The Affordable Care Act, also known as ACA, is a comprehensive healthcare reform law signed into effect in 2010. The ACA aims to increase access to healthcare, reduce healthcare costs, and improve healthcare quality in the United States.
ACA requires most individuals to have health insurance coverage or pay a penalty. But how much coverage is enough to avoid the penalty?
Essential Health Benefits Explained
Under ACA, all health insurance plans must meet certain minimum coverage requirements. These requirements are known as essential health benefits (EHBs). The EHBs include:
- Outpatient medical care, like doctor visits and diagnostic tests.
- Emergency services, like ambulance transportation and treatment in the emergency room.
- Hospitalization, like inpatient care in a hospital, surgery, and other medical procedures.
- Maternity and newborn care, like care for pregnant women and newborns, and prenatal and postnatal care.
- Mental health and substance abuse services, including treatment for mental health conditions and substance abuse disorders like therapy and medication.
- Prescription drugs with access to a wide range of medicines.
- Rehabilitative and habilitative services and devices, including physical therapy, occupational therapy, and other rehabilitative services, as well as assistive devices such as hearing aids and prosthetics.
- Laboratory services like diagnostic testing.
- Preventive and wellness services and chronic disease management, including preventive care services, vaccines, and screenings, as well as management of chronic conditions, such as diabetes and heart disease.
Other Important ACA Requirements
In addition to the EHBs, all ACA-compliant health insurance plans must also cover preventive care services without requiring a copay or deductible. This includes various services, such as vaccines, screenings, and counseling for multiple conditions.
ACA-compliant health insurance plans must also cover a certain percentage of an individual’s healthcare costs. This is known as the actuarial value. The ACA requires all plans to cover at least 60% of an individual’s healthcare costs, but plans can choose to cover a higher percentage if they wish.
Finally, ACA-compliant health insurance plans must also limit out-of-pocket costs, such as copayments, coinsurance, and deductibles.
Navigate ACA Insurance with Quality Support
In summary, the ACA requires all health insurance plans to cover essential health benefits and a certain percentage of an individual’s healthcare costs to ensure that healthcare is more affordable for individuals and families.
Want to understand your ACA insurance requirements better? Jones Insurance Group is here to walk you through your coverage from the sign-up to renewal and everything in between. Reach out to us today to learn more!