Qualified Health Plans
Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by a Health Insurance Marketplace provides essential health benefits, is a standardized plan, and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.
Essential Health Benefits
Health plans offered in the individual and small group markets,
both inside and outside of State Marketplaces, must include items and services within at least the following 10 categories:
- Ambulatory patient services
- Emergency Services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services, such as occupational and speech therapy, and devices
- Laboratory services
- Preventitive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
It can be difficult to compare health insurance plans that have different benefits and out-of-pocket costs. The Affordable Care Act addresses this problem by standardizing the types of benefits and cost-sharing allowed in health plans offered by private health insurers through the Health Insurance Marketplace into four levels of coverage.
Each plan level must cover the same minimum essential health benefits, but the amount of cost-sharing required will vary among the plan levels, as will the premiums charged (general rule – the higher the percentage of benefit costs paid by the plan, the higher the premium for that health plan):
- Bronze plans
- Must cover 60% of the benefit costs of the plan, meaning the insured is responsible for paying the remaining 40%.
- Silver plans
- Must cover 70% of the benefit costs if the plan, leaving the insured to pay the remaining 30%.
- Gold plans
- Must cover 80% of the benefit costs if the plan, leaving the insured to pay the remaining 20%.
- Platinum plans
- Must cover 90% of the benefit costs if the plan, leaving the insured to pay the remaining 10%.
Catastrophic plans, which will have lower premiums, can be purchased by young adults up to age 30, as well as by those who are exempt from the individual mandate. These plans will cover the essential health benefits, but only after a high deductible is met. The deductible cannot exceed the limits for high-deductible Health Savings Account (HSA) plans (in 2014, the HSA limit is $6,350 for an individual and $12,700 for a family). Preventive benefits and coverage for three primary care visits, however, are exempt from the deductible.