We currently do not actively assist with the application on the Federally-Facilitated Marketplace (healthcare.gov), but can help the non-Medicare eligible spouse’s of our Medicare clients understand the plan benefits of their health insurance options until age 65.
The Affordable Care Act Explained
The Affordable Care Act has changed the way we purchase and benefit from health insurance. There are no pre-existing condition exclusions or underwriting questions (except for smoking status). Meaning no one can be denied a plan or be “rated-up” due to health conditions. Although, you can only enroll or change your plan during the Open Enrollment Period (Nov 1-Dec 15) unless you qualify for a Special Enrollment Period, such as (but not limited to) a service-area move or loss of employer coverage.
The Affordable Care Act (ACA) no longer requires that all citizens have health insurance and there is no longer a tax penalty for not having insurance (as of 2018). The ACA requires all plans to include 10 Essential Health Benefits, which were chosen by the Federal government. Some of these benefits include hospital coverage, doctor visits, diagnostic tests, drug coverage, maternity care, preventative care, and pediatric services. This makes buying insurance easier because all plans must cover at the least 10 EHBs, so you know that you aren’t electing a policy with holes in it.
Based on your household composition and income in relation to certain benchmarks in the Federal Poverty Level, you may be eligible for premium or cost subsidies. These subsidies make your plan’s costs more manageable for you. The ACA sets these benchmarks and allows for the application of subsidy from the government.
Enrolling in a Health Insurance Plan
There are two different ways you can enroll in a health insurance plan:
• You may be able to purchase and enroll in a plan directly with the insurance carrier. You may want to do this if you know you will not be eligible for subsidies and the process is shorter and easier. Depending on your county and the carriers available, this may not be an option for you.
• Or you can apply through the Federally-Facilitated Marketplace, www.healthcare.gov. If you are eligible and want to apply for subsidies, you MUST apply and enroll through the FFM and file taxes. The FFM will facilitate your application for subsidies and your enrollment into a plan all in one site and application.
We find that while the marketplace is not complex, it does have its quirks. Creating a profile and entering your financial information is not always as straight forward as you would think. If you are completing your application and have questions on how to answer a question based on your unique household, we recommend that you call healthcare.gov directly to inquire. Since subsidies are all based on tax filing statuses and income, if the information on your application doesn’t match with your tax return for that year, you may have positive OR negative tax consequences.
HMO vs PPO
Currently, all of the plans in KY are Health Maintenance Organizations (HMOs). This means that you MUST see doctors in the network or you will have no coverage for those services. It is critical that you ensure your doctors are in the network or you will pay all out of pocket.
Currently, IN has limited Preferred Provider Organizations (PPOs) and HMOs. A PPO network means that you can see doctors out of the network and have coverage, but your costs will be greater than if you were to see in-network doctors.
Drug Coverage
Since all plans must include prescription drug coverage, you also need to check that your medicines are on the formulary and understand how the plan you are considering covers the medicines you need. Does it have a separate drug deductible? How does the plan tier your medicine and what are the copays for each tier?