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This is a short and easy-to-understand walk-through about the components of the NEW individual health insurance marketplace, and how healthcare reform has affected it.
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ESSENTIALS:
THE “NEED-TO-KNOWS” ABOUT THE
NEW INDIVIDUAL HEALTH
INSURANCE MARKETPLACE
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With the onset of healthcare reform, the landscape in the individual health insurance marketplace has changed
dramatically.
There are LOTS
of questions.
We’ll describe what you need to know in order to navigate the NEW individual segment of the health
insurance industry.
Get. Ready.
Let’s share a very short background about the differences between individual health insurance and employer health
insurance.
They’re not
Differences?
the same.
You’ll know that individual versus employer health
insurance are two completely different ballgames
when it comes to plan design.
There are different rules. There are different tax
incentives. There are different eligibility criteria.
The list goes on.
And THAT’S a whole
different article.
IF YOU KNOW MUCH ABOUT THE HEALTH INSURANCE INDUSTRY AT ALL…
As an individual or BUSINESS OWNER you’ll want to know the “ins and outs” of both: employer plans AND
the new individual marketplace.
BECAUSE FOR CERTAIN BUSINESS OWNERS:THE INDIVIDUAL SEGMENT WILL BE MOST IMPORTANT
NOW ANYWAYS.
HERE ARE THE “ESSENTIALS” OF THE NEW INDIVIDUAL HEALTH
INSURANCE MARKETPLACE. THIS IS WHAT YOU NEED TO KNOW.
THIS IS PROBABLY THE BIGGEST GAME-CHANGER OF THEM ALL:
“Guaranteed Issue.” One of those big insurance words.
ESSENTIAL #1: “GUARANTEED ISSUE” MANDATE
For years-upon-years, if you were going to apply for an
individual health insurance plan….
You had to go through a series of health-related
questions in order to apply for coverage. There
were 50, 60, and sometimes even 70 or more
questions. If you’ve applied for coverage before
2014, you know what this is all about.
YES. MISERY.
You heard that right: OUTA’ HERE. It’s still difficult
for many to comprehend. There are NO MORE
health-related questions on individual health
insurance applications anymore.
THIS is what is called “Guaranteed Issue” in
the insurance world.
LOVE. That.
Starting in 2014: these health related questions are all GONE.
ALL GUARANTEED ISSUE MEANS, IS THAT IF YOU APPLY FOR COVERAGE, YOU HAVE GOT TO BE
ACCEPTED.
You’re in.
Q: How does this change the ballgame?
Game changer.
A: You don’t need access to an
employer health insurance plan
to apply for coverage anymore.
This is huge. Especially for those
with preexisting conditions.
It can’t be emphasized enough how much this has freed up individual choice
in health insurance plans.
We like options.
You can literally pick any plan
from any company, and apply
for coverage now.
And to boot: if you’re eligible for subsides at the new health insurance
marketplaces…
Game changing. Again.
You could end up receiving
quite a bit of money in the
form of subsidies that will
help you pay for your
premiums.
This all sounds fine and dandy, right? It is. But there are some important
concepts that need to be understood.
Movin’ on.
In the past (before 2014), you could
apply for an individual health
insurance plan at any time during
the year.
You could go out, pick a plan, and
apply for coverage… but you might
be denied.
ESSENTIAL #2: OPEN ENROLLMENT PERIODS
WELL THAT’S ALL
HISTORY NOW.
BECAUSE TODAY (in 2014 and Beyond):
There’s now an “individual open enrollment period.”
Save the date.
Q: What’s an open enrollment period?
A: It’s a time-frame at the end of the
year when you can enroll for
individual health insurance. OPEN ENROLLMENT
PERIOD
THIS is that exact same concept. Except it’s in the new individual health insurance marketplace
now.
AND IT’S A BIG ENROLLMENT: IT’S THE ENTIRE USA.
If you’ve ever worked for an employer that has a company health insurance plan, you’ll know
that you’ve usually got to apply for coverage during yearly enrollment.
Need an appendectomy in the middle of June? It’s too late. Open enrollment is
over.
Get covered.
You’ve now got to enroll during
open enrollment each year.
This can be very important, because if you
miss open enrollment, you don’t get an
opportunity to apply again until the end of
the next year.
BUT. WHAT IF I LOSE MY COVERAGE IN THE MIDDLE OF THE YEAR? LIKE
CHANGE JOBS. OR GET DIVORCED.
BECAUSE: You’re
special.
IMPORTANT QUESTION.
Which leads us right into our next individual
marketplace essential:
SPECIAL ENROLLMENT.
ESSENTIAL #3: Special Enrollment Period
Q: What is a special enrollment period
?
A: It’s a time to enroll in the middle of
the year (outside of the open
enrollment we just described), under
special circumstances.
THIS IS SPECIAL.
WHAT ARE THESE SPECIAL ENROLLMENT CIRCUMSTANCES?
They’re events. It’s
life.
They’re “life events” that can take place in the
middle of the year. If you incur one, you can
“special enroll.” Here are examples:
• You get married.
• You get divorced.
• You have a child.
• You lose your coverage.
• You move. Plus others…
LIFE
EVENTS
In the KNOW.
Most events give you 60 days to enroll in a
plan from the time the “life event” takes
place.
HOWEVER: A Few of these events only give
you 30 days.
Be sure you know which event applies to you,
and how much time you have to enroll.
YOU’LL WANT TO MAKE SURE TO UNDERSTAND THESE LIFE EVENTS IF YOU EVER NEED TO UTILIZE THE
SPECIAL ENROLLMENT PERIOD.
Rolling.
CONGRATULATIONS: MOVING RIGHT ALONG. THERE ARE ONLY A COUPLE OF “ESSENTIALS” LEFT.
We’re going to briefly go over these
terms:
• ESSENTIAL #4: SHARED RESPONSIBILITY
• ESSENTIAL #5: MINIMUM ESSENTIAL COVERAGE
ESSENTIAL #4: “Shared Responsibility”
“Shared responsibility” is a term that has
been coined in the healthcare reform law.
It means everybody has got to be “in” in
order to make these reforms work:
• Individuals.
• Employers.
• The Government.
EVERYONE has got to have a health
insurance plan.
ESSENTIAL #5: Minimum Essential Coverage
“Minimum essential coverage” is the
type of coverage you need to have in
order to satisfy the requirements of
the Affordable Care Act (ACA). There is
a standard of coverage that has to be
met.
THE BAR HAS
BEEN RAISED.
Effectively: “Minimum Essential Coverage” has
standardized health insurance.
There are now only FOUR metallic levels of coverage when it comes to ALL
health plans:
PLATINUM. GOLD. SILVER. BRONZE.
(For those under 30yo, there’s also a “Catastrophic” plan)
It’s minimum. It’s
essential.
Roger that.
IN ORDER TO AVOID PAYING A TAX PENALTY, YOU MUST BE ENROLLED IN A “MINIMIUM ESSENTIAL COVERAGE”
HEALTH PLAN.
There’s no doubt about it.
There are tax penalties that start in 2014 if you
don’t have a health insurance plan.
You’ll need to participate in a bronze, silver, gold,
or platinum level plan in order to avoid it.
THIS is where the bar was raised.
AND: THAT PLAN WILL NEED TO CONTAIN NEW MANDATED
“ESSENTIAL BENEFITS.”
Count ‘Em:
NO “ifs, ands, or
buts.”
#1) Outpatient Care.
#2) Trips to the Emergency Room.
#3) Inpatient Hospital Care.
#4) Well Baby Care.
#5) Mental Health Coverage.
#6) Prescription Drug Coverage.
#7) Services if you’re Disabled.
#8) Lab Testing.
#9) Preventive Services.
#10) Pediatric, Including Dental.
EVERY HEALTH PLAN MUST HAVE:
AND THAT’S IT. THOSE ARE THE ESSENTIALS OF THE NEW INDIVIDUAL HEALTH
INSURANCE MARKETPLACE. THEY’RE THE “NEED-TO-KNOWS” SO THAT YOU
CAN BEGIN TO NAVIGATE THE INDIVIDUAL HEALTH INSURANCE SEGMENT
MORE EASILY.
TYSON J LESTER, RHU, REBC
President, Policy Advantage Insurance Services
Toll Free: (800) 617-0089
Los Angeles Area: (424) 442-0170
Email: [email protected]
www.policyadvantage.com | CA Insurance License #0F22799
ARTICLE WRITTEN BY
We help individuals and businesses sort out all of the aspects of employer health plans, and the NEW
individual health insurance marketplace.
Please contact us if you have questions. We share high-value information and look forward
to working with you. Thanks for stopping by.
Toll Free: (800) 617-0089
Los Angeles Area: (424) 442-0170
Email: [email protected]
www.policyadvantage.com | CA Insurance License #0F22799
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