Individual Health Insurance Q & A

What is Obamacare?

Many names have been used to describe health care reform. The Affordable Care Act was passed into law on March 23, 2010. Insurance plans sold since that date must comply with the new law. Insurance companies can no longer deny coverage or increase premiums based on health conditions.  Additionally, all insurance plans must include the same essential health benefits.

Is Obamacare a government insurance plan?

This has been one of the biggest misconceptions regarding health care reform.  The Affordable Care Act did not create a new provider of health insurance, it simply changed the rules that insurance companies must abide by.  Insurance plans are still available through the same commercial insurance companies that have always sold health insurance.  There is not an insurance plan being sold by the government bearing the name of Obamacare.

What is the difference between the Bronze, Silver, Gold and Platinum plans?

The metal tiers are designed to describe the level of benefits provided by the plans. A bronze plan will have the highest deductible while a platinum plan will have the lowest deductible.

What is cost sharing?

Cost sharing can improve the benefits on a marketplace plan by reducing the deductible, co-pays and out of pocket expenses on a marketplace plan.  It is available to insureds that fall below 250% of the federal poverty guidelines.  It is available only on a SILVER PLAN.

What is a subsidy?

More accurately known as an advanced tax credit, premium subsidies are a way to reduce the monthly premium amount for a marketplace health insurance plan. The subsidy amount is based on household income and the number of family members claimed on the federal income tax return. The income range must be between 100%-400% of the federal poverty guidelines. Additionally, you or your spouse must not be eligible for group health insurance through an employer.

Do all plans cover wellness at 100%?

Health insurance plans that fall under the guidelines of the Affordable Care Act, regardless of the metal tier (bronze, silver, gold), cover certain preventative care or wellness procedures at 100% without a deductible or co-pay.

How do I know which insurance plan my physician will accept?

An experienced insurance agent or broker can help you determine which providers (doctors, hospitals and other facilities) participate with which insurance companies. In addition, the agent can provide you with a network directory, as well as give you information about the type of network being used by each insurance company.

What is an HMO and a PPO?

This refers to the type of network that a particular insurance company uses. HMO is short for Health Maintenance Organization. Some insurance companies began using HMO’s when the Affordable Care Act was passed. These types of networks are the most restrictive. Services must be provided by doctors and hosptials that participate with the carrier’s HMO network. A referral is typically needed to see a specialist. Services rendered outside of the HMO are not covered at all unless it is of an urgent nature or an emergency.

A PPO is a Preferred Provider Organization. This type of network is not as restrictive. Services rendered by providers that participate in the PPO network are covered by the insurance company subject to the deductibles and co-pays set forth in your plan. Services rendered by a provider outside of the PPO network are also covered, but are subject to higher out of pocket costs.

What happens if I do not have health insurance?

The biggest detriment of not purchasing a health insurance plan is obvious; you are not protected should you have an illness or accident.  The Affordable Care Act includes a law that a tax penalty must be paid by those that remain uninsured.  The penalty began in 2014 and increases yearly.  Remember, paying the penalty still leaves you uninsured.

When can I purchase health insurance or change my plan?

Health insurance can only be purchased or changed during the annual open enrollment period which runs from November 1st until  January 31st each year. If you need to purchase health insurance at any other time during the year, you have to have a qualifying event. A few examples of a qualifying event include: loss of group coverage, marriage/divorce, birth or adoption of a baby, or moving outside of your coverage area.

How come my doctor no longer accepts my insurance?

Many insurance companies changed their provider networks with the implementation of the Affordable Care Act.  Some carriers changed from a PPO network to an HMO network. It is important to make sure your doctors are in-network on the plan you choose before you enroll.

Will I pay more for health insurance if I use an agent or broker?

Absolutely not! Health insurance premiums are set by the insurance companies and regulated by the insurance departments; therefore, the prices are the same whether you attempt to do it yourself or use the professional services of an experienced agent.

What happens if the subsidy I received is incorrect?

Because the subsidy is an “advanced tax credit”, it will be reconciled when the federal income tax return is filed.  This is the importance of having an experienced broker help calculate the correct subsidy amount so that there are no surprises at tax time.

What if I missed the open enrollment period and do not have a qualifying event?

Short term medical plans are available any time during the year.  While these plans do not cover pre-existing medical conditions, they can provide an inexpensive and valuable protection until the next open enrollment period.