Your Coverage Under the Affordable Care Act
The Affordable Care Act (ACA) was created to provide affordable health coverage to all Americans. The following went into effect Jan. 1, 2014:
- If you have a pre-existing health condition you cannot be denied coverage by an insurance company.
- Health plans cannot place a yearly or lifetime dollar limit on essential health benefits.
- If you're under age 65 and are not covered by your employer, Medicare, or Medicaid, you may qualify for assistance that will help you save on monthly premiums and costs at the time of service, such as copays. Washington state residents can buy health coverage through Washington Healthplanfinder, the state's online health insurance exchange marketplace.
- Health plans for individuals must include the 10 essential health benefits.
Are You Eligible for Assistance?
You may be able to save on premiums and other costs if:
- You're under age 65 and are not eligible for Medicare, Medicaid, Children's Health Insurance Program (CHIP), an employer-sponsored plan, a plan that is exempt from many ACA-mandated changes (a "grandfathered" plan), or other coverage recognized by the U.S. Department of Health and Human Services (HHS).
- You are a lawful U.S. resident.
- Your income is above 133 percent and up to 400 percent of the federal poverty level (FPL). Many middle-income households fall within this range.
- Your employer's coverage is "unaffordable" (your plan premiums would be greater than 9.5 percent of your household income) or "inadequate" (the plan pays less than 60 percent of covered benefits).
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No Coverage? Penalties Apply
Under the ACA, individuals who do not have health coverage may pay a penalty. If you go without health insurance in 2016, the penalty is 2.5 percent of your income or $695 per adult, whichever is greater, and the penalty for each child in the family without coverage will be up to $347.50. The maximum penalty is set at $2,085. For the 2017 tax year and beyond, the penalty will remain at 2.5 percent, but the flat and maximum amounts will adjust for inflation. For more information, including exceptions, see the Kaiser Family Foundation's explanations (PDF).
The 10 Essential Health Benefits
All health plans — regardless of provider — must include the following benefits:
- Ambulatory patient services. This includes care you receive without being admitted to a hospital, such as services at a clinic, physician's office, or outpatient surgery center.
- Emergency care. This includes care for conditions that, if not immediately treated, could lead to serious disability or death.
- Hospitalization, which includes room and board, medical care, tests, and prescription drugs administered during your stay.
- Maternity and newborn care, including care provided during pregnancy, during and after labor, and care to newborn children.
- Mental health and substance abuse disorder services, including behavioral health treatment. This covers evaluation, diagnosis, and treatment services.
- Prescription drugs. This includes drugs for treating urgent health issues and chronic conditions such as high blood pressure.
- Rehabilitative and habilitative services and devices for people with injuries, disabilities, or chronic health conditions.
- Laboratory services, which includes tests to diagnose conditions and monitor treatments.
- Preventive and wellness services. This includes routine physicals, screenings, immunizations, and chronic disease management.
- Pediatric services, including dental and vision care.