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

Have you become unemployed within the last 60 days and lost your health insurance?
lady with box
Back
Is health insurance available from your employer?
Back
men use laptop
Back
Do you have a spouse with access to an employer-sponsored plan?
Back
couple
Back
What is your age?
Back
three mens
Back Reset result
Our recommendation

COBRA

The Consolidated Omnibus Reconciliation Act, better known as COBRA, allows you to stay on your former employer's health insurance plan to bridge the gap until you get new coverage. COBRA is expensive, as you will pay the full premium without help from your employer. It should be considered a short-term solution.
Learn more about COBRA
You may also want to consider:
Back Reset result
Our recommendation blue shield
Back Reset result

How much is your annual household income?

$0 $250,000+

How many members are in your household?

Select
Back
family
Back Reset result
Our recommendation

Medicare

Most people over the age of 65 qualify for Medicare. Original Medicare includes Parts A and B, for medical and hospital care. Medicare Advantage plans, administered by private health insurers, are called Part C, and include everything in Parts A and B. Many Advantage plans also include extra benefits like vision, hearing and dental coverage. Medicare Part D, which covers prescription drugs, can be added to either option.
Medicare costs vary depending on which option you choose.
Learn 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

You may qualify for Medicaid based on your income. Guidelines for eligibility differ by state. To find out if you qualify in your state, contact the local Medicaid office.
You may also want to consider an ACA plan. The ACA provides subsidies for lower-income people. Learn more:
Back Reset result
Our recommendation blue shield
family
Compare and Buy Health Insurance Quotes in minutes
Back Reset result
Our recommendation

Parent's employer-sponsored health insurance

You can stay on your parent's health insurance plan until age 26 under the Affordable Care Act. For most people, this is the cheapest option. A dependent usually costs less to insure than a spouse or an individual.
You may also want to consider:
Back Reset result
Our recommendation blue shield
Back Reset result
Our recommendation

Spouse's employer-sponsored health insurance

If your spouse can add you to their employer-sponsored plan, it will likely be more affordable than seeking coverage on your own. In most cases, coverage for a spouse is available, but not always.
You may also want to consider:
Back Reset result
Our recommendation blue shield
Learn more about each plan type
  • PPO
  • HMO
  • HDHP
  • EPO
Back Reset result
Our recommendation

Employer-sponsored health insurance

Health insurance through your employer is generally the most affordable option since employers pay a large portion of the monthly premium. If an employer-sponsored plan is available, it's likely the best choice. You may have more than one plan option to choose from.
You may also want to consider:
Back Reset result
Our recommendation blue shield
Learn more about each plan type
  • 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
You should compare individual insurance plans, including those on the health insurance exchanges created by the Affordable Care Act (ACA). ACA plans have no restrictions on pre-existing conditions and must include certain coverage basics.
Learn more about individual insurance plans
Back Reset result
blue shield
To learn more about ACA plans, choose the option that best fits your needs
Back Reset result
Individual insurance
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
These plans have lower monthly premiums and higher out-of-pocket costs
Back Reset result
silver shield

Silver plans provide a good balance of monthly premiums with out-of-pocket costs. Coinsurance is 70% with a silver plan, meaning you will pay 30% of the costs after your deductible is met, up to the out-of-pocket limit. Silver plans are a good choice for people who are in generally good health but don't want high out-of-pocket costs if something goes wrong.

Bronze plans are a popular choice with those who value low monthly premiums and are willing to pay more when they need care. Coinsurance is set at 60%, meaning you will pay 40% if you do need care, up to the out-of-pocket limit. Bronze plans are good for those who don't expect to need many services outside of preventative care throughout the year.

family
Compare and Buy Health Insurance Quotes in minutes
Back Reset result
Individual insurance
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
These plans have higher monthly premiums with lower out-of-pocket costs
Back Reset result
platinum shield

ACA platinum plans have the highest monthly premiums, but the lowest out-of-pocket costs. You'll pay more monthly in return for lower deductibles, copays and coinsurance amounts. Coinsurance with platinum plans is 90%, which means you pay 10% after the deductible, up to your out-of-pocket limit. Platinum plans are good for those who anticipate a lot of medical needs throughout the year.

Gold plans cost a little less than platinum plans, and come with higher out-of-pocket costs. The coinsurance amount on a gold plan is 80%, which means you pay 20% after the deductible, up to your out-of-pocket limit. A gold plan is a good idea if you think you'll need a lot of care throughout the year, but don't want to pay platinum premiums.

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