The Top 7 Essentials
Author: Suzanne Candee, CT Agent
We may be enjoying the lazy, hazy days of summer. However … Let us pause and remember that Fall is approaching, and with it, the flurry of activity (and for many, the confusing quagmire) associated with Affordable Care Act (“Obamacare”) Open Enrollment.
In our experience, we find that what people do not understand generally upsets them. People also tend to get upset when they feel they are being told what to do, or not given a choice. Dealing with the rules, requirements and regulations of the Affordable Care Act (and the CT Healthcare exchange, Access Health CT / AHCT) definitely seems to apply here for many.
Need help?? Here some important tips that may assist you in navigating these murky ACA waters –
Our Top 7 Essentials re. The ACA and AHCT
7 “Obamacare” = The Affordable Care Act, Period.
“Obamacare” is the moniker most often given to health plans designed in accordance with the Affordable Care Act (ACA) — all of the new health plans offered since January 2014. The ACA allows for states to offer Health Insurance plans to consumers through healthcare exchanges, where applicants, if eligible, may receive federal tax credits and/or other reductions to lower their healthcare costs, or join the state Medicaid program. CT has its own healthcare exchange, Access Health CT (AHCT). Obviously, we refer to applying on AHCT as purchasing a plan “on the exchange”.
The ACA also allows for Health Insurance carriers (companies like Aetna, Anthem BCBS, CIGNA, Connecticare, Healthy CT or United Healthcare) to offer Health Insurance plans directly to consumers, at full-price. There are no tax credits or reductions offered in this case. We refer to this as purchasing a plan “off the exchange”.
There are many that have erroneously referred to “Obamacare” as plans purchased “on the exchange”.
However, whether one is purchasing a health insurance policy “on the exchange” (applying through AHCT), or “off the exchange” (directly from a Health Insurance carrier) one is purchasing an ACA health plan; participating in “Obamacare”.
6 Enrollment Periods – The Good, the Bad & the Ugly
Rules, rules, rules. The ACA has a distinct set of rules regarding when we may and may not apply for health plans during the calendar year.
Open Enrollment happens annually, and is the opportunity to buy a new plan for the coming benefit year. This year’s Open Enrollment will be November 1, 2015 thru January 31, 2016 for 2016 health plans.
When Open Enrollment is over, there are only certain life circumstances (“qualifying events”) that will allow one to be able to purchase a new health plan during the rest of the year, including marriage, divorce, having or adopting a baby, moving into the state, or losing essential coverage. These qualifying events may allow one to purchase a new health plan thru a Special Enrollment Period (SEP).
It is in the “losing essential coverage” scenarios where the bad & ugly aspects can raise their heads. For example, losing coverage from your employer is a valid qualifying event for a Special Enrollment Period. However, losing your employer-based coverage, choosing to go on COBRA, and later deciding you cannot afford COBRA does notconstitute a SEP.
In addition, Health Insurance carriers are now very strict with regards to premium payment, and strongly enforce payment grace periods. In other words, please pay your premium as billed on time, or you risk your plan being cancelled. Losing existing individual coverage due to non-payment of premiums also does not constitute a SEP.
5 Let’s Talk About Income Projection
Hmmm … Income Projection may include tax filings, profit-and-loss statements, unemployment compensation, family gifts, sheer estimation and “crystal-balling” regarding the future.
The first step we take when approaching ACA plans is one’s Adjusted Gross Income (AGI) – starting with, “Line 37 on your 1040 Form”. Modified Adjusted Gross Income per size of household is the measure that AHCT utilizes to determine eligibility for Medicaid, or for federal tax credits/subsidies to lower health insurance premiums & costs, or for full-price health plans.
If one’s household AGI has them eligible for Medicaid or federal tax credits/subsidies, we explore the process and outcomes of applying for health plans “on the exchange”, unless one is opposed (philosophically or politically) to utilizing AHCT.
If one’s household AGI has them eligible for a full-price health plan, we can look at plans thru AHCT (“on the exchange”), but we often find there are far more choices and competitive pricing for full-price health plans “off the exchange”.
Whether or not one’s household AGI would allow eligibility for Medicaid or federal tax credit/subsidy, anyone may purchase a full-price health plan, on or off the exchange.
4 Verification Documentation, Whether We Like It or Not
So, you’ve completed your AHCT application, you’ve seen your eligibility determination, you’ve chosen a plan, you’ve seen and confirmed your plan summary, you are complete, and can go on your merry way …
Not. So. Fast. AHCT is asking you to provide some sort of Verification Documentation (Proof of Identity, Proof of Income or Employment, etc.) within the next 90 days … or else.
This exercise of finding the appropriate Verification Documentation and sending it to AHCT has its very own good, bad and ugly aspects. For example, if one is self-employed, or does not have “traditional” methods of documenting Income (pay stubs, W-2, 1099, etc.), this process can prove quite challenging.
Additional administrative complications, missed communications, misunderstandings, and inaccuracies can complicate this process significantly, and cause frustration all around.
3 Verification Documentation – They Mean It, They Really Mean It
These requests for additional Verification Documentation to AHCT often appear as a flurry of annoyance; something we’d rather ignore, avoid or even forget … However, it is real, and not responding in the timing requested, or providing documents which do not match the information on the AHCT application, has real consequences.
“Failing Verification” and/or not getting information to AHCT in the 90-days-from-application window may trigger a “90-Day Determination Letter” to the insured from AHCT. This letter (difficult for many to understand) is alerting the insured that because they did not comply with the request for additional Verification Documentation (for any number of reasons), it has changed their eligibility determination, and essentially voided whatever “deal” they originally had with AHCT when they applied for coverage for that year. In some cases, a federal tax credit/subsidy is taken away (the insured remains on their chosen plan, at full-price, and may now owe additional premium to the carrier from the plan’s inception). In other cases, a cost-reduction plan may be taken away.
These new determinations from AHCT can be appealed, though require timeliness, tenacity, clarity, and often the help of a knowledgeable broker/advocate to succeed. There is a time frame for appeals, and if one waits too long to respond to a 90-Day Determination Letter, they may be left uninsured.
2 “The Point of No Return” – What Can I Do??
Are you still with us, Dear Reader?? There is light at the end of the tunnel …
If you find yourself uninsured at this point – either because you missed Open Enrollment entirely, or you fell victim to an AHCT complication … There are still Health Insurance options available for you.
The options available are not compliant with ACA (does not prevent you from paying the tax penalty for being uninsured). They do not cover pre-existing conditions or preventive (annual wellness) visits, but are designed to cover any new illness or injury, and fill the insurance gap in which you may find yourself.
1 Stop, Drop and Call a Broker
No matter where you are in your Health Insurance search or situation, the most important thing to do is to align yourself with a knowledgeable, licensed agent/broker.
You have nothing to lose, and everything to gain.
We are experts — trained, certified and experienced in Health Insurance matters, on and off the exchange.
And – Bonus — It does not cost you anything to work with a broker!
We are experts at dealing with AHCT applications, correspondence and appeals.
We work consultatively with you to find the right solution for you – your situation and circumstances. We are even trained and experienced regarding other lines of Insurance: Life, Disability, Long-Term Care, retirement plans and Medicare.
We can become your broker at any time!
Stop, drop and contact us!
Call 203-730-8304 or email firstname.lastname@example.org