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10 Obamacare Basics  – A 2016 ACA Refresher

10 Obamacare Basics – A 2016 ACA Refresher

Posted Oct 20, 2015 by Jenifer Dorsey

When the 2016 open enrollment period begins, it will be the nation’s third since the Affordable Care Act took effect. While Obamacare may seem somewhat familiar by now, it can still be confusing and sorting through plans to choose the right one is not something many people look forward to. As a matter of fact, in a Dec. 2014 Bankrate poll, nearly two-thirds of respondents said shopping for health insurance was at least as bad as having a tooth filled.1

Heading into open enrollment season is a good time for a refresher in ACA basics. Below is a primer that covers Obamacare essentials, and we hope it will help make shopping for your next health plan a little easier.

1. Open enrollment 

Under the Affordable Care Act, the time in which individuals and families can buy private health insurance plans is limited to certain months. Much like annual open enrollment for job-based coverage, Obamacare open enrollment is held once a year. People may re-enroll in their existing health plans or shop and select new coverage.  

The Obamacare open enrollment period for 2016 health insurance plans runs from Nov. 1, 2015, through Jan. 31, 2016

2. Metal levels

Obamacare health plans are separated into four metal levels based on their actuarial value—bronze, silver, gold and platinum. At each level, cost sharing for covered medical expenses is split differently between the insured consumer and health plan. For instance, a bronze plan pays, on average, 60 percent of covered medical expenses, which means you would pay about 40 percent.2

In general, before premium tax credits and cost-sharing subsidies, bronze plans have the lowest monthly premiums and the highest out-of-pocket costs for consumers, and platinum plans have the highest monthly premiums and the lowest out-of-pocket costs. You must decide which plan works best for your household budget and typical healthcare requirements in a given year. 

Learn more about what metal plans are and how they work here.

3. Essential health benefits

Major medical health insurance plans sold on and away from the Health Insurance Marketplace must cover certain categories of healthcare services. In total, there are 10 categories of essential health benefits. These include maternity and newborn care, prescription drugs and pediatric services, to name a few. 

4. Free preventive care

Free preventive healthcare is another ACA requirement for health plans sold on and away from the Health Insurance Marketplace. Major medical coverage sold on the state-based and federally facilitated exchanges as well as in the private marketplace must include certain preventive care services at no additional cost to the insured beyond his or her monthly premium.

If you have an Obamacare health plan and receive a covered preventive service, you will not be charged, even if you haven’t met your annual deductible. There are currently 66 covered preventive services for adults and children. Always confirm your healthcare benefits with your health plan, even preventive services you believe will be provided at no cost.

5. Subsidies

The Affordable Care Act was designed to help make health insurance more accessible and affordable. One way the healthcare reform law achieves this is through subsidies that reduce consumers’ health insurance premiums and healthcare costs. 

Premium tax credits and cost-sharing reductions are the two types of subsidies available to individuals and families that buy health insurance from the Health Insurance Marketplace (i.e., state-based and federally facilitated exchanges)—Obamacare subsidies are not available for coverage purchased in the private marketplace. Consumers must qualify for this financial assistance based on factors such as household size and income—changes to household size and income must be reported to maintain eligibility

You can use tools such as the Health eDeals Health Care Reform Calculator, which is updated annually for open enrollment, to estimate your tax credit, as well as your penalty for going without health insurance.

6. Penalties and exemptions

If you skip out on health insurance that is considered ACA-compliant minimum essential coverage, you could owe penalty known as the individual shared responsibility payment. This fine increases annually and is paid when you file your taxes the following year. 

Some individuals are exempt from having minimum essential coverage, and you can learn more about exemptions at IRS.gov.

7. Special enrollment 

If you miss Obamacare open enrollment or lose coverage at some point during year due to certain life events, you may qualify for a special enrollment period. A special enrollment period allows you to buy health insurance outside open enrollment, but for a limited time. You can read more about qualifying life events and special enrollment here, and you can talk to a health insurance producer or contact the Health Insurance Marketplace if you have questions about eligibility.

8. Obamacare enrollment help

Shopping for health insurance can sometimes feel confusing and overwhelming. There are many types of on- and off-exchange helpers who can assist you with the process, from choosing a plan to filling out the application. You can find local help using this widget from HealthCare.gov.

9. Terminology

It can be tempting to buy a health plan based on monthly premium alone, but doing so could mean paying more out of pocket. In addition to getting professional assistance with selecting and enrolling in a plan, you may want to brush up on your health insurance and Obamacare terms before open enrollment. Knowing key terms and concepts can help you better compare plans and make a more informed decision.

10. Dental benefits

The ACA does not require adults or children to have dental insurance. However, dental coverage is an essential health benefit that must be made available to children either as part of a health plan or through standalone coverage.3 Health plans sold through the Health Insurance Marketplace must include pediatric dental benefits. 

Depending on the state in which you live, you may also be able to purchase adult dental benefits through the Health Insurance Marketplace. There are many dental plans available in the private marketplace, and you can buy them through a producer, a carrier or websites such as healthedeals.com

To learn more about supplemental coverage options that complement your ACA-compliant major medical insurance or stay informed about Obamacare and health insurance options, visit healthedeals.com

Legal Disclaimers

1 MacDonald, Jay. Bankrate. “How Bad is Shopping for Health Insurance?” Dec. 2, 2014. http://www.bankrate.com/finance/insurance/health-insurance-poll-1114.aspx

2 HealthCare.gov. “Marketplace Insurance Categories.” https://www.healthcare.gov/choose-a-plan/plans-categories/

3 HealthCare.gov. “Dental Coverage in the Marketplace.” https://www.healthcare.gov/coverage/dental-coverage/