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ACA Compliant Health Insurance Plans

ACA Compliant InsuranceThe Affordable Care Act(ACA) passage ushered in a sweeping set of new regulations on the Texas individual health insurance marketplace and has caused a great deal of change for health insurance since 2014 in terms of plan structure and availability.  The most significant and drastic shift in the marketplace for health insurance has come from the individual major medical health insurance market which is ACA compliant plans. For those individuals and families looking for health insurance independent of their employer, ACA compliant policies offer many consumer protections and the premiums can even be subsidized for lower income thresholds.  For many people with pre-existing medical conditions that require immediate and frequent attention, ACA plans should be closely considered due to all the protections for such individuals.


ACA plans eliminated many provisions related to individual medical plans and added a whole host of new rules the insurance carriers participating in these plans have to abide by.  Specifically, ACA plans must cover the 10 essential health benefits. These include:

  1. Ambulatory patient services (outpatient services)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

In addition, ACA major medical insurance plans are now required to accept anyone regardless of pre-existing condition, apply no waiting period in order to utilize services, impose no annual or lifetime caps on services, and charge older people no more than 3 times what’s charged to a young person.  For people with catastrophic illnesses or a lot of required medical care, ACA plans offer the most protection and access to care. This means you can literally roll into an ACA major medical and not have to wait at all to be treated with no way for the insurance carrier to deny you needed coverage.

We have seen this major medical coverage change over the years from mostly PPO Medical policies to just theACA Health Insurance exact opposite today.  HMO ACA policies have become the predominant type ACA plan in today’s marketplace. Just a few years ago, to as late as 2014, there were mostly PPO plans available to individuals in the Texas marketplace and many other states across the Land. HMO plans do NOT allow you to see providers outside of the HMO network that’s been pre-selected for you.  What’s more, HMO will typically require referrals to see specialists. So, although ACA plans come with a lot of health coverage, particularly for the sick, they come with a hefty price tag in terms of provider options and access to care. One of the unintended consequences of The Affordable Care Act for Texas and other states is the severe access to care by the way if HMO implementation.  There are many doctors and hospital networks unwilling to take HMO which is concerning in this respect.

ACA plans are also very expensive relative to other types of insurance you may have been quoted in the past.  We have seen premiums increase more than 2 fold over the last several years and know how expensive it can be; unless of course, you get a tax credit to lower the outlay you and your family would come up with in the event of a catastrophic illness.  If you need assistance determining any potential tax credit you may be entitled to, please visit www.healthcare.gov to see if you qualify.  If so and you like the premium, you may decide to go with a professional at HC.gov by calling them directly or emailing a representative who can go through options and discuss premiums and deductibles with you.  Otherwise, if you do not receive tax credits of any kind to purchase ACA insurance coverage, then give us a call. One of our skilled and licensed Insurance Agents will gladly assist you with your selection. We have excellent and reliable software which allows us to see just about every plan for BCBS of Texas you might want to look at.

Another unintended consequence of ACA was the severe limitation of plan choice in many counties across the Lone Star State and many other states.  In fact, BCBS of Texas is the ONLY choice for ACA Health Care in over 75 counties in our state. That just means an individual or family will only be able to purchase an ACA certified plan from BCBS.  There are several choices for ACA health care in the metropolitan areas of Texas. However, at this time they are all relegated to HMO plans.

If you need a quote and would like to see plans and pricing from BCBS of Texas before speaking with an agent, simply click HERE.  Or, if you prefer to speak with one of our licensed insurance agents about getting a quote or have questions, don’t hesitate to pick up the phone and call us at: 866 341 8542  One of our licensed agents will take the time to explain coverage and benefits to you and to forward quotes and outlines of coverage upon request.