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Is my Health Insurance plan “Unaffordable”?  Am I exempt from the tax penalty?

When individuals and families buy their own health insurance, IF the insurance is greater than 8% of your “household income” (see definition), it is considered”unaffordable” (see definition) and you are not required to buy health insurance.  MOST Americans will find they will qualify for either Medicaid or a subsidized plan that makes insurance “affordable” (see definition).  If your employer provides insurance for you, it must be less than 9.66% of your W2 Box 1 income.

To determine if your plan is unaffordable, you must compare your plan to the cheapest plan (bronze) after all subsidies have been applied, and that amount must be more than 8% of your MAGI (Modified Adjusted Gross Income) see definition – of your household income.

So we start with your household MAGI.  Then we do the math to determine the person’s expected premium amount.  Then we determine the subsidy (based on the 2nd lowest cost silver plan) and apply that subsidy to the cheapest bronze plan available.  Then we compare the subsidized bronze plan premium to 8% of the person’s household MAGI.  If the plan costs more, then it is “unaffordable”, and the person qualifies for an exemption (no tax penalty).  If the plan costs less, then it is “affordable” and no exemption will be granted.

Example:

Family of 4 who’s household annual MAGI is $37,000

8% x $37,000 = $2,960

$2,960 / 12 months = $246.67 per month

 

2nd Lowest Silver Plan for all 4 is $400 (hypothetical)

APTC (subsidy) = $400 – $246.67 = $153.33

 

Lowest Cost Bronze Plan for all 4 = $300 (hypothetical)

$300 – $153.33 (subsidy) = $146.67 monthly premiums

 

$146.67 < $246.67 so the plan is affordable and the family gets no exemption.

Why do I need an insurance agent assigned to me when I can just sign up online by myself?

Where do we begin.  You’d be surprised how many people ask this question, so many in fact, we created a page on this website focused on answering that question.

Click Here:  Why use an insurance agent?

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Can I buy Health Insurance after “Open Enrollment” closes?

Absolutely.  However, keep in mind, there is a 90 day waiting period until your health insurance coverage will be effective.  For example, if you sign up for a plan on April 15, 2017, your health insurance will not be effective for another 90 days, then begins on the 1st.  So using this example, your insurance would start August 1st.

Also,  after “Open Enrollment” closes on 1/31/2017, you will not be able to buy a health insurance plan that has a Government “subsidy” until 11/1/2017 (that plan and subsidy will go into effect 1/1/2018).  The only exceptions are if you have a “Life Event”.

We here at Nevada Insurance Enrollment understand this information can be confusing; please call us today and we will happily assist you in securing health insurance coverage and answer any questions that you may have.

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What are “Essential Health Benefits”?

From 1/1/2014 on, all new health plans (insured small group and individual health insurance plans) must cover the 10 bulleted benefits below, in order to avoid a tax penalty.   Qualified Health Plans MUST cover these 10 items without any lifetime or annual limits on these “Essential Health Benefits”.    There are exceptions to those that have to buy these plans.  Those folks that have a State or Federal plan (Medicare, Medicaid, VA, Tricare, CHIP etc.) or are a part of an Employer Group that provides benefits or are “Grandfathered” or that the insurance is “unaffordable” (see definition) won’t need to buy. 

All the rest of us, unless we are “Exempt” (see definition) our plan must cover these benefits to be the correct kind of insurance to avoid paying the tax penalty, or until our insurance company tells us our current policy we have now (only if it’s a major medical policy) renews and we must buy a “Qualified Health Plan” that has the following benefits:

♦ Ambulatory patient services  (clinics, doctors office, same-day surgery centers, etc.)

♦ Emergency services

♦ Hospitalization

♦ Maternity and newborn care

♦ Mental health and substance use disorder services, including behavioral health treatment

♦ Prescription drugs

♦ Rehabilitative and habilitative services and devices

♦ Laboratory services

♦ Preventive and wellness services and chronic disease management

♦ Pediatric services, including dental and vision care (see below)

Dental for “Pediatrics” means anyone under the age of 19 must be offered a dental plan ON Exchange, and a built in dental plan OFF Exchange.

Vision for children under the age of 19 is covered, 1 visit per year, 1 pair of glasses per year are covered. The pediatric vision has to be covered on and off of the exchange.

Your insurance company must also allow members to request to have a drug covered that they need that the insurance company does not cover.

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Great Video!

Does dental hygiene affect more than your teeth?

What is the difference between Urgent Care and the Emergency Room?

Your primary care doctor is the best place to start when you’re sick or hurt.  They know you and your health history, including any underlying conditions you may have.  But what if you get sick or injured on the weekend or late at night when your doctor’s office is closed?

If your condition isn’t life-threatening, but needs to be taken care of right away, then urgent care may be the right choice for you.  Urgent Care centers are usually open after normal business hours, including evenings and weekends.

Emergency Rooms are the best place for treating severe and life-threatening conditions. They’re open 24 hours, seven days a week.

There are distinct differences between hospital emergency rooms and traditional urgent care centers, including the level of care that can be provided at each location.

Urgent care centers can handle a variety of medical problems that need to be treated, but are not considered true emergencies.  They fill a vital gap when you become sick or injured and your regular doctor is not available or you can’t wait for an appointment.

Hospital emergency departments provide medical care 24/7, but unlike urgent care centers, they are also equipped for critical care situations.

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What if I cannot afford health insurance?

First, you need to determine what you can “afford” and what the Government considers “affordable” for your income and family size.  You may be eligible for a Government subsidy to help you pay your monthly premium or you may be eligible to receive Medicaid (where the Government will pay for your healthcare).

Government description of “affordable”:

The definition of affordable is different for employers and individuals.  The Government defines “affordable”.  For employees receiving their benefits from an employer, if the employee portion of the health insurance the employer provides costs more than 9.66% of the employee’s income, and it doesn’t cover at least 60% (Minimum Value) of the employees medical expenses, this is considered to be “unaffordable”.  If your insurance is “unaffordable”, you are then permitted to see if you qualify for a Subsidy (see Advanced Premium Tax Credit).  If the employee’s insurance from their employer is affordable, then the employee is NOT eligible for a tax subsidy.

If you do not receive health insurance from your employer, as individuals or families.  When individuals and families buy their own health insurance, IF the insurance is greater than 8% of your “household income”, it is considered “unaffordable” and you are not required to buy health insurance.  MOST Americans will find they will qualify for either Medicaid or a subsidized plan that makes insurance “affordable”.

To see if you qualify for Medicaid or to receive a Government “subsidy”, click the blue button below and follow the prompts.

I haven’t signed up for a Health Insurance plan yet.  What are the penalties?

Don’t get penalized by the Government, let us guide you!

Are you still thinking about getting health insurance coverage?  Don’t delay, health coverage helps you protect your house, car, savings and more.  Think about everything you and your family have, and everything you stand to lose.  If you have a medical emergency without coverage, you have to think about both your health and your finances.  With health insurance, it helps cover high medical costs without having to sacrifice everything you’ve accomplished for your family. 

There is also a penalty for not having a qualifying health insurance plan in force and active beginning 1/1/2014.

2014:  $95 per adult and $47.50 per child (up to $285 for a family) OR 1% of family income, whichever is greater.

2015:  $325 per adult and $162.50 per child (up to $975 for a family) OR 2% of family income, whichever is greater.

2016:  $695 per adult and $347.50 per child (up to $2,085 for a family) OR 2.5% of family income, whichever is greater.

NOTE: the penalty is pro-rated by the number of months without coverage, no penalty for 1 gap of less than 3 months in a year.  The penalty cannot be greater than the national average premium for “Bronze” level coverage in an Exchange.

After 2016, penalty amounts are increased annually by the cost of living.

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I got a bill and I thought Preventative was now free?

New health plans must cover preventative services (FREE) and there cannot be “cost sharing”.  In other words, no co-pays or co-insurance for preventative services.  If you see the doctor for preventative only, there will not be a bill. 

Now here is the tricky part…

Make sure the doctor’s office bills you correctly for “Preventative” services.  If you see the doctor for preventative services only, you should not see a bill.  We suggest that if you go to see the doctor for preventative services, do not talk about or have any other services performed.  This way, your FREE preventative service will remain free and you should not see a bill.  

Be careful to stay within your network for preventative care.

From the Health and Human Services website, here are some examples of what is covered, without co-pays, co-insurance, or deductibles.

Those preventative services rated an A or B rating from the U.S. Preventative Services Task Force:

Children (0-17): Coverage includes regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight.

Women (18-64): Coverage includes cancer screening such as pap smears for those ages 21 to 64, mammograms for those ages 50 to 64, and colonoscopy for those ages 50 to 64, recommended immunizations such as HPV vaccination for those ages 19 to 26, flu shots for all adults, and meningococcal and pneumococcal vaccinations for high-risk adults, healthy diet counseling and obesity screening, cholesterol and blood pressure screening, screening for sexually-transmitted infections and HIV, depression screening, and tobacco-use counseling.  For plan years (in the individual market, policy years) beginning on or after August 1, 2012, additional preventive services specific to women, such as well-woman visits, screening for gestational diabetes, domestic violence screening and counseling, prescriptions, FDA-approved contraception, must be covered with no cost sharing.

Men (18-64): Coverage includes recommended immunizations such as flu shots for all adults and meningococcal and pneumococcal vaccinations for high-risk adults, cancer screening including colonoscopy for adults 50 to 64, healthy diet counseling and obesity screening, cholesterol and blood pressure screening, screening for HIV, depression screening, and tobacco-use counseling.

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How can I enroll AND get information about a subsidy?

When you are trying to determine your portion of the PREMIUM you pay when buying a health insurance plan from the Governments’ website, it is determined by your family size and income.  The SUBSIDY you may or may not receive will fluctuate based on age and the number of people in your household. 

To easily figure this information out and apply for Health Insurance, click the blue button below and follow the prompts.

Definition of “Subsidy”:

A “Subsidy” is where the Government and you share in paying your monthly health insurance payments.  The Government helps you pay your health insurance payments monthly, by sending a certain dollar amount of your insurance payment (premium) to the insurance company, and you send in the other portion of your monthly insurance payment to the insurance company.  This is called “APTC” (Advance Premium Tax Credit).  The factors that affect the percentage or portion of the health insurance premium you pay is your household income and household size (members of your family on your tax return).

Your Subsidy is based on your CURRENT household “MAGI” (Modified Adjusted Gross Income – see definition).  If your income changes, or “household” changes, like getting married, having a baby, changes in your income/employment, it’s important to call us and we’ll help you make those changes to your account as they happen throughout the year.

The only way to get a “Subsidy” is to get a health insurance plan through the Governments “Exchange” (also called the “Marketplace”), and only if your income is between 138% to 400% of the federal poverty level.  Nevada Insurance Enrollment can help you with a “subsidized” or “unsubsidized” health plan, we are a Full Service Agency.

Your income will be checked with the IRS records or a Federal Database, so if you claim a certain income, the “Exchange” will check with the IRS of your past years’ income tax records – before you get approved for a subsidy.

Individuals and families will state their income based on their MAGI or Modified Adjusted Gross Income (see definition).  That information will then be verified through the IRS against your previous tax returns.  If the stated income on the application is more than 10% lower than what the IRS shows, the State will require the individual to prove their income within 90 days, but you’ll still get enrolled.  Your financial information is run through a Data Services Hub (a tool the government is using to verify applicant information and income for the “Advanced Premium Tax Credits”) to see if you qualify for a subsidy.

BE CAREFUL HERE!!!  You do not want to understate your income or you could end up owing money to the IRS.  For example, if your premiums are $1,000/month and you get an Advanced Premium Tax Credit of $800/month and you only have to pay $200/month.  When you do your taxes and file your tax return each year, the Government will check your income.  IF you were only supposed to have received an Advanced Tax Credit of $700/month instead of $800/month, you’ll owe the IRS an extra $100/month X 12 months equals $1,200.  The Advanced Premium Tax Credit is an “estimation” of your pre-tax credit, so if you’ve received too much “credit,” you’ll end up paying it all back, or a portion of it back.  Your percentage of Federal Poverty Level determines this.  If you end up making over 400% of the Federal Poverty Level, you’ll end up paying back ALL of your subsidy.

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What is Obamacare and the ACA, Healthcare Reform and the Affordable Care Act?

On March 23, 2010, President Obama signed into law the Affordable Care Act (ACA).  They mean the same thing.  Obamacare is a nickname for the Affordable Care Act.  The new law requires most all of us to have insurance or get a tax penalty.

This is the Health Care Reform law that was passed in March of 2010 that consisted of 2 laws that together make up the ACA.  The PPACA was passed on 3/23/2010 – the Patient Protection and Affordability Care Act.  A week later the HCERA – Health Care Education Reconciliation Act was passed 3/30/2010.  These 2 bills combined are the ACA.  This bill really “Amends” (or makes changes) to other laws that already exist within the government.  These laws regulate health care and health insurance.  So the bill “amended” the SSA – Social Security Act, the IRS – Internal Revenue Service, ERISA – Employee Retirement Income Security Act, the PHSA – Public Health Safety Act, HIPAA – Health Insurance Portability and Accountability Act, FLSA – Fair Labor Standards Act.  Cobra was not amended.  

The 3 divisions of Government that will oversee the implementation and regulations of the ACA will be from the Department of Health and Human Services – HHS, the IRS, and the DOL – Department of Labor.  The ACA has been and will continue to get guidance (interpretation of the law, changes, additions, clarifications, enforcement, or delays to the bill.)  There have been thousands of additional pages of regulations that have “filled in” the framework of the ACA, and it will continue to be defined as time goes on.

The bill also made changes to Medicare and CHIP.

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Another Great Video!

Can regular eye exams help keep me healthy?

What is an Exchange?

In the realm of health insurance, an Exchange is a website with Health Insurance Plans to buy from.  Licensed Brokers (we here at Nevada Insurance Enrollment can assist you) understand the health insurance plans thoroughly and are very knowledgeable about all of Nevada’s health insurance plans from year to year.

An Exchange works kind of like how Travelocity works.  Travelocity is a website where you can shop for airline tickets with different airlines companies to choose from.  Different insurance companies (like Anthem Blue Cross and Blue Shield, Health Plan of Nevada, Sierra Health and Life, Aetna, etc.) can sell their health plans on an Exchange (website).

Insurance companies can decide for themselves if they are going to “participate” on-exchange from year to year.  Meaning the Government Exchange.

There are many “Exchanges” kind of like there are many websites for buying an airline ticket, like Travelocity, Cheap O Air, Orbitz, Priceline etc.  The Public (Government) Exchange called the Marketplace can offer “subsidized” plans and those same plans can be sold without a subsidy on their Exchange.

Private insurance companies have their Exchanges where they sell their insurance plans from their own websites.  Usually a Broker will assist with this enrollment.

The SHOP Exchange (for small businesses) does not have subsidies, but may have tax benefits for small business owners if they utilize the SHOP Exchange for health plans for their employees.

There are also Private Exchanges (like employer websites) that offer their employees plans.  You will not qualify for a tax subsidy if you have employer insurance for yourself that is “affordable” (see definition) or if you have a Federal insurance plan like the VA, Tricare, Medicare, etc., or if you get State assistance (Medicaid, etc.).

Depending on your household income, you may or may not qualify for financial assistance in paying for your health insurance plan.  If you qualify for a Government subsidy to help pay for your health insurance, you’ll need to shop “On Exchange” – the Government’s Marketplace.  We’ll assist you from beginning to end and throughout the year.  If you make too much money or don’t want a Government subsidy, we’ll assist you “Off Exchange” – shopping all the insurance companies that offer insurance outside of the Government website.

Nevada Insurance Enrollment is an Insurance Agency.   We can assist you with both subsidized plans where the government helps pay for your premiums AND also un-subsidized plans (if you make too much money or don’t want a subsidy).  Web-brokers are brokers who can sell insurance both On Exchange and Off Exchange.  Nevada Insurance Enrollment is considered a web-broker.

Call us and we’ll help you determine if you qualify to get financial assistance (subsidy) and help you make a decision on which plan is best for you.

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What is a Marketplace?

A Marketplace is a website where you can go and shop for different health insurance plans.  Different insurance companies and non-profit insurance companies will be selling their health plans in these “Marketplaces” (websites).  These Marketplaces are kind of like an online mall for insurance plans.  The word Marketplace and Exchange kind of mean the same thing and they get used interchangeably.

See “What is an Exchange?”

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If I get a bill I don’t understand or disagree with, or I get denied for a claim, what can I do?

First, ask your health care provider to itemize the bill for you.  Mistakes do happen.

If you still feel you were charged for a service you didn’t receive, feel the cost is wrong, or you get denied, you can file an appeal.

Starting in 2010, there is now an enhanced, more thorough appeals process with the passage of the ACA (Obamacare).  The purpose of this enhancement is to make it harder for insurance companies to deny claims from their members.  If you’ve had medical claims that have been denied, or if you’ve had a retroactive rescission (policy gets cancelled for months already in the past), this appeal process applies to those scenarios also.  More protection is available to you, and the ability to go outside of the internal appeals process is now available.  You can get your claim looked at by an “external review” panel up to 4 months after the internal review comes back denied, if it did indeed get denied by the internal review process.  This external review panel is called an “IRO” – an Independent Review Organization.  But this IRO review can only happen after the internal review completes its internal appeals process and gives the person appealing a “full and fair review” which means you get to review the paperwork from the insurance company that is denying your claim.  The IRO will look at the claim as if it’s a brand new appeal.  Like fresh new eyes looking at your claim.  They will have a decision back in 45 days.  If you need or if the IRO wants additional information for your case, you’ll only have 10 days to get it to them after they begin their work.  Many folks still feel like they have to get lawyers involved in denied claims process.  If a claim gets denied after the IRO completes the review, the member will become responsible for the bill.

If the insurance company denies the claim at the lower level, you may then move up in ranks until you’ve exhausted the lower level appeals.  If the 2nd level of appeals within the insurance company results in a final result called a “final adverse benefit determination” (means you are still told no,) then you are now able to move to the external review process.   The external review is conducted by a 3rd party outside entity called an IRO (Independent Review Organization) that will review the claim.  You must ask and initiate the external review, it’s not an automatic process.

Website that is available to assist with claims is: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/External-Appeals.html

Conflict of interest – the insurance company cannot hire someone that will have the interest or support of the insurance company in denying claims.  The regulation says that the first person to review the claim and deny the claim has to be someone else that reviews the appeal, so the same person is not reviewing their own denial of the initial claim, and any medical experts involved in consulting the appeal has to be different than the same person that reviewed the claim initially.

The insurance company cannot stop providing coverage for ongoing treatment without providing advanced notice.  Those that have a very serious life-threatening medical condition can have their appeal pushed through more quickly.  In addition to denied claims there are other grievances that can be appealed.

Appeal  – Items you may appeal are:

♦ Denied Payments

♦ Advanced Premium Tax Credits amounts and eligibility

♦ Cost Sharing Percentage

♦ Catastrophic plan eligibility

♦ Incarceration

♦ Minimal Essential Coverage affordability

♦ Your residency

♦ Legal Status

♦ Dependent Eligibility

♦ Tribal affiliation

♦ Social Security Number

♦ Your ability to be exempt from the bill

♦ Medicaid and CHIP (handled by DWSS (Division of Welfare and Supportive Services)

♦ Life Events like Birth, Adoption, Divorce, Loss of Job, etc.

♦ Processing

♦ System functionality

♦ Timeliness of application

♦ Dropped from an Insurance Company

♦ Misconduct by your enroller

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What is Cobra insurance?

This acronym (COBRA) refers to the Consolidated Omnibus Budget Reconciliation Act of 1985.  The law requires group medical plans covering twenty employees or more to offer participants the option to receive continued healthcare benefits for up to eighteen months after the cancellation of their group plan.

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Can I see any Doctor with Obamacare?

You must stay within your insurance plan’s “network”.  Call your insurance company to see a list of doctors and facilities.  Usually the online list is more up-to-date than a pdf list.  You can call your doctor’s office also.

Network: 

This refers to the groups of doctors, hospitals and other medical professionals who have been contracted by the insurance company to provide discounted healthcare services to you.

Out-of-Network:

This term typically refers to any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan.  Depending on your insurance plan’s guidelines, services provided by out-of-plan providers may not be covered at all (unless it’s an extreme emergency), or if services are covered out of network (usually a PPO), you’ll pay more.  See your plan details.

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I received a Summary of Benefits when I bought my health insurance, what is this?

This is a 4 page, double sided (8 pages) at-a-glance view of how your health insurance plan works and how it compares to other plans, coverage facts, and much more. 

The idea behind the Summary of Benefits is that you can easily understand how your plan works and compare it to other plans quickly, side by side.  There will be some examples of how the plan works in certain circumstances.  You will get a copy of this when you buy a health insurance plan and when your plan renews.

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What are FREE Preventative Services?

From the Health and Human Services website, here are some examples of what is covered, without co-pays, co-insurance, or deductibles.

Make sure the doctor’s office bills you correctly for “Preventative” services.  If you see the doctor for preventative services only, you should not see a bill.  We suggest that if you go to see the doctor for preventative services, do not talk about or have any other services performed.  This way, your FREE preventative service will remain free and you should not see a bill.  

Be careful to stay within your network for preventative care.

Those preventative services rated an A or B rating from the U.S. Preventative Services Task Force:

Children (0-17): Coverage includes regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight.

Women (18-64): Coverage includes cancer screening such as pap smears for those ages 21 to 64, mammograms for those ages 50 to 64, and colonoscopy for those ages 50 to 64, recommended immunizations such as HPV vaccination for those ages 19 to 26, flu shots for all adults, and meningococcal and pneumococcal vaccinations for high-risk adults, healthy diet counseling and obesity screening, cholesterol and blood pressure screening, screening for sexually-transmitted infections and HIV, depression screening, and tobacco-use counseling.  For plan years (in the individual market, policy years) beginning on or after August 1, 2012, additional preventive services specific to women, such as well-woman visits, screening for gestational diabetes, domestic violence screening and counseling, prescriptions, FDA-approved contraception, must be covered with no cost sharing.

Men (18-64): Coverage includes recommended immunizations such as flu shots for all adults and meningococcal and pneumococcal vaccinations for high-risk adults, cancer screening including colonoscopy for adults 50 to 64, healthy diet counseling and obesity screening, cholesterol and blood pressure screening, screening for HIV, depression screening, and tobacco-use counseling.

 **PLEASE NOTE – If your doctor bills 2 separate bills for your one visit, you will be billed for the portion of the office visit that was not preventative.  For example, if you see a doctor for a routine physical, and in the same visit you need your prescription refilled, IF the doctor bills 2 separate bills for that visit, the physical will be free, but the prescription refill portion of that visit will be charged.  IF the doctor bills everything on 1 bill, you will not be charged.  We suggest that if you go to see the doctor for preventative services, do not talk about or have any other services performed.  This way, your FREE preventative service will remain free and you should not see a bill.

Be careful to stay within your network for preventative care.

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Where will you fit?  What insurance will you have?

Depending on your income and what you want and are entitled to.  Starting 1/1/2014 you will most likely fit into one of these health insurance categories:

1). Medicaid (low income)

2). Receive a “Subsidy” (the government helps pay your premium)

3). A private health insurance plan / no assistance because your income is too high

4). Group Insurance at your job or spouses job if it is offered (if you missed your enrollment at work, you’ll probably have to buy a private plan.  Call us!

5). Keep your “Grandfathered” plan (a plan you had before 3/23/2010).  Call your insurance company to clarify if you are grandfathered.

6) Keep your VA, Medicare or Tricare – any Government program that you are entitled to.

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Can my agent help me enroll into Medicaid and what exactly is Medicaid?

Medicaid is a joint State/Federal health insurance program that is administered by the State.  It provides health coverage for low-income individuals, especially pregnant women, children and the disabled.

Nevada has chosen to expand Medicaid.  If your income is under 138% of the Federal Poverty Level (FPL) and you are under age 65 you may qualify for Medicaid.  Click the blue button below to see if you qualify.

Your agent cannot assist in the enrollment into Medicaid due to Medicaid being a State program.

Click this link to be taken to our Medicaid page:  Medicaid information and contact info

Click the blue button below to see if you QUALIFY for Medicaid.  Follow the prompts.

My daughter is 24 and married, can I still cover her under MY health insurance policy?

Due to Health Care reform and the new Affordable Care Act (ACA), adult children can now be allowed to stay on their parents plan up to their 26th birthday IF the plan extends coverage to dependents.

IF and emphasizing the word IF your plan covers dependents (children), your plan now must cover them up to their 26th birthday.  It does NOT matter if your children are married, live at home, are students, or are on your taxes.  Nothing matters but that they are your children.  The only exception would be that if your child is under 26 years old and you (the parent) have a grandfathered plan (a plan prior to 3/23/2010).  Check with your plan to see if you are grandfathered. 

IF your child is offered insurance at THEIR job, they must take that insurance up until 1/1/2014.  After 1/1/2014 all dependent children up to their 26th birthday may stay on their parents plan if it is offered.  If your child has severe mental and/or medical conditions, they may be able to stay on the parents plan longer, see the plan benefits.  

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I know it is now required by law, but why do I NEED insurance? Can’t I just pay the penalty?

Yes, it is the law, but did you know the majority of people declare bankruptcy or lose their homes because they don’t have health insurance to cover their medical expenses? 

Besides all the recent changes (and the tax penalties), health insurance is just a smart choice.

When you are ready, give us a call.  We can answer any questions you have and help you pick out and apply for the best plan.

FYI: here are the penalties that will be imposed for NOT having a Qualified Health Insurance plan.

2014:  $95 per adult and $47.50 per child (up to $285 for a family) OR 1% of family income, whichever is greater.

2015:  $325 per adult and $162.50 per child (up to $975 for a family) OR 2% of family income, whichever is greater.

2016:  $695 per adult and $347.50 per child (up to $2,085 for a family) OR 2.5% of family income, whichever is greater.

NOTE: the penalty is pro-rated by the number of months without coverage, no penalty for 1 gap of less than 3 months in a year.  The penalty cannot be greater than the national average premium for “Bronze” level coverage in an Exchange.

For tax year 2017 and beyond, the percentage will stay at 2.5%, but the flat fee of $695 per adult and $347.50 per child (up to $2,085 for a family) will be adjusted for inflation.

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I understand many of the Obamacare plans are HMO.  What is the difference between an HMO and a PPO?

Which one is best for you?

You’ve probably heard the terms HMO and PPO.  Remember, there is no right or wrong choice when it comes to selecting your health care plan.  Having a strong understanding of these plans and how they work will help you in choosing the plan that’s best for you, your family and your budget.

What is a PPO?

PPO stands for Preferred Provider Organization.  A PPO health insurance plan allows for more flexibility and more choices when it comes to your healthcare.  It offers a network of healthcare providers to choose from and you have the freedom to receive care from within that network or choose an out-of-network doctor, specialist or hospital without a referral.  Keep in mind, however, that your out-of-pocket medical costs are lower when you choose an in-network provider.

Flexibility

PPO plans do not require you to choose a Primary Care Physician (PCP) and do not require referrals.  Let’s say you have a doctor or specialist that you like and have been seeing for years.  With a PPO plan you could continue your visits whether they are in-network or out-of-network and without the need for a referral.

It is important to remember, that while you can receive care from any doctor, specialist or hospital you choose, you will save more money by choosing an in-network provider.

Higher Monthly Premium

The greater flexibility of a PPO often comes with a higher monthly premium, a deductible that must be met before coverage begins, and co-pays.  While you can choose to use doctors, specialists or hospitals outside of your network, there will be higher out-of-pocket costs associated with these visits.

Short Video

What is an HMO?

What is a PPO?

What is an HMO?

HMO stands for Health Maintenance Organization. With an HMO plan, you must choose a Primary Care Physician (PCP) from a network of local healthcare providers who will refer you to in-network specialists or hospitals when necessary. All your care is coordinated through that PCP.  HMO plans generally won’t cover out-of-network care except in a true emergency.

Lower Cost

With an HMO plan, your out-of-pocket medical costs and monthly premiums will generally be lower than a PPO.

Selecting a Primary Care Physician (PCP)

With an HMO plan, you’ll select a Primary Care Physician who will be your contact for all your healthcare and they will connect you to specialists or other health care providers.

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Is it true that doctors will know my medical history no matter who I see now?

As part of the Health Care Reform law, there was an addition to the HIPAA (Patient Protection) Regulation Act starting in 2013.  The new law requires streamlining (sharing) of all medical records between hospitals, doctors and health care providers.  For example, if you are admitted to a hospital in the future, all your past medical history would be available to the doctors at the hospital you are newly admitted to. 

Medical professionals (doctors) will be able to access your baseline medical history and add to your medical chart all your new diagnosis and procedures into the same system.  This applies to all health care providers.  This new system will help to cut down on duplicate ordering of tests and allow doctors to see results of prior tests.  It will assist in reducing overall medical costs and increase speed and accuracy of medical records.

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I have pre-existing conditions. Can I still get health insurance?

“Pre-existing Conditions” refers to any healthcare issues you had prior to your health insurance plan’s effective date.  Many policies will refuse to cover pre-existing conditions, while others do so only for a short time. 

Update:

After 1/1/2014 you can no longer be turned down for having pre-existing conditions.  There will be no annual or lifetime limits on the 10 “Essential Health Benefits”.  (see definition)  It no longer matters what medications you are on, your height or weight, how old you are, how young you are, your gender, what pre-existing conditions you have, if you become pregnant or not, if you’ve had a ton of medical bills in the past, your genetic information, if you have a disability.  Nothing matters.  You qualify.  You cannot be turned down for health issues.  Insurance can no longer discriminate based on pre-existing conditions.  Factors affecting your health will no longer cause your premium to go up in price either. 

Smoking, however, will make your premium go up.

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Are there yearly or lifetime limits on the new health insurance plans?

Lifetime limits on new health insurance plans are now allowed on “compliant” health insurance plans.

From 1/1/2014 on, all new health plans (insured small group and individual health insurance plans) must cover the 10 bulleted benefits below, in order to avoid a tax penalty.   Qualified Health Plans MUST cover these 10 items without any lifetime or annual limits on these “Essential Health Benefits.”

♦ Ambulatory patient services (clinics, doctors office, same-day surgery centers, etc.)

♦ Emergency services

♦ Hospitalization

♦ Maternity and newborn care

♦ Mental health and substance use disorder services, including behavioral health treatment

♦ Prescription drugs

♦ Rehabilitative and habilitative services and devices

♦ Laboratory services

♦ Preventive and wellness services and chronic disease management

♦ Pediatric services, including dental and vision care (see below)

Dental for “Pediatrics” means anyone under the age of 19 has to be offered dental coverage to purchase separately “on exchange” and covered “off exchange” to be compliant with the law. 

Vision for children under the age of 19 is covered, 1 visit per year, 1 pair of glasses per year are covered. The pediatric vision has to be covered on and off of the exchange.

Your insurance company must also allow members to request to have a drug covered that they need that the insurance company does not cover.

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