Health Insurance and the Protections of Obamacare vs. Non-Obamacare

Published on October 6, 2023, by Law Office of Matthew L. Sharp

Insurance Bad Faith

Health Insurance and the Protections of Obamacare vs. Non-Obamacare
Going to the doctor shouldn’t mean worrying about whether your appointment will be covered. Unfortunately, understanding the nuances of health insurance and the protections of Obamacare vs. non-Obamacare coverage isn’t easy.

Health insurers continue to maximize profits by shrouding coverage benefits and appeals processes in confusion. When policyholders aren’t sure of their rights, they don’t have the confidence or means to do anything about it.

That’s why at the Law Office of Matthew L. Sharp, we’re proud to demystify how health insurance works. If you need help securing coverage for your necessary medical care, give us a call or contact us online. A Reno health insurance dispute attorney is standing by to speak with you.

Obamacare—What Is It and How Has the Affordable Care Act Impacted Health Insurance?

Enacted in 2010 and then implemented in 2014, the Affordable Care Act (ACA) is a healthcare reform law that set out to accomplish three main goals:

  • Lower health care costs by supporting innovative medical care methods
  • Expand Medicaid to cover adults with annual income levels 138% of the federal poverty level (FPL)
  • Expand access to affordable health insurance through subsidies for households earning between 100% and 400% of the FPL

Commonly referred to as “Obamacare,” the ACA has helped tens of millions of people access health care coverage. According to the Office of the Assistant Secretary for Planning and Evaluation (ASPE), 40 million people in the United States have coverage through ACA plans.

The Difference Between Obamacare and Non-Obamacare Policies

Although the ACA significantly lowered the cost of affordable health care for millions of people and families, some individuals remained uninsured for a variety of reasons.

For some people with incomes that exceeded more than 400% of the FPL, the cost of insurance through the Health Insurance Marketplace® was still too high without the help of subsidies. Others were unhappy with the initial penalization of those who chose to remain uninsured, which the IRS collected on federal tax returns. (The penalty was changed to $0 in 2018, effectively removing the cost of not carrying insurance.)

Now, consumers have the choice of choosing between Obamacare (ACA) and non-Obamacare (Non-ACA) health insurance plans. The main difference between these two is that Obamacare plans must comply with the ACA’s standards, whereas non-Obamacare policies are not required to meet these same standards.

For example, Obamacare plans cannot deny coverage or charge more for pre-existing conditions. Non-compliant policies are not held to these same standards and can charge policyholders with pre-existing conditions more or may deny them coverage altogether.

Obamacare plans include services and items for the required ten essential health benefits:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventative and wellness services and chronic disease management
  10. Pediatric services (including oral and vision care)

Non-Obamacare plans must still offer appropriate coverage but are not held to the same standards. For these reasons, they tend to offer significantly less coverage and benefits. However, since these plans are also typically cheaper than ACA plans, they are more appealing to people and families who are experiencing economic or financial distress.

According to KFF (formerly Kaiser Family Foundation), 2.5 million people are covered by non-Obamacare health insurance policies.

Non-ACA Health Insurance Plans Lack Vital Protections

Health insurance plans that are not compliant with the Affordable Care Act lack vital protections for policyholders. The following plan types are some of the most common examples of non-Obamacare plans:

  • Temporary health insurance
  • Indemnity plans
  • Medical discount plans
  • Supplemental accidental coverage
  • Association health plans
  • Health care sharing ministries

In many cases, these non-qualified plans are only appropriate for people without pre-existing conditions, who are in generally good health, and who have only a small budget to pay for their insurance. People who are between jobs or who live in areas without access to providers who accept Obamacare plans also purchase this type of coverage.

Plans that aren’t compliant with the ACA can:

  • Charge more if they believe you have a pre-existing condition
  • Deny coverage based on your health history
  • Kick you off your plan if you get sick
  • Exclude prescription drug coverage
  • Exclude mental health services
  • Stick you with surprise medical bills

We purchase health insurance coverage to protect our finances and access to care. If you’re diagnosed with a serious medical condition, and your plan doesn’t cover necessary care or, even worse, your provider kicks you off your plan, where are you left?

These are outcomes that millions of Americans are at risk for.

What Can I Do if My Non-Obamacare Insurer Won’t Pay for My Care?

Denied claims are not exclusive to non-Obamacare plans. A KFF report found that insurers denied a total of 48.3 million in-network claims for both ACA and non-ACA plans in 2021.

The ACA guarantees policyholders the right to appeal denied claims. This guarantee extends to people who are self-insured under non-Obamacare insurance plans.

If your insurer denied what you believe is a covered claim for care, your first step is to file an appeal with your insurer. This can be a complex process because while the ACA mandates that insurers offer an appeals process, it does not mandate that they make it easy or seamless to do so.

And, by the time someone has exhausted the appeals process only to learn that the insurance company is sticking with its decision, they may feel so defeated that they simply accept the financial burden of their medical care. This can be devastating for patients who are trying to ensure payment for covered benefits and care.

A denied appeal is not the end of the road for your claim, though. Policyholders have the right to hold their insurers accountable for bad-faith insurance tactics through the civil claims process. While filing a lawsuit can feel like a big undertaking, it’s important to remember that your actions are about more than fighting for coverage of your own medical care.

When you file a lawsuit against a health insurance company, you are showing them that their actions have consequences. Your choices today could have a positive impact on others in the future.

The Law Office of Matthew L. Sharp—Fighting for Nevada Yesterday, Today, and Tomorrow

No one should have to spend their time fighting the insurance company when they should be focused on their health. Founding attorney Matthew L. Sharp has dedicated three decades of his career to fighting insurers on behalf of his clients.

At our law firm, we are equipped to handle a wide variety of health insurance dispute claims. Whether you’re locked in a dispute with a nationwide insurer like Aetna or a local health insurance provider like Hometown Health, we want to help.

Contact us today for a completely free case evaluation with an experienced and compassionate insurance dispute lawyer.