Health Care Insurance Reform Basics

Health Care Reform Basics

Health Care Reform? Health Care Insurance? Essential Health Benefits? Know the Health Care Reform Basics.

There is a lot to know about Health Care Reform. Start here by learning the important ideas and terms related to health care reform and insurance.

Health Care Reform Basics

  1. You might get help with your health insurance costs. If your household income is between 100% and 400% of the Federal Poverty Level (FPL), you may be able to get help paying for your health insurance. To get this help, you must buy your insurance through the Health Insurance Marketplace (Exchange). Learn more.
  2. You cannot be turned down for coverage. Health insurance plans must offer coverage to all individuals. This is regardless of health status, age, gender or other factors that might predict the use of health services. This applies even if you've been declined coverage in the past.
  3. Individuals are required to have health insurance. If you don't have a health plan that qualifies as minimum essential coverage, you may have to pay a fee every year. Learn more.
  4. Open enrollment begins November 1, 201​8. You can sign up for health insurance between November 1, 201​8 and December 15, 201​8. People can sign up other times, but only if they qualify for a special enrollment period.  You may be eligible for a special enrollment period if you experienced a qualifying life event, such as getting married or having a baby.
  5. Some preventive services are covered at no out-of pocket cost to you. Certain preventive services must be covered at no out-of-pocket cost to you when delivered by a provider that is in your health insurance network. Dozens of services are covered for all adults, women and children. View the list.
  6. All health insurance plans must cover specific health care benefits. The Affordable Care Act helps ensure that health insurance plans offer a full set of items and services. These services are called Essential Health Benefits.

Health Care Reform Terms

Advance Premium Tax Credit (APTC)
The Affordable Care Act provides a new tax credit to help you afford health care insurance purchased through the Health Insurance Marketplace. Advance payments of the tax credit can be used right away to lower your monthly premium costs. Learn more.

Cost Share Reductions
If you qualify, these can help you with the cost of health care. Your out-of-pocket costs like deductibles, coinsurance, and copayments may be reduced, depending on your income. Those that qualify can pay the premium of a Silver plan but get the benefits of a Gold or Platinum plan. Learn more.

Health Insurance Marketplace (Exchange)
The Health Insurance Marketplace (Exchange) is an open market for dental and health care insurance. You'll be able to compare types of health care insurance, check prices, find out if you qualify for subsidies, and enroll in a health care insurance plan.

Health Plan Categories (Metal Levels)
All health insurance plans are divided into five categories – Catastrophic, Bronze, Silver, Gold and Platinum. These are called the “metal levels.” The categories are based on the average total amount* your plan will pay for your covered medical costs: 60% for Bronze, 70% for Silver, 80% for Gold, and 90% for Platinum (catastrophic plans will vary).

*Plans in each category pay different amounts of the total covered costs of an average person’s care. This takes into account the plans’ deductibles, copayments, coinsurance and out-of-pocket maximums. The actual percentage you’ll pay in total or per service will depend on the services you use during the year.

Out-of-Pocket Costs
Your costs for health care that aren't paid by health insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services. Costs for other services that aren't covered by your health plan are also paid out-of-pocket.

Help with paying for your health care and insurance plan costs based on your income level. You can get help with your monthly premium (Advance Premium Tax Credit) or help with your out-of-pocket expenses (Cost Share Reductions). Learn more.

Health Insurance Terms

Your share of the costs of a covered health care service. It is calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe.

For example, if your plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. Your health plan pays the rest of the allowed amount.


Copayments (or Copays)
A fixed amount you pay for a covered health care service. It is usually paid at the time you get the service.

For example, if you have an office visit with your doctor, your copay may be a fixed amount such as $30. If you have a copay, this is usually the only fee you will have to pay when you visit your doctor (other services such as lab tests or x-rays may result in additional fees). Choosing a plan with a copay for services you receive often may help you minimize your out-of-pocket expenses.


The amount you pay for covered health care services before your health insurance begins to pay. If your deductible is $1,000, your health plan won’t pay anything until you’ve paid $1000. The deductible may not apply to all services.


Maximum Out-of-Pocket
The most you will pay in calendar year for covered health care services. This does not include your monthly premium or out-of pocket costs for benefits that are not essential health benefits.


Your costs for health care not paid by health insurance. These costs can include deductibles, coinsurance, and copayments.  They also include costs for services that aren't covered by your health insurance.


A premium is the amount that you pay each month for your health insurance.