Health & Benefits

This article gives some background on the Affordable Care Act, sometimes called “Obamacare” or the “ACA.” The ACA applies to coverage on a health insurance marketplace or “exchange.” An exchange is an organized market where individuals and their families can enroll in health coverage. 

You can find more information about the ACA by going to Healthcare.gov. Learn more about your marketplace coverage options in Illinois by going to Get Covered Illinois. 

ACA marketplace coverage

The ACA provides a way for people who do not have insurance to get health coverage. This includes people who are not covered under a group health plan, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or another coverage source. The ACA has rules that insurers must follow about coverage. It also regulates the types of coverage that insurers must make available through an exchange.  

What benefits must be offered?

Generally, the ACA requires health insurers to:

• Insure people with pre-existing conditions,
• Cover dependent A person who relies on another for support, such as a child or person with a disability children under a parent’s health plan until the child reaches age 26,
• Cover ten essential benefits with no lifetime or annual limits on the benefits, including:
  • outpatient care (sometimes called ambulatory patient services),
  • emergency services,
  • hospitalization,
  • pregnancy, maternity, and newborn care (before and after birth), birth control coverage, and breastfeeding coverage,
  • mental health and substance abuse disorder services,
  • prescription drugs,
  • rehabilitative and habilitative services and devices,
  • laboratory services,
  • preventative and wellness services, and chronic disease management, and
  • pediatric services (including oral and vision care for pediatric coverages only), and
• Provide free preventative services at no cost as long as your provider is in your plan’s network. 

These “essential health benefits” are the minimum requirements for all marketplace plans. The plans may cover or offer other benefits as well. The specific services covered in each essential health benefits category vary by state and plan.  

What are the different plan levels or categories?

The level or category of the plan has nothing to do with the quality of care provided. All marketplace plans must provide the minimum benefits summarized above.  

Marketplace plans are available in different “metal” levels or categories, including: 

• Bronze,
• Silver,
• Gold, and
• Platinum.  

The category is based on how the plan splits the cost of the health coverage with you. The cost of coverage varies based on how the costs are split. For example, the bronze plans offer the lowest monthly premiums Money that must be paid every month, such as for health insurance but have the highest cost-sharing when you need care. The platinum plans have the highest premiums, but the lowest cost-sharing when you need care. 

You generally want to select a plan level based on your family’s: 

• Needs,
• Financial resources, and
• Specialty care needs. 

Before you enroll, you can get a personalized estimate of costs. 

Each plan also has a network of doctors and other providers. Some plans let you use any provider. Other plans limit your choices or charge you more if you go to a provider outside of the network. So, you should carefully review a plan’s network before enrolling to make sure that it meets your needs.   

What does a marketplace plan cost?

There are many marketplace options to choose from. The cost varies depending on the type of coverage you choose. The cost also depends on your household income and size, where you live, and tobacco use. It is important to understand the cost of the coverage before enrolling. Remember, before you enroll, you can get a personalized estimate of costs.  

Depending on your household income, you may also be entitled to a premium tax credit Can reduce the amount of tax a person owes or increase their tax refund . The tax credit can lower your cost for marketplace coverage. It can also offer extra savings on certain coverage-related costs, such as deductibles, copayments, and coinsurance.

Who can get coverage through the marketplace?

You may be eligible to purchase and enroll in a marketplace plan if you: 

• Live in the United States,
• Are a US citizen or national (or otherwise lawfully present),
• Are not incarcerated in jail or prison, and
• You don’t have health insurance through an employer, Medicare, Medicaid, Children’s Insurance Program (CHIP), or another source. 

An insurer cannot refuse to provide you coverage based on sex or pre-existing conditions. 

When can you sign up for health insurance?

You can shop for coverage on Healthcare.gov during the open enrollment period. The open enrollment period is from November 15 through January 15. You need to enroll by December 15 for coverage starting on January 1. You need to enroll by January 15 for coverage starting on February 1.

You can also enroll during a special enrollment period if you have a qualifying life event. Examples of qualifying events include losing job-based health coverage or losing Medicaid coverage. Learn more about qualifying life events for special enrollment periods.  

How can you sign up for health insurance on the marketplace?

Generally, you should go to Healthcare.gov to enroll in marketplace coverage. There, you can compare plans, coverage options, and prices to decide what is best for you and your family. Healthcare.gov also offers free enrollment help through navigators and assisters. 

Important note: Healthcare.gov is the only place where you may qualify for financial help through premium tax credits.   

In Illinois, you can find the coverage you need by answering a few questions on the Healthcare.gov screener. You can also talk to a local navigator or application counselor if you have questions or need help. 

Get Covered Illinois provides information about special Illinois rules and alternatives. But remember, you can only qualify for financial assistance through premium tax credits by going to the Healthcare.gov website. 

What about off exchange insurance plans? 

You may also be able to get individual health insurance through an “off exchange” plan. Off exchange plans are purchased directly from an insurer or broker. They are not purchased in the marketplace. Although considered a private plan, these plans still must comply with most of the ACA requirements. This includes the requirement to provide essential health benefits.  

The main benefit of buying an off exchange plan is having a direct relationship with the insurance company. You enroll directly with the insurance company, rather than through an exchange. You may find more options available. You will not, however, be eligible for any premium subsidies. You may also find that the off exchange plans are more expensive than the marketplace plans.