Health Insurance FAQ

Tax Penalty

Q: Will I have to pay a Tax Penalty if i don't have insurance?


A: Possibly. There is no federal tax penalty. HOWEVER, if you live in California, D.C., Massachussetts, New Jersey or Vermont- guess what? Y our state has instituted a Tax Penalty at the State level to replace the Federal tax penalty. Lucky you!




Q: I thought the Tax Penalty was cancelled?


A: No Federal Tax Penalty starting January 1, 2019. HOWEVER, if you live in California, D.C., Massachussetts, New Jersey or Vermont- guess what? Y our state has instituted a Tax Penalty at the State level to replace the Federal tax penalty. Lucky you!





Application Deadlines

Q: When can I enroll?


A: Different answers for different types of health insurance. * "Obamacare" for 2019 Coverage - Closed except SEP with a QLE - ALL STATES: available if you qualify for a "Special Enrollment Period" * "Obamacare" for 2020 coverage: - Must apply between November 1, 2019 - through December 15, 2019 - CALIFORNIA: TODAY through January 15, 2019 * Private insurance - apply any time for coverage beginning as early as the following day. - We can submit applications all year, and - in most cases coverage can begin as early as the next day.





Eligibility

Q: I don't have health insurance, and I need to have some medical procedures done. But when I tried to apply for insurance, I was told the insurance companies wouldn't cover "pre-existing medical conditions." I thought they weren't allowed to do that anymore?


A: Only insurance that conforms to the Affordable Care Act (otherwise known as "Obamacare") will cover any and all pre-existing medical conditions. This is one of the many reasons that the cost of these plans can be extremely high. Imagine what auto insurance prices would look like if you could sign up for a new policy AFTER the car accident, and the insurance company would have to pay for repairs from that accident. Do you think that would raise the price of car insurance in general? Absolutely it would. Now, compare the limited value of a car and the cost of car repairs to the unlimited value of a human life and cost of medical care. Can you see what direction health insurance pricing has to go in this system?




Q: I tried to enroll in Obamacare and they said I wasn't qualified. What now?


A: We hear this a lot. It's a misunderstanding. Anyone can enroll during a specific time of year. And if you're willing to pay full price. Either you were not qualified to receive financial aid, or, you were trying to enroll outside of the "Open Enrollment" period. (Nov. 1st - Dec 15th for coverage beginning Jan 1st ) Private insurance may be a good option if you need insurance right away, or if the cost of Obamacare is more than you can pay.





Cost

Q: My friend got health insurance for her entire family for less than $100. I'm not finding quotes like that for insurance for just myself. What gives? Why is everybody trying to rip me off?


A: Your friend received financial assistance from the federal government. Financial assistance is only available if applying for an "Obamacare" plan through the Federal Marketplace. Eligibility for financial assistance is based on tax household size (the number of people on your tax return) and estimated adjusted gross income for the household (including the income of any dependent children under 26 whether or not they will be on your insurance plan, plus the income of any non-dependent children under 26 if they will be on your insurance plan). Regardless of eligibility for financial assistance, all health insurance is priced partially on several factors that you cannot control: age and location of the people who will be on the plan, for example. After that, product availability and your choices will drive pricing. For example, just like your auto insurance and homeowners insurance - if you choose a low deductible your monthly payments will be higher. Another example, PPO newtwork access gives you more choice and flexibility, and therefore typically costs more than a plan with HMO network access to care.




Q: My employer offers insurance but it's too expensive. Can I get a better deal through the Federal Exchange?


A: No, not likely. Unless the lowest cost, employee-only coverage offered through your employer is greater than 9.56% of your household income, you and anyone in your tax household are disqualified from financial assistance through the exchange. It's extremely rare that the lowest-cost plan for just the employee exceeds 9.56% of household income. Without financial assistance, the Obamacare plans typically cost much more, have higher deductibles and out of pocket expenses, and smaller doctor networks than employers' group coverage. However, we often find much better pricing and great coverage outside of the Obamacare system. That's worth exploring if health insurance is important to you, but your current options are too costly.




Q: Am I locked into my plan, or are there penalties for canceling it?


A: Different answers for different types of health insurance. NOTE: Never quit your health insurance without first speaking with a reputable health insurance broker. There can be absolutely devastating financial and medical consequenses for making the wrong decision. Job-based plans - most lock you in for the full year. You're not able to quit or make changes to the plan, unless there are specific special circumstances (major life changes such as marriage, birth, adoption, death, divorce for example). In addition, any changes to the plan must be consistent with the special circumstance. COBRA - You can quit anytime but cannot re-enroll or re-instate. Obamacare - You are not locked in, but if you quit you can't re-enroll until the next open enrollment period. Neither can you modify your plan or change insurance companies during the year (similar to job-based coverage). Private health insurance - You can quit anytime. It's month to month just like your auto or homeowners. There are no penalties for cancelling. Under most circumstances you can modify your plan or change insurance carriers. (Again, NEVER make those decisions without advice from a licensed health insurance broker.)




Q: Are there options besides Obamacare?


A: Yes. In most States there are private health insurance options. They aren't suitable for everyone. For those for whom these plans are suited, they offer some significant advantages compared to Obamacare plans. Typically:
* Much larger networks of doctors, * Greater choice of doctors (PPO access) * National in-network coverage * Lower pricing * Apply any day of the year * Coverage start dates as fast as next day * Cancellation as soon as same day




Q: I'm considering [Retiring, Changing Jobs, Moving, etc.]. Can you help me figure out what health insurance will cost?


A: Not exactly. It's an extremly dynamic market for health insurance. Anything outside of a 30-day window is tough to know for sure. Sweeping changes are happening several times each year on both a Federal and State level. However, the Federal standard for "affordabiliity" is 9.86% of Modified Adjusted Gross Income for the household. For future planning purposes, we recommend you use10% of Modified Adjusted Gross Income for a cost assumption. Depending on your unique situation, it's possible you'll pay far less.




Q: What would health insurance cost [right now]?


A: We can definitely help you explore options. Call us at 267-329-9130. We will need basic information about each family member who will be on the plan. We also need to understand your unique situation in order to determine what coverage we can get you qualified for that will match your healthcare needs.




Q: What will health insurance cost [in the future]?


A: The individual health insurance market is so dynamic right now, we can only look ahead 30-45 days with certainty. Laws, products and pricing are constantly changeing. For "retirment planning" for example, if you'll retire before you are elibible for Medicare (age 65), you should plan to pay a maximum of 10% of Modified Adjusted Gross income for monthly payments. If you require signfificant medical care, you should anticipate annual deductibles from $4,000 - $7,500 per person.





COBRA

Q: I have an offer of COBRA coverage. Can I get a better deal?


A: Possibly. Each case is completely unique. Helping you identify and understand your options, and evaluate the pros and cons is what we do all day. We'll either find you a better value, or, you'll have peace of mind knowing that your COBRA offer is the best value for you.




Q: COBRA is too expensive for my family. We can't keep it. What are my options?


A: Depending on your unique situation you may have several good options. * If you haven't yet enrolled, you may find acceptable coverage through the Federal Marketplace. * If you're already enrolled in COBRA, during national Open Erollment (Nov 1 - Dec 15) you can change to a Marketplace plan for coverage beginning January 1. * You might find that private insurance is more suitable, in which case you can quit COBRA or decline the offer. * OR - and this happens often - one or more family members may stay with COBRA because of an ongoing medical condition, while the other family members drop COBRA and enroll in private insurance. Each COBRA-eligible person in your family has the independent right to enroll, reject, keep or drop the COBRA benefits. And with fewer family members on COBRA, the cost will drop accordingly.





Pre-Existing Conditions

Q: Are pre-existing medical conditions covered?


A: Different answers for different types of health insurance. * "Obamacare" - Yes. - However, you may have to meet your deductible before your insurance pays anything. * Private insurance - Depends on the condition. - Some plans will not allow you to enroll if you've had a serious medical condition within the past 60 months. Those medical conditions are listed in the application questions. Some common examples are insulin-dependent diabetes, heart attack or stroke. - Some conditions Sometimes. Normally, pre-existing conditions are not covered. - However, some plans cover pre-existing conditions after you've had the insurance for 12 months.




Q: I don't have health insurance, and I need to have some medical procedures done. But when I tried to apply for insurance, I was told the insurance companies wouldn't cover "pre-existing medical conditions." I thought they weren't allowed to do that anymore?


A: Only insurance that conforms to the Affordable Care Act (otherwise known as "Obamacare") will cover any and all pre-existing medical conditions. This is one of the many reasons that the cost of these plans can be extremely high. Imagine what auto insurance prices would look like if you could sign up for a new policy AFTER the car accident, and the insurance company would have to pay for repairs from that accident. Do you think that would raise the price of car insurance in general? Absolutely it would. Now, compare the limited value of a car and the cost of car repairs to the unlimited value of a human life and cost of medical care. Can you see what direction health insurance pricing has to go in this system?





"TrumpCare"

Q: What is "TrumpCare?" I saw an ad for that ...


A: There's no such thing as "TrumpCare." Unfortunately, you'll see lots ot decptive, misleading, or otherwise less than truthful advertising for heatlh insurance. The Trump adimistration has reversed some restrictions that limited your health insurance options outside of the Obamacare system. So, at this time, people in most states have a broad range of choice among a viriety of health insurance options and supplemental coverage. However, insurance is regulated on a State level. Some States have further increased limitations on choice, despite the change in Federal law, effedctively making Obmacare the only option for individual/family health insurance.





Pros and Cons

Q: What's the difference [Job-based vs"Obamacare"]?


A: Each type of insurance has pros and cons, some similarities and differences. Job-based vs "Obamacare" The primary similarity of both Job-based and Obmacare is that they comply with the Patient Protection and Affordable Care Act, often shortened to the Affordable Care Act (ACA) (nicknamed "Obamacare"). That means Job-based ihealth insurance is also "Obmamacare" - but it's only available through an employer (including COBRA). They are required to accept and treat pre-existing medical conditions (subject to deductibles, medical necessity, etc.). They must cover 10 areas of essential health benefits, regardless of pre-existing need: 1. Ambulatory patient services (outpatient services) 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care They cannot limit the maximum dollar amount they will pay for covered services/treatments for necessary medical care during the plan year. Job-based coverage differs from individually-purchased Obamacare plans in several key ways: a. Job-based coverage is ususally a 12-month commitment. Even if you wish to cancel or change your insurance during the year, you may not be able to do so. b. Employers typically contribute toward the cost of Job-based coverage for the employee (sometimes also for the employee's spouse and children). c. Job-based coverage usually offers much larger doctor/hospital networks d. Employers offer plans, options and pricing that aren't available to individuals purchasing "Obamacare" on their own.




Q: What's the difference ["Obamacare" vs Private]?


A. (For "Obamacare" info, see Job-based, above) Private health insurance options are availabel in most States. They aren't suitable for everyone. For those for whom these plans are suited, they offer some significant advantages compared to Obamacare plans. Typically:
* Much larger networks of doctors, * Greater choice of doctors (PPO access) * National in-network coverage * Lower pricing * Greater flexibility in plan featuers such as deductible amounts * Month-to-month contracts you control (just like your auto or homeowners' insurance) * Apply any day of the year * Coverage start dates as soon as next day * Cancellation as soon as same day without penalty * Typically feature a 10-day "free look" period during which you can get a full refund Here are the major differences in coverage: * Pre-existing medical conditions are not covered. (Just like your auto insurance doesn't cover any accidents that you had before you had insurance.). * Many plans will decline your application if you have had serious medical conditions during the past 60 months (for example, heart attack, stroke, cancer, insulin-dependent diabetes).. * Most do not cover normal pregnancy (but will cover complications of pregnancy). * Prescription coverage is optional or subject to limitations. * Total dollar amount the insurance will pay for medical care is capped (for example, $1,000,000 per person). * Medical coverage for specific types of services may be limited or excluded as part of the original plan document. (in other words, they specify up-front what's excluded and what coverage categories are limited). * Typically does not cover matters of fertility or infertility (For example, getting an IUD is not covered. Removing an IUD that is causing a medical problem and is deeped medically necessary is covered.)





Networks

Q: Does my Dr. take this insurance?


A: One of the most important things you need to know about your health insurance is the name of the network associated with your specific plan. For example, United HealthCare has health plans that use the Choice Plus network, the Choice network, or the Multiplan network. It's a common mistake to ask the Dr's office "Do you take United HealthCare?" And - not your fault - it's a common problem that the Dr's office will just say "Yes." Then, AFTER you've had some medical attention, you find out that your Dr isn't in the network associated with your plan. Ask your doctor's office specifically, "Do you belong to the [NAME OF NETWORK]" to be sure you are getting the most benefit from your health insurance coverage. If the answer is "Yes," then your doctor almost certainly takes your insurance, regardless of the name of the insurance company itself, or the plan itself.




Q: What's a "Network" and why do I need to know?


A: When doctors contract with a health insurance company, they are said to belong to a network. A network is a set of health care providers (doctors, hosptials and other facilities) who have agreed to the contracs. When a health care provider "accepts" a health insurance plan, it means that the providers have contracted with the insurance company. It's critically important for you to understand networks, because: 1) The contracts impose limits on how much the health care provider can charge you for medical services. Typically that means a discount of 40% - 70% on medical services. This is a major benefit of having health insurance, since you may be responsible for some of your medical costs. (For example, until you've met your deductible.) 2) Some insurance plans won't pay for any medical services you receive from providers who are not in network (with the exception of emergency medical services). Some will pay a reduced benefit. Some will pay to out-of-network providers the same rates they would pay to in-network providers. Either way, you could be on the hook for medical expenses.




Q: How do I know what Network my insurance uses?


A: Several ways: 1) Your broker should tell you, before you enroll, and describe the network to you. 2) The name and logo of the network is usually printed on the front of your insurance card. 3) Some insurance plans have secondary or additional networks. The names and logos are usually printed on the back of your insurance card.




Q: How do I find a doctor or facility that takes my insurance?


A: All insurance networks provide an online search tool for you to use. Also, you can use a phone number - typically printed on your insurance card - for help to find in-network providers. NOTE: YOU SHOULD CONFIRM WITH THE PROVIDER BEFORE RECEIVING CARE. Doctors and facilities join or quit networks constantly. Although the network administrators try to keep the list current, it's not possible to keep a 100% accurate list in real time.




Q: What are "negotiated rates"


A: Doctors who take your health insurance are "in network," which means they've contracted to a discounted price for medical services. You can get a good idea of how much this matters by looking at the costs for medical treatments with and without insurance. There are several websites designed to help you do that. Here are two that we use: Healthcare Bluebook: https://www.healthcarebluebook.com/ui/consumerfront FairHealth Consumer: https://www.fairhealthconsumer.org/medical





HealthShare

Q: What is a HealthShare plan?


A: Also known as "Health Share Ministry" or "HSM." These are non-profit organizations that serve as an alternative to health insurance. They typically cost far less than health insurance, with lower monthly charges and out-of-pocket expenses. Most HSMs are "faith based organizations" and are available to people who ascribe to a specific religion. However, there are unaffiliated, "ethics/values based" health share organizations available to people who share a set of ethics and values. Some professional HSMs are nearly identical to health insurance. As with any coverage options, there are pros and cons. HSMs can be a very good option for folks who are paying too much for ACA-Compliant health insurance ("Obamacare"), or who need national coverage (typically unavailable with Marketplace ACA-Compliant plans). We work with one of the most professional, (non-religious) ethics/value-based HSMs. Our brokers are happy to help you explore whether this is a good option for you.





© 2019/2020 JoshuaFinancial    Member American Insurance Organization, one of the largest brokerages and enrollment centers specializing in individual and family health, life, and supplemental insurance coverage.