Traditional Health Insurance
A "qualified" major medical health plan is an insurance plan that’s certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act. All qualified health plans meet the Affordable Care Act requirement for having health coverage, known as “minimum essential coverage.”
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All Plans Offered in the Marketplace cover these "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)
- Plans must also include the following benefits:
- Birth control coverage
- Breastfeeding coverage
- Essential health benefits are minimum requirements for all Marketplace plans. Specific services covered in each broad benefit category can vary based on your state’s requirements. Plans may offer additional benefits, including:
- Dental coverage
- Vision coverage
- Medical management programs (for specific needs like weight management, back pain, and diabetes).
Examples of "Qualifying" Health Coverage
- Any health plan bought through the Health Insurance Marketplace
- Individual health plans bought outside the Health Insurance Marketplace, if they meet the standards for qualified health plans
- Any “grandfathered” individual insurance plan you’ve had since March 23, 2010, or earlier
- Any job-based plan, including retiree plans and COBRA coverage
- Medicare Part A or Part C (but Part B coverage by itself doesn’t qualify)
- Most Medicaid coverage, except for limited coverage plans
- The Children’s Health Insurance Program (CHIP)
- Coverage under a parent’s plan
- Most student health plans (check with your school to see if the plan counts as qualifying health coverage)
- Health coverage for Peace Corps volunteers
- Certain types of veterans health coverage through the Department of Veterans Affairs
- Most TRICARE plans
- Department of Defense Nonappropriated Fund Health Benefits Program
- Refugee Medical Assistance
- State high-risk pools for plan or policy years that started on or before December 31, 2014 (check with your high-risk pool plan to see if it counts as qualifying health coverage)
See a more detailed list of types of plans that do and don’t count as qualifying health coverage from the IRS.
You can still get coverage outside of Open Enrollment in 2 ways:
- If you qualify for a Special Enrollment Period due to a life event like losing other coverage, getting married, or having a baby.
- If you qualify for Medicaid or the Children’s Health Insurance Program (CHIP). You can apply any time.
If you don't have the need for expensive comprehensive coverage. Take a look at some of these alternative options, clients are saving THOUSANDS of dollars a year!
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Summary of the ACA
The Affordable Care Act WILL cover all pre-existing conditions (anything you've been diagnosed with, treated for, taken medication for or had symptoms of within the last 24 months prior to the start of the policy). The ACA also covers all preventative & wellness exams at 100%. This summary is a simple to understand guide of the new health insurance law.
The ACA might offer you subsidies where the government will pay a portion of your premium each month on your behalf. The amount (if any) that you will receive depends on your total household income and number of household members. Talk to a professional who can help you determine if you qualify and for how much. The financial consequences of not claiming the correct income or household members could be devastating! Click to see how much you qualify for.
Quote & Apply
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