Frequently Asked Questions About Health Insurance
Frequently Asked Questions- General Insurance Information
HMO means "Health Maintenance Organization." HMO plans offer a wide range of healthcare services through a network of providers who agree to supply services to members. As a member of an HMO, you'll be required to choose a primary care physician (PCP). Your PCP will take care of most of your healthcare needs. Before you can see a specialist, you'll need to obtain a referral from your PCP. Though there are many variations, HMO plans typically enable members to have lower out-of-pocket healthcare expenses. However, keep in mind that you'll likely have no coverage for services rendered by out-of-network providers or for services rendered without a proper referral from your PCP.
PPO plans, or "Preferred Provider Organization" plans, are one of the most popular types of plans in the market. PPO plans allow you to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician. As a member of a PPO plan, you'll be encouraged to use the insurance company's network of preferred doctors and you usually won't need to choose a primary care physician. No matter which healthcare provider you choose, in-network healthcare services will be covered at a higher benefit level than out-of-network services. It's important to check if you provider accepts your health plan so you receive the highest level of benefit coverage. Your plan may have an annual deductible before the insurance company starts covering your medical bills. You may also have a co-payment for certain services before the deductible or may be required to cover a certain percentage of the total charges for your medical bills.
A Point of Service (POS) plan has some of the qualities of HMO and PPO plans with benefit levels varying depending on whether you receive your care in or out of the health insurance company's network of providers. POS plans combine elements of both HMO and PPO plans. Like an HMO plan, you may be required to designate a primary care physician, who will then make referrals to network specialists, when needed. Depending upon the plan, services rendered by your PCP are typically not subject to a deductible and preventive care benefits are usually included. Like a PPO plan, you may receive care from non-network providers but with greater out-of-pocket costs. You may also be responsible for co-payments, coinsurance and an annual deductible.
Guaranteed issue is a term used in health insurance to describe a situation where a policy is offered to any eligible applicant without regard to health status. Often this is the result of guaranteed issue statutes regarding how health insurance may be sold, or to provide a means for people with pre-existing conditions the ability to obtain health insurance without evidence of insurability or underwriting. Under the Patient Protection and Affordable Care Act (ACA), all health insurance policies must be sold on a guaranteed issue basis.
Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts. These rules went into effect for plan years beginning on or after January 1, 2014. Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer. They cannot limit benefits for that condition either. Once you have insurance, they can't refuse to cover treatment for your pre-existing condition.
There may be more preventative services provided, depending on the plan carrier and plan type. They will also vary between the group market, individual market and Medicare market, to some degree, but these are the basic preventative services, required by ACA.
*Abdominal Aortic Aneurysm- one-time screening for men of specified ages who have ever smoked
*Alcohol misuse screening and counseling.
*Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
*Blood pressure screening
*Cholesterol Screening for adults of certain ages or at higher risk
*Colorectal cancer screening for adults 50 to 75
*Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
*Diet counseling for adults at higher risk for chronic disease
*Fall prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
*Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
*Hepatitis C screening for adults at increased risk, and one time for everyone born 1945–1965
*HIV screening for everyone ages 15 to 65, and other ages at increased risk
*Immunization vaccines for adults — doses, recommended ages, and recommended populations vary, but include:
- Hepatitis A
- Hepatitis B
- Herpes Zoster
- Human Papillomavirus (HPV)
- Influenza (flu shot)
- Varicella (Chickenpox)
*Lung cancer screening for adults 55-80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
*Obesity screening and counseling
*Sexually transmitted infection (STI) prevention counseling for adults at higher risk
*Statin preventive medication for adults 40 to 75 at high risk
*Syphilis screening for adults at higher risk
*Tobacco use screening for all adults and cessation interventions for tobacco users
*Tuberculosis screening for certain adults without symptoms at high risk
This is a fixed fee for certain kinds of office visits, prescription drugs, or other kinds of care. The health insurance copay lets you know ahead of time exactly how much you will owe. If your policy lists a health insurance copayment of 25 dollars for a doctor visit, you pay that amount each time you see the doctor.
Coinsurance is the amount, generally expressed as a fixed percentage, an insured must pay, against a claim, after the deductible is satisfied. In health insurance, a coinsurance provision is similar to a co-payment provision, except co-pays require the insured to pay a set dollar amount at the time of the service.
The out-of-pocket limit is the maximum amount a health insurance policyholder will pay for covered healthcare over the course of a policy year. The out-of-pocket limit, also called the out-of-pocket maximum, helps the policyholder control risk by placing a cap on the most they could spend. It also helps the insurer control risk by making the policyholder responsible for a portion of his or her healthcare costs. After the policyholder meets the out-of-pocket limit, the health insurance company pays 100 percent of allowed healthcare expenses, which helps the individual avoid major financial problems associated with high healthcare costs in years when they need a lot of treatment. This amount does NOT include the cost of premiums or services not covered under the plan.
Most carriers will ask you to establish an online account with them after the policy’s effective date. From that account, you can check your claims history, pay your bill or pull up a temporary copy of your ID cards. You can also order new cards from your member portal. We are always happy to assist with this as well. Just call the office.
The open enrollment period for coverage will vary with the type of coverage you have. However, there are specified times to enroll for the individual market, employer coverage and Medicare. If you miss those enrollment periods, then you would have to be experiencing a qualified event such as: a move, job change where you lost coverage, marriage, divorce or the birth of a child. If in doubt, call the office and we will discuss your options.
Frequently Asked Questions- Individual Coverage
QLE stands for qualifying life event. A SEP is a special enrollment period. Basically, a QLE or SEP is a change to your current living circumstances, or your way of life, such as: getting married, having a baby, or losing health coverage through other means. Those events could make you eligible for a SEP/QLE, allowing you to enroll in health insurance, outside the yearly Open Enrollment Period.
The Patient Protection and Affordable Care Act (PPACA) – also known as the Affordable Care Act or ACA, and generally referred to as Obamacare – is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010.
The legislation includes a long list of health-related provisions that began taking effect in 2010. Key provisions are intended to extend coverage to millions of uninsured Americans, to implement measures that will lower health care costs and improve system efficiency, and to eliminate industry practices that include rescission and denial of coverage due to pre-existing conditions. The law includes premium subsidies and cost-sharing subsidies designed to reduce the costs of coverage for Americans who qualify. Millions also gained coverage due to the law’s expansion of Medicaid in many states. Millions of American enroll in ACA-compliant health plans during an annual open enrollment period (OEP). However, many Americans can enroll outside of the OEP if they have a qualifying life event, which makes them eligible for a special enrollment period.
The Advanced Premium Tax Credit (APTC) is a federal subsidy available to individuals and families who earn less than 400% of the Federal Poverty Level (FPL). This subsidy helps to pay part of your health insurance premiums in order to make your insurance more affordable. The amount of APTC you qualify for is based on your annual income compared to the Federal Poverty Level (FPL), the lower your income the higher your subsidy. Premiums are based on the second cheapest silver plan available on the marketplace. The APTC is designed so that, if an individual or family is enrolled in the second cheapest silver plan, the premium would equal a certain percent of their annual income.
There are several factors considered when determining ObamaCare qualifications. Modified Adjusted Gross Income (MAGI), household size, age, access to coverage through an employer and tax filing status are just a few of the pieces we take into consideration when determining your qualifications for ObamaCare. If you’re thinking this might be an option for you, please contact one of our individual agents. When working with ObamaCare, there are no two situations alike. We take pride in assessing everyone’s situation and determining the best solution for our customer.
Health Insurance Marketplace Statement or a 1095A is an Internal Revenue Service (IRS) form sent to anyone who has received health insurance coverage through a Marketplace Carrier. The form details information such as the effective date of the coverage, premium amounts, and any advance payments of the premiums of the tax credit or subsidy. The form was created with the Affordable Care Act (ACA), also known as "Obamacare." This form is typically mailed out by the marketplace in January. However, if you do not receive one, it can also be found by logging into your marketplace account. We are always happy to help you locate your 1095A.
IRS Form 8962 is not only used to claim the tax credit, but also used to reconcile the credit received for a tax year. It is only for those receiving a tax credit from the Marketplace. In some cases, this may help you recoup some of the money you may have overspent on Marketplace health insurance premiums. On the other hand, if you received too much money in advance premium credits, Form 8962 may also reveal you owe the IRS. It is important to be as truthful and upfront about your household’s income as you possibly can, to avoid repayments of the tax credit. Our individual agents have been working with the Marketplace since its inception. They are very knowledgeable on how to accurately report your income and how to make sure it stays updated throughout the year.
Any changes to your existing application must be done through your Marketplace account, using your previously established username and password, or by calling the Marketplace. We strongly encourage you to contact us first, to discuss your change, before you make any changes.
Frequently Asked Questions- Medicare
Medicare is a federal health insurance entitlement program that pays for a variety of health care expenses. It’s administered by the Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health & Human Services (HHS). Medicare beneficiaries are typically senior citizens aged 65 and older. Adults with certain approved medical conditions (such as Lou Gehrig’s disease) or qualifying permanent disabilities may also be eligible for Medicare benefits. Most U.S. citizens earn the right to enroll in Medicare by working and paying their taxes for a minimum required period. Even if you didn’t work long enough to be entitled to Medicare benefits, you may still be eligible to enroll, but you might have to pay more.
There are four different parts to the Medicare program. Parts A and B are often referred to as Original Medicare. Medicare Part C, or Medicare Advantage, is private health insurance, while Medicare Part D offers coverage for prescription drugs.
Medicare Part A is hospital insurance. Part A covers inpatient hospital care, limited time in a skilled nursing care facility, limited home health care services, and hospice care. Most Medicare Part A beneficiaries do not have to pay a monthly premium to receive coverage under this part of Original Medicare; this is called “premium-free Part A.” Generally, if you’ve worked at least 10 years (40 quarters) and paid Medicare taxes while you worked, you’re eligible for premium-free Part A. Otherwise, you pay a monthly premium. Medicare Part A typically doesn’t cover the full amount of your hospital bill, so you may be responsible for a share in the cost; typically, 20% under Original Medicare. You will also have to pay a deductible before Medicare benefits begin.
Medicare Part B is medical insurance. Part B benefits cover certain non-hospital medical expenses like doctors’ office visits, blood tests, X-rays, diabetic screenings and supplies, and outpatient hospital care. You pay a monthly premium for this part of Original Medicare. The fee can be higher for people with high incomes. A different government program, Medicaid, can help cover Medicare Part B premiums for low-income beneficiaries. Medicare Part B beneficiaries are usually responsible for a portion of their health care costs. You’ll have to pay a deductible each year before your Medicare Part B benefits kick in, and then you’ll generally pay 20% when you go to a participating Medicare doctor. Medicare pays the full cost of many lab tests and services requested by your doctor.
Medicare Part C, more commonly referred to as Medicare Advantage, often includes Part A, Part B and Part D in one comprehensive health benefit plan. These plans are offered by private insurance companies, contracted through CMS, to provide the same benefits, or better, then you would get through Original Medicare. Enrolling into a Medicare Advantage plan is optional, but to obtain this private insurance, you must also have Original Medicare, Part A and Part B. You also may have to continue to pay your Part B premium if you have a Medicare Advantage plan. While Medicare Advantage plans are required to provide all Medicare Part A and Medicare Part B benefits (except hospice care), plans can also include different additional benefits, which vary among the individual private health insurers. Many Medicare Advantage plans also include prescription drug coverage, or Part D, making them comprehensive Medicare Advantage Prescription Drug (MAPD) plans. Some plans might have a lower deductible, while also allowing you to pay a smaller share of the remaining costs. Medicare Advantage plans may even cover certain health care services that Original Medicare, Part A and Part B, does not cover, like eye exams, hearing aids, dental care, or health care received while traveling outside the United States.
Medicare Part D is the prescription drug coverage component of Medicare. Medicare Part D is available as a stand-alone prescription drug plan through private insurance companies. There is typically a monthly premium associated with Part D, which varies among insurers. In addition to the monthly premium, you will also share in the costs of your prescription drugs according to the specific plan in which you’re enrolled. Those costs can include a deductible, a flat copayment amount, or a percentage of the full drug cost (called “coinsurance”). You can purchase a drug plan to pair with a supplement or Original Medicare. If you do not enroll in a qualified stand-alone drug plan, when you are first eligible to do so, but choose to enroll in one later, you may be penalized by CMS.
The late enrollment penalty is an amount added to your Medicare Part D monthly premium. You may owe a late enrollment penalty if you go without credible drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period is over. COBRA coverage through your employer, once you are Medicare eligible, DOES NOT count as credible coverage.
The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage. Medicare calculates the penalty by multiplying 1% of the "national base beneficiary premium" ($33.19 in 2019) times the number of full, uncovered months you didn't have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium. The national base beneficiary premium may increase each year, so your penalty amount may also increase each year.
Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that Original Medicare doesn't cover, like copayments, coinsurance and deductibles. Medigap policies are sold by private insurance companies and have a monthly premium cost, over and above the cost of Medicare part B. Some Medigap policies also cover services that Original Medicare doesn't cover, like medical care when traveling outside the United States. If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare approved amount for covered health care costs. Then, your Medigap policy pays its share. When you have a supplement, you will show both your Original Medicare card and your supplemental ID card for services received in a medical setting. As of 2006, Medicare Supplements, of Medi-Gap plans do NOT cover Rx drug costs. You will purchase a separate plan, often through a different carrier, for your drug coverage.
The standard Part B premium amount for 2019 is $135.50. However, it could be higher based on your income. Social Security will communicate any IRMAA adjustment to you via mail correspondence.
IRMAA is an additional amount that some people might have to pay, along with their Medicare premium, if their modified adjusted gross income (MAGI) is higher than a certain threshold. IRMAA only applies to people who are enrolled in Medicare Part B and/or Medicare Part D. The adjustment is based on your income from two years prior to qualifying for Medicare and only applies to individuals who earn more than $85,000/year or married couples, filing jointly, who earn more than $170,000/year. Realistically speaking, IRMAA only affects about 5 percent of the Medicare population. Therefore, not many people will have to worry about the added expense. However, you will be notified by Social Security if you are affected.
For 2019, the Part A deductible is $1364 for a hospital or skilled nursing facility. This is not an annual Medicare deductible, but is “per benefit period.” A benefit period starts the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF). The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care) for 60 days in a row. If you are admitted to the hospital or SNF later in the same year, you begin a new benefit period and must pay another $1,364 Medicare Part A deductible. This only applies if you are enrolled in Original Medicare. If you have a supplement or advantage plan, this responsibility will differ in accordance with your plan design.
The Medicare Part B deductible is $185 in 2019. After you have paid your deductible, you typically pay 20% of the Medicare-approved amount for most covered physician services, outpatient care, and durable medical equipment. However, if you have a supplement or advantage plan, this may differ in accordance with your plan design.
Frequently Asked Questions- Group/Employer Benefits
A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise. Most private sector health plans are covered by the Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans, including providing access to plan information.
This is a common question and the answer isn’t an easy one. However, it comes down to the size of the group. As of January 1, 2015, employers with 50 or more full time equivalent (FTE) employees are required to provide health coverage to full-time employees or pay a tax penalty. This is commonly referred to as the employer mandate. They do have to extend the coverage to children, but do NOT have to offer it to spouses. Also, employers are only required to pay a portion of the EMPLOYEE’S cost. They do not have to pay anything toward a spouse (if offered) or children’s costs. This will differ by employer. Employers with less than 50 FTE employees are not subject to these tax penalties and do not have to offer health insurance coverage. However, if your employer does provide health insurance, they might be eligible for tax credits to help them offset the cost.
If you are employed by a business, with less than 50 full time equivalent (FTE) employees, then your employer does NOT have to offer coverage. If they choose to offer coverage, as a benefit or a retention tool, they are not required to contribute a specified amount. However, there are some tax advantages if they do choose to contribute. If your employer has more than 50 FTE employees, then the ACA employer mandate requires “large employers” to provide a specified percentage of their full-time equivalent employees and those employees’ families with minimum essential healthcare insurance. This insurance must pay for at least 60% (actuarial value) of covered services. Employers can require that employees contribute toward their insurance coverage, but they can’t require them to pay more than 9.86% of their household income toward it. Large employers who fail to comply with the coverage mandate must pay a no-coverage penalty to the IRS.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan. COBRA generally requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end. COBRA outlines how employees and family members may elect continuation coverage. It also requires employers and plans to provide notice.
Although federal COBRA only covers employers with 20 or more employees, Georgia has a “mini-COBRA” state continuation coverage law in place that applies to employers with between two and 19 employees. Under Georgia’s state continuation law, individuals whose health benefits under a group plan have been terminated, and who had at least six months of continuous coverage immediately prior to the termination of benefits, may be entitled to have their healthcare coverage extended through the end of the remaining month on the policy, plus three additional months thereafter. Under Georgia law, an individual may not be entitled to continuation coverage if the employee was terminated from employment for gross misconduct.
A cafeteria plan is a type of employee benefit plan offered in the United States pursuant to Section 125 of the Internal Revenue Code. Qualified cafeteria plans are excluded from gross income. To qualify, a cafeteria plan must allow employees to choose from two or more benefits consisting of cash or qualified benefit plans. Employees of employers with cafeteria plans may obtain such benefits as health insurance, group-term life insurance, voluntary "supplemental" insurance (dental, vision, cancer, hospital confinement, accident, etc.), and flexible spending accounts through the plan. These benefits are provided by the employer, and paid for by the employee, through payroll deduction. Deductions under such agreements are often called pre-tax deductions. Contributions to these plans, made by the employer, are not actually received by the participant. Therefore, those contributions are not generally considered wages for federal income tax purposes, nor are they usually subject to FICA and FUTA. Reasons for implementing a Section 125 plan are primarily for the tax savings advantages for the employer and employee. Both parties save on taxes and therefore increase their spendable income. Employees' pretax contributions are not subject to federal, state, or social security taxes. Employers save on the employer portion of FICA, FUTA, and workers' compensation insurance premiums.
A Health Savings Account is similar to a personal savings account, but it can only be used for qualified healthcare expenses. To be eligible, you must be enrolled in a High Deductible Health Plan (HDHP). Health Savings Accounts also have some important tax advantages. Eligible expenses include a wide range of medical, dental and mental health services. Contributions can come from you, your employer, a relative or anyone else who wants to add to your HSA. The Internal Revenue Service does, however, set limits. In 2019, for example, the limit is $3,500 for individuals and $7,000 for families, plus an additional $1,000 "catch-up" contribution for anyone age 55 or older by the end of the tax year. Contributions are typically made with pre-tax dollars, through payroll deductions by your employer. As a result, they are not included in your gross income and are not subject to federal or state income taxes. If you make contributions with after-tax dollars, you can deduct them from your gross income on your tax return, reducing your tax bill for the year. Withdrawals from your HSA are not subject to federal (or in most cases, state) taxes if you use them for qualified medical expenses.
A health reimbursement arrangement (HRA), sometimes called a health reimbursement account, is an IRS-approved, employer-funded, tax-advantaged health benefit used to reimburse employees for out-of-pocket medical expenses and personal health insurance premiums. An HRA is not health insurance. Instead, employers offer employees a monthly allowance of tax-free money. Employees then buy the health care services they want, potentially including health insurance, and the employer reimburses them up to their allowance amount. HRA-eligible expenses include items such as:
- Individual health insurance premiums
- Individual dental or vision premiums
- Amounts paid toward a policy's deductible
- Office visits
- Prescription drugs
- Nonprescription drugs (with a doctor's note)
- Mileage for travel to/from eligible health care
A flexible spending arrangement, or FSA, can be used for medical expenses, dental care and vision care. The amount you decide to contribute to the account for the year is deducted from your salary before income taxes. This reduces your taxable income, saving you money on taxes. Depending on your benefit plan, your employer may contribute to your FSA as well.