What You Need to Know About Health Insurance and Your Plan
What all of our members should know and understand
General Information
When first applying for your plan we must decide if we go through the ACA (Affordable Care Act) Marketplace in order to get a Subsidy that will lower the price of your health insurance plan. This Subsidy will lower the price depending on the following:
- Total Household size
- ages of covered members
- zipcode
- Estimated income claimed for the current plan year
Every individual and family situation is different, using the above criteria we will find a plan best suited for you and your families current situation. Other benefits of going through the marketplace is the fact that there are no health qualifying questions, so regardless of your health you will be approved. There are also no maximum coverage limitations meaning regardless of what dollar amount your insurance covers, they cannot cancel your plan or stop covering you.
Some things to be aware of is that the Health Insurance Marketplace may request Income and or immigration documents from covered individuals throughout the year. We will get these documents when submitting your plan if they are needed. We will upload them as well so you don’t have to mail them in later. You never need to call or mail in documents to the marketplace because as your agents we take on this for you. After we upload the documents you may continue to receive letters such as 2nd notice, and final notice to submit documents. These letters appear as if they will cancel your plan however just let us know when or if you receive them. Usually this is part of an automated system. We always upload your documents as soon as you give them to us regardless if you continue to receive these letters. Rest assured that we monitor every plan and document due date to ensure that you will not be cancelled.
If your family is in good health and your income is on the higher end of the FPL it may be to your advantage to choose an off marketplace plan in order to save on your monthly premium. We will determine this at the time of quoting your prices. Off marketplace plans require a health questionnaire for approval.
The “Health Insurance Marketplace,” is a shopping and enrollment service for medical insurance created by the Affordable Care Act in 2010. In most states, the federal government runs the Marketplace (sometimes known as the “exchange”) for individuals and families. Here you can qualify for lower monthly premiums or savings on out-of-pocket costs based on your income.
Get ready you will be receiving a lot of mail both from your Health insurance provider and if you get a subsidy you will get a plethora from the marketplace. Don’t allow any of the letters to confuse you or scare you into thinking that you will be cancelled. As your agents we can see every letter you are sent from the marketplace and will handle them for you. We do ask that you let us know when you receive these letters just to make sure they are handled promptly and properly.
As stated above, Some things to be aware of is that the Health Insurance Marketplace may request Income and or immigration documents from covered individuals throughout the year. We will get these documents when submitting your plan if they are needed. We will upload them as well so you don’t have to mail them in later. You never need to call or mail in documents to the marketplace because as your agents we take on this for you. After we upload the documents you may continue to receive letters such as 2nd notice, and final notice to submit documents. These letters appear as if they will cancel your plan however just let us know when or if you receive them. Usually this is part of an automated system. We always upload your documents as soon as you give them to us regardless if you continue to receive these letters. Rest assured that we monitor every plan and document due date to ensure that you will not be cancelled.
Anyone who receives a subsidy for lower cost insurance must file a tax return for the year of the plan. If your plan is Jan 1 – Dec 31, 2021 then you must file a tax return for everyone on your application for that 2021 year in 2022. You will get a 1095A form to file with your tax return in January or February of the following year to file with your tax return. You MUST file the 1095A form with your return. If you end up making substantially less for some reason it’s still better to file regardless if the irs says you need to along with the 1095A form. Anyone who doesn’t file a tax return and receives a subsidy will more than likely have their plan cancelled the following year. We inform all our members to file a tax return matching the household size stated on the health insurance application so that the 1095A form will match the names and household size or your tax return. If you are in the immigration process and do not have a social # you can easily obtain a ITIN # that can be used to file a tax return all you need is a passport. Please contact us for more info.
Anyone who receives Medicare, Medicaid, Kidcare or VA benefits does not qualify for lower cost health insurance with a subsidy. You will need to cancel your other plan in order to get the ACA plan with a subsidy. The exception is if you have Share of cost or cost share medicaid, you are allowed to have that and still receive a subsidy. Please contact us before cancelling your current plan.
Subsidies are based on the following
- Total Household size
- ages of covered members
- zipcode
- Estimated income claimed for the current plan year
You also must file a tax return for the year of your plan so if you get a plan for the year 2021 then you will file that tax return in 2022 for the 2021 year and base estimated income for the year of your current health insurance plan. If Self Employed or paid as a 1099 independent contractor we use MAGI after business expense deductions and after any child support paid and before any child support received as taxable income.
Anyone who claims under the 400% FPL based on household size can receive a subsidy. We have a chart please contact us if you have any questions
Anyone with Legal presence in the US can obtain a subsidy with the following documents: You do not need to be a citizen or have a SS#. Let us know during the application which document you have so we can enter the info during the application process. you can also securely send us the document here (link to upload immigration documents on contact us page)
Permanent Resident Card, “Green Card” (I-551)
Reentry Permit (I-327)
Refugee Travel Document (I-571)
Employment Authorization Document (I-766)
Machine Readable Immigrant Visa (with temporary I-551 language)
Temporary I-551 Stamp (on passport or I-94/I-94A)
Arrival/Departure Record (I-94/I-94A)
Arrival/Departure Record in foreign passport (I-94)
Foreign Passport
Certificate of Eligibility for Nonimmigrant Student Status (I-20)
Certificate of Eligibility for Exchange Visitor Status (DS-2019)
Notice of Action (I-797)
Document indicating membership in a federally recognized Indian tribe or American Indian born in Canada
Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR)
Document indicating withholding of removal
Office of Refugee Resettlement (ORR) eligibility letter (if under 18)
Resident of American Samoa card
Alien number (also called alien registration number or USCIS number) or I-94 number
Reentry Permit (I-327)
Refugee Travel Document (I-571)
Employment Authorization Document (I-766)
Machine Readable Immigrant Visa (with temporary I-551 language)
Temporary I-551 Stamp (on passport or I-94/I-94A)
Arrival/Departure Record (I-94/I-94A)
Arrival/Departure Record in foreign passport (I-94)
Foreign Passport
Certificate of Eligibility for Nonimmigrant Student Status (I-20)
Certificate of Eligibility for Exchange Visitor Status (DS-2019)
Notice of Action (I-797)
Document indicating membership in a federally recognized Indian tribe or American Indian born in Canada
Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR)
Document indicating withholding of removal
Office of Refugee Resettlement (ORR) eligibility letter (if under 18)
Resident of American Samoa card
Alien number (also called alien registration number or USCIS number) or I-94 number
We get many potential members that have been informed by their Immigration lawyers or advisers that receiving a subsidy will hurt or affect their immigration process as receiving a public charge. this is from the government website:
“public charge” status
On February 24, 2020, new U.S. Citizenship and Immigration Services (USCIS) regulations apply to the definition and factors for “public charge” status. These regulations outline how USCIS will determine whether applications for admission to the United States or applications for adjustment to immigration status will be denied because the applicant is likely at any time to become a public charge.
Use of public benefits could be considered a negative factor in a public charge inadmissibility determination. This means it could affect your chances of admission or adjustment of status.
Enrollment in a Marketplace plan (with or without premium tax credits) is NOT a public benefit under the public charge final rule.
We are not lawyers and can not give legal advice. If you have more questions about the public charge law that was passed, please contact a professional.
We inform all our members to file a tax return matching the household size stated on the health insurance application so that the 1095A form will match the names and household size or your tax return. If you are in the immigration process and do not have a social # you can easily obtain a ITIN # that can be used to file a tax return all you need is a passport. Please contact us for more info.
You also must file a tax return for the year of your plan so if you get a plan for the year 2021 then you will file that tax return in 2022 for the 2021 year and base estimated income for the year of your current health insurance plan. If Self Employed or paid as a 1099 independent contractor we use MAGI after business expense deductions and after any child support paid and before any child support received as taxable income.
Based on the Income that you estimate on your application it will affect both the monthly premium price as well as the actual plan itself (amount of copays and deductibles). The higher the claimed income on your tax return the higher the premium monthly payment will be as well as the higher the dollar amount of the copays, coinsurance and deductibles will be. This is Just an estimate and we can adjust your income accordingly throughout the year. If you overshoot your income you may be asked to pay back some of the premium on your tax return as if you used that estimation from the start. The process is somewhat complicated with actual capped amounts of $300 – $2500 in many circumstances. If you end up going over the 400% FPL for that year then you will be asked to pay back all of the subsidy that you received that year. so that # is important to know. Please contact us with any questions regarding this for your unique situation.
If you make under the 100% FPL you will not be charged anything but you still need to file the 1095A with your return.
Remember:
If you are Self Employed or you are paid as a 1099 independent contractor we use MAGI (Modified Adjusted Gross Income)after business expense deductions and after any child support paid and before any child support received as taxable income. Income is calculated as a combined amount for all the members in the household as long as they are listed on your tax return whether or not they are covered on the plan.
*IMPORTANT* You will receive a 1095-A form that you must file with your tax return the following January or February. If you do not receive this by the time you do your taxes let us know and we will try to get the form for you. You must file this with your return as it could affect your refund or plan being cancelled.
How To Use Your Plan
When you selected your health insurance plan one of the very important deciding factors was the provider network, which are the Doctors, Hospitals, Pharmacies and facilities that will accept your plan and honor the discounted copays and coinsurance rates of your plan. if you randomly go to any Doctor, Hospital, Pharmacy and facility and they are not on your provider network list then your insurance will not be honored and you will pay full price. The price of your plan is correlated with the size of your provider network. For example: Typically the higher the price the larger the provider network. Some zip codes and counties may be an exception and have a large provider network for a low price which we will discuss during the quoting process.
I can’t stress enough how important it is to know your plans network! I get many people who dont pay attention to this aspect and think they have a horrible insurance plan when in fact its a great plan they just paid full price because they didn’t go to an in network provider. Please contact us if you have any questions about your plans network.
We will inform you of your plan network name and how to search providers when you choose your plan, however here is how it works and the links to search. Again I always recommend to confirm prior to making any appointments that your plan is accepted. DON’T TAKE THE DOCTORS WORD FOR IT. Its very confusing for them to their defense so if you have any questions you can contact us or use the links below. A good idea is to print out or at least take a picture of the provider ID where it shows that your provider is on the list. Take that with you to your appointment just in the chance that the office claims that they cannot accept your plan. A good example that the office doesn’t understand is if they ask “is it a PPO or HMO’? That question is irrelevant 90% of the time with either Florida Blue and Ambetter plans. If they ask you that then they clearly are guessing.
Ambetter plans will have all the same network regardless of the plan.
Florida Blue has 4 different provider networks which will be listed on your card
- BLUE CARE – is an HMO that really acts as a PPO because no referrals are required to see a specialist it also has a much larger provider network than BLUE SELECT and MY BLUE.
- BLUE SELECT– Is a PPO that has a small provider network, however the price point is always much less than BLUE CARE or BLUE OPTIONS
- BLUE OPTIONS – This is a PPO and has the largest Network in Florida Blue. Their network is about 20% larger that Blue care but you will be paying much more for that 20%.
- MY BLUE– this is a true HMO, referrals are needed for most services from your primary doctor. My blue also has a smaller provider network.
Links to look up your plans providers
note: you can leave the doctor name blank. When looking up Florida Blue providers at least put a 20 or 50 mile radius search to get a more complete list.
DENTAL
For Delta you must select your plan DELTA CARE USA or DELTA PPO from Drop-down box
As soon as you get your Health insurance ID # and cards immediately call and designate the primary doctor for each individual on your plan by calling:
FLORIDA BLUE 1-800-FLA-BLUE (352-2583)
AMBETTER 1-877-687-1169
you must always designate your primary doctor to ensure that your visits will be covered by your plan. You can view the doctor and provider network of your plan by searching here:
Binder Payments
Until you have made your first payment, your plan will never be effective and will just cancel upon the effective date. Always make your first payment prior to that effective date. If you don’t want to wait for the welcome letter in the mail with directions on how to pay, we can submit your initial payment. You can also call or even pay online. Use the exact name and address as stated on your health insurance application or the system will not find you. *We Highly recommended to not set up auto-pay with your insurance plan!* Auto drafts can stop unknowingly throughout the year and your plan could cancel unexpectedly. Also the price may change and you would be charged that amount unexpectedly. We recommend paying month to month or the year in advance.
Florida Blue Binder Payment 1-800-FLA-BLUE (352-2583)
Ambetter Payment 1-877-687-1169 (you can also use this link year round to make monthly payments)
If you call in make sure to use the exact name and address as stated on your health insurance application or the system will not find you. There you can select your primary doctor, order extra cards with the customer service representative as well.
Once you have paid your first premium and have received your ID Cards then you can set up an online account and make future payments this way.If you haven’t received your cards by the effective date, contact us and we can get that number for you so that you can set up your account. Below are the links to set up an online account.
One HUGE problem that I see over and over from new clients is that they never understood much of anything about their Health Insurance Plan. Most people have the notion that health insurance is very confusing and some of it can be, however here is what you should understand to make sure that your plan will work for you and get the most out of it. You should have received a PDF breakdown of your plan summary from us. If you didnt not or need another one please contact us and we can email or mail one right away to you.
Out of Pocket Maximum is both for individual and Family amounts for your plan. This figure is much more important than the deductible in most cases and really is what most people think of when they think of a deductible. The definition is: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn’t include: Your monthly premiums.
Know what services require copays and coinsurance.
Coinsurance (make sure you note if the coinsurance kicks in before or after deductible is met)
The percentage of costs of a covered health care service you pay (20%, for example)
Let’s say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%.
You pay 20% of $100, or $20. The insurance company pays the rest.
Copayment
A fixed amount ($20, for example) you pay for a covered health care service
Your copayment for a doctor visit is $20 (Example) that means that’s the cost for service usually at the time of the visit.
Copayments (sometimes called “copays”) can vary for different services within the same plan, like prescriptions, lab tests, and visits to specialists.
* VERY IMPORTANT Always know how to search for in network doctors for your plans network and designate a primary doctor for each member in your household immediately on plan effective date. (see above on how to do this)
* VERY IMPORTANT Always know what Hospitals and Walk in Clinics or Urgent care centers are in your plan networks. You can use these links to search or contact us to help you. If you just go anywhere without making sure you are in network with your plan could result in paying full price for your visit.
* VERY IMPORTANT EXCEPTION: IF you have an emergency ALWAYS go to the closest E.R. (Emergency Room) your plan should cover ER visits if there is an emergency or potentially life threatening situations. If you need to be admitted you can be transported to your nearest in network hospital upon your stabilization.
PLEASE CONTACT US WITH ANY QUESTIONS
Understanding all of the above will help to ensure that you get the most out of your health insurance plan, while paying the least amount for services and prescriptions throughout the year. Please contact us with any additional questions.
