Obama Health Care Plans
Am I eligible for health insurance through the Marketplace?
If you have legal status in the US and do not qualify for Medicaid, but wish to purchase private health insurance, you’re eligible for health care through the Marketplace. Keep in mind that just because you’re eligible for healthcare through the Marketplace that does not mean you’re eligible for the subsidies.
Mandatory to buy Obamacare?
Starting in 2019 the individual mandate was repealed and no longer will we be penalized for not having healthcare coverage. However, this does not mean you should not enroll in a major medical insurance plan, as it remains the best option for many people this year and beyond.
What do I need to bring to enroll?
You will need your basic information: address, date of birth, email address, social security number, citizenship status, documents pertaining to your employers (W-2/1099 forms, pay stubs). Names, citizenship statuses, date of births, and social security numbers for dependents you claim on your annual tax return. Bi-weekly premium for your workplace health care coverage (if offered by your place of employment).
What counts as income?
The following sources count as income: federal taxable wages, self-employment income, tips, unemployment compensation, social security disability income (SSDI), social security, pension or retirement income, alimony, capital gains, rental and royalty income, investment income, and untaxed foreign income. Note that worker’s compensation, child support, and gifts do not count as income.
What will be the monthly premium for my Obamacare insurance?
Your premium is what you pay the health insurance company every month. The monthly premium is based off several factors: Zip code, number in the household, ages of those in the household, and the yearly household income. Closer that you and your family are to the poverty line, the cheaper your premium is, farther away you get from the poverty line, the more pricier the premium becomes.
Dental and vision insurance included?
Yes! Some health plans will include (limited) dental and vision, but if you select coverage that doesn’t, you may opt for a stand-alone dental or vision plan.
What are essential health benefits?
Under the Affordable Care Act (Obamacare) all individual and small group health plans (starting from 2014) must cover what are known as essential health benefits – with no annual or lifetime dollar limits.
What are these metal tiers I keep hearing about?
Currently there are four metal tiers in the Obamacare Marketplace: Bronze, silver, gold, and platinum. The metal tiers are based on how you and your plan will split up the costs of your healthcare.
I need help with my Obamacare enrollment, who do I call for help?
The answer is hopefully obvious….us, of course! You can speak to one of our independent insurance agents via our office phone number (954) 674-1444 or you can contact one of us directly, via our cellular number, email address, or work extension.
What is the Federal Poverty Line and how does it affect me?
A measure of income that is issued by the HHS (Department of Health and Human Services). Used to determine your eligibility for programs and benefits, which include: CHIP, premium tax credits, and Medicaid.
- Income between 100% and 400% FPL: If your income is in this range, in all states you qualify for premium tax credits that lower your monthly premium for an Obamcare Marketplace plan.
- Income below 138% FPL: If your income is below 138% FPL and your state has expanded Medicaid coverage, you qualify for Medicaid based only on your income.
- Income below 100% FPL: If your income falls below 100% FPL, you probably won’t qualify for savings on a Marketplace health insurance plan or for income-based Medicaid.
What is a premium tax credit?
Refundable credit that you can use to lower your monthly health premium when you enroll in a plan through the Obamacare Marketplace. Your tax credit is based on the income estimate and household information you put on your Marketplace application.
You can use all, some, or none of your premium tax credit in advance to lower your monthly health premium.
- If you use more advance payments of the tax credit than you qualify for (based on your final yearly income) then you must repay the difference when you file your federal income tax return.
- If you use less premium tax credit than you qualify for, you’ll get the difference as a refundable credit when you file your taxes.
You are free to purchase health insurance through other sources, but the only way to get a premium tax credit is through the Obamacare Marketplace.
Are Immigrants eligible for Obamacare?
US Citizens, US Nationals, and lawfully present immigrants are all eligible for health coverage through the Marketplace. Our insurance agents can help illegal immigrants find other health coverage options outside the Marketplace.
What if my job offers health insurance?
If the health insurance that is being offered through your employer meets the minimum required standards and is considered affordable, you won’t be eligible for any premium tax credits or savings.
Healthcare Marketplace is asking me to submit documents - why?
If the Marketplace cannot verify information instantly, they will ask you to submit documents. If you don’t verify the requested information on your application, you risk losing your health insurance entirely, along with the cost-sharing benefits and premium tax credits.
I lost my job, so what kind of health insurance can I get now?
From the point you lose your job, you have a 60 day special enrollment period. Apply for a Marketplace plan with one of our insurance agents, report on the application that you will have no income, and you should qualify for cost assistance.
Buying health insurance after Open Enrollment?
You have several options – see if you qualify for a special enrollment period due to a life change. If you do not qualify, our insurance agents can help you navigate through a variety of off market health insurance options to choose from.
What if the information on my application changes during the year?
Your subsidy and tax credits are based on your annual income and the number in the household. Report your income or a household change by having your insurance agent log into your Marketplace account and report the life change. This will update your enrollment and correct your subsidy.
Medicare Advantage for Dummies
What are deductibles, co-payments and coinsurance?
Amount you pay for covered healthcare services before your insurance company begins to pay out. Let’s say you have a $1,500 deductible in your health plan, well you are then responsible for the first $1,500 of covered health services. Once the deductible has been met (paid), you will either pay a coinsurance or copay for services.
The percentage you will pay once you have met your deductible. Here are a couple of examples: The coinsurance on your health plan is 20% to see a doctor and they charge $100, this means you will be charged $20 to see the doctor and the health insurance company pays the rest.
You receive a bill from the hospital for $10,000 and your plan deductible is $2,500, your coinsurance is 20%, and your annual maximum out of pocket is $6,700. Already we know that $6,700 is the maximum we can be charged, however in this case we will only be charged $2,500 (deductible) + $1,500 (20% coinsurance) from the $10,000 hospital bill.
Fixed amount you will pay for covered health services once you have met your deductible. Here is an example: The insurance copay on your health plan is $10 to see a doctor, but the true cost is $150, this means you will be charged $10 to see the doctor and the health insurance company pays the rest. However if you have not met your deductible you will pay the full $150 charge.
What is Original Medicare?
Individuals receive their benefits directly from the federal government and it includes two parts, Medicare Part A and Part B. The benefits are the same for everybody who is enrolled and there are no pre-existing conditions, limitations, or waiting periods. You can choose to visit any healthcare provider who accepts Medicare, since there are no networks. You also pay the same amount for covered services, regardless of which provider you choose.
Part A Medicare is your hospital insurance and covers common hospital expenses, such as: Semi-private rooms in the hospital, hospice, home health care, and skilled nursing facility stays. Blood transfusions requiring more than 3 pints of blood are also covered. Medicare Part A will be free if you have worked 10 years in the US or have been married to someone who is at least 62 and has also worked 10 years in the US.
Part B Medicare covers doctor services, outpatient care, and preventive care. Including coverage for lab testing, diagnostic imaging, surgeries, ambulance rides, chemotherapy, radiation, and extensive dialysis care for people with renal failure. Part B requires that you pay a monthly premium (different depending on your income level) from either your social security income or another means in order to receive benefits. Low income individuals can apply to the State for help under a Medicare Savings Program, if they qualify, they will have their entire Part B premium paid.
***Original Medicare does not include coverage for Medicare Part D prescription drugs. You have the option of enrolling in a private Medicare Part D prescription drug plan if you wish. Contact one of our health insurance brokers for more information and they can also help you further.
What is Medicare ``Part C?``
Medicare plans issued by a private health insurance company. Typically Part C will have Part A, Part B, and usually Part D bundled together under one plan. Most plans also include the following additional benefits: Routine dental, vision, hearing aids + care, transportation, FREE gym membership, over the counter allowance, etc…Part C plans generally resemble group insurance plans you may have had with previous employers. Part C plans in some areas won’t include Part D (please mindful of this when discussing plans with your independent insurance agent).
What are Medigap plans?
Medigap (also known as Medicare Supplement) is a private insurance that pays for the “gaps” that Original Medicare will not cover (deductibles, coinsurance, co-payments, and care outside the US). You are also not bound to a network, therefore have the freedom to choose your own doctor. All Medigap plans offer the same standard benefits, but some do offer additional benefits. Eligibility in a Medigap plan is dependent on you being enrolled in both Part A + B and paying your monthly premium for the Medigap plan as well.
Medicare enrollment periods
Initial Enrollment Period (IEP)
The first time you are eligible to sign up for Medicare Part A, B, C, or D. The time frame is three months before your 65th birthday, the month of your birthday, and three months after your 65th birthday.
Part B Initial Enrollment
The start date will be dependent on which month you enrolled for Part B during your Initial Enrollment Period….
Part D Initial Enrollment
The start date, once again, will be dependent on which month you enrolled for Part D during your Initial Enrollment period…
Special Enrollment Period (SEP)
Certain life events can trigger a special enrollment period (SEP) which allows you to enroll in a Medicare Advantage plan outside the Initial Enrollment Period (IEP), Annual Enrollment Period (AEP), and General Enrollment Period (GEP).
Part A and B special enrollments are triggered when you are either still covered by an employer or union group health plan or your spouse is or during the 8 months following the month your employer or union group plan ends or when you yourself dis-enroll (whichever comes first).
Part C and D special enrollments are triggered during the 63 days after your employer or union group plan ends or when your employment ends (whichever is first). Additional triggers are when you move out of the coverage area, your plan changes or no longer serves the area, receive extra help with your prescription drugs costs, and enter, live in, or leave a nursing home.
Annual Enrollment Period
Each year, beginning on October 15th and continuing until December 7th you can enroll in a Medicare Advantage or Part D prescription drug plan (penalty fee may apply if you did not enroll when first eligible). During this period you may change various aspects of your coverage, such as:
- Switching from Original Medicare to Medicare Advantage or vice versa;
- Switching to different Medicare Advantage or Part D prescription drug plans
General Enrollment Period (GEP)
Missed out on your Initial Enrollment Period (IEP) or a possible Special Enrollment Period (SEP)? The General Enrollment Period (GEP) gives you another shot at signing up for Part A or B between January 1st – March 31st each year. Your Medicare coverage will then begin on July 1st.
What are drug tiers exactly?
Part D prescription drug plans place all drugs into different tiers. The drugs in each of the tiers have a different cost and these are expounded on below:
Cost sharing Tier 1 – Preferred generic
Tier 1 is the lowest tier. Reserved for lowest cost preferred generic drugs.
Cost sharing Tier 2 – Generic
Tier 2 includes preferred low cost generic drugs.
Cost sharing Tier 3 – Preferred brand
Tier 3 includes preferred brand drugs and non-preferred generic drugs.
Cost sharing Tier 4 – Non-preferred drug
Tier 4 includes non-preferred brand drugs and non-preferred generic drugs.
Cost sharing Tier 5 – Specialty
Tier 5 is the highest tier. It contains very high cost brand and generic drugs, which may require special handling and/or close monitoring.
SunCARE Health Option