What are ACA Plans?

ACA plans are sometimes referred to as major medical, comprehensive coverage, or even “Obamacare” - these plans meet all the requirements of the ACA and are typically the most comprehensive on the market. ACA plans must include coverage for outpatient care, emergency care, hospital stays, mental health coverage, prescription drugs, rehab services, lab services, free preventive care, maternity and newborn care, and pediatric care, with no annual or lifetime coverage maximums. These plans are available to almost everyone, and you can’t be denied based on preexisting conditions.

ACA plans have different levels – bronze, silver, gold and platinum – all of these plans offer the same essential benefits. The difference between the metal levels is how much you pay out of pocket:

• Bronze: Your insurance company pays 60%, and you pay 40%.
• Silver: Your insurance company pays 70%, and you pay 30%.
• Gold: Your insurance company pays 80%%, and you pay 20%.
• Platinum: Your insurance company pays 90%, and you pay 10%.

How Can I Purchase an ACA Plan?

You can purchase an ACA plan either through a Federal or state marketplace (or their authorized broker partners) or directly from an insurance company or broker. Purchasing through the government or state exchange site is known as buying "on-exchange." Purchasing directly through an insurer or broker is considered buying "off-exchange" or "outside the marketplace."

When Can I Enroll in an ACA Plan?

In most cases, you need to enroll in an ACA plan during the annual Open Enrollment Period, which runs from November 1 to January 15 in most states (some states have different dates).

After open enrollment ends, you can normally only enroll in an ACA plan if you have a “special enrollment period” triggered by a qualifying life event. Learn more about qualifying life events and special enrollment periods here.

Outside of the open enrollment or special enrollment periods, you may be able to purchase a non-ACA health plan, such as a short-term health insurance plan.

Is There Government Assistance to Help Me Pay For an ACA Plan?

To help make your health care more affordable, there are two forms of government assistance available. If you meet certain requirements, you may be eligible for a Premium Tax Credit or Cost Sharing Reduction from the U.S. Government to help reduce the monthly premiums.

• Premium Tax Credit. The government will help pay for, or subsidize, your monthly insurance premium if your income is at or below 4x the Federal Poverty Line. To qualify, you must not be Medicaid -eligible or have access to affordable health insurance through your employer or a family member’s employer, and you must purchase an ACA plan on-exchange. Learn more about the Premium Tax Credit and how to qualify here.
• Cost Sharing Reduction. The government will help pay for your out-of-pocket costs of health care if you enroll in a Silver ACA plan, and your income is at or below 2.5x the Federal Poverty Line. Learn more about the Cost Sharing Reductions and how to qualify here.

If you find that an Affordable Care Act (ACA) plan is financially out of reach or if you've missed the enrollment deadline, you might want to explore the option of short-term health insurance plans. These short-term plans differ significantly from ACA coverage in that they generally offer more limited coverage, generally do not cover preexisting conditions, are subject to annual and lifetime benefit maximums, and do not exempt you from state tax penalties. However, they have the advantage of being available for application throughout the year, and can provide some financial relief in the event of unexpected medical events that are unrelated to a preexisting condition. It's essential to understand that short-term health plans do not adhere to ACA regulations, potentially leaving gaps in your healthcare coverage. Therefore, it's crucial to carefully review the plan's specifics before deciding to enroll. Additionally, keep in mind that purchasing short-term health insurance may render you ineligible for other health insurance options, including ACA plans and COBRA. This is an important consideration when weighing the pros and cons of short-term plans.

If you find that an ACA plan is financially out of reach or if you've missed the enrollment deadline, another health plan option that generally offers more limited benefits than comprehensive health insurance, but at lower premiums (excluding any ACA premium subsidies), is fixed indemnity health insurance plans, often referred to as limited medical or fee-for-service plans.  These plans pay you a predetermined amount for specific healthcare services, such as $100 for a doctor's visit, regardless of the actual cost to you of the service. Some of these plans utilize PPO networks that can reduce your costs if you use in-network providers, but the plans still may not cover all of the costs of your care, particularly hospitalization costs, leaving you with significant out-of-pocket expenses. When used in conjunction with other insurance coverage, medical indemnity plans can be beneficial in offsetting out-of-pocket medical expenses like copayments and coinsurance. You may have the option to acquire a medical indemnity plan as your sole insurance or as part of a broader insurance package. 

However, similar to short-term health insurance, it's important to note that fixed indemnity plans do not adhere to the Affordable Care Act (ACA) requirements and do not exempt you from state tax penalties. Additionally, they generally do not cover preexisting conditions and may impose per-incident, yearly, and/or lifetime benefit limits. It's essential to recognize that medical indemnity plans may not be suitable for everyone, particularly as a substitute for comprehensive coverage. Therefore, it's crucial to carefully review the plan's specifics and ask questions of the broker before deciding to enroll. However, if you're seeking assistance with covering medical costs and expenses, they could be a viable option to explore further.

Healthcare sharing ministries (HCSMs) are unique entities distinct from traditional health insurance. They are formed by members who share common ethical or religious beliefs and, in accordance with those beliefs, contribute a regular payment to collectively cover the qualifying medical expenses of the members. HCSMs have long been an alternative for certain religious communities that object to traditional insurance, as they allow members to share health care costs as a community.

It's important to note that while HCSMs may resemble traditional insurance products in some respects, they are not insurance, and because HCSMs are not required to comply with the ACA’s consumer protections, coverage for preexisting conditions may be limited or excluded, medical benefits are typically far more limited than in ACA-compliant plans, and members are never guaranteed payment, even for covered services. However, HCSMs typically have lower monthly membership dues compared with full-price health insurance premiums for individuals who do not qualify for the ACA's premium subsidies. The table below summarizes some of the key differences between HCSMs and ACA plans: