Your Health Plan and You

Prior to the passage of the Affordable Care Act (ACA), insurance companies could set yearly and lifetime limits on essential health benefits coverages. The ACA put a stop to that practice. Insurance companies cannot set a dollar limit on what they spend for your essential health benefits. Unless you have a “grandfathered plan” (one in place before 2010), the insurance cannot place annual limits on those coverages, and no plans can place lifetime limits on coverages.

The ACA requires health insurance plans to provide coverage for a set of 10 categories of services. Those services include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, and mental health services. Essential health benefits are minimum requirements that all health insurance plans must cover. Plans may also offer things such as dental and vision coverage.

Except for “grandfathered” health plans (purchased before 2010), health insurance companies cannot refuse coverage or charge you more just because you have a “pre-existing” condition (a health problem that you had before you got your health insurance).

The ACA greatly expanded health insurance coverage for mental health. The law mandates that most plans cover mental health and substance abuse services. Coverage for mental health generally cannot be more restrictive than other medical and surgical services.

The ACA greatly expanded health insurance coverage for women by requiring most health insurance plans to provide coverage, without cost sharing, for certain preventative services—such as mammograms, cervical cancer screenings, and prenatal care. You do not need a referral from a primary care doctor before you get obstetrical or gynecological (OB-GYN) care. And except for certain religious employers, plans must cover contraceptive methods and counseling without a copayment or coinsurance charge. Under current law, plans are not required to cover drugs that will induce abortions. 

If a person’s health insurance plan covers dependents, the plans usually must allow the policyholder to purchase coverage for dependents up to the age of 26. For example, if a parent has a job-based health insurance plan, the parent generally is going to be allowed to purchase coverage until they turn 26 years old—even if the child gets married, has a child themselves, does not live in the parent’s home, and is not claimed as a dependent for tax purposes. That coverage typically ends when the child turns 26.

Individuals that otherwise do not have health insurance can go to www.healthcare.gov to enroll in a health insurance plan. You can compare available plans, get answers to questions, and find out if you are eligible for tax credits to help with the cost. You may also be eligible for Medicaid or the Children’s Health Insurance Program (CHIP).

Generally, health insurance plans will provide one level of care for “in-network” facilities and providers and a lesser level of coverage for “out-of-network” facilities and providers. In the past, an out-of-network provider could bill you for the difference between the billed amount and whatever the insurance company paid. This practice is generally known as “balance billing.” These “surprise medical bills” could be quite high.

New laws ban surprise bills for emergency services, even if you get them out of network and without prior approval. You cannot be charged more than in-network cost-sharing for those services and any cost-sharing you pay counts towards your deductible and maximum out-of-pocket expenses.

In addition, new law bans balance bills for supplemental care (like anesthesiology or radiology) by an out-of-network provider that works at an in-network facility. Unfortunately, these protections generally do not apply to ground ambulance services.

Insurance companies cannot cancel your coverage just because you get sick. And they can’t cancel coverage just because you made a mistake on the insurance application. You can be canceled if you put false information on the application or don’t pay the premiums, but not for a simple mistake.

If you have health insurance through your employer and you lose your job, you can stay on the employer’s health insurance plan because of protections provided by laws like the law known as COBRA. See An Employee's Guide to Health Benefits Under COBRA.