Your Complete Guide to ACA Healthcare: Finding Affordable Coverage That Works For You

Healthcare is important for everyone. The Affordable Care Act (ACA), sometimes called “Obamacare,” has made it easier for millions of Americans to get health insurance. This guide will help you understand what the ACA is, how it can help you, and how to get the best healthcare plan for your needs and budget.

The ACA has changed how healthcare works in America. Before the ACA, many people couldn’t get health insurance because of health problems they already had. Some people couldn’t afford insurance at all. Now, insurance companies can’t turn you away because of health problems, and many people can get help paying for their insurance.

This guide will explain everything you need to know about ACA healthcare in simple terms. We’ll walk you through the basics, show you how to sign up, and help you understand what kind of plan might be best for you and your family.

In This Guide:

• What is the ACA?
• Benefits of ACA Healthcare
• ACA Coverage Options
• Who Can Get ACA Healthcare?
• Understanding Costs and Savings
• How to Sign Up for ACA Healthcare
• Choosing the Right Plan
• ACA Healthcare for Families
• Special Enrollment Periods and Exceptions
• Frequently Asked Questions
• Conclusion

What is the ACA?

The Affordable Care Act (ACA) is a law that was passed in 2010. It changed healthcare in America in big ways. The main goal was to help more people get health insurance.

Here are the key things the ACA did:

• Made it illegal for insurance companies to deny coverage because of pre-existing conditions
• Created a Health Insurance Marketplace where people can shop for plans
• Provided subsidies (financial help) to make insurance more affordable
• Required most Americans to have health insurance (this requirement was later removed)
• Allowed young adults to stay on their parents’ plans until age 26
• Expanded Medicaid in many states to cover more low-income people

The ACA helps make sure that health insurance covers important healthcare needs. All ACA plans must cover what are called “essential health benefits.” These include:

• Doctor visits and outpatient care
• Emergency services
• Hospital stays
• Pregnancy, maternity, and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative services and devices
• Laboratory services
• Preventive care, wellness services, and chronic disease management
• Pediatric services, including dental and vision care for children

With the ACA, you don’t have to worry about being turned down for insurance because of health problems you already have. This is one of the biggest changes the law made.

Benefits of ACA Healthcare

ACA healthcare plans offer many benefits that make them a good choice for many people:

Protection for Pre-existing Conditions

Before the ACA, if you had health problems like diabetes, heart disease, or cancer, insurance companies could refuse to cover you or charge you much more. Now, they can’t do that. No matter what health problems you have, you can get coverage at the same price as anyone else your age in your area.

Financial Help to Lower Costs

Many people worry they can’t afford health insurance. The ACA helps with this by offering subsidies. These are like discounts that lower your monthly payments. Many people are surprised to find out they qualify for this help. In fact, about 8 out of 10 people who buy ACA plans get financial help.

Comprehensive Coverage

All ACA plans must cover a wide range of healthcare services. This means you don’t have to worry about major gaps in your coverage. Your plan will cover the care most people need, from regular check-ups to hospital stays.

Preventive Care at No Extra Cost

ACA plans cover preventive services like vaccines, screenings, and yearly check-ups without charging you extra (no copay or coinsurance). This helps you stay healthy and catch problems early.

No Lifetime or Annual Limits

Insurance companies used to be able to set limits on how much they would pay for your care in a year or in your lifetime. The ACA ended this practice. Now, your benefits can’t be capped, which protects you if you have a serious health condition that requires expensive treatment.

ACA Coverage Options

The ACA offers different types of health plans. They are grouped into four main levels, often called “metal tiers”: Bronze, Silver, Gold, and Platinum. Each level covers a different percentage of your healthcare costs.

Bronze Plans

Bronze plans have the lowest monthly payments but the highest costs when you get care. They cover about 60% of your healthcare costs, while you pay about 40%.

These plans work best if:

• You’re generally healthy and don’t expect to need much care
• You want protection from worst-case scenarios, like serious accidents or illnesses
• You can afford to pay more out-of-pocket when you do need care

Silver Plans

Silver plans are in the middle for both monthly payments and costs when you get care. They cover about 70% of your healthcare costs, while you pay about 30%.

These plans work best if:

• You qualify for extra savings called “cost-sharing reductions” (these are only available with Silver plans)
• You want a balance between monthly costs and costs when you get care
• You expect to use some healthcare services regularly

Gold Plans

Gold plans have higher monthly payments but lower costs when you get care. They cover about 80% of your healthcare costs, while you pay about 20%.

These plans work best if:

• You expect to use a lot of healthcare services
• You’d rather pay more each month and less when you actually get care
• You have ongoing health conditions that need regular treatment

Platinum Plans

Platinum plans have the highest monthly payments but the lowest costs when you get care. They cover about 90% of your healthcare costs, while you pay about 10%.

These plans work best if:

• You need a lot of care and are willing to pay higher monthly payments for lower costs when you get care
• You have complex medical needs or chronic conditions

Remember, all of these plans cover the same essential health benefits. The difference is in how you and the insurance company split the costs.

Who Can Get ACA Healthcare?

Most people living legally in the United States can buy ACA healthcare plans. Here’s who qualifies:

• U.S. citizens
• U.S. nationals
• Lawfully present immigrants

You must also live in the United States and not be in prison.

To get financial help paying for your plan, your income needs to be between 100% and 400% of the federal poverty level. For 2023, that’s about $14,580 to $58,320 for a single person, or $30,000 to $120,000 for a family of four. Recent changes have expanded subsidies to help even more people.

If your income is below 138% of the federal poverty level and your state has expanded Medicaid, you might qualify for Medicaid instead of an ACA plan. Medicaid provides low-cost or free coverage for those with lower incomes.

Important note: If you can get affordable health insurance through your job, you might not qualify for financial help with an ACA plan. However, you can still buy one if you want to.

Understanding Costs and Savings

Healthcare costs can be confusing. Here’s a simple breakdown of what you’ll pay with an ACA plan:

Premium

This is the amount you pay each month for your insurance, like a subscription. You pay this even if you don’t use any healthcare services.

Deductible

This is how much you have to pay before your insurance starts to help with costs. For example, if your deductible is $1,000, you’ll pay the full cost of most services until you’ve spent $1,000. After that, your insurance starts to share the costs.

Copayment

This is a set amount you pay for a service. For example, you might pay $25 each time you see a doctor or $10 for a prescription.

Coinsurance

This is your share of the costs, shown as a percentage. For example, after you meet your deductible, you might pay 20% of the cost of a service while your insurance pays 80%.

Out-of-Pocket Maximum

This is the most you’ll have to pay in a year. Once you reach this amount, your insurance pays 100% of covered services for the rest of the year. This protects you from very high medical costs.

Subsidies (Financial Help)

The ACA offers two main types of financial help:

1. Premium Tax Credits: These lower your monthly payment. The amount depends on your income. Lower income means more help.
2. Cost-Sharing Reductions: These lower your deductible, copayments, and coinsurance, so you pay less when you get care. They’re only available with Silver plans and for people with lower incomes.

To see if you qualify for savings, you’ll need to apply through the Health Insurance Marketplace (Healthcare.gov) or your state’s marketplace. You’ll provide information about your household size and expected income for the year.

How to Sign Up for ACA Healthcare

Getting ACA healthcare involves a few steps. Here’s how to do it:

When to Enroll

There’s a specific time each year when you can sign up for ACA healthcare. This is called Open Enrollment and usually runs from November 1 to January 15. If you sign up by December 15, your coverage will start on January 1.

If you miss Open Enrollment, you can only get an ACA plan if you qualify for a Special Enrollment Period because of a life change like:

• Losing other health coverage
• Getting married
• Having a baby or adopting a child
• Moving to a new area
• Changes in your income that affect your coverage

Where to Enroll

You can sign up for ACA healthcare plans through:

• The federal Health Insurance Marketplace at Healthcare.gov
• Your state’s own marketplace (if your state has one)
• Phone: Call 1-800-318-2596 to enroll by phone
• In-person: Get free help from trained enrollers in your community
• Mail: Complete a paper application

What You’ll Need to Apply

To make the application process smoother, have these things ready:

• Social Security numbers (or document numbers for legal immigrants) for everyone applying
• Employer and income information for everyone in your household (pay stubs, W-2 forms, tax returns)
• Policy numbers for any current health insurance plans
• Information about any job-based health insurance available to your family

Steps to Enroll

1. Create an account on Healthcare.gov or your state’s marketplace
2. Fill out the application with information about your household and income
3. Review your eligibility results to see what plans and savings are available to you
4. Compare plans based on coverage, costs, and providers
5. Choose a plan and enroll
6. Pay your first premium to activate your coverage

If you need help at any point, you can get free assistance from trained helpers called Navigators or from licensed insurance agents who specialize in ACA plans.

Choosing the Right Plan

Picking the right healthcare plan is one of the most important decisions you’ll make. Here’s how to find the plan that works best for you:

Look at the Total Cost

Don’t just look at the monthly payment. Consider all the costs:

• Premium (monthly payment)
• Deductible (what you pay before insurance kicks in)
• Copayments and coinsurance (what you pay when you get care)
• Out-of-pocket maximum (the most you could pay in a year)

Think about your healthcare needs. If you use a lot of healthcare services, a plan with a higher monthly payment but lower costs when you get care might save you money overall.

Check the Provider Network

Each plan has a network of doctors, hospitals, and other providers. Care from providers in the network costs less than care from providers outside the network.

If you have doctors you want to keep seeing, check if they’re in the plan’s network before you choose a plan. Most marketplace websites have provider directories you can search.

Review Drug Coverage

If you take prescription medications, check if they’re covered by the plan and how much they’ll cost. Each plan has a list of covered drugs called a formulary.

Some plans may require prior authorization for certain drugs or may have rules about trying less expensive drugs first.

Consider Your Health Needs

Think about what healthcare services you and your family are likely to need in the coming year:

• Do you have a chronic condition that requires regular care?
• Are you planning to have a baby?
• Do you need coverage for specific treatments or specialists?
• How often do you typically see a doctor?

Your answers will help you decide which level of coverage (Bronze, Silver, Gold, or Platinum) makes the most sense for you.

Compare Plan Types

ACA plans come in different types, like HMOs, PPOs, EPOs, and POS plans. These differ in how flexible they are and how much they cost:

• HMO (Health Maintenance Organization): Usually limits coverage to providers in the network. You need a referral from your primary care doctor to see a specialist.
• PPO (Preferred Provider Organization): Covers care from providers both in and out of the network, but you pay less for in-network care. You don’t need referrals to see specialists.
• EPO (Exclusive Provider Organization): Generally doesn’t cover care outside the network except in emergencies. You usually don’t need referrals for specialists.
• POS (Point of Service): Covers care from providers both in and out of the network, but you pay less for in-network care. You need referrals to see specialists.

HMOs and EPOs usually have lower premiums but less flexibility. PPOs and POS plans offer more choice but tend to cost more.

ACA Healthcare for Families

ACA healthcare plans offer good options for families. Here’s what families should know:

Coverage for Children

All ACA plans must cover pediatric services, including dental and vision care for children under 19. This is one of the essential health benefits required by law.

Children can stay on their parents’ health insurance plan until they turn 26, even if they:

• Don’t live with their parents
• Are married
• Go to school
• Are financially independent
• Are eligible for their own job-based coverage

This can be a big help for young adults starting their careers or going to college.

Family Plans vs. Individual Plans

When shopping for coverage, you’ll see family plans and individual plans. Family plans cover multiple people under one policy, while individual plans cover just one person.

Family plans usually have higher premiums and deductibles than individual plans, but covering everyone under one plan can sometimes be more affordable and simpler to manage than having separate plans.

Children’s Health Insurance Program (CHIP)

If your income is too high for Medicaid but you can’t afford private insurance for your children, they might qualify for the Children’s Health Insurance Program (CHIP). CHIP provides low-cost health coverage for children in families that earn too much to qualify for Medicaid.

When you apply for coverage through the Marketplace, you’ll find out if your children qualify for CHIP or Medicaid.

Maternity and Newborn Care

All ACA plans must cover pregnancy, maternity, and newborn care. This includes:

• Prenatal care visits
• Labor and delivery services
• Postpartum care
• Newborn baby care

Having a baby qualifies you for a Special Enrollment Period, so you can enroll in or change your health plan outside the regular Open Enrollment period.

Financial Help for Families

Financial help with ACA plans is based on your household income and size. Larger families can qualify for subsidies at higher income levels than smaller families or individuals.

For example, in 2023, a family of four with an income up to about $120,000 might qualify for premium tax credits.

Special Enrollment Periods and Exceptions

Usually, you can only enroll in ACA healthcare during the annual Open Enrollment period. But certain life events qualify you for a Special Enrollment Period (SEP), giving you 60 days to enroll or change plans outside the regular enrollment time.

Qualifying Life Events

Events that may qualify you for a Special Enrollment Period include:

• Loss of health coverage: If you lose job-based coverage, Medicaid, CHIP, or a student plan
• Household changes: Getting married, having a baby, adopting a child, divorce, or death in the family
• Residence changes: Moving to a new county or ZIP code, moving to the U.S. from another country, students moving to or from where they attend school
• Other qualifying events: Becoming a U.S. citizen, leaving incarceration, AmeriCorps service starting or ending

Income and Subsidy Changes

If your income changes during the year, it can affect your subsidies:

• If your income goes down, you might qualify for more financial help
• If your income goes up, you might qualify for less financial help

You should report income changes to the Marketplace to make sure you’re getting the right amount of financial help. If you get too much help and don’t report income increases, you might have to pay some money back when you file your taxes.

Medicaid and CHIP Enrollment

You can apply for Medicaid and CHIP any time, not just during Open Enrollment. If you qualify, your coverage can start right away.

When you apply through the Marketplace, you’ll find out if you or your family members qualify for these programs.

Hardship Exemptions

In some cases, you might qualify for a hardship exemption that lets you buy a catastrophic health plan (which usually has lower premiums but higher deductibles). Normally, these plans are only available to people under 30.

Hardships might include homelessness, eviction, foreclosure, domestic violence, death of a family member, bankruptcy, or substantial medical debt.

Frequently Asked Questions

Do I have to have ACA healthcare?

There’s no longer a federal penalty for not having health insurance. However, some states have their own requirements. More importantly, having health insurance protects you financially and helps you get the care you need.

What if I can’t afford ACA healthcare?

Many people qualify for financial help that makes plans affordable. If your income is low, you might qualify for Medicaid, which provides free or very low-cost coverage.

Can I keep my doctor with an ACA plan?

It depends on which plan you choose. Before enrolling, check if your doctors are in the plan’s network. You can usually do this on the insurance company’s website or by calling your doctor’s office.

What if I get health insurance through my job?

If you have access to affordable, adequate coverage through your job, you can still buy an ACA plan, but you probably won’t qualify for subsidies.

What happens if I miss the enrollment deadline?

If you miss Open Enrollment, you’ll have to wait until the next one unless you qualify for a Special Enrollment Period due to a life change like losing other coverage, getting married, or having a baby.

Will ACA healthcare cover my pre-existing conditions?

Yes. Insurance companies can’t deny you coverage or charge you more because of pre-existing conditions.

How do I know which plan is best for me?

Consider your healthcare needs, the total cost (not just the monthly premium), whether your doctors are in-network, and what drugs are covered. The Marketplace website offers tools to help you compare plans.

Can immigrants get ACA healthcare?

Lawfully present immigrants can buy Marketplace insurance and get subsidies. Undocumented immigrants aren’t eligible to buy Marketplace health insurance, but they can buy coverage outside the Marketplace.

What if my income changes during the year?

If your income changes, you should report it to the Marketplace. This helps ensure you get the right amount of financial help and avoids surprises at tax time.

Can I cancel my ACA plan if I get other coverage?

Yes, you can cancel your Marketplace plan if you get other coverage, such as through a new job. Be sure to coordinate the timing so you don’t have a gap in coverage.

Conclusion

Healthcare is important for everyone. The Affordable Care Act has made it easier for millions of Americans to get quality health insurance they can afford.

With ACA healthcare, you can:

• Get coverage even if you have health problems
• Receive financial help if you qualify
• Choose from plans with different levels of coverage to find one that fits your needs and budget
• Have access to preventive care at no extra cost
• Know that your plan covers essential health benefits

Taking the time to understand your options can help you find a plan that works for you and your family. Remember, having health insurance not only protects your health but also your finances.

The best time to sign up is during Open Enrollment, which usually runs from November 1 to January 15. But if you have a qualifying life event, you might be able to enroll anytime.

Don’t let concerns about cost keep you from getting covered. Many people are surprised to learn they qualify for financial help. In fact, most people who buy ACA plans get some assistance.

Take the first step by visiting Healthcare.gov or your state’s marketplace to see what options are available to you. Free help is available if you need it. Having the right healthcare coverage gives you peace of mind and access to care when you need it most.