I spend my days sifting through articles and research surrounding the health insurance world. Recently I’ve noticed that a lot of writers write as if they’re only trying to speak to those who understand health insurance in its entirety. Clearly, those who completely understand health insurance are not the majority. Quite the opposite actually.

That said, I think it’s important to clarify some common terms that are frequently used to explain health insurance. Specifically, I’d like to explain what “ACA-compliant” means. I know that I’ve read countless articles with this term thrown around, with little to no explanation on what it means. I’m even guilty of this.

What Makes a Plan ACA-Compliant?

An ACA-compliant plan is a major medical plan that abides by the rules of the Affordable Care Act/Obamacare. There are several things this means, and most importantly for you, the health insurance consumer:

  • Plans are guaranteed issue during Open Enrollment Period (OEP). This means that someone cannot be denied coverage because of a pre-existing condition. A qualified life event (QLE) outside of open enrollment can also allow you to enroll in plan that cannot be denied based on pre-existing conditions1
  • Compliant plans have no annual or lifetime coverage limits. That means that no matter how many medical bills you rack up, your insurance cannot put a cap on what they will cover1
  • Ten essential health benefits must be covered by every compliant plan. Although covered does not mean free, every compliant plan must offer the following1
    • Ambulatory/outpatient care
    • Emergency visits
    • Hospitalization
    • Maternity care- care for you and your baby before and after birth
    • Services for mental health and substance use disorders
    • Prescription medication
    • Rehabilitative and habilitative services
    • Laboratory services
    • Services for prevention and wellness and chronic disease management
    • Pediatric services, including vision and dental

ACA-compliant plans must follow other rules written into the Affordable Care Act, but as a consumer, these are likely the most important for you. These plans are major medical plans that are purchased on exchange (through healthcare.gov or a state health insurance marketplace) or off-exchange (job-based coverage or directly from the health insurance carrier).

What Plans Are Not ACA-compliant?

Though other plans can offer you a lot of protection, they are not ACA-compliant. Such plans include short-term medical insurance, accident and critical illness policies, vision and dental plans, and medical discount plans.1

Why Should You Care?

You should care because plans that are compliant with the Affordable Care Act offer a great deal of coverage and it’s of course always good to know what you have. Additionally, you should know if your plan is ACA-compliant so that you aren’t unexpectedly struck with a tax penalty at the end of the year.

Citations

  1. Norris, L. (2015, November 7). I’ve heard that I need to have an ACA-compliant health plan,
    but what does that mean? Retrieved from
    https://www.healthinsurance.org/faqs/ive-heard-that-i-need-to-have-an-aca-compliant-heal
    th-plan-but-what-does-that-mean/