Navigator Guide FAQ of the Week: What Does My Plan Cover?

With Open Enrollment now well underway, consumers are weighing their options for 2021 and trying to find the right plan that meets their health needs. As consumers make their decision, it is important for them to understand what they are buying and what coverage their plan provides. Throughout the enrollment period, the CHIR team is highlighting frequently asked questions (FAQs) from our recently updated Navigator Resource Guide. In this installation, we answer FAQs about marketplace plans’ coverage standards.

I heard marketplace plans have to cover certain health benefits referred to as essential. What are essential health benefits?

All qualified health plans offered in the marketplace (as well as non-grandfathered individual plans sold outside the marketplace) will cover essential health benefits. Categories of essential health benefits include:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including dental and vision care

The precise details of what is covered within these categories may vary somewhat from plan to plan.

I notice marketplace plans are labeled “bronze,” “silver,” “gold,” and “platinum.” What does that mean?

Plans in the marketplace are separated into categories — bronze, silver, gold, or platinum — based on the amount of cost-sharing they require. Cost-sharing refers to out-of-pocket costs like deductibles, co-pays and coinsurance under a health plan. For most covered services, you will have to pay (or share) some of the cost, at least until you reach the annual out-of-pocket limit on cost-sharing. The exception is for preventive health services, which health plans must cover entirely.

In the marketplace, bronze plans will generally have the highest deductibles and other cost-sharing. Silver plans will require somewhat lower cost-sharing, but this may not always be the case. If you are deciding between a bronze and silver plan, you will want to determine what the cost-sharing amounts are for the services you would use under each plan. Gold plans will have even lower cost-sharing. Platinum plans will have the lowest deductibles, co-pays and other cost-sharing. In general, plans with lower cost-sharing will have higher premiums, and vice versa. Keep in mind, however, that if you qualify for cost-sharing reductions, you must enroll in a silver plan to obtain cost-sharing reductions that lower your out-of-pocket costs.

I have a $2,000 deductible but I don’t understand how it works. Can I not get any care covered until I meet that amount?

A deductible is the amount you have to pay for services out-of-pocket before your health insurance kicks in and starts paying for covered services. Under the Affordable Care Act, preventive services must be provided without cost-sharing requirements like meeting a deductible, so you can still get preventive health care that is recommended for you.

Also, most plans must provide you with a Summary of Benefits and Coverage, which you can check to see if your plan covers any services before the deductible, such as a limited number of primary care visits or prescription drugs.

I heard not all plans have to meet all rules. How do I know if my plan has to comply?

That’s right. Plans that were in existence on or before March 23, 2010 are known as “grandfathered” plans and don’t have to meet all the rules. Grandfathered plans are exempt from many of the Affordable Care Act rules for plans, including the requirement to cover preventive services without cost-sharing and to limit out-of-pocket costs. Your plan must tell you if it is grandfathered in any plan documents they send you. Over time, all plans will lose their grandfathered status and have to comply with rules that only apply to new plans. Note, however, that some rules don’t apply to self-insured and large employer plans, even if they are new (non-grandfathered).

It is also possible that your employer renewed your current plan in 2013, before it was required to come into compliance with most of the Affordable Care Act’s consumer protections. Referred to as transitional or “grandmothered” policies, most states allow small employers to keep these noncompliant policies if they begin on or before October 1, 2020 and come into compliance with the ACA by January 1, 2021.

Other forms of coverage also do not have to comply with the Affordable Care Act’s requirements, including short-term limited duration insurance, association health plans, and Health Care Sharing Ministries. See the Navigator Resource Guide’s Other Resources and Alternative Coverage tabs for more information on how the Affordable Care Act’s insurance rules apply to different plans.

Open Enrollment runs through December 15th in most states. Look out for more weekly FAQs from our new and improved Navigator Guide, or browse hundreds of questions and answers here.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.