Health & Wellness: Health Insurance Questions

Q: When is Open Enrollment for Health Insurance?
A: Other than Employer Group Insurance, Health Insurance for Individuals and Families started November 1st and ends December 15th if you wish your insurance to begin January 1, 2024. If you miss this deadline, you have until January 15th and your insurance will begin February 1, 2024.
Q: What are the “Essential Health Benefits” of health insurance plans?
A: As of 2014, Health insurance plans must have the “Essential Health Benefits” (EHB) to be considered qualified health plans and have Pre-existing Exclusions. The EHB’s include a set of 10 healthcare categories which are, Ambulatory Patient Services, Emergency Services, Hospitalization, Maternity and Newborn Care, Mental Health and Substance Use Disorder including Behavioral Health Treatment, Rehabilitative and Habilitative Services and Devices, Laboratory Services, Preventative and Wellness Services, and Chronic Disease Management, Pediatric Services including Pediatric Oral and Vision Care.
Q: Are Preventive and Wellness Services, no charge with a qualified health plan?
A: Yes and No; there are many screening tests and procedures which do not have a charge, however if the test needs to be revisited due to a potential diagnosis, and then called a diagnostic test, usually has a charge associated with it. It also depends on where the test or procedure is performed, at the hospital as an outpatient test or procedure, or at an off-site facility.
Q: What is the difference between the insurance purchased through the Health Marketplace and what you can buy direct from a carrier?
A: Depending on your Modified Adjusted Gross Income, number of family members, age, zip code and use of nicotine, by using the Health Marketplace you may receive tax credits, aka subsidy, to help pay for the monthly cost of the health insurance. You will always pay full price for health insurance directly from a carrier, aka as an “off-marketplace” plan.
Q: Is there a difference in coverage between a Health Marketplace plan and an “off-marketplace” plan?
A: No, however, some carriers offer limited full price plans which are not available on the Health Marketplace.
Q: What is a Copay?
A: A Copay is a set rate you pay for doctor visits, prescriptions, and other types of care.
Q: What is a Deductible?
A: A Deductible is a set amount you pay for medical services and prescriptions before your Coinsurance takes effect.
Q: What is Coinsurance?
A: Coinsurance is the percentage of the cost you pay after you have met your deductible until you reach your Max-out-of-Pocket (MooP).
Q: What Max-out-of-Pocket (MooP)?
A: Max-out-of-Pocket is a cap, or limit, on the amount of money you pay for covered healthcare services in a health plan year. When you meet this MooP, your health insurance plan will then pay 100% of all covered healthcare costs for the remainder of the plan year.
Q: What is the age limit for your child to remain on the family health insurance plan?
A: The limit for children to remail on the family insurance plan is their 26th birthday.
Q: What is Obama Care?
A: Obama Care is one of many names given to all Health Marketplace insurance plans. You may also hear the Affordable Care Act (ACA), “Marketplace,” and others, but they all mean the same thing, a platform to enroll with health insurance with assistance from the government to help pay for your health insurance based on Modified Adjusted Gross Income, size of household members, age, zip code and use of nicotine.
Q: My husband’s group health insurance is too expensive for me and our children, am I eligible to purchase health insurance through the Health Marketplace?
A: It may be possible for family members to obtain assistance with the Health Marketplace based on a calculation of the total household Modified Adjusted Gross Income and the price of the plan. This calculation is set by Health Marketplace. For additional assistance a certified broker, navigator or Marketplace agent will be able to assist you.
Q: How do I “Reconcile my Tax Credits I received from the Health Marketplace every year?
A: Form 1095-A is a document provided by the Marketplace to individuals who enrolled in a health insurance plan through the Marketplace. It provides important information about coverage, including details of premium payments made, tax credits received, and the months of coverage. It is essential to have Form 1095-A when filing your federal income tax return, it determines eligibility for tax credits or repayment of excess credits received. If you have any questions or need further assistance regarding Form 1095-A, we recommend reaching out to a tax professional who can provide guidance tailored to your specific situation.