Affordable Care Act Plans or ACA Plans are major medical plans that need to follow the requirements of the Affordable Care Act (commonly known as Obamacare). They are type of individual health insurance coverage. All ACA Plans must give 10 essential health coverage benefits such as hospitalization, doctor visits, outpatient hospital care, emergency services, maternity, and newborn care, services for treating mental health disorders, prescription drug coverage, lab tests, preventive care, pediatric services for children, and rehabilitative and habilitative services.
Every ACA health insurance plan has a guaranteed issue, meaning no applicant can’t be denied based on pre-existing conditions during the open enrollment period, so everyone is eligible to purchase them, without criteria for coverage. Beyond monthly premiums, policyholders may also be responsible for deductibles (how much you have to spend for covered services before your insurance company starts to pay for them), copayments, and coinsurance (every payment you make when you get medical service after you met your deductible), and out-of-pocket maximum (the most amount of money you have spent for covered services in one year and after you reach this maximum insurance company starts to pay for all services).
TYPES OF ACA PLANS
There are four main types of ACA plans, and even though they need to cover a minimum of ten essential benefits, there are quite differences between them. Every health care provider can choose how they want to cover these essential health benefits, so you will most likely need to pay deductibles, copayments, and coinsurance for some medical services. The most known ACA plans are High Maintenance Organization, Preferred Provider Organization, Exclusive Provider Organization, and Point of Service.
So in general, the four plan options of ACA Plans are HMOs, PPOs, EPOs, and POSs. There is also a Catastrophic plan which is designed for people under the age of 30.
High Maintenance Organization (HMO)
An HMO is a type of health care plan that typically has lower premiums but you have fewer choices of doctors. When you choose an HMO you have to name a specific doctor who manages all of your care- often called a primary care physician. You must go to this specific doctor before you can see any other doctor if you are sick and need care.
For example, if you have a rash and need to see a dermatologist you first need to go to your PCP who then gives you, regarding your health condition, a referral to see a dermatology specialist. You need to choose a PCP in your area, but you can always change your PCP if you are not satisfied.
With an HMO you always need to stay in-network- this means that you’ll need to go to the doctors and hospitals within HMO’s network to avoid high out-of-pocket costs of medical bills. HMO plan doesn’t cover any out-of-network care except for medical emergencies.
Preferred Provider Organization (PPO)
Unlike the HMO plan, with a PPO plan choosing a Primary Care Physician is not required which makes it easier to see specialists (because you don’t need a referral for it). However, you can choose a PCP if you like. PPO plan has a larger provider network in comparison to the HMO so you can choose between more doctors and hospitals and that gives you flexibility.
You can go to the doctor and hospitals out of the PPO’s network, but it will cost you more money. These are one of the most popular plans on the market.
Exclusive Provider Organization (EPO)
Just like with the HMO, to receive care with an EPO plan you’ll need to stay in a network of providers because there is no coverage if you go to out-of-network doctors. If you use an out-of-network doctor you will have to pay for out-of-pocket costs. You don’t need referrals to see specialists or choose a primary care provider. The only thing you need to do is choose exclusively doctors and hospitals within the network to avoid larger costs.
Point-Of Service (POS)
Point-of-Service plans are actually a hybrid between HMO and PPO Plans. Just like with the HMO plan you need to determine a Primary Care Physician who will coordinate your every medical need and make referrals to see specialists when you require them. But, like the PPO plan, you can receive care from out-of-network doctors but you may have to pay higher copayments for such a visit.
