What Constitutes an ACA Compliant Health Plan? 

The Affordable Care Act (ACA) set specific criteria for health plans to meet ACA compliance, regardless of where they are purchased. In this article, we will explore the relevant ACA compliance criteria for individual plans, discuss the importance of insurance brokers and clients being aware of compliance, identify the governmental department overseeing compliance, and understand the role of the Employee Retirement Income Security Act (ERISA) in ensuring adherence to ACA regulations. 

ACA Compliance Criteria for Individual Plans 

To be ACA compliant, individual health plans must meet important criteria, including: 

  1. Essential Health Benefits: ACA compliant plans must cover essential health benefits, such as preventive care, mental health services, prescription drugs, and maternity care. 
  1. No Lifetime or Annual Limits: ACA compliant plans cannot impose lifetime or annual dollar limits on essential health benefits, ensuring individuals have access to necessary medical services. 
  1. Preventive Services: ACA compliant plans must cover preventive services, including vaccinations, screenings, and check-ups, without requiring cost-sharing from individuals. 
  1. Coverage for Pre-existing Conditions: ACA compliant plans cannot deny coverage or charge higher premiums based on pre-existing conditions, ensuring individuals with health conditions have access to affordable insurance. 

These criteria are designed to ensure that individual health plans offer comprehensive coverage and protect individuals from excessive medical expenses. 

Importance for Insurance Brokers and Clients 

Insurance brokers and clients need to be aware of the ACA compliance status of individual health plans purchased outside the Exchange or Marketplace. While plans bought directly from insurance companies may still be ACA compliant, it is crucial to review them carefully before enrolling. By being proactive, both brokers and clients can ensure they have comprehensive coverage that meets ACA regulations. 

Governmental Department Responsible for Compliance 

The Centers for Medicare & Medicaid Services (CMS) oversees the compliance of individual health plans with the ACA regulations. They monitor and enforce the requirements for essential health benefits, coverage limits, and preventive services. CMS ensures that individual health plans adhere to the ACA’s consumer protection provisions, promoting access to quality healthcare for all. 

Role of ERISA in Ensuring Compliance 

The Employee Retirement Income Security Act (ERISA) does not directly oversee the compliance of individual health plans with ACA regulations. ERISA primarily focuses on employer-sponsored benefit plans, such as group health plans. However, ERISA does play a role in ensuring compliance with the disclosure and reporting requirements for employer-sponsored health plans, providing transparency to participants. 

While ERISA does not directly address compliance for individual health plans, it remains an essential piece of legislation for employee benefits in general. 


An individual health plan can be ACA compliant even if it is not purchased through the Exchange or Marketplace. Brokers and clients must review the plan’s compliance with essential health benefits, coverage limits, preventive services, and protection for pre-existing conditions. The Centers for Medicare & Medicaid Services (CMS) oversees compliance for individual health plans, and insurance brokers and clients should be informed about the ACA compliance status of the plans they consider. While ERISA does not directly address individual health plan compliance, it is still important for ensuring compliance with employer-sponsored benefit plans. 

By being knowledgeable about the ACA compliance criteria and remaining vigilant, insurance brokers and clients can access individual health plans that provide comprehensive coverage and align with the regulations set forth by the Affordable Care Act. Consult an industry expert at Enrollment First, Inc. for support in finding or determining if a plan is ACA Compliant. 


[1]: HealthCare.gov: Essential Health Benefits 

[2]: HealthCare.gov: Lifetime and Annual Limits 

[3]: HealthCare.gov: Preventive Care Benefits for Adults 

[4]: HealthCare.gov: Pre-existing Conditions 

[5]: Centers for Medicare & Medicaid Services 

[6]: U.S. Department of Labor: Compliance Assistance Group Health and Disability Plans