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Frequently Asked QuestionsFrequently Asked Insurance Questions (FAQs)

The questions and answers below will help you as you begin researching insurance products and plans.

Q: What is the first thing I should know about buying health coverage?

A: Your aim should be to insure yourself and your family against the most serious and financially disastrous losses that can result from an illness or accident. If you are offered health benefits at work, the plans’ literature can answer most of your questions, so you can select the plan that best fits your needs. Your management or your company’s benefit specialists can answer additional questions you may have.

If you purchase individual coverage, buy a policy that will cover major expenses and pay them to the highest maximum level. Save money on premiums, if necessary, by taking large deductibles and paying smaller costs out-of-pocket.

Q: Can I buy a single health insurance policy that will provide all the benefits I’m likely to
need?

A: Although many policies cover most medical, hospital, surgical, and pharmaceutical bills, no single policy covers everything. Consider additional single-purpose policies like long-term care or disability income insurance. If you are over 65, a Medicare supplement policy may fill in the gaps in Medicare coverage. Any one of our experienced agents can answer your questions in more detail.

Q: I’m planning to keep working after age 65. Will I be covered by Medicare or by my
company’s health insurance?

A: If you work for a company with 20 or more employees, your employer must offer you (through age 69) the same health insurance coverage offered to younger employees. After you turn 65, you may choose between Medicare and your company’s plan as your primary insurer. If you stay enrolled in the company plan, it will pay first – for benefits covered under the plan – before Medicare is billed. In most cases, it is to your advantage to accept continued employer coverage.

Be sure to enroll in Medicare Part A, which covers hospitalization and can supplement your group coverage at no additional cost to you. You can save on Medicare premiums by not enrolling in Medicare Part B until you finally retire. Bear in mind, though, that delayed enrollment is more expensive and entails a waiting period for coverage.

Q: I’ve had a serious health condition that appears to be stabilized. Can I buy individual
health coverage?

A: Yes, under the Affordable Care Act, insurance companies are not allowed to deny coverage to anyone for a pre-existing medical condition. There are no more medical underwriting questions to answer prior to acceptance.

Q: One of my medical bills was turned down by the insurance company (or health plan). Is
there anything I can do?

A: Ask the insurance company why the claim was rejected. If the answer is that the service isn’t covered under your policy, and you’re sure that it is covered, your next questions should be to the provider – be sure they entered the correct diagnosis or procedure code on the insurance claim form. Also check that your deductible was correctly calculated.

Q: What are metal levels?

A: This is how the federal government under the Affordable Care Act (Obamacare) has defined how all qualified health plans must be categorized.
Bronze = Fair Plans 60% Actuarial Value
Silver = Good Plans 70% Actuarial Value
Gold = Better Plans 80% Actuarial Value
Platinum = Best Plans 90% Actuarial Value

Q: What is a subsidy and how do I get approved?

A: A subsidy is also known as an Advanced Premium Tax Credit (APTC), which is determined by the Health Insurance Marketplace Healthcare.gov. The dollar amount is determined by your household size and your total family income. If you fall under 400% of the federal poverty level, you will qualify for financial assistance to help pay for your health insurance plan. You may also qualify for cost share reductions.

Q: What are Cost Share Reductions?

A: Cost Share Reductions are benefits offered through the Marketplace specifically designed into silver metal level plans. Cost Share Reductions are provided to reduce out of pocket costs associated with the insurance plan, such as annual deductible, co-pays, prescriptions, hospital stays, etc. These reductions are provided when your family income and household size fall under 250% of the federal poverty level.

Q: I’m not a U.S. citizen. Can I still get health insurance with a subsidy?

A: Yes, as long as you are in the country legally. If you have either an I-94, Permanent Resident Card, or one of several other immigration documents, you can still qualify for health insurance that comes with subsidy approval. If you are not provided a subsidy you can still get health insurance directly from the insurance company. Thomas & Associates can answer your questions in more detail.

Q: I missed the annual enrollment period. Can I still enroll? What is a Special Enrollment Period?

Questions about enrollment and eligibility are very common. The annual Marketplace enrollment period starts 10/15 and continues through 12/7 each year. This is the time period where individuals and families can enroll into guaranteed issue health coverage on the Marketplace Exchange. If you do not enroll during this period you will not be able to acquired coverage until the next Annual Enrollment Period in the following year unless you qualify for a Special Enrollment Period. Special enrollment periods are granted when individuals or families experience significant life changes outside the annual enrollment period. The special enrollment period typically lasts 60 days from the qualifying event. Here are a few
typical special enrollment qualifying life change situations:

  • Residential Move, change to different county
  • Marriage/Divorce
  • Birth of a child / adoption /gaining a dependent through marriage
  • Loss of Medicaid Benefits
  • Loss of Group Employer Coverage / Future loss of Minimum Essential Coverage
  • Release from Incarceration
  • Changes in Citizenship Status
  • Group or Non ACA coverage renewal
  • Gain or loss of Advance Premium Tax Credit (APTC)
  • Member receiving APTC’s may be eligible to a Cost Share Reduction (CSR) plan
  • Current health plan closes
  • Non-calendar year individual plan anniversary date
  • Unresolved Inconsistency resulting in loss of APTC or change in CSR eligibility
  • Member provided documentation after the deadline to resolve inconsistencies
  • COBRA ending

Q: How do I verify my income with the Heathcare.gov Marketplace?

Often information concerning personal / family income is not immediately verified by the Marketplace data-hub during the marketplace application. Subsequently the marketplace will require additional proof of income be uploaded or mailed to the marketplace within 90 days of the marketplace application. Examples of income documents you can send include:

  • Wages and Tax statements
  • Pay Stub
  • Letter from Employer
  • Self-employment Ledger
  • Cost of living adjustment letter and other benefit verification notices
  • Lease agreement
  • Copy of a check paid to the household member
  • Ban or investment fund statements
  • Document or letter from Social Security Administration (SSA)
  • Form SSA 1099 Social Security benefits Statement
  • Letter from government agency for unemployment benefits

Q: If I’m separated from my spouse can I qualify for subsidy if I file a separate tax return?

Married couples must file a joint tax return in order to receive annual premium tax credits (APTC) on the marketplace. Simply stated, married couples, even separated, will not receive APTC though the marketplace if they file an individual tax return. Divorced couples can receive APTC when they file an individual tax return.

Q: Should I re-enroll each year with the Marketplace?

Yes, for several reasons. Each January health policy premium rates will renew and increase due to increasing ages of the covered individuals. If you recertify your income each year, often the APTC will increase as well, offsetting the increasing premium. Premiums go up and tax credits go up.

If you do not re-certify through the marketplace and simply roll over your coverage to the new year, the APTC from the past year will follow over but at last year’s level. This will often result in a significant premium net increase starting each January.

Q: Why did the marketplace discontinue my premium subsidy?

Often income verification or citizenship / legal residence status was not verified by the Marketplace Data-hub during the marketplace application. In this situation, further information was requested by the Marketplace and duly noted on the Marketplace Eligibility Report. The requested date must be processed within 90 days from the original marketplace application. Failure to satisfy the marketplace with verifiable information in the designated time period will result in a loss of the APTC. Thomas & Associates Brokers can assist with uploading this information into your marketplace account.

Q: What is the tax penalty for not having qualified health insurance for me and my family?

The fee for not having coverage in 2017

If you don’t have coverage in 2017, you’ll pay the higher of these

2.5% of your yearly household income. (Only the amount of income above the tax filing threshold, about $10,150 for an individual, is used to calculate the penalty.) The maximum penalty is the national average premium for a Bronze plan.

$695per person for the year ($347.50 per child under 18). The maximum penalty per family using this method is $2,085.

Q: Does being offered group insurance through my employer disqualify me and my family for Marketplace premium subsidy tax credits.

Typically yes. If an individual is offered group insurance by their employer and the cost of employee only coverage is deemed “affordable” (annual premium cost less than 9.5% of the household income) then that individual will not qualify for APTC through the Marketplace. This individual should weigh the cost of the group plan verses the cost of ACA coverage without APTC. Usually, the group employer coverage is a better option. We would be happy to evaluate your coverage options.

Q: How can I terminate my health insurance?

On-Marketplace coverage must be terminated through the Marketplace. Off-Marketplace, insurance company direct coverage, can be terminated by contacting the insurance company directly.

Q: How can I get my 1095 tax credit tax form generated by the Marketplace?

The 1095 APTC IRS statements are mailed out by the Marketplace, typically around February, to all covered individuals / families receiving the premium subsidies tax credits. This information is needed to complete Individual Federal Tax Returns. If you are missing this 1095 statement, you can download this information through your personal account found Healthcare.gov. Log into your Healthcare.gov account, view your prior year application, and click on tax forms tab. You will be able to download the pdf document.

Q: Is dental and vision coverage included in my ACA health plan.

Pediatric Dental and Vision benefits (for dependent children 18 and younger) are a required essential health benefit mandated by the ACA law. You can receive these benefits as part purchased ACA health plan or through a stand-alone qualified dental plan. Typically the stand alone qualified dental plans offer better benefits and better provider networks compared to health plans with integrated pediatric dental. Please discuss what dental options best suites your family needs with your agent.

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