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HEALTH COVERAGE FOR FAMILIES AND INDIVIDUALS

ACA Open Enrollment: November 1, 2023 - January 15, 2024

Health Coverage Resources

  • ACA Enrollment Checklist

  • ACA Enrollment FAQ

  • Health Insurance Terms

  • Understanding ACA Metal Plans

Finding the Right Plan for Each Individual and Family

Healthcare isn’t one size fits all. That’s why it is important to get the plan that is the best fit for each individual or family.
Our Affordable Care Act (ACA)-licensed insurance benefits experts take the time to listen to what’s important to you.  Then we look for affordable plans available in your area that meet those unique medical and lifestyle needs. We also check to see if you are eligible for tax credits to lower your monthly costs.
And we are here for you year-round, to answer your insurance questions and advocate on your behalf. Often, you can speak with the same expert who enrolled you in your plan.
Need help comparing costs of plans in your area? Call our ACA experts:

1-800-550-8246

TIPS TO HELP YOU CHOOSE THE RIGHT ACA HEALTH PLAN

  • Medicare Part A: Hospital Insurance
    Medicare Part A covers: • Inpatient care in a hospital • Care in a skilled nursing facility • Hospice care • Some home health care Once you turn 65, Medicare Part A is premium-free to most older Americans if you or your spouse worked for at least 10 years and paid Medicare taxes. Medicare is also available for people who get Social Security or Railroad Retirement Board disability insurance, and those with End-Stage Renal Disease (kidney failure) and Lou Gehrig's disease (ALS).
  • Medicare Part B: Medical Insurance
    Medicare Part B helps pay for: • Doctor visits • Outpatient care • Lab services, like X-rays, blood work, and other diagnostic services • Home health services • Certain therapies, like physical and occupational • Durable medical equipment, like wheelchairs, oxygen equipment, and other medical equipment • Mental health service • Many preventive services, like flu shots and cancer screenings. 0 Medicare Part B Costs You must pay a monthly premium for Medicare Part B. The premium could be higher depending on your income. After you meet your Part B deductible, you will pay coinsurance, which is 20% of the Medicare-approved amount for the services you receive. For example, if the Medicare-approved amount for a service is $100,Medicare would pay 580, and you would pay $20. To help you pay for Medicare Parts A&B deductibles and coinsurance, some people choose to purchase a Medigap policy. Medigap There are a lot of different Medigap policies to choose from. They are lettered: A, B. C, D, F, G, K, L. M. and N. Not all plans are available, depending on when you enrolled in Medicare. And Massachusetts, Minnesota, and Wisconsin plans are a bit different. To try to make it easier for you, all plans in each letter group must offer the same basic benefits — theyVe been standardized. The cost may vary, and some may offer more coverage than others. For example, all companies offering Plan A in Tennessee must all cover the same benefits; they can just charge you more or add a few perks. Medigap plans do not cover prescription drugs. Medigap Costs Remember, you do not have to buy a Medigap plan. You can choose to pay the costs that Medicare Parts A&B do not cover out of your own pocket. A Medigap policy just protects you from unexpected costs. Medigap policies vary in price. The price goes up the deeper into the alphabet you go. Plans A and B will cost you less than plan G.
  • Medicare Part C: Medicare Advantage
    Medicare offers more of a one-stop-shop to get your covered benefits called Medicare Advantage Instead of having to sign up for Medicare Parts A&B and choosing to enroll in a Medigap plan, you can get all of the same coverage as Original Medicare. Medicare plans set limits on how much you will have to pay out of pocket each year, like deductibles and coinsurance. This protects you from costs you weren't expecting. Most plans even cover prescription drugs, so you wouldn't need Medicare Part D. There are many Medicare Advantage plans to choose from. Lower cost plans usually require you to get all of your services from in-network healthcare providers. The most common types of plans include: • Health Maintenance Organizations (HMO), which cover the same services as Medicare Parts A&B. • They can offer additional covered services, like dental insurance • You must get your care from your plan's in-network providers or you could have for some or all of those services • Preferred Provider Organizations (PPO), which cover the same services as Medicare Parts A&B • They usually offer a wider network of providers and pay for a greater share of the services you receive from out-of-network providers • More choice usually means you pay higher premium costs each month. There are other types of plans for people meeting certain income or health requirements: • Special Needs Plans (SNP) • These plans are for people with specific diseases, certain health care needs, or limited incomes. • Programs of All-inclusive Care for the Elderly (PACE): • This Medicare and Medicaid program allows people who would need a nursing home-level of care to remain in the community. It is available in most states.
  • Medicare Part D: Prescription Drugs
    Original Medicare — Part A and Part B — does not cover your medicines. If you want help paying prescription drug costs, you will need to get Medicare Part D. You may not need this if your retirement plan covers benefits. Call your retirement plan to find out if you are covered. What you pay will depend on the plan you choose. Most plans have premiums, deductibles, copayments, and coinsurance. Plans change each year. so it is important to check your options.

Getting the coverage you need at an affordable price is important. Here are some things you should know before choosing a plan for you or your family.

WHAT WE PROVIDE

Affordable Care Act

Affordable ACA Health Insurance

If your annual income is below 150% of the federal poverty limit, you are eligible for zero-premium coverage, depending on what plan you pick. In 2022 the limit is:

  • $20,385 for an individual

  • $27,465 for a couple

If your income is between 150% and 400% of the federal poverty level, you are eligible for premium subsidies. The amount of the subsidy depends your income and what plan you pick.

  • $54,360 for an individual

  • $73,240 for a couple

If your income is above 400% of the federal poverty level, you are eligible for subsidies if your premium payments would be more than 8.5 percent of your income.

Affordable Care Act

What Will My ACA Health Plan Cover?

All ACA health plans cover 10 essential health benefits:

  1.  Ambulatory patient services (outpatient care you get without being admitted to a hospital)

  2. Emergency services

  3. Hospitalization (like surgery and overnight stays)

  4. Pregnancy, maternity, and newborn care (both before and after birth)

  5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)

  6. Prescription drugs

  7. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)

  8. Laboratory services

  9. Preventive and wellness services and chronic disease management

  10. Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Affordable Care Act

Adult Dental and Vision Coverage

Dental and vision coverage are not considered essential health benefits for adults. Some plans do cover vision and dental care, so check your plan.


We Can Help you Enroll in a Dental or Vision Plan

If You Have a Pre-existing Medical Condition

All ACA marketplace plans, unless grandfathered, must cover treatment for pre-existing medical conditions:

  • No ACA insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any conditions you had before your coverage started.

  • Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.

  • If you’re pregnant, coverage starts the day your plan starts.

Grandfathered plans don’t have to cover pre-existing conditions. If you have been enrolled in the same plan since before March 23, 2010, you could be in a grandfathered plan that doesn’t have to cover pre-existing conditions or preventive care.

Pre-existing mental and behavioral health conditions

  • Your ACA plan can’t deny you coverage or charge you more for any pre-existing condition, including mental health and substance use disorder conditions.

  • Coverage for treatment of all pre-existing conditions begins the day your coverage starts.

  • Your plan can’t put yearly or lifetime dollar limits on coverage of any essential health benefit, including mental health and substance use disorder services.

Affordable Care Act

Pregnancy Care

f you’re pregnant when you apply, your plan can’t reject you or charge you more because of your pregnancy. Pregnancy and childbirth coverage begins the day your plan starts.


Your plan must also provide breastfeeding support, counseling, and equipment for as long as you breastfeed your child. These services may be provided before and after birth.

Birth Control

ACA health plans must cover contraceptive methods and counseling for all women, as prescribed by a health care provider.


Plans must cover these services without charging a copayment or coinsurance when provided by an in-network provider, even if you haven’t met your deductible.

Preventive Health Services

Your ACA health plan must cover services to find and prevent diseases and health problems before they get worse. These services include shots and screening tests.
Visit healthcare.gov to get see what’s covered:

Adult
Women
Children

Mental Health and Substance Abuse

Mental and behavioral health services are essential health benefits All plans must cover:

  • Behavioral health treatment, such as psychotherapy and counseling

  • Mental and behavioral health inpatient services

  • Substance use disorder (commonly known as substance abuse) treatment

Your specific behavioral health benefits will depend on the state you live in and the health plan you choose. Phoenix Alliance can help you compare plans available to you to see what mental health and substance abuse services are covered.

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