The Affordable Care Act (ACA) and Marketplace Coverage

The Affordable Care Act, aka the ACA, changed the way many people receive and use health care coverage. The ACA aimed to make benefits more affordable by supplying premium subsidies, or tax credits, and cost-sharing reductions for those who qualify. These subsidies lower costs for households with incomes between 100% and 400% of the federal poverty level. Even those beyond these general guidelines may qualify for subsidies under specialized circumstances.
 
The ACA also set out terms and conditions to make health insurance coverage more uniform, regardless of which insurance company is offering the plan, and among the various plan types.
 
Let’s talk about the Marketplace, also known as the health insurance exchange. The Marketplace is where U.S. citizens or legal residents can buy ACA-compliant health insurance plans, known as Qualified Health Plans, or QHPs for short. In Kentucky, the Marketplace is known as kynect.

There are ten things ACA-compliant plans on the Marketplace must cover:

  • Preventive and wellness services, including chronic disease management 

  • Mental health and substance use disorder services, including behavioral health treatment 

  • Prescription drugs 

  • Hospitalization 

  • Maternity and newborn care 

  • Emergency services 

  • Pediatric services, including oral and vision care 

  • Rehabilitative and habilitative services and devices to help patients get, maintain, or improve skills necessary for daily functioning

  • Laboratory services 

  • Ambulatory patient services

Choosing the right plan can feel overwhelming. kynect offers access to kynectors, who are authorized health insurance navigators that can help with eligibility, enrollment forms, and applying for both Medicaid and Qualified Health Plans.

The ACA provides for four metal-named tiers on the Marketplace – Bronze, Silver, Gold, and Platinum – each of which have defined cost structures. Generally, the lower the metal value, the lower the premiums, but the higher the deductibles and out-of-pocket maximums. Kentucky’s Marketplace does not offer Platinum plans.

​It’s important to know that the Marketplace considers your household to be you, your spouse, and any child or family member you claim as a dependent. Eligibility for savings is based on the combined income of all household members.

An important aspect of the Marketplace is the Premium Tax Credit, also known as premium subsidies. This feature can lower your monthly insurance premium payment based on your household income. Premium subsidies are only available on plans purchased through the Marketplace.

Another way that the ACA helps you save money is through cost-sharing reductions, or CSRs. These are discounts that lower the amount you pay for such costs as your copays, coinsurance, deductible, and out-of-pocket maximum. To have access to CSRs, you must enroll in a Marketplace plan in the Silver tier category. They are not available for Bronze, Gold, or Platinum plans.

​Understanding these details is an important step towards making informed Marketplace plan decisions.

These materials were supported by funds made available by the Kentucky Department for Public Health’s Office of Population Health from the Centers for Disease Control and Prevention, National Center for STLT Public Health Infrastructure and Workforce, under RFA-OT21-2103.​

​The contents of these materials are those of the authors and do not necessarily represent the official position of or endorsement by the Kentucky Department for Public Health or the Centers for Disease Control and Prevention.