Healthcare Exchange and Marketplace insurance coverage is available at affordable rates. There are no medical questions to answer, pre-existing conditions are covered without waiting periods or exclusions, and generous federal tax subsidies can substantially reduce your rates. Single, family, and business-owner plans are offered. As future changes are proposed by current and future Administration, we keep you informed of all new rates and requirements. Generally, Senior Medicare plans, including Medigap, Part D, and Advantage plans, are not impacted. However, it is possible that the eligibility age for Medicare could be reduced from 65 to 62 or 60.
The Affordable Care Act, also known as “Obamacare,” often provides lower healthcare prices along with many questions and concerns. We answer many of them below:
Who Is Allowed To Buy An Exchange Policy?
You must be a legal citizen of the United States and not be incarcerated. Just as importantly, you can only apply in the state that you reside. For example, if you live in New Jersey most of the year and spend the winter in Florida, you must apply for coverage in New Jersey. However, if your permanent residency status changes, you may purchase coverage at any time of the year. Rates can vary greatly from one state to another, so your established state of residency is important. If policies are approved to be sold across state lines, prices of coverage will be determined by your primary residence zip code.
You also must not be receiving benefits from Medicare or Medicaid to apply for a Marketplace plan. However, if your status changes, you can become eligible to enroll in coverage. For example, if you are single, and your income increases from $15,000 to $23,000, suddenly, you may be eligible for subsidized medical coverage instead of re-enrolling for a Medicaid plan. Conversely, when you reach age 65 and are Medicare-eligible, you can not purchase a subsidized policy. It is possible that one family member may be eligible for a federal subsidy, while another family member is covered through Medicare or CHIP. It is allowable for a Medicaid-eligible applicant to enroll in a Marketplace plan, although no federal subsidy will be offered.
What Happens If I Miss Open Enrollment?
Open Enrollment typically ends on December 15th each year, although exact dates can change. States that operate their own Exchanges have more flexibility, and can choose alternative Open Enrollment dates. Pennsylvania runs its own Marketplace (Pennie) and extends the OE deadline to January 15th instead of December 15th. Colorado also extends its deadline to January 15th while California and the District Of Columbia have permanently extended their deadline to January 31.
If you miss the deadline, and you have existing coverage, of course, you can keep the plan you have. You can also purchase an alternative policy that is non-compliant, although an IRS tax may apply and many essential benefits may not be included. Often, these non-compliant plans are less expensive, and can be kept for as long as 12 months. Applying for coverage may require answering several medical questions, although a physical is not required. Household income documentation may be required if a federal subsidy is granted.
Temporary plans can offer as much as $2 million of coverage per policy period, although benefits vary by state. Length of available coverage is typically 3-24 months, depending upon your state of residence. Occasionally, a PPO network is available, with countrywide access. Indemnity plans are also offered, which allows the applicant to seek treatment from most providers. However, indemnity coverage often requires immediate payment since it is a “fee for service” plan. Also, there my be daily or procedure benefit maximums that can result in large cash outlays by the consumer.
A “Special Enrollment Period” may be available all year to anyone, regardless if you are presently covered. To qualify for this “SEP,” there are several accepted situations, including termination from your current plan, divorce, reaching age 26, moving to a different state, losing qualified benefits, or pregnancy (for the baby). A 60-day window becomes available to compare options and enroll in a plan. If you miss the deadline, several plans will be available, although pre-existing conditions are unlikely to be covered, and federal subsidies will likely not be offered until the next OE period.
Do Older Persons Pay Higher Rates?
Yes, they do, but not as much as in the past. Older applicants can not be charged more than three times (300%) more than the youngest persons applying for coverage. For example, if the premium on a specific policy for a 25 year-old is $120 per month, $360 is the approximate maximum price for an applicant in their 60s. This difference compares to a price of about $500-$700 before The Affordable Care Act was passed. Premiums for younger applicants are typically low, regardless of household income.
This does not take into account federal subsidies, which can substantially reduce premiums, especially for applicants over the age of 50. When there are dependents in the household, the subsidy increases, even if those children are covered through an outside plan (for example, a university medical plan). The dependents must be listed on the parent’s tax return to earn the extra financial aid. Once they reach age 26, they must purchase coverage through a separate plan. However, the new plan is also eligible for a federal subsidy. Note: Applicants between the ages of 60 and 65 can qualify for the largest subsidies.
What Are The Metal Plans And How Do They Differ?
The “Metal” plans are the classifications of coverage that are used. It simplifies the comparison process, especially when multiple policies are being considered. The four tier choices are Platinum, Gold, Silver and Bronze. The basic difference is the out-of-pocket costs that are expected to be paid. This is also referred to as “cost-sharing.” Lower tiers are more likely to place a deductible on prescriptions and specialty office visits.
For example, the Platinum contract (the most expensive), has copays, coinsurance, and deductibles that are expected to pay 90% of anticipated healthcare costs. The Gold contract is 80% and the Silver plan 70%. The cheapest contract (Bronze) is expected to pay about 60% of the average anticipated medical costs. Thus, it is the least expensive Metal option.
However, often, the “Silver” options provide the best combination of value and benefits. Through cost-sharing, which is unique to Silver-tier plans, you can enroll in a plan that has Gold or Platinum features at a discounted rate. This is because at certain income levels, the deductible and copays reduce by as much as 75%. It’s not unusual for a monthly premium to reduce from $1,000 to $150 with a deductible reduction from $6,000 to $600. Office visit and prescription drug copays also reduce. And most importantly, maximum out-of-pocket expenses reduce.
During Open Enrollment, you can change from one plan/tier to another without any penalty or medical underwriting. Thus, if during the prior year, you were treated for expensive medical conditions that were no longer a concern, you could conceivably change to an alternative policy with a lower premium and higher deductible. And vice verse of course. Once you reach age 30, a catastrophic plan can no longer be purchased, although future legislation may allow more consumers to buy basic major medical coverage.
How Are My Pre-Existing Conditions Covered?
Medical conditions do not factor in rate calculations. It does not matter if treatment is planned in the future, or there were health issues in the past. The prices of coverage are solely based on your age, state of residence, zip code, household income, and your tobacco usage. Medical questions are not asked on the short application, and a physical examination is not required for enrollment. There is also no cap on the amount of benefits paid for a specific illness or for the entire year.
NOTE: If you need immediate treatment, it’s important to select the plan that will minimize your out-of-pocket expenses for the surgery/procedure you are going to schedule. In some situations, an HMO may be the best option. However, in others, a low-deductible PPO may be a better and more suitable alternative, especially if you will be utilizing out-of-network providers. Each year, insurers make changes to their provider networks, and to their prescription formulary lists.
Also, if it is cost-effective, you can choose a Gold or Platinum plan to provide benefits the year you have a major surgery. Assuming all treatment has been completed, changing back to a less-expensive Silver or Bronze contract can be considered. This concept only works if the out-of-pocket costs of your medical treatment are significantly lower than the increase in premium from one Metal-tier to another. Once a plan is selected, unless you qualify for an SEP, Medicaid, or Medicare, you can not change until the next OE period.
Will You Help With The Enrollment Process?
We help simplify the entire process. Of course, we’re aware of the glitches, security issues and delays that were present five years ago. Thanks to improved and updated software and servers, the process is not as “clunky” and applications are submitted much faster and easier. Our average submission time is about 12 minutes, and the application can be completed online or by telephone. Submitting changes is also much easier.
Initially, it’s important that you understand your options, the amount of your subsidy (if you qualify) and which plans best cover the benefits that you are most likely to utilize. Any pre-existing condition should be considered. You also need to choose a deductible that’s practical and affordable. Up to two deductibles per family may have to be met for major medical claims. Currently, the maximum total out-of-pocket expenses per family are $17,100 ($8,550 for an individual).
Once we have identified the plan you are going to apply for, we walk you through the process so it becomes much easier and quicker than if you were attempting do apply without assistance. And you might also come away from the process with more hair since you won’t be pulling any out! Once finalized, all billing statements come directly from the insurer. Also, we are available at any time to assist you with your policy. There are never any fees.
How Do I Tell If I Have A Grandfathered Plan I Can Keep?
If your policy has an effective date of March 23, 2010 (or earlier), and there have been no major changes (such as deductible increases), it may qualify as a grandfathered plan. If the coverage was bought after that date, it does not qualify for a grandfathered plan, and the Department Of Health And Human Services may force the cancellation of the contract. If a carrier no longer offers Exchange plans, your policy will generally be terminated at the end of the year, and you can choose a new policy.
However, there are exceptions that can be made in accordance with each individual state’s guidelines. Although health insurance Exchange prices may be a lower-cost option, in some instances, a grandfathered policy should be kept. Unless you are notified (by letter in mail), you should be able to retain your existing coverage, even if it does not meet current Affordable Care Act (ACA) guidelines.
Company-sponsored policies can also be considered for grandfathered status. However, if there were material changes to the coverage, eligibility may be lost. In those situations (private or group), you can change to a new plan issued through your state or federal Exchange Marketplace. Of course, if you have a grandfathered plan, you can also terminate it and apply for a new policy during Open Enrollment. But you will not be able to return back to the original policy.
Are Prescriptions Covered On Most Plans
RX benefits are included on all policies. Since it is a mandatory required benefit, often the difference from one plan to another, is the amount of the copay and whether a deductible applies before you can use coverage. A popular feature is that if you currently take drugs or medicine, it will be fully covered as a pre-existing condition. If a deductible applies to your prescription, often a discount can be applied instead. Occasionally, drug companies will offer steep discounts on the most expensive drugs, depending upon your insurance coverage, including copays and deductibles.
Before determining which plan to apply for, always compare the out-of-pocket costs you must pay before the drug expenses are covered. For example, if a deductible and coinsurance apply, and you need a non-generic prescription covered, another plan that has a slightly-higher premium may actually provide much better RX benefits. When purchasing many generic drugs, it may be advantageous (and cheaper) to pay directly, instead of using your plan copay. This situation occurs if your generic drug copay is $15 or higher.
Also, it’s quite important to know the “tier” classification of your drug. For example, a “Preferred Brand” will will be treated differently than a “Preferred Generic.” And specific plans may feature a small copay instead of a high coinsurance for your particular prescription. By knowing this information in advance, it will help you save hundreds (or thousands) of dollars by enrolling in the most suitable policy.
How Do I Get The Tax Credits To Pay Premiums?
These credits (federal subsidies) are automatically applied towards your premium. Thus, you do not have to file your tax return to receive the credit. Your Marketplace plan costs are based on your household income and its relation to the Federal Poverty Level (FPL). If you become eligible for Medicare, Medicaid or CHIP, the subsidy will be impacted.
The closer you get to 400% of the FPL, the lower your subsidy becomes. If you reach or exceed 400%, no subsidy is paid and you have to pay the full cost of the policy you purchase. The financial aid you receive is based on your estimated income for the following year. So if you underestimate your wages, you may owe extra money the following year. Also, if you overestimated the household income, a tax refund may be due to you.
Also, if you receive federal aid, the following year, you are required to file IRS tax form 1095-A, which will assist you with form 8962 (Premium Tax Credit). The combination of forms will ensure you are correctly calculating your subsidy. A pdf file of these forms is available upon request. If audited, a copy of the forms may be required.
Is It Better To Use A Broker Or The Government Website To Compare Plans And Enroll?
Most importantly, rates are the same, regardless of which option you choose. The Department of Insurance for each state mandates that prices must be identical when the same plans are purchased. Although the government website is larger, provides more data, and offers plan information for all states, most consumers prefer utilizing an experienced broker and/or a website like ours. When reviewing options, it’s important to understand the differences in plans, including the maximum out-of-pocket expenses, network provider availability, and prescription drug copays.
Since there are no fees or extra paperwork to complete, generally, our website and other similar online resources have become popular destinations to obtain benefits. We provide answers to common health insurance questions, and discuss future anticipated changes. You can choose to speak to an expert live, or via email, and once a plan is chosen, it takes less than 15 minutes to apply. And of course, non-Obamacare plans are also available, including 12-month short-term options.
Is It Possible To Get Free Health Insurance?
Depending on your income, you may not have to pay (at all) for your coverage. If your income is low enough, you’ll qualify for Medicaid, which is free. The Federal Poverty Level (FPL) determines your eligibility. Any household income under 100% of the FPL will qualify. The larger your household, the larger the income allowed for inclusion becomes. Medicaid offers medical coverage to millions of Americans, and is jointly funded by the federal and each state government.
The Federal Poverty Levels (except Alaska and Hawaii) are $12,140 (1 person), $16, 460 (2 persons), $20, 780 (3 persons), $25,100 (4 persons), $29, 420 (5 persons), $33,740 (6 persons), and $38, 060 (7 persons).
Several states, however, have raised the Medicaid threshold to 138%, which allows more income to be earned without jeopardizing eligibility. If you are barely ineligible for Medicaid, then your federal subsidy on a Marketplace plan will be quite high, and many “free” options will be available. If your projected household income reduces during the year because of a specific event, the subsidy-eligibility could be impacted.
“Free plans” will likely be Bronze contracts, which will generally feature high deductibles of $,6000-$7,900. A Silver-tier plan should be strongly researched since special “cost-sharing” will reduce the deductible, and copays, which can save thousands of dollars each year.
What Is IRS Form 1095-A?
This form started to be sent to consumers (about four years ago) who received tax credits (subsidies) for paying their healthcare premiums. It is needed when filing your federal taxes for the year after you receive subsidies. When purchasing a qualified plan, the premium tax credits you receive in advance must be reconciled with your income so they match. It is possible that you may receive additional money, or have to pay a specific amount because your income was understated.
Also, once your 1095-A form is completed, you will be able to use the information to complete required IRS form 8962 (Premium Tax Credit). If you received any subsidy (regardless how small), the 8962 must be submitted. The amount of subsidy you receive each year is likely to change, regardless if your household income remains the same or changes. The 1095-A form does not apply to persons that are receiving Medicare benefits.