Health insurance law is complicated, our job is to make it easy for you!
Don't see a question you would like answered? Contact us!
Medicare has neither reviewed nor endorsed this information. Wisconsin Health Insurance Advocate and its brokers are not connected with the Federal Medicare Program or the Health Insurance Marketplace.
Medicare has neither reviewed nor endorsed this information. Wisconsin Health Insurance Advocate and its brokers are not connected with the Federal Medicare Program or the Health Insurance Marketplace.
|
When is Open Enrollment for individuals/families?
November 1st to December 15th for January 1st coverage. Individuals/families without access to other insurance can enroll during this period. Seniors, people on BadgerCare/Medicaid, and people with insurance through their employer have different programs and rules. You can enroll by using this secure link: https://myacaplans.com/stuescher/. Your information is protected and never sold or shared. Why can't I just buy insurance any time of year? The rationale behind holding an Open Enrollment Period and not allowing people to sign up any time of year (except those with a Special Enrollment Period) is to ensure that everyone is paying their fair share and not just buying insurance when they get sick. |
|
I'm uninsured and I missed Open Enrollment. Is there any way I can buy an ACA plan that starts this year?
You would need a qualifying event to trigger a Special Enrollment Period (SEP) to enroll, or you have to wait for Open Enrollment which runs November 1st to December 15th for January 1st coverage. Mid-year Qualifying events include getting married, adopting or having a child, divorcing, or moving to another state. A SEP only lasts for 60 days, so be sure to take action right away. While you're uninsured, you may want to consider a short term medical policy. Short term policies are your best option (your information is protected and never shared or sold while using my link). While not fully qualified insurance, these policies may provide peace of mind and coverage to protect you from catastrophic bills.
What is the Advanced Premium Tax Credit (APTC)?
When you sign up for an Affordable Care Act policy through the marketplace, you may be eligible for help paying for coverage in the form of the APTC. The APTC is based on your estimated income for the year. When you file taxes for 2016 in 2017, you will find out if your income was more or less than what you reported, and your APTC will be adjusted.
What is a premium?
A premium is the set amount you pay monthly, quarterly, or annually for an insurance plan ("coverage"). On the Affordable Care Act marketplace, your premium amount is determined by your age, income, smoking status, and the level of coverage you choose. If you apply for coverage through healthcare.gov, you may be eligible for tax credits to help you pay for a plan.
On the Affordable Care Act marketplace, companies cannot change the premium amount during a calendar year. However, if your income changes during the year and you are eligible for a tax credit, you may see the amount you owe toward the premium increase or decrease along with your income change. The amount insurance companies charge for everyone can change yearly. You would see the price change during the Open Enrollment Period for the next plan year (November 1st-December 15th).
What is "cost-sharing"?
Cost-sharing is the amount you pay toward your care: premiums, copays and/or coinsurance, deductible, and out of pocket maximum. Each item is detailed below.
What is a copay?
A copay is the amount of “cost-sharing” you might have when you see a doctor, go to a hospital, or pick up a prescription. Copays are set amounts, such as $30 for a doctor’s office visit or $10 for a generic prescription. Copays usually start after you have met your deductible. Over the year of your plan, the copays you pay will count toward your out of pocket maximum. After you have paid up to the out of pocket maximum, your plan pays 100% (you still pay premiums).
What is coinsurance?
Coinsurance is the amount of “cost-sharing” you might have when you see a doctor, go to a hospital, or pick up a prescription. Coinsurance is a percentage (%), such as 30%. Coinsurance usually starts after you have met your deductible. Over the year of your plan, the coinsurance you pay will count toward your out of pocket maximum. After you have paid up to the out of pocket maximum, your plan pays 100% (you still pay premiums).
What is a deductible?
The deductible is the amount you pay before the plan starts paying for certain services. Preventative care is available to you without cost-sharing of any kind. Some plans offer services that are not subject to the deductible, like a regular doctor's visit, while others make all services subject to the deductible before the plan pays. The deductible is not a lump sum you pay over to the insurance company, it is the amount in bills you have to accrue before the plan kicks in. You also pay your monthly premium, which does not count toward your deductible. Once you “meet your deductible” you will just need to pay copays and/or coinsurance until you meet the out of pocket maximum.
What does out of pocket maximum mean?
The out of pocket maximum is the maximum cost to you for the year of your plan plus premiums. You meet the out of pocket maximum by paying the deductibles, copays, and coinsurance. Once you have paid up to the out of pocket maximum, you will have no copays or coinsurance when you get services for the remainder of your plan year. That means if your out of pocket maximum is $5000, the maximum you will pay over the year of your plan is $5000 plus your monthly premiums. You must continue to pay your premiums.
What does the term "in-network" mean? Most health insurance plans have networks of providers (doctors, hospitals, clinics, urgent care facilities, laboratories, and so on) that have a contract with your insurance plan, and thus you are "covered" while in-network. This also means that there are out-of-network providers, doctors or hospitals who either do not have a contract with your insurance and thus cannot or will not accept payments from your insurance, or possibly accept lower payments from your insurance. Many HMOs do not have any out-of-network coverage, which means that if you go to an out-of-network provider, you will pay full price and your insurance likely will not make any payments or count that amount you have paid toward your deductible or out of pocket maximum. The bottom line is that it is very important to check before you buy a plan that any doctors/hospitals you might want to go to are in-network, or if you already in a plan check with your plan and your provider to see if they are in-network.
Can I switch plans mid-year if I'm unhappy with my coverage? Usually not. You need a qualifying event to switch plans mid-year. Qualifying events include changes in family size, moving to a new address, and some income changes. If you are unhappy with your coverage and do not have a qualifying event in order to change, you do have options for getting your issue resolved. If you used an agent/broker to apply for the plan originally, I recommend going back to that agent and asking for help. You may want to consider filing a grievance with the plan. If that doesn't work, filing a complaint with the Office of the Commissioner of Insurance might help get your issue resolved. If you are unhappy with your plan because of the costs, I recommend reviewing your options during the Open Enrollment Period (November 1st-January 31st). If you live in Wisconsin, I can help at no-cost to you.
I was just laid off from my job. I got notice that COBRA will be $1700 per month! Do I have any other options?
Yes, thanks to the Affordable Care Act, you have options other than COBRA. Within 60 days of your qualifying event (losing your job) you have a Special Enrollment Period to sign up for coverage through the Affordable Care Act. If your income is below 400% of the Federal Poverty level, you may qualify for tax credits to help pay for your plan. If you live in Wisconsin, feel free to contact us for no-cost assistance. Otherwise, visit healthcare.gov to find local help or get started on your own.
My employer just notified me that they are ending our insurance. What do I do now?!
Before the Affordable Care Act (ACA), there wasn't a law or rule requiring employers to offer insurance. The ACA now mandates that large employers (over 100 full time employees) offer insurance, and for 50 employees or more the mandate is set to go into effect in 2017. The good news is that ACA makes insurance available to you now without pre-existing condition limitations. You are likely eligible to buy a plan through the ACA, you may be eligible for tax credits to help you pay for the premium and cost sharing. Be sure to act within 60 days of losing your employer-based coverage. If you live in Wisconsin, we may be able to help you compare your options.
I lost my employer-based health insurance more than 60 days ago. What are my options? We recommend that you look into Medicaid to see if there's any chance you are eligible. If you're not, then your best option to get covered is a short term medical plan but remember that you may face a tax penalty. Short term medical plans vary in availability, price, and benefits, and many don't qualify as minimum essential coverage. Keep in mind that even if you do buy a short term medical plan, you might face a tax penalty when you file because you didn't buy qualified health coverage when you were eligible.
My spouse gets health insurance through his/her job, but the employer doesn't offer coverage for spouses. Can I buy an Affordable Care Act plan?
You might be able to buy a plan at full price. Sadly, this is one problem with the ACA. When one spouse gets coverage through an employer but that employer doesn't offer family coverage, the other spouse is still not able to get a tax credit through the ACA. However, the non-covered spouse will be able to buy a plan off-exchange for full price during the open enrollment period. So, for married couples above 400% of the Federal Poverty level, this won't be a problem. Unfortunately for couples who would otherwise be eligible for a tax credit based on income, they will have to pay full price for a plan. Luckily, at tax time, the uncovered spouse may request an exemption from the tax penalty for failing to buy qualified coverage.
When does Affordable Care Act (ACA) insurance start?
If you have already lost coverage, you will have to apply by the 15th of the month before for coverage to start. So, if you lost coverage September 30th and you wait until October to apply, you must apply by October 15th for November coverage. This means you will have no coverage in October. As soon as you find out you are losing insurance, contact an agent, navigator, application counselor or the marketplace directly to apply. If you are still insured but will be losing coverage at the end of the month, you have the whole month to apply for a plan to start the next month. For example, if you find out your coverage will end October 31st, you will have until October 31st to complete and submit your marketplace application, submit your proof of loss, AND ENROLL in a plan. Act earlier rather than later!
Do I have to prove I lost other coverage to enroll in an ACA plan?
Yes. Very stringent rules went into effect in June 2017 that no longer give consumers 30 days to prove their loss. Now, you must prove you lost coverage before you can complete enrollment in a new plan. Part of the problem is that Wisconsin State Law only requires insurers to send this proof to consumers 10 days after coverage has ended. I often have to help consumers get letters from their previous employers to prove their coverage will end. This is causing gaps in coverage for many consumers. Act sooner rather than later!
If I want to leave my ACA plan mid-year, can I just stop paying premiums and it will go away?
No! New rules went into effect in June 2017 that allow insurance companies to charge you backdue premiums during your grace period (which is activated when you don't pay a premium). This can affect your future enrollment. I am seeing some companies sending past due premiums to collections. Health insurance is not like life insurance or car insurance. If you want to end your coverage, you have to do so actively by consulting your broker, calling 800-318-2596, or by logging on to healthcare.gov. This is important too for people who gain employer coverage or Medicare/Medicaid during the year, you need to cancel your ACA plan as soon as you can.
If I need to cancel my ACA plan, when do I have to do it?
At least 14 days in advance. Either call your broker, call the Marketplace call center at 800-318-2596, or log on to healthcare.gov to terminate your policy. Be careful, once you terminate there is no going back and you will have to wait for Open Enrollment to sign up again. Keep in mind too that the marketplace auto-enrolls people who don't actively make a choice during Open Enrollment, so if you want to stop coverage for the next calendar year, you must take action.
What happens if my income changes? If you have a marketplace plan then your change in income may change the amount you pay toward your premiums and cost-sharing. You should contact the marketplace as soon as possible to update your income information. If you fail to update your income information, you may end up paying more at tax-time.
I'm on Medicare, can I get an Affordable Care Act plan to supplement my coverage?
No. If you are interested in more comprehensive coverage than just Medicare A and B alone, we recommend you look into a Medicare supplement plan or possibly an Advantage plan. If you or your spouse works for an employer that offers health insurance, oftentimes those plans can help supplement Medicare A and B.
What if I’m unhappy with my current coverage?
Before you drop anything, be sure to talk to an agent, navigator, application counselor, or the marketplace to review your options.
-If you don’t have Medicare or Medicaid: Keep the Open Enrollment Period (November 1st-December 15th every year) in mind to see if you can get an Affordable Care Act plan or change plans for the following year.
-If you do have Medicare: Keep the Medicare Annual Enrollment Period (October 15th-December 7th every year) in mind to review your Medicare options for the following year.
-If you have Medicaid: Contact your state for help resolving problems.
-If you have Medicare AND Medicaid: talk to an agent or 1-800-MEDICARE to see what options you might have.
Copyright 2017 © All Rights Reserved
You would need a qualifying event to trigger a Special Enrollment Period (SEP) to enroll, or you have to wait for Open Enrollment which runs November 1st to December 15th for January 1st coverage. Mid-year Qualifying events include getting married, adopting or having a child, divorcing, or moving to another state. A SEP only lasts for 60 days, so be sure to take action right away. While you're uninsured, you may want to consider a short term medical policy. Short term policies are your best option (your information is protected and never shared or sold while using my link). While not fully qualified insurance, these policies may provide peace of mind and coverage to protect you from catastrophic bills.
What is the Advanced Premium Tax Credit (APTC)?
When you sign up for an Affordable Care Act policy through the marketplace, you may be eligible for help paying for coverage in the form of the APTC. The APTC is based on your estimated income for the year. When you file taxes for 2016 in 2017, you will find out if your income was more or less than what you reported, and your APTC will be adjusted.
What is a premium?
A premium is the set amount you pay monthly, quarterly, or annually for an insurance plan ("coverage"). On the Affordable Care Act marketplace, your premium amount is determined by your age, income, smoking status, and the level of coverage you choose. If you apply for coverage through healthcare.gov, you may be eligible for tax credits to help you pay for a plan.
On the Affordable Care Act marketplace, companies cannot change the premium amount during a calendar year. However, if your income changes during the year and you are eligible for a tax credit, you may see the amount you owe toward the premium increase or decrease along with your income change. The amount insurance companies charge for everyone can change yearly. You would see the price change during the Open Enrollment Period for the next plan year (November 1st-December 15th).
What is "cost-sharing"?
Cost-sharing is the amount you pay toward your care: premiums, copays and/or coinsurance, deductible, and out of pocket maximum. Each item is detailed below.
What is a copay?
A copay is the amount of “cost-sharing” you might have when you see a doctor, go to a hospital, or pick up a prescription. Copays are set amounts, such as $30 for a doctor’s office visit or $10 for a generic prescription. Copays usually start after you have met your deductible. Over the year of your plan, the copays you pay will count toward your out of pocket maximum. After you have paid up to the out of pocket maximum, your plan pays 100% (you still pay premiums).
What is coinsurance?
Coinsurance is the amount of “cost-sharing” you might have when you see a doctor, go to a hospital, or pick up a prescription. Coinsurance is a percentage (%), such as 30%. Coinsurance usually starts after you have met your deductible. Over the year of your plan, the coinsurance you pay will count toward your out of pocket maximum. After you have paid up to the out of pocket maximum, your plan pays 100% (you still pay premiums).
What is a deductible?
The deductible is the amount you pay before the plan starts paying for certain services. Preventative care is available to you without cost-sharing of any kind. Some plans offer services that are not subject to the deductible, like a regular doctor's visit, while others make all services subject to the deductible before the plan pays. The deductible is not a lump sum you pay over to the insurance company, it is the amount in bills you have to accrue before the plan kicks in. You also pay your monthly premium, which does not count toward your deductible. Once you “meet your deductible” you will just need to pay copays and/or coinsurance until you meet the out of pocket maximum.
What does out of pocket maximum mean?
The out of pocket maximum is the maximum cost to you for the year of your plan plus premiums. You meet the out of pocket maximum by paying the deductibles, copays, and coinsurance. Once you have paid up to the out of pocket maximum, you will have no copays or coinsurance when you get services for the remainder of your plan year. That means if your out of pocket maximum is $5000, the maximum you will pay over the year of your plan is $5000 plus your monthly premiums. You must continue to pay your premiums.
What does the term "in-network" mean? Most health insurance plans have networks of providers (doctors, hospitals, clinics, urgent care facilities, laboratories, and so on) that have a contract with your insurance plan, and thus you are "covered" while in-network. This also means that there are out-of-network providers, doctors or hospitals who either do not have a contract with your insurance and thus cannot or will not accept payments from your insurance, or possibly accept lower payments from your insurance. Many HMOs do not have any out-of-network coverage, which means that if you go to an out-of-network provider, you will pay full price and your insurance likely will not make any payments or count that amount you have paid toward your deductible or out of pocket maximum. The bottom line is that it is very important to check before you buy a plan that any doctors/hospitals you might want to go to are in-network, or if you already in a plan check with your plan and your provider to see if they are in-network.
Can I switch plans mid-year if I'm unhappy with my coverage? Usually not. You need a qualifying event to switch plans mid-year. Qualifying events include changes in family size, moving to a new address, and some income changes. If you are unhappy with your coverage and do not have a qualifying event in order to change, you do have options for getting your issue resolved. If you used an agent/broker to apply for the plan originally, I recommend going back to that agent and asking for help. You may want to consider filing a grievance with the plan. If that doesn't work, filing a complaint with the Office of the Commissioner of Insurance might help get your issue resolved. If you are unhappy with your plan because of the costs, I recommend reviewing your options during the Open Enrollment Period (November 1st-January 31st). If you live in Wisconsin, I can help at no-cost to you.
I was just laid off from my job. I got notice that COBRA will be $1700 per month! Do I have any other options?
Yes, thanks to the Affordable Care Act, you have options other than COBRA. Within 60 days of your qualifying event (losing your job) you have a Special Enrollment Period to sign up for coverage through the Affordable Care Act. If your income is below 400% of the Federal Poverty level, you may qualify for tax credits to help pay for your plan. If you live in Wisconsin, feel free to contact us for no-cost assistance. Otherwise, visit healthcare.gov to find local help or get started on your own.
My employer just notified me that they are ending our insurance. What do I do now?!
Before the Affordable Care Act (ACA), there wasn't a law or rule requiring employers to offer insurance. The ACA now mandates that large employers (over 100 full time employees) offer insurance, and for 50 employees or more the mandate is set to go into effect in 2017. The good news is that ACA makes insurance available to you now without pre-existing condition limitations. You are likely eligible to buy a plan through the ACA, you may be eligible for tax credits to help you pay for the premium and cost sharing. Be sure to act within 60 days of losing your employer-based coverage. If you live in Wisconsin, we may be able to help you compare your options.
I lost my employer-based health insurance more than 60 days ago. What are my options? We recommend that you look into Medicaid to see if there's any chance you are eligible. If you're not, then your best option to get covered is a short term medical plan but remember that you may face a tax penalty. Short term medical plans vary in availability, price, and benefits, and many don't qualify as minimum essential coverage. Keep in mind that even if you do buy a short term medical plan, you might face a tax penalty when you file because you didn't buy qualified health coverage when you were eligible.
My spouse gets health insurance through his/her job, but the employer doesn't offer coverage for spouses. Can I buy an Affordable Care Act plan?
You might be able to buy a plan at full price. Sadly, this is one problem with the ACA. When one spouse gets coverage through an employer but that employer doesn't offer family coverage, the other spouse is still not able to get a tax credit through the ACA. However, the non-covered spouse will be able to buy a plan off-exchange for full price during the open enrollment period. So, for married couples above 400% of the Federal Poverty level, this won't be a problem. Unfortunately for couples who would otherwise be eligible for a tax credit based on income, they will have to pay full price for a plan. Luckily, at tax time, the uncovered spouse may request an exemption from the tax penalty for failing to buy qualified coverage.
When does Affordable Care Act (ACA) insurance start?
If you have already lost coverage, you will have to apply by the 15th of the month before for coverage to start. So, if you lost coverage September 30th and you wait until October to apply, you must apply by October 15th for November coverage. This means you will have no coverage in October. As soon as you find out you are losing insurance, contact an agent, navigator, application counselor or the marketplace directly to apply. If you are still insured but will be losing coverage at the end of the month, you have the whole month to apply for a plan to start the next month. For example, if you find out your coverage will end October 31st, you will have until October 31st to complete and submit your marketplace application, submit your proof of loss, AND ENROLL in a plan. Act earlier rather than later!
Do I have to prove I lost other coverage to enroll in an ACA plan?
Yes. Very stringent rules went into effect in June 2017 that no longer give consumers 30 days to prove their loss. Now, you must prove you lost coverage before you can complete enrollment in a new plan. Part of the problem is that Wisconsin State Law only requires insurers to send this proof to consumers 10 days after coverage has ended. I often have to help consumers get letters from their previous employers to prove their coverage will end. This is causing gaps in coverage for many consumers. Act sooner rather than later!
If I want to leave my ACA plan mid-year, can I just stop paying premiums and it will go away?
No! New rules went into effect in June 2017 that allow insurance companies to charge you backdue premiums during your grace period (which is activated when you don't pay a premium). This can affect your future enrollment. I am seeing some companies sending past due premiums to collections. Health insurance is not like life insurance or car insurance. If you want to end your coverage, you have to do so actively by consulting your broker, calling 800-318-2596, or by logging on to healthcare.gov. This is important too for people who gain employer coverage or Medicare/Medicaid during the year, you need to cancel your ACA plan as soon as you can.
If I need to cancel my ACA plan, when do I have to do it?
At least 14 days in advance. Either call your broker, call the Marketplace call center at 800-318-2596, or log on to healthcare.gov to terminate your policy. Be careful, once you terminate there is no going back and you will have to wait for Open Enrollment to sign up again. Keep in mind too that the marketplace auto-enrolls people who don't actively make a choice during Open Enrollment, so if you want to stop coverage for the next calendar year, you must take action.
What happens if my income changes? If you have a marketplace plan then your change in income may change the amount you pay toward your premiums and cost-sharing. You should contact the marketplace as soon as possible to update your income information. If you fail to update your income information, you may end up paying more at tax-time.
I'm on Medicare, can I get an Affordable Care Act plan to supplement my coverage?
No. If you are interested in more comprehensive coverage than just Medicare A and B alone, we recommend you look into a Medicare supplement plan or possibly an Advantage plan. If you or your spouse works for an employer that offers health insurance, oftentimes those plans can help supplement Medicare A and B.
What if I’m unhappy with my current coverage?
Before you drop anything, be sure to talk to an agent, navigator, application counselor, or the marketplace to review your options.
-If you don’t have Medicare or Medicaid: Keep the Open Enrollment Period (November 1st-December 15th every year) in mind to see if you can get an Affordable Care Act plan or change plans for the following year.
-If you do have Medicare: Keep the Medicare Annual Enrollment Period (October 15th-December 7th every year) in mind to review your Medicare options for the following year.
-If you have Medicaid: Contact your state for help resolving problems.
-If you have Medicare AND Medicaid: talk to an agent or 1-800-MEDICARE to see what options you might have.
Copyright 2017 © All Rights Reserved