Compare Health Plan Coverage and Costs under the Affordable Care Act

Copyright © 2014 AARP. All rights reserved.

When choosing a health plan under the Affordable Care Act (ACA), be sure to consider and compare the major factors of a plan’s coverage and cost to make sure you know how it works and how it would work for you. Each has its own unique set of questions. By considering each of these factors, you can choose the plan that works for you and your family.

Health plan coverage under the ACA

Coverage refers to the range of health services your plan covers, such as doctor visits, hospital visits, maternity care, emergency room care, and prescription drugs. You want to see what the plan offers, whether it has limits on types of services, and how often you can use them in a year. You can start to understand your coverage using your Summary of Benefits and Coverage. Here’s how:

  • Find out if the plan limits which doctors, hospitals, and other providers you can use. Is your favorite doctor part of the network? What happens if you want to see an out-of-network provider? Will you have to pay more? Are the in-network doctors and hospitals conveniently located for you?

  • If you spend a lot of time out of state, check to see if you can get healthcare services in other states. Also determine what the provider network looks like outside your home state or whether care will be out of network.

  • Find out which services are excluded from the plan. If you know you will need a specific type of care — for example, bariatric surgery — you want to make sure the plan offers that type of coverage.

  • Check out the prescription drug coverage. Make sure the plan covers the prescription drugs you take regularly and find out whether it requires any pre-authorization and works with a pharmacy in your area. See if you can receive your prescriptions by mail.

Health plan cost under the ACA

Be sure to understand the costs of your coverage:

  • Premiums are the regular monthly payments you pay to your plan.

  • The deductible is the amount you have to pay for health services each year before the plan covers costs. Say you have a $1,000 deductible. You will have to pay $1,000 out-of-pocket for covered services before your plan will cover any costs. Once you’ve paid this amount, you’ve satisfied the deductible for the rest of the calendar year.

  • Some services you can get without having to pay a deductible, such as preventive care.

  • Coinsurance or copayment is a portion of the cost you may have to pay when you go to the doctor, get a prescription, or use other covered care.

    • Coinsurance is a percentage amount, such as 20 percent of the allowed cost of a doctor visit.

    • A copayment (or copay) is a set dollar amount. For example, you may pay $15 for each prescription or doctor’s visit.

    Note: Prescription drugs may have copayments for some drugs and coinsurance for others.

  • Out-of-network providers are doctors or other health professionals who are not part of your plan. Check to see if you have to pay more for an out-of-network provider.

If you qualify for financial help on the Marketplace (meaning that you’re currently uninsured, you have an individual plan now, or your employer’s plan isn’t deemed sufficient per the ACA requirements), you can expect to pay between 2 and 9.5 percent of your income to purchase a plan.

The span reflects the fact that your income level determines the amount of financial assistance available to you. The Marketplace offers the greatest financial help to those at the lower end of the income scale. Plus, many low-income people are finding that they qualify for Medicaid in their state.

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