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Individual & Family Health Insurance Definitions

You can search for a term by manually scrolling down this page (all definitions are in alphabetical order), or you can use the search box below.  The search box is quicker, but it searches the entire list and may return multiple results.

Individual and Family Health Insurance Definitions

[usa_container toggle=”true” closeall=”true” animate=”fade” search=”true” theme=”theme-blue” highlight_bg=”#eeee22″ highlight_color=”#000000″ nav_box=”square” nav_icon=”angle_double” placeholder=”Type your search term here” msg_item_found=”> is the total number of categories your search phrase was found under. Each one is under a separate word or phrase below.” msg_no_result=”We couldn’t find anything…try another search term” limit=”3″][usa_item acc_title=”ACA / Affordable Care Act / “Obamacare””]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.[/usa_item][usa_item acc_title=”Advanced Premium Tax Credit (Subsidy)”]A subsidy is an “Advanced Premium Tax Credit” that is available on the Individual Exchange but NOT the SHOP Exchange for small businesses.  A “subsidy” means that you get a reduced premium payment to pay for your medical insurance.  The factors that affect the premium you pay (the subsidy you receive), would be your income and the number of family members on your tax return.

The only way to get a “Subsidy” is to get a health insurance plan through the Governments “Exchange” 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 Private Marketplace.

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.

How do you avoid this?  Read the “Redetermination for Income Changes” and the “Reconciliation of Premium Credits” definition(s).

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 back.

Please note:  If you are providing health insurance to your employees, and only to your employee, in Nevada the employee’s spouse and children are able to get a subsidized plan.  But the subsidy is based off of the “household” income.  HOWEVER, if you DO OFFER coverage to the spouse and dependents and they elect not to take the coverage for whatever reason (the spouse may feel your employer plan is too expensive), then that spouse is NOT able to get a subsidized plan!  Please keep this in mind.  You may repel employees if you are not careful.[/usa_item][usa_item acc_title=”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, if your portion of the health insurance premium costs more than 8% of your household income, it is considered “unaffordable,” which means you don’t have to buy a medical plan “excludable.” [/usa_item][usa_item acc_title=”Age 26″]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,) then 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.  [/usa_item][usa_item acc_title=” Annual Enrollment Period (2nd year and beyond of Obamacare)”]Begins each October 15th through December 7th (not much time hugh?)  If you’ve enrolled in the public exchange, they will notify you between Sept. 1st and Sept 30th each year that it’s time to enroll (if you are already enrolled you should be fine, but it’s always a good idea to verify each year your plan options/choices) starting in October.   If you enroll in October, November or December up to the 15th of December, your start date will be Jan. 1st.    Enrollment stops December 16th, if you haven’t enrolled, you are out of luck for a subsidized plan.  You’ll have to wait until the next year to enroll for a subsidy (unless you qualify for a “special election period.)  If you don’t qualify for a subsidy, or you are ok with paying full price for a health insurance policy, you may buy a qualified health insurance plan anytime you would like, however, there is a 90 day waiting period and the coverage will begin on the 1st  day of the next month after the 90 day wait, and the coverage can’t go back in time, and you’ll be subject to a Tax Penalty for not having coverage.  It is not wise to wait until you are sick to try and get coverage because you won’t be able to.
[/usa_item][usa_item acc_title=”AV (Actuarial Value)”]This is a percentage of the costs that are covered by the insurance company.   It is the larger percentage of coverage the insurance company pays for.  This is not what the employee or employer is paying.  It is the insurance company’s portion.  Your portion will be the smaller portion for example, 40% for Bronze, 30% for Silver, 20% for Gold, and 10% for Platinum.  Don’t worry that your percentage goes on forever, there is always an “Out of Pocket Maximum” for you and your family.  This Out of Pocket Maximum you’ll see mentioned is your pocket.  This means the most you’d have to pay out of your pocket in the year.   There are no lifetime or annual limits for these 10 Essential Health Benefits the insurance company has to pay for:

♦ 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 (read below)

♦ Rehabilitative and habilitative services and devices

♦ Laboratory services

♦ Preventive and wellness services and chronic disease managemen

♦ Pediatric services, including dental and vision care (read 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.[/usa_item][usa_item acc_title=” Benchmark Plan”]The State of Nevada is using the “Benchmark” plan from HPN – Health Plan of Nevada’s plan POS Group 1 C XV 500 HCR.  This plan will set the standard as to how all the other “Qualified Health Plans’” in Nevada will be.   It creates a baseline for the 10 “Essential Health Benefits” (see definition) that all other health insurance plans in Nevada are required to cover on the Individual and SHOP Exchanges, so all other plans must have essentially the same level of coverage as Nevada’s chosen “Benchmark” plan for these “Essential Health Benefits.” 

This benchmark plan will define the essential health benefits that must be covered in Nevada health insurance plans to follow from 1/1/2014 and beyond (except for grandfathered plans and large group insurance plans.)   

(See Essential Health Benefits definition.)[/usa_item][usa_item acc_title=”Catastrophic Plan”]There is a “Catastrophic” plan for adults under 30 years old.  This plan is only available on the individual exchange, not the SHOP (small business exchange.)  This plan is only available to those under 30 years old who are exempt from the “Individual Mandate” (see definition) because “affordable” (see definition) coverage is not available, or they have some “hardship” (see definition) exemption.  The plan provides no benefits until the 50/50 is paid by the member, however, the member is entitled to 3 family primary care Doctors visits before this 50% has been paid. [/usa_item][usa_item acc_title=”CDHP (Consumer Driven Health Plans) HSA, FSA, HRA and Archer MSA”]FSA’s and HSA’s are allowed to reimburse for medicines and prescription drugs with tax free funds, but only if there is a prescription, whether the medication is OTC or not OTC (over the counter,) you MUST have a prescription.  Medical devices like crutches, and medical supplies like Blood Sugar kits do not require a prescription.  Make sure you have your receipt for reimbursement.[/usa_item][usa_item acc_title=”Child Only Plans – Kids”]Each insurance company that has plans on the Exchange for an individual or family MUST also have the same plan available for “children only” under age 21.  The plans will be the same as they are for adults; Platinum, Gold, Silver, or Bronze.    [/usa_item][usa_item acc_title=”CHIP (Children’s Health Insurance Program)”]Kids whose parents make less than 200% of the federal poverty level are eligible for CHIP.  Funding was extended to 2015.[/usa_item][usa_item acc_title=”Claims Appeal”]Starting in 2010, there is now has 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.

Websites that are available to assist with claims is:  www.dol.gov/ebsa/healthreform and on that page look for the section “Internal Claims and Appeals and External Review” or 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 at the State of Nevada Exchange are:

♦ 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

[/usa_item][usa_item acc_title=”Clinical Trials”]Starting 2014 there will be increased coverage in your health insurance plan for clinical trials phases 1-4 for qualified members.  You must use an in network provider.  The trials must be participating in cancer research, approved clinical trials, any life threatening disease that is funded by the Federal Government and conducted with an investigational drug (or exempt from an investigational drug).  In order to participate you may need an in network doctor’s recommendation to participate, or provide “medical and scientific information” showing that it is appropriate for you to participate in the trial.  Clinical trial participants cannot be discriminated against or charged more for routine patient costs for the trial, but the participant must see a provider in the network.  Ask your insurance company if your plan participates in clinical trials.  If yes, the clinical trial must also accept you.    [/usa_item][usa_item acc_title=”CO-OP (Consumer Operated and Oriented Plans)”]This is a new government program with the ACA (Obamacare) that gives loans to nonprofit companies to create member run (the board is elected to run the CO-OP and it must be members that are covered under these plans) consumer governed insurance plans.  These medical plans must be “Qualified Health Plans” and be on the public exchange and SHOP exchange and have interest in the well being of our community. [/usa_item][usa_item acc_title=”Co-Insurance”]Co-insurance means 2 parties will be paying for the bill.  “Co” means joint, mutual, 2 or more.  The insurance company will usually pay the larger amount (example 70%) and you the member will usually pay the lesser amount (example 30%).  This would be a co-insurance 70/30. 

This (co-insurance) usually happens AFTER the deductible.

A deductible is an amount you pay before the Insurance Company starts paying (plans will have different “deductibles” $250, $500, $2,000 etc., so read your plan).  Think of it like 1st base in a game of baseball.  Once you’ve paid all of your deductible, you are standing on 1st base.  Now you’ll begin to move towards 2nd base – “Co-insurance”.  During this time, co-insurance is where you and the insurance company split the medical bills, for example 70/30 or 80/20.  Usually the insurance company will pay the larger amount and you pay the lesser amount.

Your next step is 3rd base or your “out of pocket maximum”.  This is the maximum YOU have to pay in a year, not the insurance company.  In 2014 it is $6,350 for individuals and for a family it is $12,700.  For 2013 the limits were $6,250 for individuals and $12,700 for families.  Once you’ve met your “out of pocket maximum”, you are now done paying anything else.  The insurance company will pick you up on 3rd base, and carry you to home plate.

Note:  This is an annual accrual, meaning it starts January 1st and ends December 31st each year.[/usa_item][usa_item acc_title=”Co-Pay”]A Co-pay is a set dollar amount you pay for a procedure or office visit.  (Look at your plan summary very carefully)  A co-pay is helpful because you’ll GENERALLY pay just the co-pay (unless other procedures are billed by your doctor in addition to the co-pay).  For example, let’s say you see your family doctor for a sore throat.  If your plan had a co-pay of $35 dollars, you’d pay the $35. 

But wait, there’s more: Sometimes you can be billed more than just a co-pay.  For example, let’s say you went to a specialist (specialist co-pays are generally more than a primary care doctor) to have a spot on your skin looked at.  The office co-pay may be $50.  You’d pay the $50 for the office visit.  But if the doctor wanted to remove the spot, he could charge you/your insurance company for a “procedure”.  That charge would be in addition to the co-pay.  So the procedure could be billed to your insurance company and you’d pay whatever your insurance company had negotiated with the doctor for that procedure.
[/usa_item][usa_item acc_title=”Cost Containment Strategies”]These were strategies employers and insurance companies used to help contain costs: medical underwriting, waiting periods, high deductibles, yearly maximums, limited number of co-pays, lifetime maximums, etc.  The ACA – Health care reform will not allow a lot of these techniques.  As a consequence, we can expect better health plans, but with it, costs are likely to rise. [/usa_item][usa_item acc_title=”Cost Sharing Reduction – Additional Financial Assistance”]What this means is if your family size and income ranks you at having under a 250% Federal Poverty Level (see definition,) your deductible and out of pocket maximum, and co-pays and co-insurance will be less.  Cost sharing reductions reduce deductibles, co-pays and co-insurance.   What this means is if your family size and income ranks you at being under 250% of the FPL – Federal Poverty Level, you will qualify for additional cost reductions.  

This cost reduction will reduce your total out of pocket responsibilities in overall medical costs.  You’ll get additional financial assistance to cover more of your portion of the medical expenses for your “Silver” plan (70/30.)  So in addition to getting the “Advanced Premium Tax Subsidy,” you’ll also have the “Cost Sharing Reductions” to reduce deductibles, co-pays, and co-insurance.   Your overall medical costs will be a smaller percentage of your income to pay for medical bills and expenses.     [/usa_item][usa_item acc_title=”Deductible”]A deductible is an amount you pay before the Insurance Company starts paying (plans will have different “deductibles” $250, $500, $2,000 etc., so read your plan).  Think of it like 1st base in a game of baseball.  Once you’ve paid all of your deductible, you are standing on 1st base.  

Now you’ll begin to move towards 2nd base – “Co-insurance”.  During this time, co-insurance is where you and the insurance company split the medical bills, for example 70/30 or 80/20.  Usually the insurance company will pay the larger amount and you pay the lesser amount.  

Your next step is 3rd base or your “out of pocket maximum”.  This is the maximum YOU have to pay in a year, not the insurance company.  In 2014 it is $6,350 for individuals and for a family it is $12,700.  For 2013 the limits were $6,250 for individuals and $12,700 for families.  Once you’ve met your “out of pocket maximum”, you are now done paying anything else.  The insurance company will pick you up on 3rd base, and carry you to home plate.

Note:  This is an annual accrual, meaning it starts January 1st and ends December 31st each year.[/usa_item][usa_item acc_title=”Dental Insurance”]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.

The pediatric dental has to be offered on exchange and covered off of the exchange.[/usa_item][usa_item acc_title=”Dependent Child – Dependents on Taxes”]Could be Biological, Adopted, Foster, Step Child (check your tax filing,) Legal Custody.  Children who are defined as not being a dependent child would be:  grandchildren, domestic partners’ children that are not adopted (check your tax filing), spouse of an adult dependent (age 26 and younger who is married) and is receiving benefits from their parent.  A dependent child may stay on his parents plan until the age of 26 if coverage is offered for dependents, or a child may enroll in a “child only” plan (til age 21) also.  The age 26 rule has possible exceptions for severe cases of medically/mentally challenged dependents to possibly stay on the parents plan beyond age 26.  (See Age 26 definition)   We HIGHLY recommend you speak with your tax accountant in that this definition is based on the IRS’s definition of a dependent.[/usa_item][usa_item acc_title=”Do Not Qualify for Tax Credit or Subsidy (Financial Assistance) “]You will not qualify for a tax subsidy if you have been offered employer insurance for yourself that is “affordable” (see definition), or your spouse or kids have been offered insurance, or If you have a Federal insurance plan like the VA, Tricare, Medicare, etc., or if you get State assistance (Medicaid, etc.). 

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.[/usa_item][usa_item acc_title=”Doctors Bills and Free Preventative Visits”]If your doctor bills the insurance company 2 different bills for 1 visit, you will get a medical bill to pay.  For example, if you see a doctor for a routine preventative visit like a “check-up,” or a “well child check” or a “Female exam” and in the same doctor visit have your prescription for asthma medication renewed, if your doctor sends the insurance company 1 bill, you will not be billed.  If your doctor bills 2 bills, one for preventative and 1 for the asthma follow up, you’ll get a bill for the asthma. 

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.  [/usa_item][usa_item acc_title=”Essential Health Benefits (EHB’s)”]What are “Essential Health Benefits” and who has to have them?  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.[/usa_item][usa_item acc_title=”Exchange”]An Exchange is a website with Health Insurance Plans to buy from.  It 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 BCBS, United Health Care, HPN, Sierra, Aetna, Humana, St. Mary’s, Nevada Health CO-OP) can sell their health plans on an Exchange (website).  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 can offer “subsidized” (see definition) plans and unsubsidized plans on their Exchange.  They cannot, however, sell insurance companies plans that do not offer subsidies.  For 2014, most of the subsidized plans that are on the Government Exchange are HMO’s.

There are also Private Exchanges (like this website here at the Nevada Insurance Enrollment Marketplace).  We are a full service “Private” exchange.  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 to qualify to get help in paying for your insurance).

Depending on your household income, you may or may not qualify for financial assistance in paying for your health insurance plan.  We have a full spectrum of choices, HMO’s, PPO’s, Medicare and other supplemental plans like Dental, Vision, Critical Illness, Disability Insurance and many others – to keep you well covered.

You will not qualify for a tax subsidy if you have employer insurance for yourself that is “affordable” or if you have a Federal insurance plan like the VA, Tricare, Medicare, etc., or if you get State assistance (Medicaid, etc.)  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.

Only the “Individual Exchange” offers subsidies, the SHOP Exchange does not have subsidies.     [/usa_item][usa_item acc_title=”Exchange Notice”]By 10/1/2013 your employer is required to hand out a notice about the government Public Exchange.  It is required by law for almost all employers to inform their employees about the public exchange and that employees may be eligible for tax subsidies.[/usa_item][usa_item acc_title=”Exempt and Exemptions. Not Subject to Buying Health Insurance”]From 1/1/2014 and beyond we all must have health insurance that is considered to have “Minimal Essential Coverage” or have a “Qualified Health Plan” or have a State or Federal plan, or a “Self-Funded” plan. 

There are exceptions to that rule:  prisoners, anyone who’s health care goes against their religious conscious or healthcare ministry members, undocumented aliens.  Then we have those that are “Exempted” – those who’s wages are so low that they are not required to file a tax return, Native Americans, children of exempted adults (an example would be kids of prisoners), those that can prove they have a hardship (ex: death, extreme medical bills, etc.), those that live out of the USA, coverage is “unaffordable” (more than 8% of their household income).[/usa_item][usa_item acc_title=”Federal Poverty Level”]Everyone has a “federal poverty level” (FPL), even wealthy people.  They just have a higher FPL.  People that have a “household” income that falls between 138% up to 400% of the FPL (Federal Poverty Level), can get assistance with paying for their health insurance premiums called an “Advanced Premium Tax Credit.” If you make less than 138% of the FPL, in Nevada you qualify for Medicaid which is Free. 

To see if you qualify for a subsidy, click here: Individual and Family Health Insurance

The less money you make the more financial help you will get, the more money you make, the less financial assistance you get.  If you make over 400% of the FPL, you won’t qualify for any financial assistance (AKA – subsidy.)  You can buy your “qualified health plan” (see definition) insurance anywhere you want, but if you want a “subsidy” your income must be between 138% – 400% FPL.  Call us for help with all Subsidized and Unsubsidized health plans.    [/usa_item][usa_item acc_title=”Federally Facilitated Exchange”]A state that chooses to have the Federal Government set up and run their public Exchange for them is called a “Federally Facilitated Exchange.”  The State of Nevada initially operated its own public (Government run) Exchange, it was a State run exchange called a “State Based Exchange” but has now switched to a Federally Facilitated Exchange. [/usa_item][usa_item acc_title=”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.
[/usa_item][usa_item acc_title=”Free Preventative + Decrease in out of pocket expenses like Deductibles, Co-Insurance, Co-Pays”]With Health Care Reform –insurance companies (and group insurance plans) are required to limit how much they make their members pay (you and me) in deductibles, co-insurance and co-pays.  For example, with Preventative health care there are no co-pays, co-insurance or deductibles.  Preventative is FREE.   If you see the doctor for preventative services only, when you visit, you should not see a bill.  (See Cost Sharing Reduction definition.)

The most (out of your pocket maximum) in 2014 a single person would have to pay would be $6,350 and for families it would be $12,700.  This is for these “Essential Health Benefits.”  This does NOT include your premium payments, or for additional benefits your health insurance plan may offer.

Individuals and families without insurance from an employer whose income is less than 250% of the federal poverty level, their “cost sharing” is reduced even further.  This means your portion of the deductible, co-insurance, and co-pays will be less than what someone making over 300% or 400% or more of the federal poverty level would pay.

For Small Businesses buying on the SHOP exchange, the deductibles will be $2,000 for singles and $4,000 for families.  There may be provisions for that deductible limit in the SHOP exchange to be more in the bronze level, plus there can be adjustments for medical inflation cost increases also.   There are NOT cost sharing reductions on the SHOP Exchange for medium or for Large Employers.  Only on the “Individual Exchange” but preventative is free.    [/usa_item][usa_item acc_title=”FSA (Flexible Spending Accounts)”]An FSA allows employees to set aside a portion of their pre-tax income to pay for “qualified expenses” from their cafeteria plan.  FSA’s are commonly used for medical expenses but can be used for childcare or other expenses.  A disadvantage to using an FSA is that money not used in the FSA by the end of the year is lost, there is the “use it or lose it” rule.  Starting in year 2013 Flexible Spending Accounts had their “contribution amount” limited from the employee’s salary reduction to $2500.  The same limit but indexed for inflation for 2014 also.  There is not a limit however, for the employer to contribute.  A debit card program can be used to pay for eligible expenses tax free from the FSA but there are stipulations to make it eligible.

You must have a prescription for OTC (over the counter) medications, otherwise you cannot use your FSA for OTC purchases.  This $2,500 cap applies to grandfathered plans too.  If 2 adults in the home are working and both have FSA accounts, they both can have their separate $2,500 per account.  Starting in 2011 and beyond, in order for an employee to get their medical expenses processed for reimbursement out of their FSA, the employee needs to have a prescription and/or a copy of the prescription and can require a receipt.
[/usa_item][usa_item acc_title=”Goals for Health Care Reform – The ACA”]Insure more American’s, expand Medicaid to make more citizens eligible to qualify for Medicaid.  Make health care more affordable with subsidies.  Include many preventative care services for free to help reduce the overall cost of medical care by catching problems early before they turn into more serious expensive treatments.  To improve the quality of health care customers receive (Accountable Care Organizations – see definition).  Make costs more transparent for the customer.  Shift the burden of health care costs away from the customer.[/usa_item][usa_item acc_title=”Grandfathered Plans”]If you had your health insurance plan in place before 3/23/2010 and it has been continuously paid for and you have not taken any “restrictive actions” (see definition below) since 3/23/2010 and the required “notice” and “recordkeeping” requirements have been kept up to date, it may be a grandfathered plan.

Is there value in keeping your grandfathered status?  Some of the expensive changes to health care reform, grandfathered plans don’t have to comply with which may mean in the future you’d pay less for your premiums, but you’ll be missing out on some of the benefits.  Some of the DISADVANTAGES OF GRANDFATHERED PLANS is you lose flexibility in what you can and cannot do with your health plan.  Grandfathered plans are kind of considered frozen in time.

Probably one of the most important aspects to think about is, will your insurance company or your employer maintain the grandfathered plans?  Some of the insurance companies and employers that have grandfathered plans in existence today will not keep grandfathered plans because it is too costly for them to administer 2 different types of plans.  Grandfathered plans and the new Health Care Reform Qualified Health Plans.

If you are grandfathered, by law, the insurance company is required to describe benefits in any of its plan materials, and state that the plan is believed to be grandfathered.  You really should speak with your insurance company or employer to see if your plan is still grandfathered, and if yes, do they plan to keep that plan after 1/1/2014 grandfathered?  If they do not, you would be losing your grandfathered status.  Keeping a grandfathered plan will require homework and planning and patience.  You can keep your grandfather status indefinitely, but you must keep “Notice” and “Recordkeeping” regulation requirements indefinitely, as long as you have your grandfathered plan, to prove that it is grandfathered.  Keep your original records (policy) to prove you have a grandfathered plan in case you get audited, challenging your plan’s grandfathered status.

By 2014 Grandfathered plans must comply with all these changes from the ACA – Health Care Reform:

♦ Eliminate Lifetime and Annual maximums on “Essential Health Benefits.” (see definition)

♦ No more retroactive coverage rescission (see definition.)

♦ Dependents up to age 26 can go on parents plan

♦ There can be no more than a 90 day waiting period for new employees on a group plan before coverage starts

♦ Pre-existing conditions are covered for children under 19 years old, then total prohibition on all pre-existing conditions on grandfathered health plan members starting 1/1/2014

♦ Must get a copy of “Summary of Benefits and Coverage” which outlines what the plan covers

♦ Medical Loss Ratio Requirements– This is a new law that insurance companies MUST pay a minimum of 80% – 85% of all the dollars they collect in premiums MUST pay a medical claim.  In other words, if an insurance company collects $100 in a premium, $80 MUST pay a claim.  Not necessarily your claim, but some claim, or improve quality.

 

Grandfathered need NOT comply with these changes from the ACA – Health Care Reform:

♦ Transparency in coverage

♦ Clinical Trials (see definition)

♦ Quality of care reporting requirements

♦ Preventative health services

♦ Patient protections

♦ The new internal claims and appeals process

♦ Non-discrimination for health plans (means the plan can still underwrite)

♦ Fair health insurance premiums

♦ Guaranteed renewability/availability

♦ Essential health benefits (10 mandatory benefits – see definition)

♦ Comprehensive coverage

If you lose your grandfathered status on your plan, you can still keep the plan, it’s just the plan would then need to comply with ALL of the provisions of the ACA.

 

What is “Restrictive action?”  This means changes to your insurance plan that really are a disadvantage to the member – this causes a loss of the grandfather status.  These are restrictive actions that if taken will cause a loss of grandfathered status:

♦ Your insurance plan cannot reduce benefits or eliminate benefits.  Like if your plan covered mental health benefits on 3/23/2010, you must maintain mental health benefits coverage to maintain being grandfathered.

♦ The co-insurance cannot increase for the member, meaning going from an 80/20 down to a 70/30 (going from 20% to 30% for the employee to pay) is not allowed.

♦ Deductibles, an inflation adjustment of the “medical inflation” on your deductible or out of pocket max is allowed starting from 3/23/2010, (plus a maximum increase on deductible up to 15% for the life of your plan from 3/23/2010), but anything above that would cause you to lose your grandfathered status.  See your plan administrator to verify your grandfathered status.  There are mathematical calculations in this equation.

♦ Co-pays for the most part must be left alone with very minimal changes from the day the health care reform bill passed.  Like $5 or 15% above medical inflation for the life of the plan is the only allowed amount.  See your plan administrator before making changes to your co-pays to avoid losing grandfather status.  There are some mathematical calculations in this equation.

♦ Certain changes on “annual limits” or “lifetime limits” is a trigger to losing grandfather status.

♦ On employer plans, if the employer decreases his contributions to their employees over 5%  from what the employer contributed on 3/23/2010 could cause grandfather status loss.

♦ Anything that reduces benefits to the employee/member could cause you to lose your grandfathered status.   Your plan may still be “Grandfathered.”  You’d need to speak with your insurance company or plan administrator to see if you are still grandfathered.

You need to make sure the right paperwork has been filed and kept as long as you keep your grandfathered plan.  Notice and record keeping requirements means you can prove that your policy is still grandfathered, meaning you’ve not made “restrictions” or changes that are not allowable, and these records must be kept forever until you lose your grandfathered status.

The Can’s – You can change carriers, can eliminate coverage for a segment of your company, you can add benefits to the plan, you can change 3rd party administrators, and you can add new members.[/usa_item][usa_item acc_title=”Hardship”]An application that grants the applicant a waiver to buy insurance due to the “hardship.” (see also “Exempt.”) [/usa_item][usa_item acc_title=”HIPAA Coverage Insurance”]HIPAA plans will go away after 1/1/2014 because Nevadans will not need to go through underwriting anymore with the Affordable Care Act (Obamacare).  We are all guaranteed to get a health plan.[/usa_item][usa_item acc_title=”Household Income”]Everyone in the household’s income is factored into the health insurance premium.  So if you have a 21 year old adult child that is going to be on their parents plan, you must include their income as part of the “Household income” whether they live at home or not to figure out the Advanced Premium Tax Credit. 

Read below: “All other individuals who were taken into account in determining the taxpayers family size.”  (See below)  Remember this, it is important, because at the end of the year, when you settle up with the IRS while doing your taxes, your “Advanced Premium Tax Credits” you received cannot be greater than your allowances, or you will owe the IRS money back.

IMPORTANT  Household Income is defined in 26 US Code 36B(d)(2)(A):

The term “household income” means, with respect to any taxpayer, an amount equal to the sum of

♦ the modified adjusted gross income of the taxpayer, plus

♦ the aggregate modified adjusted gross incomes of all other individuals who

♦ were taken into account in determining the taxpayer’s family size under paragraph (1), and

♦ were required to file a return of tax imposed by section 1 for the taxable year

[/usa_item][usa_item acc_title=”HRA’s – Defined Contribution (Health Reimbursement Arrangements)”]An HRA or Health Reimbursement Arrangement, is nothing more than a reimbursement, and there is no cap for reimbursement.  The HRA works the same way requesting reimbursements for a business trip would be.  If an employee needed to get reimbursed for their work related travel expenses, they would turn in their receipts to their employer for reimbursement. 

The same works for an HRA.  The employer with 100% tax deductible money reimburses the employee’s receipt tax free from the HRA for items like: dental and vision premiums, critical illness, accident coverage, for seniors MAPD’s, Med Sup plans, Part B.   The employer agrees to reimburse a certain dollar amount of receipts yearly or monthly, and that amount can roll over year after year and pay the above expenses.     [/usa_item][usa_item acc_title=”HSA’s (Health Savings Account)”]A Health Savings Account is an account that the employee puts money into that is tax free for medical expenses.  This money can grow year after year and can accumulate interest.  The HSA MUST be set up with a proper plan.  You cannot just choose any high deductible plan and open up an HSA at your bank.  You must have a plan that is HSA compatible.  You also must use the HSA funds properly for approved medical expenses only.  You can use your HSA account for OTC medications, but you MUST have a Doctor’s Prescription for it.  Otherwise, there is a hefty tax of 20% on top of your normal tax rate.  Be careful!

The contribution limits increase in 2014 to $3300 for individuals and $6550 for families.  The 2013 contribution limits for individuals are $3,250 and $6450 for families.[/usa_item][usa_item acc_title=”Individual Mandate”]We All Must Buy or Have Health Insurance.  This means we all must buy insurance or have a “Qualified Health Plan” (see definition) in place or “Minimum Essential Coverage” (see definition) or have a State or Federal plan, or a “Self-Funded” plan.  If you do not, you’ll pay a tax penalty (unless you are exempt – see below). 

Congress passed the Law and made it Constitutional to make everyone buy health insurance by Congress’ power to tax.  Your penalty for not buying health insurance will be:

♦ Penalty for 2014:  1% of your income OR $95/adult, $47.50/kid or $285 max – whichever is greater

♦ Penalty for 2015:  2% of your income OR $325/adult, $162.50/kid or $975 max – whichever is greater

♦ Penalty for 2016:  2.5% of your income OR $695/adult, $347.50/kid or $2085 max – whichever is greater

Those that are exempt are: prisoners, anyone who’s health care goes against their religious conscious or healthcare ministry members, undocumented aliens.  Then we have those that are “Exempted” – those who’s wages are so low that doesn’t require them to file a tax return, Native Americans, children of exempted adults (an example would be kids of prisoners,) those that can prove they have a hardship (ex:  death, extreme medical bills, etc.,) those that live out of the USA, coverage is “unaffordable” (more than 8% of their household income.)  Those individuals or families that had a short gap in coverage of less than 3 months.  The penalty is collected by taking the penalized amount from your tax return.
[/usa_item][usa_item acc_title=”Initial Enrollment Period (1st year of Obamacare)”]Initial Enrollment Period (1st year of Obamacare) is October 1st 2013 through March 31st 2014. 

This is when we all enroll (unless you already have a major medical plan in place).  If you enroll in October, November or December up to the 15th of December in 2013, your start date will be Jan 1st 2014.  After December 15th 2013, you’ll have a Feb 1st, 2014 start date.  Each month, if you enroll before the 15th, you’ll start the next month.  If you sign up after the 15th of Jan or Feb or March, you’ll start not the next month but the month after.  

If you don’t qualify for a subsidy or you didn’t buy a health plan during the enrollment period, you may buy insurance anytime you would like, however, there is a 90 day waiting period and you’ll be subject to a tax penalty for not having coverage.  The coverage can NOT go back in time. 

It is not wise to wait until you are sick to try and get coverage because you won’t be able to because of the 90 day wait.

Small and Large businesses may buy health insurance at any time. [/usa_item][usa_item acc_title=”Innovation Waiver”]On or After 1/1/2017 our State may be allowed to apply to wave any or all of the below requirements in the Health Insurance Exchange Market if we develop our own “innovative strategies” to provide our Nevadan residents with high quality affordable health coverage.  Waivable requirements are:

♦ Qualified Health Plans

♦ State Exchanges

♦ Individual Mandate (all must buy or get a tax penalty)

♦ Play or pay for large employers

♦ Cost Sharing reductions (see definition)

♦ Refundable tax credits for those that qualify

[/usa_item][usa_item acc_title=”Insurance Price Increases”]By law, 80-85% of all dollars collected in medical premiums will go towards paying for medical bills (claims) and improve quality.  So if your rate goes up, it’s because medical costs are going up, and overall there are more benefits and coverage in the new plans (called “Essential Health Benefits”) than there used to be with the new health care reform health plans, and no one can be turned down for insurance anymore for having pre-existing conditions.  These factors will cause premiums to rise.  New taxes and fees are in the end being passed down to members, law suits make prices go up, unhealthy choices in the way we eat makes prices go higher, new technological advances in health care makes prices go higher.  Many factors make insurance prices go higher. 

If the insurance company collects too much money from you, by law, they are required to send you back a check or give you credit.  With the price of health insurance, you may qualify for financial assistance call a “Subsidy” to help you afford a health insurance plan.  You may even qualify for Medicaid depending on your income.  Keep in mind, from now on, all dollars paid in medical claims, 80-85% of those premium dollars must pay claims or improve quality.[/usa_item][usa_item acc_title=”Life Events (Marriage, Divorce, Birth, Adoption, Death + Loss or Increase in Income)”]Any of these “life events” will give you an opportunity and a responsibility to adjust your plan.  If any changes like these in your family occur, and if you are or are not receiving a subsidy, you’ll want to call us to make the necessary changes to your plan.  Especially if you ARE receiving a subsidy. 

Ignoring life events like this can cost you, so don’t take chances.  Call us to make the necessary changes to your subsidy, and take the opportunity to make changes to your plan if you’d like and if you qualify.  If you have any changes like these, you’ll have 60 days from the date of the event to make changes. 

We’d recommend making the change the same week the event occurs if at all possible.

♦ Birth, Adoption or being placed for Adoption (your babies’ coverage would begin the day they are born)

♦ Marriage or Domestic Partnership (your coverage would begin the 1st day of the upcoming month after you’ve made the change – Domestic Partner must be on file with the Secretary of State)

♦ Losing your coverage

♦ Become a Citizen or change in your Residency Status

♦ If there was a mistake or problem with your enrollment

♦ If there was a mistake made on your behalf when enrolling

♦ Change in your income of any kind

♦ Change in your family of any kind – Family Size including Divorce

♦ Your employer’s plan is “Unaffordable” (see unaffordable definition)

♦ You move in or out of the coverage area

♦ Any other circumstance that you feel would change your status

♦ American Indian/or Alaskan – you may make monthly changes

Read the paragraph above – very important!

If you need to make a change because of the circumstances above, and you make that change before the 15th of the month, you’ll start the next month.  If you make the change after the 15th of any month, you’ll start not the next month but the month after that on the 1st.  See exceptions above (birth or marriage, etc.)   [/usa_item][usa_item acc_title=”MAGI (Modified Adjusted Gross Income)”]The Modified Adjusted Income for most folks will be the Adjusted Gross Income on line 37 of your 1040, or 21 of your form 1040A or line 4 of your 1040EZ of your tax return.  The safest way to find out is to speak with your tax preparer to determine this number.

Modified Adjusted Gross Income coming from the IRS website is your AGI (Adjusted Gross Income) without:

♦ Any passive loss or passive income, or

♦ Any rental losses (whether or not allowed by IRC § 469(c)(7)),  or

♦ IRA, taxable social security or

♦ One-half of self-employment tax (IRC § 469(i)(3)(E)) or

♦ Exclusion under 137 for adoption expenses or

♦ Student loan interest

♦ Exclusion for income from US savings bonds (to pay higher education tuition and fees)

♦ Qualified tuition expenses (tax years 2002 and later)

♦ Tuition and fees deduction

♦ Any overall loss from a PTP (publicly traded partnership)

We suggest you refer to your federal income tax return to get a quick estimate of your AGI.  On your tax return, please refer to:

♦ Line 4 if you filed a Form 1040EZ

♦ Line 21 if you filed a Form 1040A

♦ Line 37 if you filed a Form 1040

Keep in mind, the subsidies are based off the “Household Modified Adjusted Income.”   [/usa_item][usa_item acc_title=”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.  There are also Private Marketplaces (like this website here at the Nevada Insurance Enrollment Marketplace).  We are a full service “Private” marketplace.  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 to qualify to get help in paying for your insurance).

The word Marketplace and Exchange kind of mean the same thing and they get used interchangeably.  A Marketplace works kind of like how Travelocity works when you are shopping for an airline ticket with all the different airlines.  Different health insurance companies (like Anthem BCBS, United (Golden Rule,) Sierra, Coventry, HPN, Aetna, Humana etc.) and many other types of coverage like Dental, Vision, Critical Illness, Medicare Supplements, Wellness, Property and Casualty, Life Insurance and much more can sell their health plans here at the Nevada Insurance Enrollment Marketplace.  We can also assist with subsidized plans from the Government.

Factors like your income and the number of family members on your tax return, all determine how much your premiums will cost if you are looking for a “subsidized plan.”  You will NOT qualify for a tax subsidy if you have employer insurance for yourself or your spouse or kids, or If you have a Federal insurance plan like the VA, Tricare, Medicare, etc., or if you get State assistance (Medicaid, etc.)  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.   [/usa_item][usa_item acc_title=”Maximums – Annual and Lifetime Maximums”]By 2014 all Individual and Family and Small Business Group Plans will be health care compliant and they will not have annual or lifetime maximums.  This applies to dollar limits and days in the hospital or days visiting your doctor also.  These unlimited benefits apply to the below benefits also called the “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 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.[/usa_item][usa_item acc_title=”Medicaid”]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.  Now adults with or without children or women pregnant or not pregnant are now eligible for Medicaid with this new ACA law, depending on their income.[/usa_item][usa_item acc_title=” Medical Expenses / Deductions on your Taxes”]Starting 2013, a change to tax payers that allows a deduction of allowable medical expenses from your taxes has gone from 7.5% of your adjusted gross income to 10% of your adjusted gross income.  This means you must spend more of your income on medical bills in order to receive a tax deduction.[/usa_item][usa_item acc_title=”Medical Loss Ratio – Claims”]Starting in 2012, this law states that insurance companies MUST pay a minimum of 80%-85% of all the dollars they collect in premiums towards medical bills they receive (claims.)  In other words, if an insurance company collects $100 in a premium, $80 to $85 MUST pay a medical claim.  If at the end of the year they have collected too much from their members, they have to send their members back a “rebate” check, or give the members a credit for a future premium.  The insurance companies must pay 80% of all dollars collected for small businesses and families and individuals for medical claims.  The insurance companies must pay 85% of all dollars collected for large businesses medical claims.  Within the 80%-85% ratio’s, the insurance company can spend money on things that improve healthcare quality also.   If insurance companies worry that the health insurance market in Nevada will become unstable due to the strict MLR requirements, they can request the Department of HHS to make an adjustment to the MLR.  When you hear someone talk about their Premiums Going up, have them read this definition and explanation.

This medical loss ratio requires all insurance companies to send detailed reports to the Government about money being spent.  All States, all plans, the reports are a big responsibility and will be very time consuming for the insurance companies to comply with.  Self-insured plans do not have to comply with this requirement (this is a big deal) which means we’ll probably see more self-insured plans.  Grandfathered plans do have to comply. [/usa_item][usa_item acc_title=” Medical Records System – HIPAA”]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 and 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.[/usa_item][usa_item acc_title=”Mini Medical Plans”]Are inexpensive low life time maximum plans.  These plans are not “Major Medical”.  There were some employers that were allowed to keep their employees on these plans without having to make some of the mandatory changes with health care reform if they got a waiver.  These waivers for employers to keep these “Mini Medical” plans will expire on 1/1/2014 when insurance can be purchased without any preexisting conditions, and subsidies become available to those whose income qualifies.  In 2014, all Americans with few exceptions will be required to have a “QHP” – qualified health plan.  An employee losing their mini medical plan may apply for a subsidized plan (based on their income and other factors) for an Effective Date of 1/1/2014.  Open enrollment for these subsidized plans begins 10/1/2013.  Subsidized means the premium will be reduced a percentage based on your income.  All of us MUST have a “qualified health plan” health insurance by 1/1/2014 or we’ll get a tax penalty when we file our taxes the following year with a few exceptions (see “Exempt, Exemptions, Not Subject to Buying Health Insurance” definition). 

If you don’t have a “QHP” – Qualified Health Plan now, or you are not covered by your employer, or if you don’t have a State or Federal insurance plan, or you had any kind of a change to your income or family, call us here at the Nevada Insurance Enrollment Marketplace and we’ll get you taken care of.[/usa_item][usa_item acc_title=”Minimum Essential Coverage”]This is a term that is used mainly for Large Employers to cover at least 60% of their employee’s medical costs if the employer offers coverage.  It is also a term that describes the Bronze plan on the Individual and SHOP Exchanges.  The Bronze plan covers at least 60% of all medical bills and is the lowest priced plan you can buy.  So the Bronze plan is the lowest tiered plan you can buy that meets the “Minimum Essential Coverage.”[/usa_item][usa_item acc_title=” Multi-State Plans – Employees and College Students”]If you have a child in college out of state, or an employee working out of state, you may want to refer them to the Exchange in the state they are residing.  For college students, maybe look into a “Child Only” plan in the state in which they reside.  Nevada is working on a “Multi-State” plan, but we are waiting on more info on these “Multi-State” plans.  You can add them to your policy, however, you’ll need to understand the “network” of your insurance plan/company.   If you add your college student to your policy, what doctors will be “In Network” for them?[/usa_item][usa_item acc_title=”Network”]In Network:

This refers to the groups of doctors, hospitals and other medical professionals who have been contracted to provide discounted healthcare services to your insurance carrier’s customers.

 

Out-of-Network:

This term typically refers to any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan (HMO, POS, or PPO).  Depending on your plans guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.[/usa_item][usa_item acc_title=”No more lifetime maximums”]Before healthcare reform, if your medical bills added up to be more than your lifetime maximum on your plan, you could be re-enrolled.  The new ACA from the time it passed in 2010 and beyond, no longer has lifetime maximum amounts the insurance company must pay.  In other words, your medical bills could be unlimited and it would be covered, minus your share.[/usa_item][usa_item acc_title=”Non Discrimination Regulations”]Insurance can no longer discriminate based on pre-existing conditions.  Some factors that may affect your premium is if you smoke, your age, the number of family members you are covering, and your income.  But factors affecting your health will no longer cause your premium to go up in price.

After 1/1/2014 you can no longer be turned down for having pre-existing conditions.  There will not be 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 are pregnant now, if you’ve had a ton of medical bills in the past, genetic information or disabilities.  Nothing matters.  You qualify.  You cannot be turned down for health issues.  Insurance can no longer discriminate based on pre-existing conditions.[/usa_item][usa_item acc_title=”Obamacare”]A nickname for the ACA – Affordable Care Act[/usa_item][usa_item acc_title=”OFF Exchange”]Starting October 1st, 2013, you can buy health insurance that does not have a subsidy, referred to as “Off Exchange” (which means not on the Government site) for Nevada Residents.  Whether you do or do not qualify for a subsidy, you can always buy through our Private Exchange here at the Nevada Insurance Enrollment Marketplace.  We can assist you in enrolling into the same health insurance plans that are “on exchange” (these plans have subsidies) AND “off exchange” (plans that don’t have a subsidy).

The Nevada Insurance Enrollment Marketplace is a private exchange “Off Exchange”, so you’ll have the same choices that are on the public exchange (Government website with subsidies) PLUS off exchange health insurance plans (without a subsidy) and much much more!  We have full time licensed, experienced, and courteous health insurance agents with years of experience and a staff to assist you with any of your future customer service problems.  We can assist you with all the major insurance companies you’ve heard of before like Anthem BCBS, Aetna, United Health One-Golden Rule, HPN/Sierra, Coventry, St. Mary’s, Humana, many of which have PPO plans, and we also have dental, vision, accident coverage, critical illness, Medicare, disability and more!
[/usa_item][usa_item acc_title=”ON Exchange”]For Nevada Residents, Health Insurance Companies that are selling their insurance plans ON the Public (Government) Individual Health Insurance Exchange (website) will have access to subsidized health insurance called an “Advanced Premium Tax Credit” also called a “Subsidy” (see Advanced Premium Tax Credit definition).  This means you’ll pay a reduced amount for your health insurance premium payment, but the subsidized amount depends on your income.  Not everyone will qualify for a subsidy.

Here at the Nevada Insurance Enrollment Marketplace we can assist with this enrollment, and there is no cost to you or your employees.  We have full time licensed, experienced and courteous health insurance agents with years of experience and a staff to assist you with any of your future customer service problems.  The Nevada Insurance Enrollment Marketplace is a private exchange (not Government), so you’ll have the same choices that are on the public exchange (Government) PLUS “off exchange” (see off exchange definition) health insurance plans without a subsidy, PLUS dental, vision, accident coverage, critical illness, Medicare, disability and more!  You’ll also want to read the “Open Enrollment” and “Off Exchange” definitions too.
[/usa_item][usa_item acc_title=”Open Enrollment”]2017 Open Enrollment for Individual and Family health insurance will be from November 1st through January 31st 2017.  For families and individuals to have a January 1st, 2017 effective date with a subsidy, you must apply for a plan between November 1st and December 7th of 2016.

Starting in 2018, and from then on, the Open Enrollment dates will be from October 1st through December 15th.

The 1st year of health care reform had an extended “Open Enrollment” of 6 months (October 1, 2013 through March 31st, 2014).

After open enrollment, the enrollment period will close for the remaining part of the year until enrollment opens back up each October 1st.  The only way to make changes to your plan would be if you or your family has a Qualifying Life Event (QLE).

If you don’t qualify for a subsidy, you may buy insurance anytime you would like, however, there is a 90 day waiting period and the coverage will begin on the 1st day of the next month after the 90 day wait.  Also, the coverage can’t go back in time and you’ll be subject to a Tax Penalty for not having coverage.

Small and Large businesses may buy health insurance at any time.

Call us here at Nevada Insurance Enrollment to assist you with all your enrollment needs.[/usa_item][usa_item acc_title=”Out of Pocket Maximum”]The most you’ll have to pay for covered services in a policy period (one year).  After you reach this amount, your health plan will pay 100% for covered “essential health benefits” (see definition).  This doesn’t count your monthly premiums or services from out-of-network providers.

The maximum out-of-pocket limit for a health insurance plan for 2016 is $6,850 for an individual plan and $13,700 for a family plan.

In 2014 it was $6,350 for individuals and for a family it was $12,700. 

In 2013 the limits were $6,250 for individuals and $12,700 for families.

To get to your “Out of Pocket maximum”

Think of it like a game of baseball and 1st base is your “deductible”.  Once you’ve paid all of your deductible, you are standing on 1st base.  A deductible is an amount you pay before the Insurance Company starts paying (plans will have different “deductibles” $250, $500, $2,000 etc., so read your plan).
Now you’ll begin to move towards 2nd base – “Co-insurance”.  During this time, co-insurance is where you and the insurance company split the medical bills, for example 70/30 or 80/20.  Usually the insurance company will pay the larger amount and you pay the lesser amount.  Your next step is 3rd base or your “out of pocket maximum”.  This is the maximum YOU have to pay in a year, not the insurance company.  Once you’ve met your “out of pocket maximum”, you are now done paying anything else.  The insurance company will pick you up on 3rd base, and carry you to home plate.

Note:  This is an annual accrual, meaning it starts January 1st and ends December 31st each year.

[/usa_item][usa_item acc_title=”Out of State”]If a company’s main headquarters are here in Nevada, but has employees outside of Nevada, the State of Nevada in the SHOP exchange is required to allow those Full Time employees to enroll.  However, the employees would need to be aware that their services may be out of network, so it may be best if they could get insurance through the individual exchanges in the state in which they work.  Employers can look at “Multi-State” group plans.[/usa_item][usa_item acc_title=”Patient Centered Outcomes Research Institute”]This is a new Non-Profit Corporation instituted with the Affordable Care Act (Health Care Reform) who’s responsibility it is to conduct research to find out what medical procedures and medical tests are most effective.  This corporation is paid for by fees charged to “Specified Health Insurance Policies” and “Self Insured Health Plans.”[/usa_item][usa_item acc_title=”Patient Protections (there are 4 main items)”]With health care reform, there are new protections and benefits for Nevada’s Citizens on the new health plans. 

You can choose for yourself whomever you’d prefer to go to for your family doctor.  Just make sure the doctor is in the network of the plan you select.

♦ You can choose for your children whomever you’d prefer to take your children to as a family doctor, and this includes choosing a pediatrician.   Just make sure the doctor is in the network of the plan you select.

♦ You do not need a referral or a pre-authorization for Maternity or to see an OB-GYN for female members.

♦ With emergency room visits, you will now be charged the same for a hospital that is out of your network as you would for a hospital that is in your network, and you won’t need pre-authorization.  This is for true emergency situations only.

Additional Patient Protections with health care reform.

♦ Coverage for Pre-Existing Conditions

♦ Your policy can’t be unfairly canceled

♦ Up until your child’s 26th birthday, they may remain on your plan no matter if they are married, live at home, are on your taxes, or are a student.  The only exception is if you have a grandfathered plan and your child is offered insurance from their job until 1/1/2014, they must accept that insurance instead of the parents.   Then after that date it doesn’t matter if your child has a job from their employer or not.

♦ You may appeal a health insurance decision.  If you feel your insurance should pay for a medical bill and the insurance refuses to pay, you can appeal the decision (see Appeal definition) and the insurance company will be required to review the decision.  If you still are not satisfied, you have the right to have an outside independent agency review the appeal.

♦ Your policy may not deny participation in an approved clinical trial, deny routine patient costs in connection with the clinical trial, or discriminate against the individual participating in the trial.

♦ Free preventative care – 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 Department of Health and Human Services Website:

◊ 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, and prescription, 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 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 one bill, you will not be charged.  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.[/usa_item][usa_item acc_title=”Penalty For Not Buying Health Insurance”]In order to avoid a tax penalty, you MUST buy a plan that covers the “Essential Health Benefits” (see bullet points below) or you must have a group health plan that covers the “Minimum Essential Coverage” (60% AV – actuarial value) or have a grandfathered plan, or a “self-funded” plan, or a Federal or State Government plan. 

Insurance companies began selling these new health insurance plans 10/1/2013.

If you get a penalty, a tax refund you may get or could have gotten will be reduced by the amount of your penalty.  You won’t go to jail.

Penalty for 2014:  1% of your income OR $95/adult, $47.50/kid or $285 max – whichever is greater

Penalty for 2015:  2% of your income OR $325/adult, $162.50/kid or $975 max – whichever is greater

Penalty for 2016:  2.5% of your income OR $695/adult, $347.50/kid or $2085 max – whichever is greater

The Essential Health Benefits (does not apply to large employers) that your plan must cover to be the correct kind of insurance to have to avoid the penalty covers all these benefits at a minimum without lifetime or annual limits:

♦ 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.[/usa_item][usa_item acc_title=”PCIP (Pre-Existing Condition Insurance Program)”]This program was set up in 2010 when Health Care Reform was first passed to assist those folks that were turned down after applying for a health insurance plan and they hadn’t had health insurance for at least 6 months.  They could apply for this program to get a major medical plan until 1/1/2014 when pre-existing conditions are no longer a factor.  These members of the PCIP program can then receive a health plan guaranteed and not be turned down.[/usa_item][usa_item acc_title=”Platinum, Gold, Silver, Bronze”]From 1/1/2014 on, all individual and family health insurance plans will have these “Metallic” names whether they buy health insurance “On Exchange” or “Off Exchange” or on the “SHOP Exchange” (see definitions.)

The Platinum plan covers 90% of your medical bills, up until the “out of pocket maximum.”

Gold covers 80% of your medical bills, up until the “out of pocket maximum.”

Silver covers 70% of your medical bills, up until the “out of pocket maximum.”

Bronze covers 60% of your medical bills, up until the “out of pocket maximum.”

The Out of Pocket maximums for 2014 for individuals is: $6350 –  For families is: $12,700

Don’t worry that your percentage goes on forever, there is always an “Out of Pocket Maximum” so you’ll only pay your portion of the expenses until you’ve paid your out of pocket maximum.

Example of how this works.  You break your leg, it costs a total of $10,000 to fix your leg.  If you had the Silver plan, you’d pay 30% of $10,000 which would be $3,000, and your insurance would pay the rest.  If your FPL (federal poverty level) is less than 250%, you’ll pay less than the $3,000.

Another more dramatic example.  You have a massive heart attack and the medical bill is $1,000,000.  If you had the Gold plan, you’d pay  20% up until you’ve paid your “out of pocket maximum” which would be $6,350 for a single individual in 2014.  The insurance company pays the rest of the medical bill.

There is a “Catastrophic” plan for adults under 30 years old.  See definition.[/usa_item][usa_item acc_title=”Pre-Existing Conditions”]After 1/1/2014 you can no longer be turned down for having pre-existing conditions.  There will not be 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.[/usa_item][usa_item acc_title=”Prices (Rates) for Health Insurance”]From 2014 and beyond, premiums will be based on 1). Age  2). Number of family members  3). Smoking and  4). Household income.  Taking into consideration these 4 items, if you make under 400% of the Federal Poverty Level, your premiums will be reduced.

There is NOT a reduction in the premium for the smoking portion of the premium, in fact, this substantially raises the premium.

The Rates “On the Exchange” (Government Website) and “Off the Exchange” (Private Website like here at the Nevada Insurance Enrollment Marketplace) has to be the same rate for the same health insurance company.  For example, if Anthem BCBS has a plan “On the Exchange” the same Anthem BCBS plan “Off of the Exchange” has to be the same rate.[/usa_item][usa_item acc_title=”Private Exchange VS Public Exchange”]1).  The Public Exchange (run by the Government) will not sell health insurance companies’ plans that do not offer subsidies.  If an insurance company does not offer a subsidy, the Government website will not have their health insurance plans.  These plans can be found on Private Exchanges like here at the Nevada Insurance Enrollment Marketplace.  The Government states that they have “no authority to sell off the Exchange.”  The Nevada Insurance Enrollment Marketplace is a Full Service Private Exchange Marketplace.  We are appointed with major insurance companies in Nevada, including United Health One (Golden Rule,) Sierra Health and Life, Humana, Aetna, Anthem BCBS, HPN/Sierra, Coventry One, Assurant, and plans on the Public Exchange too!  We have HMO’s and PPO’s.

2).  Customer Service and knowledge.  The Public exchange will not address customer service problems, they will refer your questions and concerns to the insurance companies’ 1-800 number for things like billing issues, problems with claims, problems with your card, etc.  They will not service your plan after they sell you your plan.  Here at the Nevada Insurance Enrollment Marketplace we will help you in every way we can.  We have full time licensed, experienced and courteous health insurance agents with years of experience, and a staff to assist you with any of your future customer service problems.

3).  Options.  We offer many other products like Life Insurance, Dental and Vision Insurance, Accident Coverage, Disability Income, Long Term Care, Property and Casualty, Wellness programs, Medicare plans, Final Expense Coverage, Defined Contribution programs, Homeowners and Renters Insurance, Financial Services, and much more.  In other words, we can assist you with all the plans that the Government Exchange has to offer and so much more!

COMPANIES That Offer Insurance In NV (No  Subsidy )

(available on a Private Exchange)

Government Subsidized Plans  (with Subsidy)

(available on the individual Exchange)

  

Enroll in Open Enrollment or anytime w/90 day wait

Can Enroll Only in “Open Enrollment” (or life events)

  
*Anthem BCBS*Anthem BCBS (HMO)
*HPN – Health Plan of Nevada*HPN Health Plan of Nevada (HMO)
*Nevada Health Co-op*Nevada Health Co-op (HMO)
*St. Mary’s*St. Mary’s (HMO)
*United Health One (Golden Rule) 
*Aetna 
*Humana 
*Coventry  
*Assurant 
*Sierra Health and Life 
  
**Nevada Insurance Enrollment Marketplace can assist you with any of these plans**Nevada Insurance Enrollment Marketplace can assist you with any of these plans

 

 [/usa_item][usa_item acc_title=”Prohibit Retroactive Rescission”]The insurance companies cannot go back to a past date and cancel your health plan now because of simple “clerical” errors.  They still can “Rescind” (take away/cancel) your health insurance plan if you lie on your application or if you forget to make your payments.  If you smoke, you must be truthful about smoking.  Just make sure you are truthful on all your documentation.  The insurance company can also retroactively rescind for “normal course of business.” – This is where the employer has a chance to get caught up with their documentation with the status of their employees that are not paying premiums anymore due to loss of income or loss of job or whatever the circumstances are, or if you don’t tell your health plan that you got divorced.[/usa_item][usa_item acc_title=”Public Exchange Health Insurance Plans vs. Private Exchange Health Insurance Plans”]The government’s exchange is a “Public Exchange” that has subsidies that help you pay for your medical insurance.  In 2014 they have the following insurance companies that are offering government subsidies:  Anthem BCBS, HPN, St. Mary’s, and Nevada Health Co-op.  Currently they only offer HMO plans.  We can assist with enrolling into these subsidized plans.

A “Private Exchange” (The Nevada Insurance Enrollment Marketplace is a private exchange) has the flexibility to sell the health insurance companies that decide NOT to sell subsidized plans, their plans cannot be found on the public (Government) exchange.  Here at the Nevada Insurance Enrollment Marketplace we are considered a full Private Exchange.  

We can help you enroll into health insurance plans that are on the Government website that are subsidized AND the major insurance companies that are NOT selling their health plans on the Government Exchange.  Many of these plans are PPO plans.  An individual or family can determine if they are eligible for a subsidy and shop for a “qualified health plan” in platinum, gold, silver, or bronze levels and either get a subsidy or not depending on their income and if they qualify, and if they want the plans that are available that ARE subsidized.  If you do not want a subsidized plan, that is fine, but we all must get health insurance coverage that is called a “Qualified Health Plan” to avoid the tax penalty (unless we are excluded – see “excluded” definition.)  

We can enroll you into any of the below plans:

COMPANIES That Offer Insurance In NV (No  Subsidy )

(available on a Private Exchange)

Government Subsidized Plans  (with Subsidy)

(available on the individual Exchange)

  

Enroll in Open Enrollment or anytime w/90 day wait

Can Enroll Only in “Open Enrollment” (or life events)

  
*Anthem BCBS*Anthem BCBS (HMO)
*HPN – Health Plan of Nevada*HPN Health Plan of Nevada (HMO)
*Nevada Health Co-op*Nevada Health Co-op (HMO)
*St. Mary’s*St. Mary’s (HMO)
*United Health One (Golden Rule) 
*Aetna 
*Humana 
*Coventry  
*Assurant 
*Sierra Health and Life 
  
**Nevada Insurance Enrollment Marketplace can assist you with any of these plans**Nevada Insurance Enrollment Marketplace can assist you with any of these plans

 [/usa_item][usa_item acc_title=”Qualified Health Plans (QHP’S) – Health Care Reform Compliant”]All the major medical plans that will be sold from 1/1/2014 and on that sell on the individual “Exchange” and the “SHOP Exchange” must comply with all the rules and regulations in order to be a “Qualified Health Plan”.  All health insurance plans for families and individuals MUST cover these 10 items called “Essential Health Benefits.” These 10 benefits must be covered without any lifetime or annual limits on the “Essential Health Benefits.”

From 1/1/2014 and beyond, all new health plans (insured small group and individual health insurance plans) must cover the 10 bulleted benefits below.  These are the plans you’ll want to have in order to avoid a tax penalty.  These “Essential Health Benefits” will be covered.  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 part of an Employer Group that provides benefits, or are “Grandfathered,” or if the insurance is “unaffordable” (see definition) then you won’t need to buy.  All the rest of us, unless we are “Exempt” (see definition) our health insurance 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.

**This list does not apply to large employers in 2015 or Self-Funded Insurance plans.  Starting in 2015 Large employers (see definition) have to have plans that are “affordable” (employee’s portion is not more than 9.66% of the employees Box 1 income) and cover at least 60% of the medical costs, and cover their dependents (kids.)

The Nevada Insurance Enrollment Marketplace can assist with any of these plans.
[/usa_item][usa_item acc_title=”Quality of Care Reporting”]Starting 2012, one of the goals to improve patient outcomes can be accomplished through “Quality of Care Reporting.”  The Department of HHS is instructing health insurance companies that they must report back to The Department of Health and Human Services (HHS) once a year on how benefits are being delivered to their customers and how they pay their doctors and providers in their networks.  The Department of HHS wants to accomplish results in improving patient outcomes through case management and health care coordination, with chronic disease management and maintenance, through “medical homes” that will treat and serve members, including medical care and prescription care.

Quality of Care Reporting emphasizes chronic disease management for medical conditions like diabetes, also by reducing hospital readmissions after being discharged from a hospital or facility, reducing medical errors, and improving patient safety with new computer electronic software and technology for record keeping.  These methods have been successful in the past for improved patient outcomes.  Health and wellness programs will become a big deal in the near future.  Large employer’s plans must submit reports on “Quality of Care” along with the insurance companies.  Other functions that are meant to improve the Quality of Care for patients will be “W2 reporting,” MLR (Medical Loss Ratio) and “Transparency in Coverage Reporting” (see definitions.)   [/usa_item][usa_item acc_title=”Reconciliation of Premium Credits”]The amount of money received in “Advanced Premium Tax Credits” is based on the prior year’s income tax returns.  When you do your taxes each year for the year before, if your income had changed, and you should have received a higher subsidy amount, this additional credit will be included in your tax refund for the year.  However, any extra amount that was overpaid in advanced premium tax credits (Government gave you too much money) will have to be paid back to the IRS.  The ACA put limits on the excess amounts to be paid back under some conditions.

For those with household incomes between 350% – 400% of the FPL (federal poverty level), the maximum pay back to the IRS would be $2500 for a family and $1250 for a single individual.

For those with household incomes between 300% – 350% of the FPL (federal poverty level), the maximum pay back to the IRS would be $2000 for a family and $1000 for a single individual.

For those with household incomes between 200% – 300% of the FPL (federal poverty level), the maximum pay back to the IRS would be $1500 for a family and $750 for a single individual.

For those with household incomes under 200% of the FPL (federal poverty level), the maximum pay back to the IRS would be $600 for a family and $300 for a single individual.

Please call us ANY TIME YOU HAVE AN INCOME CHANGE OR A CHANGE IN FAMILY STATUS.  It’s best to keep on top of your correct subsidy amount, you don’t want to underpay and owe money back to the IRS.  It’s just best to stay on top of this.

You will want to speak to your tax accountant on this issue.  Please see our list of recommended Accountants that have a sound understanding of The Affordable Care Act (Obamacare.)   [/usa_item][usa_item acc_title=”Redetermination for Income Changes”]If your income goes up or goes down, it’s very important to contact us so we can update your new income.  This way you can have your Subsidy adjusted to either get less “Subsidy” or get more “Subsidy” based on your new income, or ANY changes in your family status.  You don’t want to have to owe the IRS money back at the end of the year because you received too much Subsidy, and if your income went down, you’ll probably be eligible for more subsidy.   BE VERY CAREFUL NOT TO GET TOO MUCH SUBSIDY

The reason we emphasize this is, you’d have to pay the extra back.  For example:  If your health insurance premiums are $1,000/month and you get a Government Subsidy of $800/month and you only have to pay $200/month.  At the end of the year when you have to settle up with the IRS when you do your taxes on April 15th of each year, the Government will check your income, and IF you were only supposed to have received an Advanced Tax Credit of $700/month instead of $800/month, you’ll owe the Government an extra $100/month X 12 months is $1,200.  (Read the “Reconciliation of Premium Credits” definition also.) [/usa_item][usa_item acc_title=”Smoking”]If you smoke, you cannot get a subsidy on that portion of the upcharge you’ll get for smoking.  You can be charged up to 50% more on your insurance if you smoke.  You must be honest about smoking if you smoke when you apply for insurance.[/usa_item][usa_item acc_title=”Special Enrollment Period”]If you have any of the following “Life Events” you can make changes to your insurance: lose your coverage, get married, domestic partnership (Domestic Partner MUST be on file with the Secretary of State), have a baby, adopt or adoption placement, gain legal status as a citizen, gain legal status, show there was an error when you signed up during annual enrollment, violated a provision, become newly eligible for a subsidy (like lose your job or loss of income) if the government made a mistake in any calculations, if you get a raise or make more money that pushes you out of getting a subsidy (this is very very important, if your income changes, or family size changes you absolutely should make a change to your subsidy, either up or down depending on if you lose income or gain income, gain a family member or lose a family member, this will affect your subsidy).  If you move, have other exceptional circumstances deemed by the exchange.  If any of these apply to you, you have 60 days to make the change.  We’d recommend making the change the same week the event occurs if at all possible.  If you are an American Indian, you may change your plan 1 time each month.  If you enroll before the 15th, you’ll start the next month, if you sign up after the 15th, you’ll start not the next month but the month after. 

Again that list includes:

♦ Birth, Adoption or being placed for Adoption (your babies’ coverage would begin the day they’re born)

♦ Marriage or Domestic Partnership (your coverage would begin the 1st day of the upcoming month after you’ve had a change.  Domestic Partner Must be on file with the Secretary of State)

♦ Losing your coverage

♦ Become a Citizen or change in your Residency Status

♦ If there was a mistake or problem with your enrollment

♦ If there was a mistake made on your behalf when enrolling

♦ Change in your income of any kind

♦ Change in your family of any kind – Family size including Divorce

♦ Your employer’s plan is “Unaffordable” (see unaffordable definition)

♦ You move in or out of the coverage area

♦ Any other circumstance that you feel would change your status

♦ American Indian/or Alaskan – you may make monthly changes

Read the paragraph above – very important

If you need to make a change because of the circumstances above, and you make that change before the 15th of the month, you’ll start the next month.  If you sign up after the 15th of any month, you’ll start not the next month but the month after that on the 1st.  See exceptions above (birth or marriage, etc.)[/usa_item][usa_item acc_title=”Subsidy (Advanced Premium Tax Credit)”]A subsidy is an “Advanced Premium Tax Credit” that is available on the Individual Exchange but NOT the SHOP Exchange for small businesses.  A “subsidy” means that you get a reduced premium payment to pay for your medical insurance.  The factors that affect the premium you pay (the subsidy you receive), would be your income and the number of family members on your tax return.

The only way to get a “Subsidy” is to get a health insurance plan through the Governments “Exchange” 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 Private Marketplace.

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.

How do you avoid this?  Read the “Redetermination for Income Changes” and the “Reconciliation of Premium Credits” definition(s).

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 back.

Please note:  If you are providing health insurance to your employees, and only to your employee, in Nevada the employee’s spouse and children are able to get a subsidized plan.  But the subsidy is based off of the “household” income.  HOWEVER, if you DO OFFER coverage to the spouse and dependents and they elect not to take the coverage for whatever reason (the spouse may feel your employer plan is too expensive), then that spouse is NOT able to get a subsidized plan!  Please keep this in mind.  You may repel employees if you are not careful.[/usa_item][usa_item acc_title=”Summary of Plan Benefits”]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.[/usa_item][usa_item acc_title=”Transparency in Coverage Report”]All QHP’s (qualified health plans) health insurance plans must have this Financial Disclosures report available for the Department of Health Human Services, the State Insurance Commissioner and the State Exchange Board.  This Transparency in Coverage Report is part of the “Quality of Care” requirement.

If the plan is offered through the public (Government Exchange), all the same following information will be reported publicly for anyone to see on their website:

♦ Whatever the Health and Human Secretary wants them to report

♦ Claims payment information

♦ How the insurance company rates their policies (data on rating policies + why they charge what they charge)

♦ Enrollment and disenrollment – people on and people off an insurance company’s enrollment

♦ How many claims have been denied – medical bills denied

♦ Enrollee rights

♦ The claims that have been paid for – medical bills paid for

[/usa_item][usa_item acc_title=”Tribal Clients”]For those members that are recognized to be in a tribe (American Indians / Alaskan Natives), they can earn up to 300% of the Federal Poverty Level and they will have their “essential health benefits” costs covered at 100% and pick any plan they’d like and they may change plans every month.[/usa_item][usa_item acc_title=”Unaffordable”]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.” 

If your employer provides insurance for you, it must be less than 9.66% of your W2 Box 1 income.  Call us here at the Nevada Insurance Enrollment Marketplace to verify if this is for you.[/usa_item][usa_item acc_title=”Underwriting”]Starting in 2014, health insurance companies cannot underwrite anymore.  This means that anyone with any medical condition cannot be turned down.  Insurance companies used to look at your individual medical conditions, your age, your height and weight, if you smoked, what medications you took, your medical claims history, any of your pre-existing conditions, your gender, etc.  Now, the only factors that can affect your premium is:

♦ Age – A 60 year old cannot charged more than 3 times what is charged to a 20 year old

♦ Geographic location (where you live)  (Nevada)

♦ Family composition (number of members in the family)

♦ Smoking – rate can be higher by up to 50% and this 50% does not receive a subsidy

♦ Income    [/usa_item][usa_item acc_title=”Vision”]Children under the age of 19 are 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.[/usa_item][usa_item acc_title=”What types of health plans must comply with the ACA?”]All Major Medical plans – government health plans, group insurance, individual plans, insurers (insurance companies), church group plans, wellness programs that are attached to a group health plan, EAP’s (employee assistance programs), self-insured plans (must comply with some of the provisions).[/usa_item][usa_item acc_title=”What types of coverage does NOT have to comply with the ACA?”]Also called “Excepted Benefits” –  Accident only plans, Wellness plans (that are not associated with a major medical plan that are considered “stand alone”), retiree only plans, stop loss plans, Medicare, Tricare, Medicaid, CHIP, group plans that have fewer than 2 employees, disability income, long term health care, workman’s comp, auto medical, liability insurance, on-site medical clinics, limited scope benefits, mini-medical plans, credit-only, and non-coordinated benefits. 

Check with your plan to see if it is an “Excepted Benefits” plan.
[/usa_item][usa_item acc_title=”Changes For Each Year: 2010, 2011, 2012, 2013, 2014, 2015, 2017, 2018 – “]

2010

Annual limits on health insurance policies increased to pay a minimum of $750,000.00 in 2010 and by the time 2014 comes around there will be no annual limits on the EHB’s (see definition or below in “2014”.)No more lifetime maximums (your medical bills could be unlimited and it would be covered.)  Those that had met their lifetime limits before 2010 could be re-enrolled, (Transition Rule) and in the future, no more life time limits.
Dependent coverage up to the day they turn Age 26 (see dependent definition.)  HIGH RISK POOL – PCIP – Pre-existing Condition Insurance Program for those with pre-existing conditions that couldn’t get insurance and didn’t have insurance for at least 6 months
Patient Protections (these are important, read the definition for “Patient Protection”)ERRP – the Early Retiree Reimbursement Plan (see definition)
No declining children under 19 for pre-existing conditions and their pre-existing conditions must be covered, preventative visits free (see definition)No more retroactive “rescission” on medical claims or policies for small clerical errors except for fraud – can’t be kicked off a plan so easily.  If intentionally committed fraud or non-payment can be rescinded.
A new appeals process begins (see definition)Small Business Tax Credit for small business owners (see definition)
Prohibit higher paid employees from getting better benefit packages than lower paid employeesMedicaid expanded up to 138% of the FPL – Federal Poverty Level and expanded CHIP
A $250 rebate check to seniors that hit their donut holeCreated the definition of “grandfathered plans” 
www.Healthcare.gov.Free Preventative care – (see definition)
Medical costs write off for taxes increased from 7.5% of income to 10% of income 

 

 2011

For FSA’s and HSA’s you must have a prescription for OTC (over the counter) medications, otherwise you cannot use your FSA or HSA monies.  If you use your HSA monies incorrectly, if you pay for items you’re not supposed to, you’ll pay a 20% tax penalty on top of your normal tax rate.  Be careful.  New “Simple Cafeteria Plans” (see definition) are now available for employers as a new benefit for their employees.   
MLR – Medical Loss Ratio  – See DefinitionWellness program grants – See Definition

 

2012

A 4 page “Summary of Benefits” is required to be available for anyone buying a health insurance policy that describes how their policy works in straight forward terms.There is a W2 reporting requirement for large employers that have over 250 employees, they must report what they pay and what the employee pays for their health insurance plan. 
New MLR (medical loss ratio) requirements (see definition.)  Quality of care reporting began (see definition.) 

 

2013

Notice of Exchanges – by 10/1/2013 Employers must give their employees a Notice of Exchange to inform all employed citizens about the formation of these Health Insurance Exchanges.  There is a $2500 cap on salary reductions from the employee’s salaries for their FSA plans.  There is not a cap for employer contributions into the FSA for the employee. 
There is an increase in the medical expense deduction ratio to write off medical bills on your taxes from 7.5% to 10% of your Adjusted Gross Income.New Hipaa Regulations for electronic payments.  Streamline medical records and systems used by hospitals and health care providers to reduce costs.  To avoid duplicate tests that have already been run.  Eliminating duplicated baseline tests. 

 

2014

The Individual Mandate (most Nevadan’s MUST have insurance or get a tax penalty.)No more annual maximum limits on the EHB (essential health benefits – see definition.) 
Insurance companies will covers Clinical Trials (see definition.)  Out of pocket maximum limits (see definition)  – will match the OOP maximums of CDHP’s.
Comprehensive coverage on all Pre-Existing Conditions (see “essential health benefits” definition – no more underwriting)Big time fees to insurance companies who will ultimately have to pass these fees down to us. 
90 day maximum waiting time for new employees getting their insurance through an employer.Deductible limits (on the SHOP exchange only.)  
Fair health insurance premium requirements.  The HHS and State Exchange will monitor insurance rates, if rates get too high the Exchanges can refuse to allow the plans onto the Exchanges.“Exchanges” begin 1/1/2014 (Nevada Insurance Enrollment Marketplace IS a private exchange – see “exchange” definition.)
A law requiring automatic enrollment for employees from employers that are offering health insurance to 200 or more full time employees (pushed back to 2015 or maybe further)Guaranteed renewable and availability (can’t be turned down when you plan renews, and coverage is available) 
Comprehensive coverage with the 10 “Essential Health Benefits” (see definition.)Advanced Premium Tax Subsidies and Cost Sharing Limits (see definitions.)

 

2015

Pay or play tax (see definition)    

 

2017

Large group employers may enter into the Exchanges 

 

2018

“Cadillac plans” are imposed with a high tax 

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