The Affordable Care Act (ACA) has transformed how millions of Americans access healthcare, making insurance more affordable and accessible. However, it’s also sparked a variety of myths and misconceptions. Whether you’re exploring your own options or helping others through the process, it’s essential to separate fact from fiction. Let’s clear up some of the most common misunderstandings about ACA marketplace plans.
Myth #1: ACA Plans Don’t Cover Out-of-Network Care
A popular myth surrounding ACA health insurance is that out-of-network care is completely off-limits. While it’s true that most ACA plans focus on in-network providers to keep costs low, that doesn’t mean you’re completely out of luck if an emergency occurs.
The Truth
In emergencies—like accidents or sudden health crises—ACA plans are required to cover out-of-network care, just as they would for in-network providers. This includes situations like a medical emergency while traveling out of state. No prior approval is needed, and the care is covered as if it were in-network. However, be sure to review your plan’s specific details for non-emergency out-of-network care.
Also, most ACA plans feature a national prescription drug network, so you’ll likely still be covered when picking up your medications while traveling.
Myth #2: You Can’t Get a PPO Through the ACA Marketplace
Some people believe that ACA plans no longer offer PPOs (Preferred Provider Organizations), but that’s not entirely true. While PPOs are less common today due to the emergence of other plan types like HMOs (Health Maintenance Organizations) and EPOs (Exclusive Provider Organizations), they are still available in certain areas.
The Truth
Although PPOs are less prevalent in the ACA marketplace, they do exist in some regions. The main reason PPOs are less common is cost. These plans offer more flexibility, allowing you to visit out-of-network providers or specialists without needing a referral. However, that flexibility comes at a higher price.
Most ACA plans default to HMOs or EPOs because they help keep premiums lower while still offering good coverage, especially if you’re comfortable staying in-network. It’s important to check the specifics of the plan, as many PPOs offered by employers don’t include substantial out-of-network benefits anymore, making them function more like EPOs in practice.
Myth #3: ACA Plans Are Only for Low-Income Families or the Uninsured
A common misconception is that ACA plans are only available for individuals who are uninsured or have low incomes. In reality, ACA coverage is for a wide range of individuals, including full-time workers, freelancers, part-timers, early retirees, and even those who obtain coverage through ICHRA (Individual Coverage Health Reimbursement Arrangements).
The Truth
ACA plans are designed to help people at various income levels. Subsidies are available to individuals and families with incomes up to 400% of the Federal Poverty Level (FPL). For example, a family of four earning up to $125,000 could still receive help with premiums. This means middle-income households can also access affordable health coverage.
Additionally, ACA subsidies are based on household income, not just poverty levels. You don’t have to be near the poverty line to qualify. Many people who don’t consider themselves “low income” can still benefit from ACA subsidies.
Myth #4: ACA Plans Are the Same Everywhere
It’s often assumed that ACA plans offer identical options and coverage across the country. But this is not the case.
The Truth
While all ACA plans must meet federal guidelines, the specific plans, insurers, and costs vary by state. Some states run their own health insurance marketplaces, while others use the federal marketplace. For example, California has a robust state marketplace with extensive choices, including discounted premiums and occasional PPO availability. On the other hand, New York has a state marketplace with some of the highest premiums.
In states like Texas, which uses the federal marketplace, you may see a broad range of options, but PPO plans are less common. To get the best plan for your needs, it’s important to research what’s available in your state during the enrollment period.
Myth #5: ACA Health Plans Are Only for Individuals, Not Families
Many people mistakenly believe that ACA plans are designed only for individuals, not families. This is far from the truth.
The Truth
ACA health plans cover families, including children who can stay on a parent’s plan until they turn 26. Subsidies are calculated based on household income, so family coverage can often be more affordable than traditional employer-sponsored plans. In fact, ACA plans may provide better coverage at a lower cost for many families, thanks to lower premiums and more flexible options.
Clearing Up the Confusion
The ACA has made health insurance more accessible for millions of Americans, but misconceptions can lead to confusion. Whether you’re shopping for yourself or helping others explore their options, understanding how ACA plans really work is key. Take the time to research your state’s offerings, look at all available plans, and choose the one that fits both your healthcare needs and budget. With the right information, you can confidently make informed decisions about your health coverage.
