACA?
Anyone can apply for ACA health insurance for themselves and their families, but it’s especially helpful for:
- People who do not get insurance through work
- Have preexisting conditions
- Need financial help to afford coverage. Even if you were denied insurance in the past, you can get coverage under the ACA.
When can I enroll or change my coverage?
During a valid enrollment period you’re able to enroll in, renew, or change your plan.
Open Enrollment Period
- November 1: Open Enrollment starts — first day you can enroll in, renew, or change health plans through the Marketplace. Coverage can start as soon as January 1.
- December 15: Last day to enroll in or change plans for coverage to start January 1.
- January 1: Coverage starts for those who enroll in or change plans by December 15 and pay their first premium.
- January 15: Open Enrollment ends — last day to enroll in or change Marketplace health plans for the year. After this date, you can enroll in or change plans only if you qualify for a Special Enrollment Period.
- February 1: Coverage starts for those who enroll in or change plans December 16 through January 15 and pay their first premium.
Special Enrollment Periods (Individuals who have a qualifying life event at anytime throughout the year)
- Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
- Had a baby, adopted a child, or places a child for foster care. Your coverage can start the day of the event – even if you enroll in the plan up to 60 days afterward.
- Got divorced or legally separated and lost health insurance. Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
- Died. You’ll qualify for a Special Enrollment Period if someone on your Marketplace plan dies which causes you to lose your current health plan.
Changes in residence
You may qualify for a Special Enrollment Period if you move to:
- New home in a new ZIP code or county
- The U.S from a foreign country or United States territory
Or, move to or from:
- Place you attend school (if you’re a student)
- Place you both live and work (if you’re a seasonal worker)
- Shelter or other transitional housing
Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for a Special Enrollment Period.
You must prove you had qualifying health coverage for one or more days during the 60 days before you move. You don’t need to provide proof if you’re moving from a foreign country or United States territory.
Loss of health coverage
You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying coverage in the past 60 days OR expects to lose coverage in the next 60 days.
Job-based coverage
You may qualify for a Special Enrollment Period if you lose health coverage through your employer or the employer of a family member, including if you lose health coverage through a parent or guardian because you’re no longer a dependent.
Notice: Voluntarily dropping coverage you have as a dependent doesn’t qualify you for a Special Enrollment Period unless you had a decrease in household income or a change in your previous coverage that made you eligible for savings on a Marketplace plan.
Individual health coverage
You may qualify for a Special Enrollment Period if you lose individual health coverage, including if:
- Your individual plan or your marketplace plan is discontinued (no longer exists).
- You lose eligibility for a student health plan.
- You lose eligibility for a plan because you no longer live in the plan’s service area.
- Your individual or group health coverage year is ending in the middle of the year and you chose not to renew it.
- Your household income decreased, and now you qualify for savings on a Marketplace plan.
Notice: You won’t qualify for a Special Enrollment Period if you lost coverage because you didn’t provide required documentation.
Medicaid or the Children’s Health Insurance Program (CHIP) coverage (or were denied Medicaid/CHIP)
You may qualify for a Special Enrollment Period if you lost Medicaid or CHIP since March 31, 2023.
You may also qualify if you lose or were denied Medicaid or CHIP coverage because:
- You’re no longer eligible, like if you had a change in household income that makes you ineligible for Medicaid.
- Your child ages off CHIP.
- You applied for Medicaid/CHIP or Marketplace coverage during Open Enrollment or with a different Special Enrollment Period and were told you might be eligible for Medicaid/CHIP. But, when your state agency told you that you weren’t eligible, Open Enrollment or your Special Enrollment Period had already ended.
Eligibility for Medicare
You may qualify for a Special Enrollment Period if you lose premium-free Medicare Part A.
You don’t qualify for a Special Enrollment Period if you lose:
- Medicare Part A because you didn’t pay your Medicare premium.
- Medicare Parts B or D only.
Coverage through a family member
You may qualify for a Special Enrollment Period if you lose qualifying health coverage if you had a parent, spouse, or other family member. This might happen if you lose health coverage because:
- You turn 26 (or the maximum dependent age allowed in your state) and can no longer be on a parent’s plan.
- A family member loses health coverage for their dependents.
- A divorce or legal seperation.
- The death of a family member.
- You’re no longer a dependent.
You won’t qualify for a Special Enrollment Period if you chose to drop the coverage you have as a dependent, unless you also had a decrease in household income or a change in your previous coverage that makes you qualify for savings on a Marketplace plan.
An employer offers to help with the cost of coverage
You may qualify for a Special Enrollment Period if you (or anyone in your household) were offered an individual coverage HRA or a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) in the past 60 days OR expects to in the next 60 days.
Your employer may refer to an individual coverage HRA by a different name, “ICHRA.”
If you qualify to enroll in Marketplace coverage through this Special Enrollment Period, contact us to complete your enrollment.
More qualifying changes
Other situations that may qualify you for a Special Enrollment Period:
- Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
- Becoming a U.S citizen
- Leaving incarceration
- Starting or ending service as an AmeriCorps State and National, VISTA or NCCC member
Notice: You may have to submit documents. When you apply, you must attest that the information you provide on the application is true, including the facts that qualify you for a Special Enrollment Period. You may have to submit documents that confirm your life event.
Affordable Care Act Coverage Options
There are different metal levels of ACA plans.
Bronze, Silver, Gold, and Platinum. Each level covers a percentage of your healthcare costs.
Bronze: covers 60% and you pay 40%.
Silver: covers 70% and you pay 30%
Gold: covers 80% and you pay 20%
Platinum: covers 90% and you pay 10%
Bronze plans have lower premiums but higher out-of-pocket costs, while Platinum plans cover more but cost more upfront. It’s important to choose a plan that fits your health needs and budget.
What Does it Cover?
All ACA plans must cover 10 essential health benefits:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both before and after birth)
- 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, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)
It’s designed to cover your basic health needs so you don’t have to worry about missing out on important care.
What Does ACA Cost?
The cost of your plan depends on which metal level you choose and your personal situation. Many people qualify for financial assistance, which can lower your monthly premiums and out-of-pocket costs. It’s best to look at your options to find a plan that works for your budget.
The four kinds of payments you might have:
Premium (Flat monthly fee)
Affordable Care Act plans have a monthly premium, however, some qualify for low or no premium plans depending on your subsidy level. Your subsidy level is based upon your household income.
Example: You pay $100 a month to have your plan.
Deductible (Contribute up to a limit)
A set amount you pay for covered services before your plan pays.
Example: You pay up to a limit of $500, and the plan pays the rest.
Copay (Fixed rate fee)
A fixed amount you pay at the time you receive a covered service.
Example: You pay a fixed amount of $20 when you get a particular service rendered, and the plan pays the rest.
Coinsurance (Percentage fee)
A percentage of the cost you pay for a covered service.
Example: You pay 20% of a bill when services are rendered.
How Do I Choose?
Answering the following questions can help you decide which coverage options best fits your health and lifestyle needs:
Your Health
How often do you go to the doctor? Do you have any health conditions? What medications do you take regularly?
Your Budget
What are you able to pay each month in premiums? How comfortable are you meeting your deductibles and covering copays or coinsurance for services? How willings are you to accept the risk of high out-of-pocket costs?
Your Preferences
Which doctors, hospitals and pharmacies do you like to go to? How important is it for you to have access to health care while traveling? What other coverage do you have, such as an employer or retiree plan?