What do ACA plans cover?

The ACA outlines a list of things that every ACA plan must cover.

The essential benefits under the ACA are:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder
  • Prescription drugs
  • Rehabilitation services
  • Laboratory services
  • Preventive and wellness services
  • Pediatric services, including oral and vision care

By law, an ACA plan can’t turn you down due to pre-existing conditions like chronic illnesses. 

“If someone has a chronic condition and medical concerns, they should be on an ACA plan to get the robust coverage they need,” Jan Dubauskas, vice president and senior counsel at Health Insurance Innovations says.

Are short-term plans an alternative to ACA plans?

Short-term health plans should be considered as an alternative to COBRA rather than to an ACA plan.

Short-term plans are not meant as long-term health insurance plans to cover people with ongoing health issues. A short-term plan is meant to fill the gap when you’re in between jobs or have started a new job and don’t have health benefits yet.

COBRA plans allow you to keep your former employer’s coverage for up to 18 months after leaving a job. However, they’re usually very expensive since the employer is no longer paying part of the cost.

Short-term health insurance plans can fill that gap at a lower cost, but don’t provide the same level of coverage.

Some states don’t allow short-term plans, while others have limitations.

States that don’t allow short-term plans are:

  • California
  • Hawaii
  • Massachusetts
  • New Jersey
  • New York

States that restrict short-term plans to six months:

  • Colorado
  • Illinois

Places that allow short-term plans for only three months with no renewals:

  • Delaware
  • District of Columbia
  • Maryland
  • New Mexico
  • Vermont
  • Washington

What isn’t covered by a short-term plan?

Short-term plans are only meant for the unexpected, like an accident or sudden illness, rather than regular, ongoing medical care. Unlike ACA plans, short-term plans can turn you down for your past medical history and won’t cover any pre-existing conditions. The essential benefits of an ACA plan don’t apply, which means they don’t cover all of the same things.

Short-term plans can exempt coverage of those services or place limits on them. An example is prescriptions. A short-term plan may cover medication if you go to the hospital for an unexpected condition. However, the plan likely won’t cover a prescription for a pre-existing chronic condition like asthma.

In addition, short-term plans don’t usually cover maternity care.

ACA marketplace vs. short-term plans: Cost comparison

Short-term health plans are inexpensive. Dubauskas estimates you can find plans that cost about $100 a month.

The average cost of an ACA plan depends on a lot of factors, but here are the average rates nationwide for each tier, according to the Kaiser Family Foundation.

PlanBronzeSilverGold
Nationwide average premium, monthly$342$448$472

If you qualify for subsidies based on your income, you can find ACA plans for less than a short-term plan. There are also catastrophic plans available through the ACA that are cheaper, but have strict requirements to qualify. It’s worth looking into both options to find a cheaper rate.

Health insurance finder tool

Are you unemployed and lost your job within the past 60 days?
lady with box
Back
Can you get health insurance from your job?
Back
men use laptop
Back
Do you have spouse who can get health insurance through a job?
Back
couple
Back
What is your age?
Back
three mens
Back Reset result
Our recommendation

COBRA

Consolidated Omnibus Budget Reconciliation Act
People who lose their employer-sponsored health insurance may qualify for a COBRA plan. COBRA lets you keep your former employer's health plan, but you're responsible for paying all of the costs, including your former employer's portion.
Know more about COBRA
You can also opt for
Back Reset result
Our recommendation blue shield
Back Reset result

How much is your family income?

$1,000 $100,000

How big is your family?

Select
Back
family
Back Reset result
Our recommendation

Medicare

People who are 65 and over qualify for Medicare. You can choose Original Medicare (also called Parts A and B), which is offered by the federal government, or Medicare Advantage (also called Part C), which private insurers provide. The average annual premium for Original Medicare is about $1,600. Medicare Advantage's average yearly premium is $336, but you may have higher out-of-pocket costs than Original Medicare.
Find out more about Medicare costs
Back Reset result
Our recommendation blue shield
family
Compare and Buy Health Insurance Quotes in minutes
Back Reset result
Our recommendation

Medicaid

Low-income Americans qualify for Medicaid. Thirty-eight states expanded Medicaid eligibility, so lower-middle-class Americans may also be eligible in those states. Medicaid offers comprehensive benefits, but at little to no cost depending on your income. Each state has its own eligibility. Some states are flexible with Medicaid eligibility for people who are pregnant, a parent or disabled. If your household income is below 138% of the federal poverty level, you're likely eligible for Medicaid if you live in a Medicaid expansion state. That level is $17,609 for an individual, $23,791 for a family of two, $29,974 for a family of three and $36,156 for a family of four. Non-Medicare expansion states have stricter income guidelines. Check with your state's Medicaid program to see if you qualify.
You can also opt for
Back Reset result
Our recommendation blue shield
family
Compare and Buy Health Insurance Quotes in minutes
Back Reset result
Our recommendation

Parent's employer-based health insurance

The Affordable Care Act lets children stay on a parent's health plan until the age of 26. Having a child on a parent's health plan may or may not increase premiums. It depends on whether you already have family coverage when adding the child to the plan. If a parent already has family coverage, adding a child won't likely increase premiums. However, going from single or couple to family coverage could cause premiums to skyrocket. The average single coverage employer-sponsored plan premium is $1,186. The average family plan is $5,447.
You can also opt for
Back Reset result
Our recommendation blue shield
Back Reset result
Our recommendation

Spouse's employer-based health insurance

Most employers allow employees to add spouses to their health insurance. Going from single health coverage to a family plan may triple or quadruple your premiums. The average single coverage employer-sponsored plan premium is $1,186. The average family plan is $5,447. Not all jobs allow for spouse's coverage, so you'll want to check with your employer to make sure it's an option.
You can also opt for
Back Reset result
Our recommendation blue shield
Find out more about
  • PPO
  • HMO
  • HDHP
  • EPO
Back Reset result
Our recommendation

Employer-based health insurance

Most people with private health insurance get their coverage through a job. employer-sponsored health insurance is usually cheaper than individual health insurance unless you qualify for Affordable Care Act subsidies. Job-based plans are generally less expensive because businesses often pick up more than half of employer-sponsored health insurance premiums. Kaiser Family Foundation estimates the average premiums for a single coverage employer-sponsored health plan is $1,186 and the average family plan is $5,447 annually.
You can also opt for
Back Reset result
Our recommendation blue shield
Click to each one of find out more
  • PPO
  • HMO
  • HDHP
  • EPO
Back Reset result
Employer plans are often one of these types of four plans. Click on each one to find out more.
  • PPO
  • HMO
  • HDHP
  • EPO

Preferred-provider Organization (PPOs)

  • Pay higher premiums with a lower deductible
  • You have access to more providers, but pay much more for health insurance
  • You don't want to choose a primary care physician
  • You don't want to get a referral
  • You want the ability to get out-of-network care
Preferred-provider organization (PPOs) plans are the most common type of employer-based health plan. PPOs have higher premiums than HMOs and HDHPs, but those added costs offer you flexibility. A PPO allows you to get care anywhere and without primary care provider referrals. You may have to pay more to get out-of-network care, but a PPO will pick up a portion of the costs.
Find out more about the differences between plans

Health maintenance organization (HMO)

  • Pay higher premiums with a lower deductible
  • Restricted network of providers with lower premiums
  • You want to choose a primary care physician
  • You don't mind getting a referral
  • You don't care about the ability to get out-of-network care
Health maintenance organization (HMO) plans have lower premiums than PPOs. However, HMOs have more restrictions. HMOs don't allow you to get care outside of your provider network. If you get out-of-network care, you'll likely have to pay for all of it. HMOs also require you to get primary care provider referrals to see specialists.
Find out more about the differences between plans

High-deductible health plans (HDHPs)

  • Pay lower premiums with a higher deductible
High-deductible health plans (HDHPs) have become more common as employers look to reduce their health costs. HDHPs have lower premiums than PPOs and HMOs, but much higher deductibles. A deductible is what you have to pay for health care services before your health plan chips in money. Once you reach your deductible, the health plan pays a portion and you pay your share, which is called coinsurance.
Find out more about the differences between plans

Exclusive provider organization (EPO)

  • Restricted network of providers with lower premiums
  • You don't want to choose a primary care physician
  • You don't want to get a referral
  • You don't care about the ability to get out-of-network care
Exclusive provider organization (EPO) plans offer the flexibility of a PPO with the restricted network found in an HMO. EPOs don't require that members get a referral to see a specialist. In that way, it's similar to a PPO. However, an EPO requires in-network care, which is like an HMO.
Find out more about the differences between plans
Back Reset result
green shield
family
Compare and Buy Health Insurance Quotes in minutes
Back Reset result
Individual insurance/Affordable Care Act
The Affordable Care Act created insurance exchanges that allow people to compare plans. The health law also requires insurers to accept everyone and not charge them exorbitant rates. People who make below 400% of the federal poverty level qualify for subsidies to help pay for an ACA plan.
Know more individual insurance / ACA
Back Reset result
blue shield
To find the kind of ACA plan for you, would you rather...
Back Reset result
Individual insurance/Affordable Care Act
The Affordable Care Act created insurance exchanges that allow people to compare plans. The health law also requires insurers to accept everyone and not charge them exorbitant rates. People who make below 400% of the federal poverty level qualify for subsidies to help pay for an ACA plan.
Know more individual insurance / ACA
People who would prefer to pay lower premiums with a higher deductible may want the below plans
Back Reset result
silver shield

Silver is the second most popular plan in the ACA exchanges, with 35% of people with a Silver plan. Silver has lower premiums than any plan except for Bronze. However, it has lower out-of-pocket costs than Bronze. Silver plans pick up 70% of the costs, while members pay 30% The average single coverage in a Silver plan is $481 monthly and $1,179 for a family plan.

Bronze is the most popular type of plan in the ACA exchanges, with 41% of members with a Bronze plan. These plans have the lowest premiums, but also the highest out-of-pocket costs in the exchanges. Bronze plans pick up 60% of the costs, while members pay 40%. The average single coverage monthly cost in a Bronze plan is $440 and $1,080 for a family plan.

family
Compare and Buy Health Insurance Quotes in minutes
Back Reset result
Individual insurance/Affordable Care Act
The Affordable Care Act created insurance exchanges that allow people to compare plans. The health law also requires insurers to accept everyone and not charge them exorbitant rates. People who make below 400% of the federal poverty level qualify for subsidies to help pay for an ACA plan.
Know more individual insurance / ACA
People who would prefer to pay higher premiums with a lower deductible may want the below plans
Back Reset result
platinum shield

Platinum plans have the highest premiums but the lowest out-of-pocket costs. So, you pay more for the coverage initially but less than other plans when you need health care services. Platinum plans pick up 90% of the costs, while members pay 10%, Not many health insurers offer Platinum plans. Only 2% of members in ACA plans have a Platinum plan, so you may have trouble finding one. The average monthly premiums for single coverage in a Platinum plan is $706 and the average family coverage costs $1,460.

Gold plans have lower premiums than Platinum, but higher premiums than Silver and Bronze. Gold also has lower out-of-pocket costs than Silver and Bronze, but higher than Platinum. Gold plans pick up 80% of the costs, while members pay 20%. The average monthly premium for a single Gold plan is $596. Family coverage averages $1,426 per month.

family
Compare and Buy Health Insurance Quotes in minutes

ACA marketplace vs. short-term plans: When can you enroll?

ACA plans allow you to enroll or make changes to your plan during open enrollment. That is between November 1 and December 15 in most states.

There are a handful of states with longer open enrollment:

  • California: November 1 to January 31
  • District of Columbia: November 1 to January 31
  • Massachusetts: November 1 to January 23
  • Minnesota: November 1 to December 22
  • New Jersey: November 1 to January 31
  • New York: November 1 to January 31
  • Rhode Island: October 15 to December 31
  • Washington, D.C.: November 1 to January 31

You can also sign up or make changes to these plans if you qualify for a special enrollment period. These periods are only if you have a qualifying life event, including:

  • Divorce
  • Marriage
  • Birth or adoption of a child
  • Death of a spouse or partner that leaves you without coverage
  • Your spouse or partner, who has you covered, loses his/her job and health insurance
  • You lose your job and with it your health insurance
  • Your hours are cut making you ineligible for your employer's health insurance plan
  • You are in an HMO and move outside its coverage area

On the other side, you can enroll in a short-term plan at any time.

“The premise of (short-term plans) is you never know when someone is going to lose a job,” Dubauskas says.

Continue reading