Under the Affordable Care Act, plans sold to individuals and small businesses are required to meet federal standards for the adequacy and affordability of coverage. The federal rules establish minimum standards for benefits and cost sharing, limit the factors that insurance companies can use to set premiums, and require plan benefits to be more standardized so that it’s easier for consumers to make comparisons among plans. Some Affordable Care Act reforms also apply to group health plans sponsored by large employers, including limits on out-of-pocket costs, coverage of preventive services with no cost-sharing, and a prohibition on annual and lifetime benefit limits. Whether and how the Affordable Care Act rules apply to coverage will vary based on insurance market, type of coverage, and status as a grandfathered or otherwise non-ACA compliant health plan.
The Affordable Care Act also established new appeal rights for consumers facing a denial of a benefit or service from their health plan. Consumers in new (non-grandfathered) plans have a right to an “internal appeal,” in which consumers have a right to ask their health plan for a full and fair review of an unfavorable decision, and an “external review,” which allows consumers to appeal their insurer’s decision to an independent third party.
Certain forms of coverage do not have to comply with the Affordable Care Act’s requirements, including short-term limited duration insurance, association health plans, and Health Care Sharing Ministries. See the Alternative Coverage section for more information on types of coverage that do not meet ACA protections.