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What will my insurance cover?

Required benefits

Plans sold after Jan. 1, 2014, must include benefits in 10 categories:

  • Ambulatory (outpatient) services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

How can I tell how much a plan covers?

Plan labels will help you understand the level of coverage you are buying. The levels of coverage are:

  • Bronze - The plan covers 60 percent of expected costs for the average individual
  • Silver - The plan covers 70 percent of expected costs for the average individual
  • Gold - The plan covers 80 percent of expected costs for the average individual
  • Platinum - The plan covers 90 percent of expected costs for the average individual

What are catastrophic plans?

Catastrophic plans meet all of the requirements applicable to other health plans, but do not cover any benefits other than three primary care visits per year before the plan's deductible is met.

The premium amount you pay each month for health care is generally lower than for other plans, but the out-of-pocket costs for deductibles, co-payments, and co-insurance are higher.

These plans can be sold only to people younger than 30 and to others exempt from buying insurance because of financial hardship.

Are there limits on my share of costs?

All plans must limit your annual out-of-pocket costs (such as co-pays) to $6,600 for an individual and $13,200 for families in 2015. For 2016, this is $6,850 for an individual and $13,700 for a family

  • Lifetime coverage limits: Insurance companies cannot place a dollar limit on how much they will cover over your lifetime.
  • Annual coverage limits: For plans sold or renewed on or after Jan. 1, 2014, federal law prohibits annual dollar limits on coverage of essential benefits.

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File a complaint online or contact us:

Consumer Hotline
888-877-4894 (toll-free)


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