What Does ACA Insurance Cover and What's Not Included

ACA insurance covers essential health benefits, including preventive care services such as annual physicals, vaccinations, and screenings.

Preventive care services are covered without copays or coinsurance, which means you won't have to pay out-of-pocket for these services. This is a big perk of having ACA insurance.

Preventive care services include a wide range of services, such as mammograms, colonoscopies, and well-woman visits. These services are designed to help prevent illness and detect health problems early.

Preventive care services are covered for adults and children, and they're an essential part of maintaining good health.

The ACA requires all qualified health benefits plans to cover essential health benefits, including those offered through the Marketplaces and those offered in the individual and small group markets off-exchange.

These plans must cover at least 10 categories of items and services, such as ambulatory patient services, emergency services, hospitalization, and pediatric services, including oral and vision care.

Essential health benefits are a minimum standard, and plans can offer additional health benefits, like vision, dental, and medical management programs.

However, the premium subsidy does not cover non-essential health benefits, meaning that people enrolling in a plan with non-essential benefits may have to pay a portion of the premium for these additional benefits.

Plans are allowed to apply cost sharing, but preventive health services are required to be covered without cost sharing, including vaccinations, cancer screenings, and birth control.

The premium tax credit (or premium subsidy) reduces enrollees’ monthly payments for insurance coverage, while the cost-sharing reduction (CSR) reduces enrollees’ deductibles and other out-of-pocket costs when they go to the doctor or have a hospital stay.

There are health insurance Marketplaces in every state for individuals and families, and some small businesses can buy coverage for their employees through separate exchanges called Small Business Health Options Program (SHOP) Marketplace plans.

The Marketplaces offer a choice of different health plans, certify plans that participate, and provide information and in-person assistance to help consumers understand their options and apply for coverage.

You can get financial assistance to make your health insurance more affordable through the Affordable Care Act (ACA). There are two types of financial assistance: premium subsidies and cost-sharing reductions. Premium subsidies reduce your monthly payments for insurance coverage, while cost-sharing reductions lower your out-of-pocket costs when you go to the doctor or have a hospital stay.

To receive premium subsidies, you must enroll in a plan offered through a health insurance Marketplace, and your household income must be between 100% and 400% of the federal poverty level (FPL). You can receive subsidies if you are a lawful resident or other legally present immigrant, as long as you have U.S. citizenship or proof of legal residency.

The amount of subsidy you receive is based on your income, and it can be used for any plan available on the exchange, except for catastrophic plans. The subsidy may not exceed the premium for the purchased plan.

Here's a breakdown of the maximum net premium after subsidies for a family of four in 2019:

Cost-sharing reductions are available to people with incomes between 100% and 250% of the FPL, and they can only be applied to silver plans. These reductions lower the deductibles and copays under the silver plan, making it more similar to a gold or platinum plan.

Medicaid is a joint federal-state program that provides health insurance to low-income individuals and families. The Affordable Care Act (ACA) revised and expanded Medicaid eligibility starting in 2014, making all U.S. citizens and legal residents with income up to 133% of the poverty line eligible for coverage in participating states.

The federal government initially paid 100% of the increased cost for Medicaid expansion in 2014, 2015, and 2016, and then gradually decreased the funding share to 90% in 2020 and subsequent years.

Some states chose not to expand Medicaid, including Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, and Wisconsin. These states have not implemented Medicaid expansion, and their residents may not be eligible for Medicaid coverage.

States that have implemented Medicaid expansion include Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, Washington D.C., and West Virginia.

Here is a list of some states that implemented Medicaid expansion and the date they went into effect:

You'll need to have a good understanding of what's covered by your ACA insurance to make the most of it.

Preventive Care is covered at 100% by most ACA plans, including annual check-ups, vaccinations, and screenings for cancer and other conditions.

You can also get free or low-cost birth control and family planning services.

Some ACA plans also cover certain preventive services for children, such as vision and hearing tests, and vaccinations for diseases like flu and HPV.

Dependents can remain on their parents' insurance plan until their 26th birthday. This change was implemented starting September 23, 2010.

This means that dependents who are no longer living with their parents can still be covered. They don't have to be a student, a dependent on a parent's tax return, or even married to qualify.

In fact, the law applies to any dependent, regardless of their living situation or financial status.

Deductibles and cost sharing have become a significant aspect of health insurance plans. The average deductible for Bronze plans in the ACA Marketplaces is a staggering $7,258 in 2024, up from $5,113 in 2014.

Many people qualify for cost-sharing reductions, which can significantly lower deductibles and other out-of-pocket costs. For example, the average deductible for the most generous cost-sharing reduction plans is just $90 in 2024.

In the group market, deductibles have been rising rapidly. Between 2011 and 2016, deductibles grew by 63%, while premiums increased by 19% and worker earnings grew by 11%.

The average deductible for workers in the group market is $1,478, with 51% of workers having a deductible of at least $1,000. This number drops to 38% after taking employer contributions into account.

Here's a breakdown of the average deductibles for workers in the group market:

It's worth noting that many people are satisfied with their choice of doctors and hospitals, but are less satisfied with their annual deductible.

The Affordable Care Act (ACA) brings a lot of changes to the way health insurance works. One of the key aspects is the regulation of insurance policies. In the individual market, new policies must cover essential health benefits, which include ambulatory patient services, emergency services, hospitalization, and more.

These benefits are a minimum standard, and plans can offer additional benefits like vision, dental, and medical management programs. However, preventive health services are required to be covered without cost sharing, such as vaccinations, cancer screenings, and birth control.

Insurance companies are also required to implement an appeals process for coverage determination and claims on all new plans. Additionally, they must spend at least 80-85% of premium dollars on health costs, and rebates must be issued if this is not met.

Here is a breakdown of the four tiers of coverage: bronze, silver, gold, and platinum. Each category offers essential health benefits, but varies in their division of premiums and out-of-pocket costs: bronze plans have the lowest monthly premiums and highest out-of-pocket costs, while platinum plans are the reverse.

The Affordable Care Act (ACA) made significant changes to U.S. health coverage, affecting millions of Americans. The law caused a significant reduction in the number and percentage of people without health insurance, with the uninsured rate dropping from 16.0% in 2010 to 8.9% from January to June 2016.

The ACA required all qualified health benefits plans to cover essential health benefits, including 10 categories of items and services such as ambulatory patient services, emergency services, and mental health and substance use disorder services. This means that plans can offer additional health benefits, like vision, dental, and medical management programs, but these are not included in the essential health benefits package.

States that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not had a 14.1% uninsured rate, among adults aged 18–64. This highlights the importance of Medicaid expansion in reducing the number of uninsured individuals.

The ACA prohibited abortion coverage from being required as part of the essential health benefits package, and the premium subsidy does not cover non-essential health benefits. This means that people enrolling in a plan with non-essential benefits may have to pay a portion of the premium for these additional benefits.

Here are the four tiers of coverage established by the ACA: bronze, silver, gold, and platinum. Each category offers essential health benefits, but varies in its division of premiums and out-of-pocket costs.

The ACA also established that insurers must spend at least 80–85% of premium dollars on health costs, and rebates must be issued if this is violated. This ensures that a significant portion of premium dollars goes towards actual healthcare costs rather than administrative expenses.

The law also required that standard benefits should offer at least that of a "typical employer plan", and states may require additional services. This means that plans must provide a minimum level of coverage, but can offer more comprehensive coverage if desired.

In terms of cost, the individual mandate tax was $695 per individual or $2,085 per family at a minimum, reaching as high as 2.5% of household income (whichever was higher). The tax was set to $0 beginning in 2019.

The King v Burwell case was a significant ruling in the United States. On June 25, 2015, the U.S. Supreme Court ruled, 6–3, that federal subsidies for health insurance premiums could be used in the 34 states that did not set up their own insurance exchanges. This decision had a major impact on the Affordable Care Act. The court's ruling meant that millions of people in those states could continue to receive financial assistance to help pay for their health insurance. The 34 states that didn't set up their own exchanges were able to provide subsidies to their residents.

Health benefits under ACA insurance cover a range of essential health benefits, including ambulatory patient services, emergency services, hospitalization, and pregnancy, maternity, and newborn care. These benefits are a minimum standard, and plans can offer additional health benefits, such as vision, dental, and medical management programs.

The essential health benefits package must include at least 10 categories of items and services, which are broad and subject to interpretation. For example, there could be limits on the number of physical therapy services an enrollee receives in a year. The federal government allows states to select a "benchmark" health plan as a standard for interpreting these requirements.

Preventive health services, such as vaccinations, cancer screenings, and birth control, are required to be covered without cost sharing. However, plans can apply cost sharing (deductibles, copayments, and coinsurance) to other essential health benefits, meaning enrollees may still face some out-of-pocket costs when receiving these services.

Here are the 10 categories of essential health benefits:

The Affordable Care Act (ACA) introduced a new standard for health benefits, known as Essential Health Benefits, which must be covered by all qualified health benefits plans.

These essential health benefits include at least 10 categories of items and services, such as ambulatory patient services, emergency services, hospitalization, and mental health and substance use disorder services.

The scope of benefits must be equal to that of a "typical employer plan." However, plans can offer additional health benefits, like vision, dental, and medical management programs.

The ACA requires that preventive health services, such as vaccinations, cancer screenings, and birth control, be covered without cost sharing.

Here are the 10 essential health benefits categories:

The contraception mandate has been a contentious issue since the Affordable Care Act (ACA) was passed in 2012. The Roman Catholic Church voiced concerns that the mandate covering contraception and sterilization violated the First Amendment right to free exercise of religion and conscience.

The Church's concerns led to various lawsuits, including Burwell v. Hobby Lobby Stores, Inc., which examined private corporations' duties under the ACA. This lawsuit was a significant case in the debate over the contraception mandate.

In 2020, the Supreme Court ruled in Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania that employers with religious or moral objections to contraceptives can exclude such coverage from an employee's insurance plan. The court's decision was a major victory for those who opposed the contraception mandate.

The Supreme Court's ruling was not without its critics, however. Justices Ginsburg and Sotomayor dissented, arguing that the decision would leave women workers to fend for themselves.

Habilitative Services and Devices are crucial for people with disabilities or chronic conditions.

The EHB benchmark plans may not cover habilitative services and devices, which means you might not find them included in the standard plan.

Pursuant to 45 CFR 156.110(f), the State has the authority to decide which services are included in the habilitative services and devices category if the base-benchmark plan doesn't cover them.

If the State doesn't supplement the missing habilitative services and devices category, issuers should cover habilitative services and devices as defined in 45 CFR 156.115(a)(5)(i).

Mental Health Parity is a crucial aspect of health benefits. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, also known as MHPAEA, requires that EHB plans comply with its standards.

EHB plans must comply with the standards implemented under MHPAEA. This means that they must provide equal coverage for mental health and substance use disorder services as they do for medical and surgical services.

However, the EHB-benchmark plans may not comply with MHPAEA. This is because they may not meet the requirements set by the Act.

EHB Benchmark Plans are a crucial aspect of ACA insurance coverage. They serve as a standard for essential health benefits that must be included in all qualified health benefits plans. States have the flexibility to select their own EHB-benchmark plans, which can change over time.

For plan years 2020-2025, states had three options to select their EHB-benchmark plans: selecting a plan used by another state in 2017, replacing categories of EHBs with those from another state's plan, or selecting a new set of benefits. This flexibility was intended to reduce the burden on states and improve the EHB-benchmark plan update process.

To select a new EHB-benchmark plan, states must submit specific documentation, including an EHB State Confirmation Template, Actuarial Certification/Report, EHB-Benchmark Plan Document, EHB-Benchmark Summary Chart Template, and Formulary Drug List Template (if changing prescription drug EHBs). These requirements have been in place since plan year 2020.

As of plan year 2026, states have a simpler process for changing their EHB-benchmark plans. They can now select a new set of benefits without the need for additional documentation. This change is intended to make it easier for states to update their EHB-benchmark plans and ensure compliance with federal requirements.

Here is a list of the EHB-benchmark plans for the 50 states and D.C. that were applicable for plan years 2014-2016:

These EHB-benchmark plans serve as a starting point for states to design their own plans, and issuers may need to conform plan benefits to comply with current federal requirements.

ACA insurance plans have some limitations and exclusions to be aware of. Routine non-pediatric dental services are excluded from Essential Health Benefits (EHB) for plan years beginning on or before January 1, 2026.

Long-term/custodial nursing home care benefits are also excluded from EHB, as are non-medically necessary orthodontia services. Routine non-pediatric eye exam services are excluded as well.

Annual and lifetime dollar limits are allowed in EHB-benchmark plans, but they can't be applied to essential health benefits. These limits can be converted to actuarially equivalent treatment or service limits.

A plan can't exclude coverage of an EHB category, with the exception of pediatric services. This means that even if a plan has limits, it can't exclude coverage of a specific category.

For example, a plan can't exclude coverage of maternity and newborn coverage for dependent children of plan subscribers. This ensures that essential health benefits are covered, even if limits exist in the EHB-benchmark plan.

Routine non-pediatric dental services, routine non-pediatric eye exam services, and long-term/custodial nursing home care benefits are excluded from Essential Health Benefits (EHB), even if an EHB-benchmark plan covers them.

For plan years starting on or before January 1, 2026, non-medically necessary orthodontia is also excluded from EHB.

Abortion services are not required to be covered as part of EHB, although an issuer may choose to cover them.

Starting on or after January 1, 2027, issuers of plans offering EHB may include routine non-pediatric dental services.