The Affordable Care Act, commonly referred to as Obamacare, guarantees healthcare coverage for all Americans. Furthermore, the law offers financial assistance that helps lower healthcare costs for those earning a certain income level.
But sometimes it can be confusing to determine which Obamacare policies are accepted. That’s why eHealth is here to help!
In-Network Providers
In the world of health insurance, “in-network” refers to doctors, other healthcare providers, pharmacies and facilities that contract with an insurer to provide care for its members. These ‘in-network’ providers usually charge lower prices for services which could mean lower copays or deductibles.
However, the Affordable Care Act also implemented some restrictions that may make it difficult to find in-network providers for certain medical specialties.
At open enrollment for this year’s health insurance plans, the Obama administration has attempted to address these concerns by adding a search tool that allows people to determine if specific doctors and hospitals are covered under their plan networks.
Insurers must maintain a network of providers to guarantee members receive the care they need and aren’t charged more than necessary for it. To do this, insurers negotiate discounts with in-network providers which help lower costs for everyone involved.
Out-of-Network Providers
If you need medical treatment from an out-of-network provider, it is essential to understand your rights under Obamacare. In general, emergency services are covered as if they were in-network (as of 2022, there won’t be any balance billing for any out-of-network emergency medical services).
Non-emergency services from out of network providers may require you to pay the difference between their charges and what an insurer pays, so it’s best to discuss this in advance with your medical provider.
Obamacare also protects you by mandating insurance companies to offer an OON make available benefit that pays the provider’s UCR (Unlimited Charge Rate) for out-of-network services after meeting your 20% coinsurance threshold. The UCR, determined by FAIR Health, is equal to the 80th percentile of charges for each service requested.
Premium Subsidies
Premium subsidies help those with low to moderate incomes afford health insurance. These subsidies come in the form of credits that reduce enrollees’ monthly payments for Marketplace plans.
In addition to premium tax credits, ACA enrollees are also eligible for cost-sharing reductions (CSR). CSR help lower out-of-pocket expenses associated with deductibles and copayments when using covered health care services.
The Affordable Care Act (ACA) offers premium tax credits to help people who earn between 100 percent and 400 percent of the Federal Poverty Level purchase health insurance through the Marketplace. Subsidies usually increase in accordance with premium increases, protecting people from rising premium costs.
Coverage for Pre-Existing Conditions
Before the Affordable Care Act (ACA), those with health conditions like cancer, diabetes, asthma or pregnancy could face great difficulty finding affordable coverage. Plans in the individual market would often charge much higher premiums to those with preexisting conditions (or “rated up”) or deny them coverage altogether.
Beginning in 2014, Obamacare made it illegal for health insurance companies to discriminate against individuals based on pre-existing conditions or other medical issues. Furthermore, if you have a family member with such a condition, Obamacare rules prevent insurers from charging you more due to their history.
The Affordable Care Act also funded the Pre-Existing Condition Insurance Plan, designed to give Americans with severe and expensive preexisting conditions access to affordable health care. Estimates estimate that 20 million people were covered under this program between 2010 and 2013, acting as a connector between private insurers and those suffering from such conditions.
Medicaid
Medicaid is a government-run health insurance program that offers free or low-cost medical care to those unable to afford it on their own. In most states, you may qualify for Medicaid if your income falls below a certain level; however, rules vary between locations.
The Affordable Care Act allowed some states to expand Medicaid eligibility under the ACA, meaning they could cover more people with household incomes below a certain level. Nonetheless, other states have chosen not to expand.
Although fewer people in these expanded states can enroll in Medicaid, they have seen greater improvements in access to care, financial security and health outcomes – particularly among Black and Hispanic individuals.
