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Raising a Newborn

Affordable Care Act Basics (ACA)

The ACA, enacted in March of 2010, includes preventive services to help you stay healthy and catch any potential health issues early on. Plans include comprehensive coverage for medical care, including hospital and physician services, and cover preexisting conditions.

ACA Market Basics

What is an Advance Premium Tax Credit (APTC)

A tax credit you can take in advance monthly to lower your health insurance payment and is commonly called a subsidy since it subsidizes your monthly premium.

-APTC is based on your estimated expected income for the covered plan year.

-This matters because your payment is a percentage of what you earn–not a percentage of the total premium price.

-APTC is based on the premium for the second-lowest-cost silver plan, not your chosen one.

What are cost-sharing reductions (CSR)?

CSRs provide lower dollar amounts for copayments or coinsurance, paid at the time of service for things like doctor visits, prescription refills, or deductibles, which must be paid before the plan begins paying toward the service.

The ACA offers a cost-sharing discount for people who earn between 138% and 250% of FPL and purchase a Silver plan.

How are premium subsidies calculated?

People with income over 400% of the Federal Poverty Level (FPL) pay 8.5% of the benchmark. If household income is more than 400% of FPL, the premiums are 8.5% of the second-lowest-cost silver plan available in their area. If 8.5% of the household’s income is more than the premium for the second-lowest-cost silver plan available in their area, then the household pays the full premium.

Types of plans and network types - Many ACA networks are HMO, PPO, POS, or EPO. Some plans allow you to use any doctor or healthcare facility in their network, while others may charge you more if you use providers outside their network.

Your total costs for health care - You pay a monthly bill (premium) to the insurance carrier regardless of using your benefits. When you receive care, you pay the out-of-pocket costs, including deductible(s), copayments, or coinsurance.

Four categories of health insurance plans through the ACA - The four metal categories include Bronze, Silver, Gold, and Platinum. These categories reflect how you and your carrier share costs. Each type of plan covers the same quality of care.

  • Bronze plans - The insurance carrier pays 60%, and you pay 40%

    • Lowest premiums with the highest out-of-pocket costs​

  • Silver plans - The insurance carrier pays 70%, and you pay 30%

    • Moderate premium with moderate out-of-pocket costs when you utilize care​

  • Gold plans - The insurance carrier pays 80%, and you pay 20%

    • High monthly premiums with low out-of-pocket costs when you utilize care​

  • Platinum plans - The insurance carrier pays 90%, and you pay 10%

    • Highest monthly premiums with the lowest out-of-pocket costs

All ACA plans cover ten essential health benefits:

  1. Ambulatory patient services

  2. Emergency services

  3. Hospitalization

  4. Pregnancy, maternity, and newborn care

  5. Mental health and substance use disorder services

  6. Prescription drugs

  7. Rehabilitative and rehabilitative services and devices

  8. Laboratory services

  9. Preventive and wellness care and chronic disease management - Some preventive services are free

  10. Pediatric services, including oral and vision care

 

You can find more information at healthcare.gov.

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