ACA plans, also called Marketplace or “Obamacare” plans, are health insurance options available through the Affordable Care Act. These plans are designed to meet federal guidelines for essential health benefits and cannot deny you for pre-existing conditions.

ACA plans can be a great fit for people who are:

- People with Lower to Moderate Income

- Those With Pre-Existing Conditions

- Young Adults Aging Off a Parent’s Plan

- People Who Recently Lost Coverage

- Those Who Want Coverage Without Medical Questions

The 10 Essential Health Benefit Categories

1. Ambulatory Patient Services

Care you get without being admitted to a hospital, like primary care visits, specialist appointments, and outpatient surgeries.

2. Emergency Services

Coverage for ER visits, including life-threatening conditions. Plans can’t require prior approval.

3. Hospitalization

Inpatient hospital stays, surgeries, and overnight care.

4. Maternity and Newborn Care

Prenatal visits, childbirth, and care for the baby after birth, even if you're pregnant before you apply.

5. Mental Health & Substance Use Disorder Services

Includes therapy, counseling, inpatient mental health care, and substance abuse treatment. Must be treated the same as physical health services.

6. Prescription Drugs

Each plan must cover at least one drug in every approved category and class.

7. Rehabilitative & Habilitative Services

Helps you recover from injuries (rehab) or gain/develop skills you never had (habilitation), like therapy for kids with developmental delays.

8. Laboratory Services

Diagnostic tests, blood work, and screenings used to diagnose or manage conditions.

9. Preventive & Wellness Services and Chronic Disease Management

Includes free (no copay) services like:

o Annual checkups

o Vaccines

o Cancer screenings

o Birth control

o Chronic condition monitoring (e.g., diabetes, asthma)

10. Pediatric Services (including Dental & Vision)

Coverage for children under 19 must include dental and vision—like eye exams, glasses, cleanings, and fillings.

How ACA Subsidies Work

ACA plans use two main pieces of information to calculate your subsidy (discount):

- Your Total Household Size – Everyone you claim on your tax return (not just who needs insurance)

- Your Estimated Annual Income – What you expect to earn for the year you're getting coverage, not what you earned last year

- The lower your income, the higher your subsidy

- If your income is too high, you may not qualify for any discount

*This means choosing the wrong income estimate can cost you thousands—either in monthly premiums or surprise IRS bills later.* 

Pros and Cons of ACA Plans

Pros

- Subsidies can make coverage very affordable

- Guaranteed acceptance

- Covers pre-existing conditions

- No health questions asked

- Includes preventive care at $0

Cons

- Income-based, your costs can change yearly

- Narrow networks (not all doctors accept it)

- Higher deductibles for many lower-cost plans

- Limited out-of-network coverage

- Must qualify for Open Enrollment or SEP

Even the best ACA plans can leave some holes, like high deductibles, coinsurance, or limited doctor access. That’s where supplemental plans come in.

We often recommend pairing your ACA plan with options like:

• Accident – Pays you cash if you get hurt

• Hospital Indemnity – Helps cover hospital stays and major events

• Critical Illness – Pays lump sum for cancer, heart attack, stroke

• Dental & Vision – These are not always included in ACA plans

These add-ons can dramatically lower your real out-of-pocket risk and give you more peace of mind without breaking the bank.

Everyone’s situation is different. Some clients save more on private coverage, others qualify for $0 ACA plans, and many land somewhere in between. I’ll walk you through it step by step and explain your options in plain English, no pressure, no guessing.