Affordable Care Act Provisions

• Preventive medicine covered at 100% with no cost sharing.
• Children can stay on parent’s plan until age 26.
• No lifetime limits on health insurance coverage.
• Annual maximum-out-of-pocket limits on copays/deductibles/coinsurance.
• Closing the donut hole for Medicare recipients.  
• Prohibiting discrimination due to pre-existing conditions or gender.
• Establishment of insurance exchanges/marketplaces for individuals to use to buy coverage in qualified plans that meet certain benefits and cost standards.
• The Employer Mandate – employers with more than 50 employees are required to offer affordable health insurance benefits or be taxed on a per employee basis.
• Tax credits will be available for people between 100% and 400% of the poverty line to help pay for the mandatory health insurance.
• “Cost Sharing Reductions” or “Extra Savings” on Silver plans through the ACA Marketplace.  At lower incomes, the deductibles/copays/annual max out-of-pocket limits are decreased significantly. 

What are Exchanges?

The government has established a Federal health insurance Exchange/Marketplace where individuals and small businesses can go and easily shop for and compare health insurance plans. The plans are offered by traditional insurance carriers but must meet the standards and rules regulating plans on the Exchange.   Pennsylvania has set up its own Marketplace at www.pennie.com (called Pennie).

All plans on the exchanges must meet certain “essential health benefits” including mental health benefits, maternity care, and pediatric vision and dental care.  Tax credits are available for people between 100% and 400% of the poverty line to help pay for the health insurance through the exchanges.

What are Essential Health Benefits?

All plans (both on the Exchange/Marketplace and through private insurance companies outside the Exchange) must include certain benefits.  These include hospitalization, prescriptions drugs, emergency care, preventive/wellness services, mental health services, maternity, pediatric services (including vision and dental), lab work, and rehabilitative and habilitative services and devices.

To calculate an estimate of your tax subsidy for buying health insurance on Pennie, see this subsidy calculator.