Jeffrey Wade
A Qualified Health Plan (QHP) is a health insurance plan that meets the requirements set by the Affordable Care Act (ACA), also known as Obamacare. QHPs are typically for people who don't have employer-provided coverage and don't meet eligibility requirements for Medicare or Medicaid. They are sold online or by phone in federal- or state-run forums called Health Insurance Marketplaces. QHPs must follow cost-sharing limits and provide essential health benefits, such as emergency services, prescription drugs, and preventive care. They also cover pre-existing conditions and have no dollar limits on annual or lifetime benefits. People shopping for insurance may also come across short-term limited duration (STLD) plans and association health plans (AHPs), but these plans are not required to meet the same standards as QHPs and may not provide comprehensive coverage.
| Characteristics | Values |
|---|---|
| Definition | A health insurance plan that meets the requirements of Obamacare/Affordable Care Act (ACA) |
| Who is it for? | People who don't have employer-provided coverage and who don't meet eligibility requirements for Medicare or Medicaid |
| Where to buy? | Sold online or by phone in federal- or state-run forums called Health Insurance Marketplaces |
| When to buy? | During annual open enrollment or outside of open enrollment if you lose your health coverage, get married, or have another qualifying life event |
| Cost-sharing | Offered at Bronze, Silver, Gold, and Platinum levels with average out-of-pocket costs of 40%, 30%, 20%, and 10% respectively |
| Essential health benefits | Emergency services, prescription drugs, preventive and wellness services, mental health services, and more |
| Pre-existing conditions | Covers pre-existing conditions |
| Annual/lifetime benefit caps | No caps |
| Tax credits | May be eligible for premium tax credits and/or cost-sharing reductions |
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What You'll Learn
QHPs are specific to Obamacare/the ACA
A Qualified Health Plan (QHP) is a health insurance plan that meets the requirements of the Affordable Care Act (ACA) or Obamacare. QHPs are specific to Obamacare/the ACA and are designed for people who do not have employer-provided coverage and do not meet the eligibility requirements for Medicare or Medicaid.
QHPs are certified by the federal or state-run Health Insurance Marketplace/Exchange. The certification process occurs annually before the marketplaces' annual enrolment period. QHPs must be licensed in the state where coverage is provided, cover pre-existing conditions, follow cost-sharing limits, and cover the ACA's ten essential health benefits with no dollar limits on annual or lifetime benefits.
QHPs provide essential health benefits (EHBs), follow established limits on cost-sharing (such as deductibles, copayments, and out-of-pocket maximum amounts), and meet other requirements outlined within the application process. Issuers seeking QHP certification must review and submit the QHP Application and complete the certification process.
While all QHPs must cover essential health benefits, there are different metal levels associated with the plans. The metal level is based on actuarial value, with lower metal-level policies (e.g. Bronze) paying less of the average covered health care costs than higher metal-level policies (e.g. Gold). It is important to note that QHPs are typically not for individuals with Medicare, and it is illegal for someone to sell a QHP if the buyer has Medicare coverage.
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QHPs are sold online or by phone
A Qualified Health Plan (QHP) is a health insurance plan that meets the requirements set by the Affordable Care Act (ACA), also known as Obamacare. QHPs are sold online or by phone in federal- or state-run forums called Health Insurance Marketplaces. These plans are certified by the federal or state-run health insurance marketplace/exchange and must meet specific standards, including providing essential health benefits, following established limits on cost-sharing, and covering pre-existing conditions.
When shopping for a QHP, individuals will find various health plans to choose from, including Bronze, Silver, Gold, and Platinum levels of cost-sharing. The choice depends on the individual's financial situation and desired level of coverage. QHPs are typically not for people with Medicare, and it is illegal to sell a QHP to someone with Medicare coverage.
QHPs are available for purchase during the annual open enrollment period. However, individuals may be eligible to buy a plan outside of this period if they experience certain life events, such as losing their health coverage, getting married, or other qualifying changes in circumstances. It is important to note that QHPs are also sold off-exchange directly by some health insurance companies, but purchasing through the Marketplace is necessary to qualify for the ACA's premium tax credits and cost-sharing reductions.
To determine if their insurance is a QHP, individuals can consider the following:
- Is the plan sold online or by phone in a Health Insurance Marketplace?
- Does the plan provide essential health benefits, such as coverage for emergency services, prescription drugs, and preventive care?
- Does the plan follow established limits on cost-sharing, such as deductibles, copayments, and out-of-pocket maximums?
- Is the plan certified by the Health Insurance Marketplace and compliant with ACA requirements?
- Does the plan cover pre-existing conditions without annual or lifetime benefit caps?
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QHPs must cover pre-existing conditions
A qualified health plan (QHP) is a health insurance plan that meets the requirements of the Affordable Care Act (ACA), also known as Obamacare. QHPs are certified by the federal or state-run health insurance marketplace/exchange and cover essential health benefits, including pre-existing conditions.
QHPs are required to cover pre-existing conditions, which means that they cannot deny coverage or impose restrictions based on an individual's medical history. This is an important protection for individuals with pre-existing conditions, as it ensures that they have access to comprehensive health insurance coverage. Without this protection, individuals with pre-existing conditions may struggle to find affordable and adequate health insurance.
All QHPs must cover the ACA's ten essential health benefits, which include maternity and newborn care, mental health services, prescription drugs, and more. These benefits are designed to provide comprehensive coverage and ensure that individuals have access to a range of necessary health services.
In addition to covering pre-existing conditions and essential health benefits, QHPs are also subject to cost-sharing rules. These rules limit the amount that individuals are expected to spend out of pocket on deductibles, copayments, and out-of-pocket maximums, making healthcare services more affordable. The specific cost-sharing limits and out-of-pocket maximums may vary depending on the state and the specific QHP.
It is important to note that while QHPs offer comprehensive coverage and consumer protections, they may not be the best option for everyone. For example, individuals with very low incomes may find that a non-qualified health plan is more affordable, even if they have pre-existing conditions. It is essential to carefully consider your health and financial needs when choosing a health insurance plan.
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QHPs are offered at different levels of cost-sharing
A qualified health plan (QHP) is a health insurance plan that meets the requirements of the Affordable Care Act (ACA) and is certified by the federal or state-run health insurance marketplace/exchange. QHPs are subject to cost-sharing rules and limits set by the ACA, which ensure that out-of-pocket expenses such as deductibles, copays, coinsurance, and out-of-pocket maximums do not exceed a certain amount. These cost-sharing limits make healthcare services more affordable for individuals.
The silver plans within the QHP structure are particularly noteworthy as they are required to offer cost-sharing reductions to eligible individuals. These reductions are based on income levels, allowing individuals to pay a reduced cost-sharing amount that is appropriate for their financial situation. The standard silver level plan has an actuarial value (AV) of 70%, covering 70% of the costs of coverage. The silver plan variations have corresponding AV levels of 94%, 87%, and 73% for individuals with incomes ranging from 100-150%, 150-200%, and 200-250% of the federal poverty level (FPL), respectively.
Cost-sharing designs can vary significantly among QHPs, and this information is often complex and not very transparent. As a result, it can be challenging for consumers to estimate their potential out-of-pocket costs accurately, even for anticipated healthcare needs. It is important for individuals to carefully review the cost-sharing features of different QHPs to make informed decisions about their healthcare coverage.
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QHPs are not for people with Medicare
Qualified Health Plans (QHPs) are health insurance policies that meet protections and requirements set by the Affordable Care Act (ACA), also known as Obamacare. They are typically not for people with Medicare.
QHPs are sold in federal- or state-run forums, referred to as Marketplaces or Exchanges, where individuals can shop for coverage online or over the phone. It is important to note that no type of Medicare coverage is sold through these Marketplaces. If an individual is already enrolled in Medicare, they do not need to change their health coverage and will not receive coverage through the Marketplaces.
It is illegal for anyone to sell a QHP to an individual if they know they have Medicare. There is no coordination of benefits between QHPs and Medicare, so a QHP would not provide any additional benefits to someone with Medicare coverage. Furthermore, in most cases, individuals with Medicare are ineligible for cost assistance (tax credits) to help pay for a QHP premium.
QHPs are specific to Obamacare/the ACA and are intended for people who do not have employer-provided coverage and do not meet eligibility requirements for Medicare or Medicaid. Therefore, if an individual is on Medicare, they will not need to enroll in a QHP.
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Frequently asked questions
QHP stands for Qualified Health Plan. It is a health insurance plan that meets the requirements set by the Affordable Care Act (ACA).
QHPs must be licensed in the state where coverage is provided, cover pre-existing conditions, follow cost-sharing limits, and cover the ACA's essential health benefits with no dollar limits on annual or lifetime benefits.
QHPs are sold online or by phone in federal- or state-run forums called Health Insurance Marketplaces.
If you don’t have health insurance through a job, Medicare, or Medicaid, you can choose a QHP from the Marketplace during annual open enrollment.
QHPs are offered at the Bronze, Silver, Gold, and Platinum levels of cost-sharing. The Bronze QHPs have the lowest monthly premiums but the highest out-of-pocket costs, while Platinum plans have the highest monthly premiums and lowest costs for care.
