Getting health insurance is an excellent investment, especially If you don’t want to be buried in a load of medical debt. However, there are many options in the market, so choosing the right one for you might be tricky.
Today, we’ll be talking about one of your options: qualified health plans, and discuss its coverage and how much they cost.
Read on to learn more about qualified health plans.
What is a Qualified Health Plan?
Qualified health plans aren’t that complicated.
In simple words, qualified health plans are health insurance policies sold in the health insurance exchange (or health insurance marketplace). These plans are certified by the marketplace and meet the Affordable Care Act (ACA) specifications that cover essential health benefits.
Under the ACA, health insurance plans must meet requirements to be considered qualified health plans. For these plans to be sold in the exchange, they must:
- Be certified by the Federally Facilitated Marketplace (FFM);
- Not have pre-existing condition restrictions;
- Follow the cost-sharing guidelines provided by the ACA; and
- Cover the essential health benefits with no maximums (lifetime or annual) for coverage.
Keep in mind that some ACA-compliant medical plans sold through the exchange meet the same specifications as qualified health plans. However, they’re not certified by any exchange.
Also, qualified health plans can be purchased with an advanced premium tax credit, while ACA-compliant medical insurance can’t.
Essential Health Benefits of Qualified Health Plans
Like we’ve mentioned, qualified health plans are those sold in and certified by the exchange. They follow limits on cost-sharing, including deductibles and copayments, and meet other ACA requirements.
These plans, also known as QHPs, must also provide coverage for “essential health benefits.
But what exactly are these essential health benefits?
The ACA requires all health insurance plans to cover essential health benefits. These essential health benefits are mandatory benefits that you should receive from qualified health plans and other health insurance plans.
These essential health benefits are:
- Laboratory services
- Emergency services
- Prescription drugs
- Mental health and substance abuse disorder services
- Maternity and newborn care
- Pediatric services
- Rehabilitative and habilitative services (including devices)
- Ambulatory services
- Preventive and wellness services
- Chronic disease management
Besides these health benefits, qualified health plans also have metallic benefit levels, which we’ll discuss later on.
Moreover, there are also plans, called catastrophic plans, which are offered to people under 30. These plans generally have fewer benefits.
Also, people under 30 who’d like to purchase a catastrophic plan must meet other criteria before they’re considered eligible.
Types of Qualified Health Plans
As mentioned, there are different metallic benefit levels of qualified health plans in the market.
Each level gives you an idea of how much you’ll pay for the healthcare services you avail of. Keep in mind that the costs are split between your out-of-pocket expenses and what the plan covers.
Also, insurance providers aren’t required to sell plans at every metal level.
Below are the metal levels of qualified health plans you can purchase from the marketplace.
Platinum-level plans must cover 90 percent of your expected healthcare services’ costs. Under this level, you only pay 10 percent of your remaining expenses.
Under the gold level, plans are required to cover 80 percent of your expected healthcare services’ costs. You pay the remaining 20 percent of the costs if you have a gold-level plan.
Plans in the silver level must cover 70 percent of your expected healthcare expenses. In turn, you pay the remaining 30 percent.
Bronze-level plans are required to cover 60 percent of your expected healthcare services’ costs. You pay the remaining 40 percent with a bronze-level plan.
Expanded Bronze Level
Expanded bronze-level plans are the last type of qualified health plans in the market. With an expanded bronze-level plan, you get between 55% to 62% for coverage on your expected healthcare costs.
Additionally, some expanded bronze-level plans can cover between 56% to 65% of your expected healthcare costs if:
- They cover and pay for at least one primary healthcare service (excluding preventive services) before the deductible;
- They meet the requirements to be considered as high-deductible health plans.
How Much Does a Qualified Health Plan Cost?
Now that you’ve seen how much qualified health plans cover, it’s time to know how much they’d cost.
Like other health insurance plans, qualified insurance plans also have premiums that you have to pay monthly.
On average, premiums people pay for individual coverage costs $456 a month. On the other hand, the average premium rates people pay for family plans are $1,152 a month.
However, keep in mind that the rates you’ll get will still depend on other factors, including the metallic level your plan is on. On average, people pay for the following monthly rates:
- Bronze Level: $448
- Silver Level: $538
- Gold Level: $569
- Platinum Level: $732
- Catastrophic Plans: $195
Aside from these average costs, we’ll also provide a table showing the comparison of these different metallic levels.
Below is a table to help you decide which plan level to get.
|Best For||People who don’t plan on using many healthcare services||People who want a balance between monthly premiums and out-of-pocket costs||People who want to save on monthly premiums and out-of-pocket expenses||People who plan to use many healthcare services|
Qualified Health Plans vs. Other Health Plans
Like we’ve said, qualified health plans are just like other health plans. However, remember that qualified health plans are plans certified by the marketplace.
In this section, we’ll be discussing other plan types that you can get from insurance providers or the marketplace.
Gap Plans (Short-term Plans)
Gap plans are a type of group supplemental health plans purchased by policyholders with high-deductible major health plans. High-deductible health plans (HDHP) are plans whose deductibles cost at least $1,300 per person and $2,600 for a family.
Like the name says, a gap health plan helps policyholders pay for healthcare expenses before receiving the deductible.
Typically, gap plans are also called ”insurance on insurance.”
Major Health Plans
Major health plans are health insurance policies that people refer to when talking about typical health insurance policies.
Generally, these plans meet the ACA’s requirements for qualifying health plans. Also, these policies are made to lessen the policyholder’s out-of-pocket costs.
Like qualified health plans, major health plans also cover expenses for the essential health benefits under the ACA.
Another health insurance option you can find on the market is catastrophic plans.
Like we’ve said earlier, these plans are for people under 30. However, catastrophic plans can also be purchased by people who meet the requirements for a hardship exemption.
Generally, catastrophic plans are made to protect you against the burdens of a worst-case scenario. For instance, you can’t afford to pay the medical bills you incurred from a medical emergency.
While regular health insurance premiums come at an affordable cost, you’ll still have to pay the costs out-of-pocket unless you’ve reached your plan’s annual deductible.
This is where catastrophic plans come in. Catastrophic plans cover several health benefits, including primary visits, even if you haven’t reached your deductible yet.
Qualified Health Plans vs. Other Health Plans: At a Glance
Aside from what we’ve mentioned, there are also other differences that these plans have.
To help you decide which to purchase, we made a table showing some of their other differences. Below is the table to help you see them easily.
|Gap Plans||Major Health Plans||Qualified Health Plans||Catastrophic Plans|
|Start of coverage||Within 14 days||Within 45 days||Within 45 days||Within 45 days|
|You can buy it on a state exchange||✖||✖||✓||✓|
|Disapproval of application due to pre-existing conditions||✓||✖||✖||✖|
How to Apply for a Qualified Health Plan
Now that you know all these things, you might be wondering how you can get a qualified health plan for yourself or your family.
You have to prepare several things if you’re planning to get a health plan sold in the exchange.
Remember to keep these ready for each individual you want to enroll in a plan.
- Personal information: name, address, birthday, social security number, and citizenship status (You might be required to present proof of lawful residency status, too.)
- For people who are planning to apply for premium subsidy: Household size and income (You’ll need proof of income, like pay stubs or W2s)
- For people who have employer-sponsored health plans: Insurance coverage details (regardless if you’ve accepted or declined the plan)
- For people who want to purchase a catastrophic plan (you should be 30 or older): Hardship exemption notice
Once these documents are ready, you can visit your local FFM that sells qualified health plans. This can either be through HealthCare.gov or your state exchange.
Also, remember to talk to your health insurance provider. They can help you find which plan is right for you that’s suited to your health needs and budget.
Some insurance providers can also help you find qualified health plans from private marketplaces, which can be more affordable.
To Wrap up
While premiums can be expensive, the benefits of health insurance will help you save money in the long run. If you don’t have health insurance yet, now’s the time to purchase one for yourself.
If you think a qualified health plan isn’t for you, remember that you have many options. Just keep in mind that you have to find one that suits your health needs and your budget.
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