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How do I know if my health insurance is ACA compliant?

“To sum it up…”

  • In order for your health insurance to be compliant with the Affordable Care Act, it must cover the 10 essential health benefits
  • It must also have no annual or lifetime coverage maximums
  • Your healthcare coverage must comply with these standards whether the plan was purchased on or off the healthcare exchange
  • You or your employer may be responsible for paying a penalty fine for not meeting the minimum essential coverage requirements

There are several guidelines that a health insurance plan must meet in order to be compliant with the Affordable Care Act. The plan must offer coverage for the ten essential health benefits and it must not have any annual or life time maximum restrictions.

Additionally, pre-existing conditions must not affect someone’s eligibility for coverage. Plans that are compliant with the Affordable Care Act are also not permitted to rescinded for random reasons and carriers must be in compliance with the Medical Loss Ratio rules. These rules state that carriers must spend at least 80 percent of the premium income on medical expenses. For larger group plans, this amount increases to 85 percent.

There are some plans that may have been in existence prior to the establishment of the Affordable Care Act in 2014 that are grandfathered in and therefore exempt from some of this regulations. These plans must have been in effect prior to March 23, 2010.

Plans that are not grandfathered in must be compliant with ACA standards whether or not they were purchased on the healthcare marketplace.

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What are the 10 essential health benefits?


There are 10 essential health benefits that insurance plans must cover under the new Affordable Care Act rules. The 10 benefits include hospitalization, emergency services, maternity care and coverage for newborns, prescription drugs coverage, and necessary lab tests.

Additionally, ambulatory services must be covered which includes visits to any healthcare professionals you need to see and any necessary outpatient hospital care. Those who are struggling with mental health disorders or need recovery services for substance abuse disorders must also be covered under these essential health benefits.

Dental and vision care must be offered for children, however, there is some flexibility with the dental coverage requirement if the plan was purchased specifically on the healthcare marketplace exchange.

Insurance carriers must also cover chronic disease management, preventative services, and rehabilitative services.

Some of the preventative services that are recommended by the United States Preventative Services Task force that must be covered are screenings for breast cancer, colon and rectal cancers, blood pressure, and obesity.

Counseling for obesity must be covered, as well as counseling for tobacco use and breast feeding. Rehabilitative services also include habilitative services that help to improve a person’s quality of life or overall ability to function. Some examples of these habilitative services include early intervention therapy, speech therapy, and other treatments that might improve the health or well-being of those with disabilities.

What are some examples of plans that are compliant with Affordable Care Act?


Any plan that meets these minimum essential coverage requirements is considered compliant with the Affordable Care Act. Any health plan available for purchase through the market place meets these standards, as does COBRA coverage, Medicare Part A and a Part C advantage plan. However, Medicare part B alone does not qualify as minimum essential coverage.

Most Medicaid plans are also considered compliant unless it is a limited coverage plan. There are some limited Medicaid coverage options that only pay for certain services such as family planning, emergency care, outpatient hospital treatment, or tuberculosis care. These plans do not meet minimum essential coverage requirements.

The Children’s Health Insurance Program meets these standards, as do most university student health plans, health coverage offered through the Peace Corps, and most TRICARE plans and certain types of other coverage for veterans.

What is the penalty fine for not being ACA compliant?


If you can afford health insurance but chose not to buy it or you have a plan that does meet the minimum essential coverage requirements, you may be responsible for paying a penalty fine known as the individual mandate.

You will pay this fee when you file your tax returns for the previous year. You will either pay a fine of 2.5 percent of your household income or $695 per adult in your household and $347.50 for any child under the age of 18. You will pay whichever of the two options is higher.

If you only went without coverage for a short period of time, you may qualify for a short coverage exemption and will not be responsible for paying the fee.

To qualify for the short coverage exemption, you must not have gone without health insurance for more than two consecutive months.

You can only claim this exemption once in any given year. If you had coverage for part of the year, you may only be responsible for paying 1/12th of the yearly amount that you owe for each month that you did not have qualifying health insurance.

If your employer offers you health insurance, but your job-based coverage does not meet the minimum essential coverage requirements, your employer may be responsible for paying a fine. This fine is the lesser of either $2,000 for each full-time employee with an exemption for the first 30 employees or it is $3,000 for each full-time employee receiving subsidies to help cover their health care needs.

How do I get a plan that is ACA compliant if mine is not?


You do not need to buy a health insurance plan online through the healthcare marketplace in order for it to be compliant with the Affordable Care Act regulations. You can buy it directly through an insurance company or in various other ways.

If you do wish to buy an insurance plan through the marketplace, you can be assured that it will be compliant. You can buy a plan online at any time during the open enrollment period between November 1, 2016, and January 31, 2017.

Depending on certain circumstances that occurred in your life, you may also be eligible for a special enrollment period to purchase an insurance plan outside of those dates.

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  1. https://www.healthinsurance.org/faqs/ive-heard-that-i-need-to-have-an-aca-compliant-health-plan-but-what-does-that-mean/
  2. https://www.healthcare.gov/glossary/medical-loss-ratio-MLR/
  3. https://www.healthinsurance.org/obamacare/essential-health-benefits/
  4. https://www.healthcare.gov/fees/plans-that-count-as-coverage/
  5. https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/#limitedbenefits
  6. https://www.healthcare.gov/fees/fee-for-not-being-covered/
  7. https://www.healthcare.gov/exemptions-tool/#/results/2016/details/short-gap
  8. http://obamacarefacts.com/obamacare-employer-mandate/
  9. http://obamacarefacts.com/obamacare-open-enrollment/