The Health Insurance Marketplace is the portal through which a person applies to receive financial assistance provided under the Affordable Care Act. Marketplace is located at healthcare.gov. Eligible individuals must have income between 100-400% of the Federal Poverty Level (FPL) and do not have access to other affordable health insurance such as an employer plan.
Two types of financial assistance are available.
- The Premium Tax Credit may be used to reduce your monthly premium cost.
- The Cost Share Reduction Subsidy reduces the out-of-pocket expenses under your health insurance plan.
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If you misplaced your card you can visit your carriers website to print out a temporary card. To get a new card you may contact us or your carrier to replace the old one.
Most insurance companies have Member portals where you can view claims, see benefits, find an in-network doctor and print an ID card. Many sites also include options for viewing the cost of different procedures and finding the best priced facility for a certain service.
All policies include first dollar Preventive Care benefits, which means FREE to you. As long as the visit is billed as Preventive by the physician’s office and falls within the approved category you will have no charge.
ACA plans are not always more expensive. Even though they include benefits like maternity coverage and pediatric dental, those plan designs and rates should be considered. The ACA compliant plans can be less expensive for groups that have an older population or high claims experience.
Every insurance company offers benefits through a specific network of physicians, hospitals and other providers. Your benefits will be reduced if you use a provider that is not in the network. Each insurance company’s website offers a “Provider Search Tool.” You can also contact your doctors’ office to find out if they are in your network. Look on your insurance card to find the website URL.
A formulary is a list of prescription medications that are covered by an insurance plan. The medications are categorized as Tier 1 through Tier 4 with Tier 1 being the least expensive and Tier 4 being the most expensive. Some insurance companies use more than 4 tiers. If your pharmacy tells you that a drug is not covered, then the first step is to call the customer service number of your insurance company to find out why the medication is not covered. The most common reasons are that a drug is new and not yet on the formulary, has been replaced by a generic medication, or requires that you try less expensive medications before the more expensive one will be approved. There is also a process where your doctor can submit a request that the medication be approved because of special circumstances.
When you make a permanent move from one state to another, you will need to change your health insurance to a plan that is based in your new home state. You have a 60 day Special Enrollment Period to select a new plan.
Coverage can vary from one insurance company to another, so check it out before you travel. It is typical for US based coverage to provide benefits for emergency services only when you are out of the country. It is wise to purchase a travel policy that provides additional medical insurance benefits plus coverage for other expenses you might incur if a medical event happens while you are traveling. Benefits such as emergency travel home or evacuation expenses may be available on travel policy. The cost is minimal and provides valuable benefits when something unexpected happens.
You can cancel your policy at any time. However, you can only purchase a new policy during the annual Open Enrollment (November 1 through January 31) or when you are eligible for a Special Enrollment Period after a qualifying event has happened. An example would be getting married, having a new baby, losing coverage from an employer plan or moving to a new state. If you cancel your policy, you would be subject to paying a penalty for not having health insurance when you file your tax return. Not having ACA compliant coverage will cause you to be accessed the penalty on your tax return for the months you did not have compliant coverage. Penalty is $325 per person or 2% of income, whatever is greater.
Give our office a call and we can assist with researching the formulary of your prescribed medication. Also suggest to contact your prescribing doctor to find other alternative medications that may be covered.
An EOB is an Explanation of Benefits. It explains how the insurance company processed your claim.
If you are not enrolled in a compliant plan, you will be penalized on your tax return $695 per person or 2.5% of your total income.
No, the over 65 market is not subject to the Affordable Care Act laws.
This is not an unusual situation for doctors offices and pharmacies to deal with at the beginning of the year. Call ComPro we will help you get the information that is necessary for you to go ahead and get your medical services taken care of.
To pay your premium, go to this link: https://www.medica.com/payments, or the Medica’s member portal: https://www.medicamember.com/account/login?returnUrl=/
College students under the age of 26 are usually insured on their parents’ or spouse’s plan. However there are many situations when a college student may need their own health insurance plan. These include:
- Students who are 27 years or older and don’t have access to other coverage.
- Students who have come from another state to attend college in Nebraska, and don’t have access to in-network doctors here.
- International students
- Students who are participating in NCAA sanctioned sports and must satisfy the NCAA insurance requirements.
The answer is different for this question depending on how you received your coverage.
If you are enrolled through the Health Insurance Marketplace, you may not be “required”to do anything, but it is definitely in your best interest to update your information on the Marketplace and look at the options for 2016. Your Premium Tax Credit will change, and there are new plans available for 2016.
If you health coverage comes directly from an insurance company than you don’t need to do anything, and your plan will renew. But there are new options available that may be a better fit than your current policy. Check out Chris’s video for more in-depth information about renewing coverage through the Marketplace.
A Special Enrollment Period (SEP) can occur anytime there is a qualifying life event (new baby, death, marriage, etc.) or other health insurance coverage has been lost. There are time frames to do the open enrollment so contact your agent as soon as possible.
Contact your agent or ComPro if you do not have an agent to review your options for 2016. We are certified on the Marketplace and can guide you according to your health insurance needs.
If a family member loses eligibility for Medicaid benefits, he will be eligible to enroll in a health insurance plan through the Health Insurance Marketplace. You will have 60 days in which to select a new plan or add him to an existing policy. This is a qualifying event that creates a Special Enrollment Period for those who are losing their benefits. Contact us and we can assist with getting your children added to your current medical coverage or look into getting them their own coverage.
You should contact the Health Insurance Marketplace to update your application. This can be done online or you can call the Marketplace. Your Premium Tax Credit will most likely be lower if your income is higher. The portion of premium that you are responsible for can increase. The final calculation for the amount of Premium Tax Credit you are eligible for is done with your tax return and is based on your reported adjusted gross income. If you contact the Marketplace now, it should lessen the amount of Premium Tax Credit that you will have to pay back at tax time.
When you lose employer provided coverage, you qualify for a Special Enrollment Period (SEP). This means you can enroll in an individual policy through the Health Insurance Marketplace or directly with an insurance company or you can choose the COBRA benefits from your employer. It’s a financial decision based on your total costs for the remainder of 2015. There will be an Open Enrollment from November 1st through January 31st to select a plan for 2016.
During the annual Open Enrollment that begins November 1 – January 31 2016 or during a Special Enrollment Period (SEP). If you want a January 1 effective date, a selection needs to be made by December 15, 2015.
Outside of Open Enrollment an SEP is the only other time to enroll in an Affordable Care Act (ACA) compliant plan.
An (SEP) can occur anytime there is a qualifying life event (new baby, death, marriage, etc.) or other health insurance coverage has been lost.
Enrollments are NOT allowed at other times.
SBC stands for Summary of Benefits & Coverage. This is a required form by the ACA. It explains the benefits of your plan in layman’s terms. It also provides two examples of how claims will be paid for specific situations.
No. Open enrollment for your employer’s plan will depend on when that policy renews. It typically occurs in the month prior to the renewal and coverage would be effective on the renewal date.