One of the biggest health insurance companies in the United States has decided to go back into a market where it was before. This means that people will have more choices for individual and family health insurance plans through the individual health insurance marketplace.

“As the ACA has evolved there’s evidence of market stabilization and remedies to earlier structural issues. It is now time for us to participate in these markets,” Karen Lynch, president and chief executive officer of CVS Health, said on the earnings call. “We will show that we can bring great value to those who seek coverage. You can expect to hear more about our exchange reentry plans in future updates.”

Aetna is going to sell products under the CVS Health brand. Aetna left the individual health insurance market in 2017. The deal closed one year later, but it took effect on January 1, 2022. However, some of the details are not yet available. For example, we do not know in which state and county Aetna’s health insurance plans will be available.

“Our goal is to make health care more accessible, more affordable and simpler,” Lynch said in a statement. “In order to do this, we will accelerate the pace of our progress through targeted investments in key areas that will drive our consumer-focused strategy. We believe that solving consumer health needs will deliver better health outcomes and lower costs while creating future economic benefit for CVS Health and its shareholders.”

In the early days of the affordable care act, the health plan decided to withdraw from the health insurance marketplace due to questions surrounding the stability and structural issues caused by the government and implementation of the ACA law.

Individual Health Insurance Marketplace

When the Affordable Care Act (ACA) was created, people who were buying health insurance for themselves could no longer be discriminated against for having a pre-existing condition. Persons within a set income range qualify for tax credit to offset the cost of the health insurance plan premium. This made it easier for them to buy their own health insurance.

Each year individuals and families are allowed to choose or update their health care coverage during the open enrollment period. For those who lost their employer coverage or other qualified health care insurance qualify for a special enrollment period to search for a new health insurance plan.

What are health insurance marketplaces and who are they meant for?

Health insurance marketplaces are online websites where people can buy health coverage for themselves and their families. The marketplace is meant for you if:

  • You don’t have health insurance from your employer or the government, like Medicare, Medicaid, military coverage, etc.;
  • You don’t qualify for Medicaid, but your income is below 400% of the federal poverty level;
  • Your employer doesn’t provide health coverage and you make too much to qualify for a public program like Medicare or Medicaid.

What are the different types of health insurance plans?

  • Health maintenance organizations (HMOs)
    • HMO’s often use the Primary Care Physician (PCP) as the “gatekeeper”. A patient receives all primary and preventative care from the PCP. Any care needs outside the PCP’s scope of practice would be referred out and coordinated by the PCP. Any care, other than emergency care, not coordinated through the PCP would not be covered by the HMO.
  • Exclusive provider organizations (EPOs)
    • EPO’s have a network of providers who have agreed to provide care for the members at a discounted rate. If the patient chooses to go outside the network, there is no reimbursement.
  • Point-of-service (POS) plans.
    • The Point-of-Service Plan is a combination of a PPO and HMO. The patient can choose to receive care in network at little or no cost, or to go out of network and have larger out of pocket expenses.
  • Preferred provider organizations (PPOs)
    • PPO’s contract with providers to dispense care at a discounted rate. The providers with whom they contract are considered “network providers or preferred providers”. If the patient uses a provider that is not part of the network, they will have a larger financial responsibility.

What is the main type of healthcare system does the United States currently have?

The main type of healthcare system in the United States is a “managed care system.” In this health insurance coverage, individuals receive their benefits based on how healthy they are and what medical services they use (rather than receiving all-inclusive treatment).

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