ACA Patient Access

Advocacy Resource - January 26, 2018

Federal Insurance Markets

Many practices are engaged in educating patients about the intricacies of our healthcare system. The following information is designed to help practices with their patient education efforts related to understanding the basics of health insurance and the new Affordable Care Act (ACA) health insurance exchanges or marketplaces. 

ACA Marketplaces

In the fall of 2013, ACA health insurance exchanges or marketplaces began providing access to health insurance plans providing coverage that went into effect as early as January 2014. Individuals and families can apply for coverage at

  • The open enrollment periods, during which eligible individuals and families may enroll in Qualified Health Plans in the Marketplace, are as follows:
Coverage year Open enrollment start date Open enrollment end date
2016 Nov. 1, 2015 Jan. 31, 2016
2015 Nov. 15, 2014 Feb. 15, 2015
2014 Oct. 1, 2013 Mar. 31, 2014
  • Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience a Qualifying Life Event
  • If a patient’s income and household size haven’t changed, they don’t need to do anything to maintain their existing coverage if it is being offered again for the next year. They will be re-enrolled automatically. However, if income or household size has changed, consumers need to report those changes so they receive the correct tax credit. Patients should also keep in mind that there could be changes to their premium, cost-sharing or network, so they should visit during the open enrollment period to compare plans for the next year and select the best option. Additional information on renewing and maintaining ACA health insurance policies can be found here
  • Many consumers qualify for financial assistance with insurance plans purchased on the ACA exchanges, which can help lower monthly premiums and/or cost-sharing. Consumers can check whether they are eligible for a subsidy using a subsidy calculator offered by the Kaiser Family Foundation.
  • CMS resources for patients:
  • If your practice is looking for printed resources geared towards educating patients on health insurance basics and the ACA marketplace, CMS provides a number of materials and brochures that can be ordered in quantities of up to 500 on their website from coverage to care

Helping patients understand health insurance

Health insurance is complicated and often confusing. Below are some resources and definitions to help patients better understand their coverage. 
  • Consumers have the right to get an easy-to-understand summary about a health plan’s benefits and coverage. More information on the summary of benefits and coverage is available here
  • CMS explains different kinds of health insurance, including PPOs, high deductible health plans, catastrophic health plans and more.

Common health insurance terms

See a full glossary at
  • Claim: A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
  • Coinsurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
  • Cost Sharing: The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
  • Copayment: A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
  • Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
  • Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
  • Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
  • Premium: The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
  • Preauthorization (or, prior authorization): A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.



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