45 facts for 45 days of Obamacare open enrollment

Jeanine Skowronski


Jeanine Skowronski

Jeanine Skowronski

Former Head of Content at Policygenius

Jeanine Skowronski is the former head of content at Policygenius in New York City. Her work has been featured in The Wall Street Journal, American Banker Magazine, Newsweek, Business Insider, Yahoo Finance, MSN, CNBC and more.

Published November 1, 2017|8 min read

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Healthcare is confusing under the best of circumstances. And, well, 2018 isn’t exactly the best of circumstances for Obamacare. But ACA open enrollment is still happening. Right now actually. And, if you don’t have health insurance, you only have until Dec. 15 to shop the federal exchange.

We want to make things less confusing — and remind people to sign up. (Because if you don’t buy health insurance, you won’t have health insurance, you know?) Here are 45 facts for 45 days of Obamacare. (Psst: Friends don’t keep friends in the dark about health insurance, so please share this facts with the hashtag #SpreadtheHealth).

1. All ACA plans cover pre-existing conditions.

The ACA mandates coverage for pre-existing conditions under health insurance with one exception: grandfathered plans, which are individual policies purchased on or before March 23, 2010 — and only "grandfathered" through next year.

2. Parents can keep kids on their plan until they’re 26 years old.

Even if that kid’s married, living away from home, attending school, financially independent or eligible for an employer-sponsored plan.

3. Insurers can’t cap your essential health benefits.

No lifetime or annual dollar limits — which were prominent pre-ACA — allowed.

4. Most health plans offer free preventative care.

Preventative healthcare includes vaccinations, screenings and counseling services for adults at risk for certain diseases.

5. The ACA still provides premium tax credits.

Donald Trump did away with cost-sharing reductions, but the ACA still provides premium tax credits to people who earn between 100% and 400% of the federal poverty level and purchase a plan through the exchange.

6. A premium is your monthly health insurance bill.

That payment gives you access to the plan. You still have to pay your deductibles, copays and coinsurance. Higher premiums mean lower out-of-pocket costs (and vice versa).

7. To get a premium credit, you must buy a plan on the exchange.

These subsidies are provided on a sliding scale and can be received in advance.

8. You can buy health insurance off the ACA exchange.

And, if you won’t qualify for a premium tax credit, plans from private insurers are worth looking into, given companies have more flexibility in structuring off-exchange plans. (Policygenius can help you compare on- and off-exchange health insurance here.)

9. Insurers can’t raise premiums based on health, medical history or gender.

Premiums are now set solely by five factors: age, location, solo vs. family coverage, plan category and tobacco use.

10. You can shop the ACA exchange if your job-based care is crummy.

But you won’t qualify for a premium tax credit if your employer-sponsored plan is considered “affordable” by the federal government. More on that here.

11. A deductible is how much you pay before coverage kicks in.

So, for example, if you have a $5,000 deductible, you’ll pay $5,000 before your health insurance company starts footing the bill. You’ll still have to pay premiums, copays and coinsurance after that, though. And certain expenses might be deductible-exempt, so check with your insurer.

12. The ACA limits out-of-pocket medical expenses.

In 2018, that limit is $6,650 for individuals and $13,300 for families. The out-of-pocket limits don’t include premiums or services your plan doesn’t cover.

13. The average cost of a 3-day hospital stay is around $30,000.

Plus, to put out-of-pocket expenses in context, fixing a broken leg can cost $7,500 and cancer care can cost several hundred thousand dollars.

14. ACA plans are categorized by how costs are shared.

They’re Platinum, Gold, Silver or Bronze, depending on how you and your insurer split the bill. Those designations have nothing to do with the quality of care.

15. A Platinum plan has the highest premium, but the lowest cost for care.

In exchange for that big monthly payment, insurers pay around 90% of the costs related to your healthcare.

16. A Bronze plan has the lowest premium, but the highest cost for care.

Bronze plan deductibles could be thousands of dollars a year. We’ve got more on the Obamacare metal tiers here.

17. An HSA helps with a high deductible.

So if you’re looking into a plan with one, you’ll want to open a tax-deferred Health Savings Account to cover medical expenses. We’ve got a full explainer on HSAs here.

18. FSAs, which help with medical expenses, are ‘use it or lost it’.

Job-based Flexible Spending Accounts are tax-deferred, but, unlike an HSA, you can’t roll that money over from year-to-year or between jobs. In other words, be sure to use the money in your account regularly.

19. High-deductible plans offer free preventative coverage, too.

Almost all HDHP cover the same services non-HDHP plans cover, so no need to avoid screenings and checkups you can actually get for free.

20. All health plans must cover prescription drugs.

That doesn’t mean meds aren’t free. You’ll likely have a copay to make at the pharmacy.

21. A copay is a fixed payment for covered care.

So you might have to pay $15 every time you see a primary care doctor or $25 every time you see a specialist.

22. Coinsurance is a fixed percentage you pay for care.

So, if your coinsurance is 20%, you pay 20% on all covered services until reaching your out-of-pocket maximum.

23. The total cost of a health plan includes its premium, copay & deductible.

Or coinsurance, if that’s how your plan is structured. You can go here to learn more about picking a healthcare plan that’s affordable for you.

24. Every health plan must cover mental healthcare.

That includes behavioral health treatment, like counseling, health inpatient services and substance abuse treatment.

25. You can’t get denied coverage because you’re pregnant.

It’s considered a pre-existing condition. Plus, pregnancy, maternity and newborn care is one of the ten categories all health insurance plans must cover as a result of the ACA.

26. The ACA provides women & kids with extra free preventative care.

These free services are largely related to pregnancy (for women) and developmental disorders (for kids). But also includes mammograms and screenings for gender-specific cancers.

27. People under 30 are eligible for a catastrophic plan.

These plans have very, very, very high deductibles and effectively provide only worst-case scenario coverage. You’ll pay most medical expenses yourself.

28. Catastrophic plans cover 3 primary care visits per year.

That’s pre-deductible. They also cover the ten essential health benefits and free preventative care.

29. You can buy dental insurance on Healthcare.gov.

But only if you’re buying a health plan simultaneously. Dental expenses might be rolled into that plan or purchased as a separate policy.

30. All health plans include vision insurance for kids under 18.

Only some exchange plans cover adults, but you can buy a standalone vision policy on- or off-exchange.

31. All ACA plans cover rehabilitation services.

That’s for injuries, disabilities, chronic conditions or to recover mental and physical skills.

32. Getting medical care out-of-network can be costly.

Exactly how much it’ll cost you depends on what type of health insurance you have. Some health plans won’t even cover medical expenses incurred out of network.

33. You can cancel an exchange plan if you get a job-based one.

Just be sure to wait until you’re sure when your job-based insurance starts.

34. Private health plans come in 4 flavors: HMO, PPO, EPO & POS.

Be sure you understand how each one works before selecting a plan with your employer or through the ACA exchange. You can find a full explainer on the types of health insurance here.

35. HMO plans limit coverage to a network of doctors & hospitals.

Plus, Health Maintenance Organizations require you choose a primary care physician. And you’ll need a referral from this doc in order to see a specialist.

36. PPO plans cover in-network and out-of-network expenses.

But out-of-network doctor and hospital visits generally cost more. Preferred Provider Organizations don’t require referrals for specialists.

37. EPO plans limit coverage, but don’t require referrals.

With an Exclusive Provider Organization, you’re not covered for out-of-network care, but you don’t have to see a primary care physician before heading to a specialist.

38. POS plans are a hybrid of HMO & PPO plans.

You can go out-of-network care (for a higher cost), but if you want to see a doctor in the plan’s HMO network, you’ll need a referral from your primary care physician.

39. COBRA lets you keep a plan from an ex-employer for up to 36 months.

You’ll pay 100% of your premiums, though, plus a small administrative fee to COBRA yourself.

40. Open enrollment may be longer in your state.

Some state-run exchanges have extended open their enrollment periods. You can find out your state’s deadline here

41. Hurricane victims have more time to find a health plan.

People in areas struck by Hurricanes Harvey, Irma or Maria have until Dec. 31 to enroll buy a plan through the federal exchange. We’ve got more on who’s eligible for the extension here.

42. Under the ACA, 31 states expanded Medicaid.

The federal and state-run program provides low-cost healthcare to people with limited income. It’s also available to children, the elderly, blind or disabled.

43. You can enroll in Medicaid any time of year.

Eligibility varies by state. In states that expanded Medicaid post-ACA, you can qualify on income alone. Healthcare.gov lets you check whether you qualify in your state.

44. People over the age of 65 can qualify for Medicare.

You can apply for Medicare through Healthcare.gov or your state exchange.

45. Certain life events qualify you for special enrollment.

That includes losing health insurance through a job, relocating, getting married (or divorced), having a baby or adopting a child.

Image: Darrin Klimek