We currently do not actively assist with applying for health insurance through Kynect (Kentucky’s healthcare exchange) or Healthcare.gov (most states use the Federal government’s system: the Federally-Facilitated Marketplace/FFM/healthcare.gov), but can guide the non-Medicare eligible spouse’s of our Medicare clients to understand 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 tobacco use.) This means no one can be denied a plan or be rated-up due to health conditions. Enrollments and plan changes are limited to one time period per year unless you are eligible for a Special Enrollment Period (like moving out of state, losing other coverage, marriage, birth, etc.) The Open Enrollment Period is November 1st to December 15th and is the only time you can get health insurance if you don’t have it, or to make a change to a different plan if you already have a plan.
The Affordable Care Act (ACA) does NOT require that all citizens have health insurance and there is NOT a tax penalty for not having insurance (these rules ceased in 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 the same core benefits, so you know that you aren’t choosing 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 (Advanced Premium Tax Credits/APTC) or cost subsidies. These subsidies make your plan’s costs more manageable for you. Since subsidies are tax credits, you must file a tax return every year and reconcile your subsidies with your actual income using the 1095-A form. Failure to do so could result in further tax obligations and loss of your premium subsidies moving forward.
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 are not eligible for subsidies making the process shorter and easier. Depending on your county and the carriers available, this may not be an option for you as some carriers only offer their plans through the Exchange.
• Or you can apply through the Kentucky state marketplace (www.kynect.ky.gov). If you do not live in KY, then your state likely uses the Federal Marketplace (healthcare.gov) unless your state has their own exchange (most do not.) If you are eligible and want to apply for subsidies, you MUST apply and enroll through Kynect or the FFM (or your state’s marketplace.) Kynect 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 kynect (or a local independent insurance agent) directly to ask questions about your situation. Since subsidies are based on tax filing status and income, if the information on your application doesn’t match with your tax return for that year, you may owe or be entitled to more refund depending on your actual income. You are required to report income changes during the year within 30 days in order for your subsidy to be as correct as possible throughout the year.
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? Consider all of your routine and fixed costs when selecting a health plan because the premium is not the only important factor to making the right choice for you.