By Sadie Tuescher

Every year, a few clients of ours go through a loss of their tax credit because of processing errors from the Marketplace. These are people who have been honest and done everything right, and I have ample proof of this. They have sent me their proof (such as proof of income or immigration status) and I have uploaded and mailed copies of their documents, keeping proof of my uploads and what I sent on their behalf. I have checked the status of these uploads repeatedly and seen no processing. I've called and spent hours on the phone with Marketplace representatives who either cannot or will not help. 

This happens to thousands of people every year. They do everything they were asked to do, and yet the Marketplace still pulls their tax credit for failure to provide proof of something or another. 

As an advocate for my clients, I track their applications and, if given permission, upload proof on their behalf. I know we're doing it right. We're going above and beyond. When the worst happens and the Marketplace unjustly decides to cut them off, we appeal. We wait for the appeal to come to a judge. In the meantime, the client has to pay the full cost of their premium, sometimes upwards of $2000 per month, to keep their coverage. If they fail to pay, the insurance company ends their coverage. And there's no getting it back that calendar year. 

Over the past few years, with each of these cases, I have virtually met a handful of judges. All my clients in such a situation have won their cases with my help. All the judges have quickly ruled in our favor and expressed the ridiculousness of the situation. Once the client has won,  the judge sends their ruling to the Marketplace. The Marketplace then sits on the decision for up to 90 days. During which time, my client has to somehow come up with the money to pay the premium they will eventually get refunded. 

It is a very frustrating situation. I can only imagine the number of people every year who do not work with an advocate and don't know how to fight their case, so they lose their coverage. If you buy insurance without the help of a broker, my best advice is to closely and repeatedly check your application (under the section titled Application Details) if you've been asked to prove something such as income or your Social Security Number. Keep screenshots of the proof you sent.

The bottom line is that you (or your advocate) should keep copies of everything, write down dates, and pay attention to your notices. Appeal any decision you think is wrong or unfair, and present evidence with your appeal. This is something we do on behalf of our clients for no cost (or for non-clients for a small fee). The most important advice Mary and I can ever give you is this, though: read your notices and take action! Like with any branch of the federal government, the Marketplace is unforgiving, and it will be an uphill battle to win your case. But it's worth fighting. 

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By Mary Fenner

I just had a phone call from a very upset woman whose brother had lost his health insurance months before, missing his 60 day deadline to enroll in a plan. He had also missed the open enrollment from Nov. 1st – December 15th, and was now on medication that made him incoherent.  Sadly, I had to tell her that her brother missed the open enrollment deadline. She was just devastated and cried, “There are sooo many rules and no one tells us!”

Yes, there are a ton of rules. We’re here to help people navigate those confusing and sometimes overwhelming restrictions and requirements. Using a broker who knows the rules and can help guide can relieve the stress of not knowing.

NUMBER 1 Rule:  You can only get health insurance within 60 days of losing coverage, and if you don’t have insurance you can only enroll during the open enrollment period November 1st – December 15th.
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Knowing these basic facts can help you and your family members avoid the awful consequences of not having health coverage! Which I’m sure you all know can be devastating both financially and emotionally. 

Don’t feel bad if you don’t know when you can enroll in a major medical individual or family through the Marketplace, most people don’t.  So here you go! The answer is simple between November 1st and December 15th. 

But of course there is always an unless. . . .

You qualify for a Special Enrollment Period (SEP).  Special Enrollment Periods are times other than November 1st and December 15th that lets people with special circumstances enroll in health care. Special rules apply to some of these so check with a health insurance agent if you have questions.
 
These are SOME of the SEP’s. 

• Loss of Health Coverage

• Losing existing health coverage from a job, individual plans or student plans
• Losing eligibility for Medicare, Medicaid (Badger Care or Forward Wisconsin) or CHIP.
• Turning 26 and losing your parent’s coverage

• Changes in Household

• Getting married or divorced
• Having a baby or adopting a child (this does not include pregnancy)

the birth of the baby is covered and then going forward.

• Death in the family

• Changes in Residency

• Moving to a new Zip Code or County
• Students moving to a new school
• Seasonal Workers moving
• Moving to and from shelters or other transitional housing

• Other qualifying events

• Changes in income that could affect the coverage you qualify for
• Being a member of a federally recognized tribe or status as an Alaska Native
• Becoming a US citizen
• Leaving incarceration
• AmeriCorps members starting or ending their service

 
 You have 60 days once you have any of the above changes to enroll. 

I hope this clears any questions you may have about when to enroll.  If not, call us at 414-797-3408 and we will be glad to help you in any way we can!

Some recent events in my personal life have me thinking a lot about our ethical responsibilities to others, especially in a professional setting. I experienced a fellow agent failing to uphold his fiduciary responsibility to me as a client, and it made me take a step back. I've been taking for granted that other professionals uphold the same ethical standards as I do. 

Generally speaking, a fiduciary is a professional who is bound by either a code of ethics or a law to act in your best financial interest. 

As a health and life broker, I work on behalf of both my client and an insurance company and I have a legal fiduciary responsibility to both. Here are Wisconsin Health Insurance Advocate, LLC, we take our fiduciary role very seriously and a step further than our legal mandate. In fact, it's the first thing I talk about when interviewing potential new team members and something I go over in detail on our first day of training new staff.  To us, it's more than a legal or ethical obligation, it's the right thing to do and the best thing to do for our business. 

But not everyone can see the forest for the trees. I am prompted now to ask more questions, and to walk away when a situation doesn't feel right. I am still working on how to reconcile knowing that a violation, however minor, of my trust occurred. 

My current take away is this: ask any professional with whom you are dealing in money or insurance matters (health, life, retirement products, and so on) if they are going to act as a fiduciary for you. And, think about walking away if the answer is no. 

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The Affordable Care Act's full implementation on January 1st, 2014 significantly changed the health insurance landscape for many Americans. The new law's requirements that there be no pre-existing condition discrimination helped millions of Americans gain long overdue access, and was especially helpful for people with disabilities  and chronic conditions. Really though, prior to 2014, insurance companies could discriminate against people due to any pre-existing condition. I wrote in a prior blog post about how in my mid-20s and very healthy, I was denied an individual plan due to a resolved sports injury and mild depression. 

One of the unintended, and I would argue unforeseen, consequences of the ACA was that insurance companies decided to use omissions in the law's language to refuse coverage to part time employees and groups where only the owner and their spouse or immediately family were applying. This meant that many owner-operated small businesses (the Mom and Pop shops of yesteryear) couldn't buy a group plan. Instead, they would have access to the Marketplace. Up until 2018, this was a good option and equally cost effective as the old group plans. However, as we keep seeing pricing increasing, the Marketplace is no longer a viable financial option for owner-operated businesses with income over $65,000 per year. 

As of recently, one intrepid insurance company in Wisconsin has decided to allow small business insurance plans for spouses/immediate family operating their small businesses. This is welcome news, as employer-based plans are tax deductible for the business. The plan is Level Funded, which means there is medical underwriting. Rates are determined by the health of the group. But finally, spouses running a business will have some access to health insurance. I can only hope other companies follow suit, soon. 

​Sadie Tuescher, owner 

The Affordable Care Act made it possible for over 11 million Americans to access health insurance that covers preexisting conditions and essential health benefits. We saw the uninsured rate in the US drop dramatically, and many people were able to leave corporate jobs to start their own businesses because they could buy their own insurance on the Marketplace.

The law didn’t anticipate the exploratory nature of many millennials. The law did create network standards for health insurance plans, called Qualified Health Plans (QHPs), but those standards don’t extend beyond a plan’s service area. All plans must cover emergency care anywhere in the US, but ongoing or less-expensive routine care may be out of network most places. With plan selection based solely on permanent address (which not everyone has), and all plans in Wisconsin being HMOs or EPOs (narrow networks, no out of network coverage), these plans lock people into their immediate area for care. 

For example, only one plan in Wisconsin covers some limited providers out of state, and those providers are located just across the Minnesota border. That plan is only available in select western counties. No plan in all of Wisconsin has a national network. Some have such narrow networks that only one hospital system is available. This leaves travelers access only to emergency care, which can be extremely costly. I just looked at a balance bill from a hospital in Las Vegas for $29,000 after insurance covered at their in-network rate.

Adding to the problem is the fact that once you’re in a fully qualified plan (on or off marketplace), you can’t pause the plan while you’re traveling. Once you stop the plan, you can’t get back in until Open Enrollment (November 1st to December 15th) for the following year.

This leaves traveler types with a tough decision: pay premiums for insurance they can’t really use, or stop their coverage for the rest of the year, even if they are coming back to Wisconsin after their travels. Frankly, this system isn’t set up for our modern world, where more people are working remotely and young people are choosing travel over settling down.

What can be done? Write your representatives about improving the portability of ACA,  and write your insurance company about wanting a travel benefit and better emergency room coverage. 

For people who buy their insurance through either the individual Marketplace or through an insurance company directly have only until midnight on December 15th to complete their plan enrollment. 

Prices have changed a lot for 2019, including some decreases in price! It is always suggested to complete a renewal, especially if you get a tax credit. It's also the only time of year you can change your selection. 

We've been hearing a lot of feedback from clients that they have been sold or marketed short term policies that cover very little as if they were full insurance plans.  If the company you're buying from isn't local, you might be signing up for junk insurance. Almost all legitimate full medical insurance plans are not the big names you might recognize. For example, of the big named carriers in the US (UHC, Humana, Aetna, Anthem, etc) not a single one offers full insurance plans. That means if you've purchased a UHC plan in Wisconsin as an individual, that plan is not fully qualified insurance. Full insurance plans can be viewed on the Marketplace or by calling a broker like Wisconsin Health Insurance Advocate, LLC for no-cost enrollment help. 

Shop carefully, and get help! There is no cost to you for our enrollment help. 

By Mary Fenner, Consumer Advocate

While visiting a good friend, he was saying what a great cook his neighbor was.  Just then, the neighbor’s daughter came over with homemade egg rolls, and sauce with one tiny sliver of red pepper.  She said 'just don’t eat the pepper.'  Of course, he immediately did just that.  

The fire in his mouth exploded and he started to cry…and I thought…well I’ll keep that to myself.

That’s how some people feel about health care. HOT, PAINFUL and FIERY!!
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Please let us put out that fire.   It is my one-year anniversary as a Health Care Advocate and believe me, I get how confusing it can be to choose an insurance plan that fits your and your family’s needs.  
 
Reasons to use us as an Agent/Advocate:

• No cost to you!
• Proven fact that people who use an Advocate are happier with their insurance choice.
• We do the heavy lifting for you, you just answer questions and provide proof if needed.
• If the Marketplace asks for more information such as Pay stub or W-2’s, we will help by uploading it for you and saving proof that your information was verified.
• If you use us for a broker, anytime during the year if you have questions, we will be there for you!

 
So don’t get burned--call us and we will put the fire out!