ACA Health Insurance Basics

We offer a variety of Individual & Family plans through the Affordable Care Act (ACA). Here, we’ll help you understand what these plans are, what they cover, how to enroll, and more.

What is ACA?

What is ACA?

The Affordable Care Act, or ACA, is the comprehensive health care reform law that allows people to buy their own health insurance plan if they aren’t provided one by their employer, Medicaid, Veterans Affairs, Medicare, or TRICARE. ACA plans are not short-term plans. If eligible, these plans guarantee health coverage with no exclusions for preexisting conditions.

 

Who is eligible for ACA?

To enroll in an ACA plan, you must be a U.S. citizen, currently living in the U.S., without access to health insurance offered by your employer. You also cannot enroll in an ACA plan if you’re enrolled in Medicare or Medicaid.

Member ID Card

Every ACA plan covers:

  1. Outpatient care
  2. Emergency services
  3. Hospitalization, surgery, and overnight stays
  4. Pregnancy, maternity, and newborn care
  5. Mental health and substance use disorder services, including behavioral health
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

Where to buy your plan

There are two ways to buy an ACA plan: through the Exchange or outside the Exchange. Which one you choose depends on your personal needs and financial situation, but our licensed representatives can help you make the decision.

 

Through the Exchange

These are Highmark plans that are bought through the federal or state government Marketplace, also called the Exchange. These plans offer extra savings to those who are eligible that can lower monthly premiums and out of-pocket costs.

Outside the Exchange

These plans are bought directly through Highmark and do not offer financial help. Additional plans may be available off the Exchange.

Save money on your ACA plan

Save money on your ACA plan

Eighty percent of Highmark ACA plan members qualify for extra savings. So, if you’re worried about paying for your health plan, we have two ways to help:

  • Advanced Premium Tax Credits (APTC) – These can lower your monthly premium and are based on your household income and household size.
  • Cost-Sharing Reduction (CSR) – This program can help lower the out-of-pocket costs that come when you receive care, like deductibles and copays. Depending on your household size and income, you may be eligible for both an APTC and a CSR.

 

Choose your metal level

ACA plans are organized by metal levels.When signing up for a plan, you can choose how you want to split up your costs with your insurer. The quality of care is the same for every level.

Gold – Higher monthly premiums, lower out-of-pocket costs.

Silver – Moderate premiums and out-of-pocket costs. You must select this metal to utilize CSR.

Bronze – Lower monthly premiums, higher out-of-pocket costs.

Catastrophic – Only for people under 30 or for people undergoing certain hardships. Protects people from the large health bills that come with catastrophes, like being diagnosed with a complex illness.

Learn the lingo

Health insurance is full of buzz words. That’s why we try to make health insurance simpler and easier to understand for our customers by simplifying how we talk about health insurance. Here are a few terms you’ll probably come across in your search for a plan.

Coinsurance

The percentage you may owe for certain covered services after reaching your deductible. For example, if your plan pays 80%, you pay 20%.

Claim

The request for payment that’s sent to your health insurance company after you receive covered care.

Copay

The set amount you pay for certain covered services, could be $20 for a doctor visitor $30 for a specialist.

Deductible

The set amount you pay for health services or drug costs before your plan starts paying.

Maximum Out-Of-Pocket

The most you’d pay for covered care. If you hit this amount, your plan pays 100% after that.

Premium

The monthly amount paid so you have coverage.

Provider

Whether it’s your primary doctor, a lab technician, or a physical therapist, the person or facility where you get care is referred to as a health care provider.

Stars Ratings

What do the stars ratings mean?

Starting in 2019, the star ratings system began to appear alongside health plans as part of the Quality Rating System (QRS) required by the Affordable Care Act. The stars, which rate eligible health plans on a 1-5 scale (5 being the best), are designed to provide consumers with information about the quality of health care services and the overall experience of people who bought their plans on the Marketplace.

The ratings are based on three categories:

Medical care – How well the plan’s in-network doctors provide care, like helping patients stay healthy, monitoring and treating their conditions, and providing them with regular screenings and vaccines.

Member experience – Based on how customers answer surveys about how easy it is for them to get appointments and medical tests, their satisfaction with doctors and other health care providers, and their overall happiness with their health coverage.

Plan efficiency – Based on how customers answer surveys about their level of satisfaction with aspects of their health plan including customer service, access to information, and affordability.

You can see these three categories under the Plan Details section on the Marketplace.

*Some plans may be designated as “Not Rated”. However this does not mean that they are low quality. The reasons why a plan may be listed as “Not Rated” are:

  • The plan hasn’t been on the market for three full consecutive years.
  • Its enrollment is too low.
  • It did not have enough data to support a rating for the “Medical Care” category.
  • It did not have enough data to support ratings for two of the three categories (even if the plan does have a “Medical Care” rating)