Are you looking for health insurance and overwhelmed by the array of different plans and coverage options to consider? You may have heard of Qualified Health Plans (QHPs). Although sometimes referred to as ACA Health Insurance or ACA Compliant Plans, QHPs can also be found outside of the Health Insurance Marketplace.
What are Qualified Health Plans?
A Qualified Health Plan, or QHP, is a health insurance policy that meets certain standards established under the Affordable Care Act (Obamacare or ACA). The ACA was designed for people without access to affordable health insurance through their employer or other sources.
QHPs are available through the Health Insurance Marketplace (healthcare.gov or state based Marketplace websites). QHPs are available to anyone who meets certain eligibility requirements, including US citizens or legal residents who live in the state where the plan is offered.
Qualified Health Plans can also be purchased through private insurance companies and brokers licensed by the state and certified by the Health Insurance Marketplace. An example of a QHP available from private insurance companies is a Medicare Advantage Plan, which is not part of original Medicare available from medicare.gov or the Health Insurance Marketplace.
If you see “QHP” on your insurance card, your health insurance plan is ACA-compliant. It provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the Affordable Care Act.
Qualified Health Plans Essential Coverage
All Qualified Health Plans (QHPs) meet the ACA requirement for having minimum essential coverage, or the 10 essential health benefits. This is true for all plan categories (all “metal levels,” including Catastrophic plans) and all plan types (like HMO and PPO).
Specific services covered in each broad benefit category can vary by state. Some plans may offer additional benefits. You need to understand the level of coverage you are purchasing, as well as your policy’s benefits and exclusions. You’ll see a full list of what each plan covers when you compare plans in the Marketplace.
10 Essential Health Benefits
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both before and after birth), including birth control and breastfeeding coverage
- Mental health and substance use disorder services, including behavioral health treatment (including counseling and psychotherapy)
- Prescription drugs
- 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)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care (adult dental and vision coverage aren’t essential health benefits, but some plans still cover them)
Large employers who “self-insure” — meaning they pay employees’ health care costs directly — don’t have to provide essential health benefits. But many do. Check with your employer to find out if it’s self-insured and what services are covered.
ACA Health Insurance Protections
The Affordable Care Act (ACA), or Obamacare, offers many protections to consumers. What you pay for medical services depends on your insurance plan, subject to your choice of healthcare provider, copayments, coinsurance, and deductibles.
No Lifetime Limits:
QHPs can’t impose lifetime spending limits on the amount of coverage you can receive.
Coverage for Pre-existing Conditions:
QHPs can’t exclude pre-existing conditions, including mental and behavioral health conditions.
Preventive Care:
QHPs must cover many preventive care services, such as annual checkups, vaccines, and screenings, at no cost to you.
Access to Networks:
QHPs offer access to a network of healthcare providers and facilities, which can help you find the care you need and avoid higher out-of-pocket costs for out-of-network care.
Financial Assistance or Cost-Sharing Reductions
Depending on your household income, you may be eligible for financial assistance or subsidies for QHPs purchased on the Health Insurance Marketplace (healthcare.gov). ACA subsidies can help pay for your premiums and other healthcare costs. Furthermore, you may be eligible for cost-sharing reductions that lower your out-of-pocket costs, such as deductibles, copays, and coinsurance. To learn more about ACA subsidies, check out What If I Can’t Afford Health Insurance?
If you don’t qualify for financial assistance, you may find cheaper insurance sold outside of ACA Health Insurance Marketplace. Read the fine print of these policies, as many don’t offer the same coverage and protections as QHPs. Learn more in our article, Health Insurance Alternatives to the Affordable Care Act (ACA) or Obamacare.
In addition, if you are uninsured or underinsured because of a high deductible, you may also find healthcare options in the article Cash for Healthcare and Options for the Underinsured and Uninsured.
Takeaways
- A Qualified Health Plan (QHP) is a health insurance policy that meets certain standards established under the Affordable Care Act (ACA compliant).
- QHPs must cover the essential health benefits required by the ACA, which include services such as doctor visits, prescription drugs, hospitalization, maternity and newborn care, mental health, and more.
- QHPs cover many preventive care services, at no cost to you.
- QHPs provide coverage for pre-existing conditions, no lifetime limits, and access to healthcare networks.
- If you are considering enrolling in a QHP, it is important to compare your options and choose a plan that meets your healthcare needs and budget.
- Additionally, there are also health coverage options outside of the ACA Health Insurance Marketplace. They may cost less but not have the same coverage and protections as QHPs.