Goals of the Affordable Care Act (ACA)
Expand access to health insurance
Improve quality and reduce health care costs
Protect consumers from insurance company abuses
Who must comply?
The ACA applies to:
Employers offering group health plans
Third Party Administrators (TPAs) managing ACA-compliant plans
Health insurers (individual and group markets)
Healthcare providers delivering covered services
Consumers who must maintain Minimum Essential Coverage (MEC) unless exempt
Key ACA Terms
Term | Definition | |
|---|---|---|
Minimum Essential Coverage (MEC) | The type of coverage an individual must have to meet the ACA mandate | |
Essential Health Benefits (EHB) | A set of 10 benefit categories that must be covered by ACA-compliant plans | |
Preventive Services | Services that must be covered with no cost-sharing when delivered in-network | |
Qualified Health Plan (QHP) | An insurance plan that has been certified by the health insurance Marketplace (Exchange) and meets specific requirements under ACA | |
Dependent Coverage to Age 26 | All ACA-compliant plans must allow coverage for dependents up to age 26 | |
Additional ACA Provisions
No Pre-Existing Condition Exclusions
No Lifetime or Annual Benefit Limits on Essential Health benefits
Rate Restrictions: Limits on premium variation (e.g., age, location)
Medical Loss Ratio (MLR): Insurers must spend a certain % of premium on care or refund the difference
Summary of Benefits and Coverage (SBC): Must be provided in clear standaridized format to members
Grandfathered plans are exempt from some ACA requirements
What is Covered Under the ACA?
All ACA-compliant plans must cover the following 10 categories (Essential Health Benefits):
Ambulatory patient services (outpatient care)
Emergency services
Hospitalization (e.g., surgery, overnight stays)
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive wellness services and chronic disease management
Pediatric services, including dental and vision care
Preventive Services with No Cost-Sharing
ACA-compliant plans must cover specific preventive services at 100% when provided by an in-network provider. Examples include:
Adults | Women | Children |
|---|---|---|
Blood pressure, cholesterol, and diabetes screenings Colonoscopies (aged-based) Cancer screenings (e.g., lung, prostate) Immunizations (e.g., flu, shingles) | Well-woman visits - includes GYN and Annual with Primary Mammograms and Pap smears Birth control and contraceptive counseling Breastfeeding support and supplies | Developmental screenings Routine immunizations (e.g., MMR, DTaP) Autism screening |
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