The Patient Protection and Affordable Care Act (PPACA), also known as the Affordable Care Act (ACA), is a federal statute that has transformed the healthcare industry in America. Although it was signed into law in 2010, there is still a lot of confusion about what the ACA means for individuals and businesses.1
So, just what is the Affordable Care Act? HealthMarkets can help you learn more about the ACA.
Americans can struggle to understand key concepts about insurance, such as copays, deductibles, coinsurance, and out-of-pocket maximums. This guide to the ACA can help you understand more about the law, why it was enacted, and how it may affect you.
If you’re ready to discover your health insurance options, you can compare health insurance plans right now, at no additional cost to you.
Why Was the Affordable Care Act Created?The Affordable Care Act (ACA) was created to give consumers more power over their own healthcare. A Patient’s Bill of Rights2 was established to “help children (and eventually all Americans) with pre-existing conditions gain coverage and keep it, protect all Americans’ choice of doctors and end lifetime limits on the care consumers may receive.”3
Are Obamacare and the Affordable Care Act the Same Thing?Yes, Obamacare and the Affordable Care Act (ACA) are the same thing. The health care reform law was nicknamed after President Barack Obama, who formally signed the ACA in March 2010. “Obamacare” and the “Affordable Care Act” are synonymous terms that can be used interchangeably.
How Does the Affordable Care Act Affect Medicaid?The Affordable Care Act (ACA) aimed to increase access to affordable health insurance by expanding Medicaid eligibility. Medicaid is a jointly funded federal and state health insurance program. States can choose whether or not they want to expand Medicaid. As of October 2020, 39 states and the District of Columbia have adopted the Medicaid expansion. Twelve states have chosen not to expand their Medicaid programs at this time.4
The ACA expanded the mandatory Medicaid coverage to include nearly all adults under the age of 65 with household incomes at or below 133% of the Federal Poverty Level (FPL).5 In 2020, this would mean a family of four making less than $36,156 annually would qualify for Medicaid. An individual making less than $17,608 would also qualify.6 Between 2014 and 2016, the federal government paid for Medicaid expansion in full; by 2020, government funding had gradually decreased to 90%.7 The Congressional Budget Office (CBO) estimates that, in 2019, 17% of uninsured Americans were eligible for Medicaid or the Children’s Health Insurance Program (CHIP).8
What Are My Rights Under the Affordable Care Act?The Affordable Care Act (ACA) established several basic patient rights. These rights give consumers the ability to make informed decisions about their health insurance and prevent health insurance companies from excluding or dropping people from their policies. Your rights as a patient include:9
The Right to Essential Benefits
No, this doesn’t mean that you get as much free health care coverage as you want. But it does mean insurance companies can’t set yearly or lifetime limits on what they spend on essential health benefits.10
What Are the 10 Essential Benefits of the ACA?
Under the Affordable Care Act (ACA), every health plan must cover certain basic benefits. These include:11
- Ambulatory patient services (any health care services that don’t require you to stay in a hospital)
- Emergency services
- Pregnancy, maternity, and newborn care
- Mental health and substance abuse disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services
- Chronic disease management
- Pediatric services, including oral and vision care
- Birth control coverage such as FDA-approved contraceptive methods and counseling12
- Breastfeeding coverage, including lactation consulting and the cost of a breast pump13
Some religious employers can apply for an exemption, so they do not have to cover contraceptives and birth control counseling. If you receive your plan through an exempt employer, you might have to pay out-of-pocket for these services.12
The Right to Coverage for Patients With Pre-Existing Conditions14
Insurers cannot exclude coverage of pre-existing conditions from their policies.
The Right to Young Adult Coverage Under a Parent’s Plan15
The Affordable Care Act (ACA) makes it possible for some individuals under the age of 26 to stay on their parents’ healthcare plans. If the parent has dependent coverage through an employer, a young adult can stay or get back on that plan even if he or she has a job that offers coverage.
The Right to Choose Your Doctor16
If your plan requires you to choose a primary care provider, you can choose any primary care physician in the plan’s network. You can also choose any available in-network pediatrician as your child’s primary care doctor. The Affordable Care Act (ACA) also expressly states that you may see a specialist for obstetrical or gynecological care (OB-GYN care) without getting a referral from your primary care doctor.
The Right to Emergency Care16
Under the ACA, you will not be charged a higher copay or coinsurance if you get emergency care from an out-of-network hospital. You also don’t need to get prior approval before you receive those emergency services. The plan must pay the same rates they would pay for an in-network hospital.
In some instances, a healthcare provider might charge higher rates than an in-network hospital would. In that case, you might get a bill from the hospital for the difference between what your insurer will pay and what the hospital charges. This is called balance billing.17 In order to minimize the bills that you might have to pay for emergency care, your health insurance plan must pay the greatest of these amounts:18
- The amount it pays in-network providers
- An amount calculated using the same methods the plan uses to pay for other out-of-network services
- The amount Medicare would pay for the service
Click here to see how your state handles balance billing.
The Right to a Policy that Can’t Be Unfairly Canceled19
Your health plan can only be rescinded if you commit fraud. You must knowingly and willingly misrepresent or leave out information relevant to your health plan for it to be rescinded. If the insurer wants to rescind your coverage due to fraud, they must give you 30 days’ advance written notice and you have the right to appeal.
This doesn’t mean that your policy can’t be canceled. Your health insurance policy can be canceled if:
- You stop paying your premiums,
- Your insurer stops offering that plan or no longer offers any plans in your area, or
- If you move to a new residence that isn’t in your health insurance provider’s service area.
The Right to Appeal a Health Plan Decision
You can appeal a health plan decision if the health plan says the care is experimental or not medically necessary or that you are not eligible for coverage.20 According to the U.S. Department of Health & Human Services (HHS), appeal rules were established for health plans created after March 23, 2010, and to some older plans that were altered. These rules “don’t apply” to plans that started on or before this date.21
Each plan follows its own appeal procedures, and an appeal will likely go through an internal review by the insurer. If the plan still refuses to pay for a treatment, you can appeal to an independent reviewer. A recent study by the Kaiser Family Foundation found that 14% of appeals were successful in overturning health plan denials, and less than 200,000 appeals are filed annually.22
The Right to Preventive Care
Preventive care is essential to reducing overall healthcare costs in America. The Affordable Care Act (ACA) requires insurance plans to cover certain preventive health services at no cost to you, as long as you see an in-network provider. Services include:23
- Alcohol misuse screening and counseling
- Blood pressure screening
- Cholesterol screening for older and high-risk adults
- Colorectal cancer screening for adults over 50
- Depression screening
- Type II diabetes screening for adults with high blood pressure
- Diet counseling for high-risk adults
- Hepatitis C screening for some adults
- HIV screening
- Lung cancer screening for older, high-risk adults
- Obesity screening and counseling
- Tobacco use screening and cessation interventions
- Several vaccines
- Special services for pregnant women or women who may become pregnant
- Behavioral assessments for children
- Screenings and tests for newborns and children
If you’re unsure about a test or screening, check the full list of covered preventive care services.
Who Is Eligible for the Affordable Care Act?
You may be eligible for coverage via the Affordable Care Act (ACA) if you are a U.S. citizen, reside in the U.S., and are not incarcerated.24
The ACA provides patients with more rights, but it also puts the onus of responsibility on them. As an enrollee in a health insurance plan, it’s important to stay up to date on the details of your plan.
The health insurance industry can be complex, and you may not have the time to evaluate your healthcare choices.
HealthMarkets Can Help You Understand the Affordable Care ActStill not sure about what is the Affordable Care Act? HealthMarkets can help you compare the individual health insurance options that may work best for you and your loved ones with our innovative FitScore®.
Answer a few questions about your needs, and we’ll rank health plans side-by-side. Start comparing your health insurance plan options with HealthMarkets today.
1. HealthCare.gov. Retrieved from https://www.healthcare.gov/glossary/patient-protection-and-affordable-care-act/. Accessed on January 8, 2021.
2. CMS. Retrieved from https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Patients-Bill-of-Rights. Accessed on January 8, 2021.
3. CMS. Retrieved from https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca-new-patients-bill-of-rights#ftn1. Accessed on January 21, 2021.
4. KFF. November 2020. Retrieved from https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
5. Medicaid. Retrieved from https://www.medicaid.gov/about-us/program-history/index.html Accessed on January 8, 2021.
6. WebMD. September 2020. Retrieved from https://www.webmd.com/health-insurance/medicaid-application-eligibility-coverage#1
7. KFF. March 2019. Retrieved from https://www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/view/print/
8. CBO. September 2020. Retrieved from https://www.cbo.gov/publication/56658
9. HealthCare.gov. Retrieved from https://www.healthcare.gov/health-care-law-protections/. Accessed on January 8, 2021.
10. HealthCare.gov. Retrieved from https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/. Accessed on January 8, 2021.
11. HealthCare.gov. Retrieved from https://www.healthcare.gov/coverage/what-marketplace-plans-cover/. Accessed on January 8, 2021.
12. HealthCare.gov. Retrieved from https://www.healthcare.gov/coverage/birth-control-benefits/. Accessed on January 8, 2021.
13. HealthCare.gov. Retrieved from https://www.healthcare.gov/coverage/breast-feeding-benefits/. Accessed on January 21, 2021.
14. HealthCare.gov. Retrieved from https://www.healthcre.gov/coverage/pre-existing-conditions/. Accessed on January 8, 2021.
15. HealthCare.gov. Retrieved from https://www.healthcare.gov/young-adults/children-under-26/. Accessed on January 8, 2021.
16. HealthCare.gov. Retrieved from https://www.healthcare.gov/health-care-law-protections/doctor-choice-emergency-room-access/. Accessed on January 8, 2021.
17. HealthCare.gov. Retrieved from https://www.healthcare.gov/glossary/balance-billing/. Accessed on January 8, 2021.
18. HealthSystemTracker. February 2020. Retrieved from https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them-3/
19. HealthCare.gov. Retrieved from https://www.healthcare.gov/health-care-law-protections/cancellations/. Accessed on January 8, 2021.
20. HealthCare.gov. Retrieved from https://www.healthcare.gov/appeal-insurance-company-decision/appeals/. Accessed on January 8, 2021.
21. HHS. Retrieved from https://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html. Accessed on March 17, 2021
22. KFF. February 2019. Retrieved from https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/
23. HealthCare.gov. Retrieved from https://www.healthcare.gov/preventive-care-adults/. Accessed on January 8, 2021.
24. HealthCare.gov. Retrieved from https://www.healthcare.gov/quick-guide/eligibility/. Accessed on January 8, 2021.
HealthMarkets’ FitScore intends to identify plans that fit your needs. You should carefully review official plan materials.