Individual and Family Plan FAQs
The security of strong medical coverage and preventative care.
The Patient Protection and Affordable Care Act of 2010, known as ACA or Obamacare, has provided many previously uninsured and underinsured people the security of strong medical coverage and preventative care.
Along with this good news comes expected confusion that can result from such large changes. You are not alone – there are a lot of people who are still questioning: “What is Obamacare, exactly?” and “Does the Affordable Care Act affect me?”
The comprehensive health care reform law enacted in March 2010. Sometimes it’s referred to as ACA, PPACA, or “Obamacare.”
The law has 3 primary goals:
- Make affordable health insurance available to more people. The law provides consumers with Cost-Sharing Subsidies and/or Advanced Premium Tax Credits (APTC) that lower costs for households with incomes between 100% and 400% of the federal poverty level.
- Expand the Medicaid program to cover adults with income below 138% of the federal poverty level.
- Support innovative medical care delivery methods designed to lower costs of health care generally.
The ACA offers rights and protections that make coverage fairer and easier to understand. Some rights and protections apply to plans in the Health Insurance Marketplace or other individual insurance, some apply to job-based plans, and some apply to all health coverage. The protections outlined below may not apply to grandfathered health insurance plans.
- Requires insurance plans to cover people with pre-existing health conditions, including pregnancy, without charging more
- Provides free preventive care
- Gives young adults more coverage options
- Ends lifetime and yearly dollar limits on coverage of essential health benefits
- Helps you understand the coverage you’re getting by requiring insurance companies and job-based health plans to provide you with a short, plain-language Summary of Benefits and Coverage, along with a Uniform Glossary of terms used in health coverage and medical care
- Holds insurance companies accountable for rate increases with the 80/20 rule which requires them to spend at least 80% of the money from premiums on health care costs and quality improvement activities
- Makes it illegal for health insurance companies to cancel your health insurance just because you get sick
Health insurance coverage under any of the following:
- A group health plan
- Individual health insurance
- Student health insurance
- CHAMPUS and TRICARE
- Federal Employees Health Benefits Program
- Indian Health Service
- The Peace Corps
- Public Health Plan (any established or maintained by a State, the U.S. government, a foreign country)
- Children’s Health Insurance Program (CHIP)
- State health insurance high-risk pool
ACA plans and options are available through the Health Insurance Marketplace. Some states operate their own health insurance marketplaces. In Wisconsin, however, individuals can enroll through www.healthcare.gov, with a local broker, navigator, or by calling the Marketplace directly at 1-800-318-2596.
Alternatively, some employers may offer affordable coverage that is Affordable Care Act compliant, otherwise known as Creditable Coverage. In order to avoid paying a penalty or making a mistake by enrolling in a plan that does not meet your needs, speak with a licensed broker who is certified and can assist you with choosing the right plan. FHK Insurance agents are licensed and certified to assist you with your ACA choices and would be happy to help.
The yearly period when people can enroll in a health insurance plan.
Outside of the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You’re eligible if you have certain life events, like getting married, having a baby, or losing other health coverage.
- Job-based plans may have different Open Enrollment Periods, so it’s important to check with your employer
- You can apply and enroll in Medicaid or the Children’s Health Insurance Program (CHIP) any time of year
If you have employer-based coverage, you might be able to change to a Marketplace plan. But you probably won’t qualify for a Premium Tax Credit or other savings. As long as the employer-based plan is considered affordable and meets minimum standards, you won’t qualify for savings. Most employer-based plans meet these standards.
Deciding whether or not to take COBRA is similar. Losing employer-based coverage qualifies you for a Special Enrollment Period on the Health Insurance Marketplace, and gives you up to 60 days to make a selection. If your income does not provide you with help paying for the premium, one of our agents would be happy to assist you in determining which option is more suitable for you.
If you already have COBRA and aren’t sure what your options are, click here.
Exchange is another term for the Health Insurance Marketplace, a service in every state that helps consumers shop for and enroll in insurance.
If your annual household income is between 100% and 400% of the federal poverty level, you would most likely be eligible for Advanced Premium Tax Credits (APTC) and/or Cost-Sharing Subsidies to help pay your premiums and/or reduce your out-of-pocket expenses. The APTC and Cost-Sharing Subsidies are only available through the Health Insurance Marketplace. Therefore if your income is between those levels you would want to go ‘On Exchange’.
If your income is over 400% of the federal poverty level, you are still eligible to purchase insurance through the Health Insurance Marketplace. However, you won’t be eligible for lower costs. You can also get insurance in other ways such as purchasing a policy directly through the company, an online insurance seller, or through an agent or broker like FHK.
A Premium Tax Credit is a tax credit you can use to lower your monthly insurance payment when you enroll through the Health Insurance Marketplace. Your tax credit is based on the income estimate and household information you put on your Marketplace application.
If your estimated income falls between 100% and 400% of the federal poverty level for your household size, you qualify for a premium tax credit.
This online calculator will help determine what your tax credit is. You can use all, some, or none of your Premium Tax Credit in advance to lower your monthly premium.
Yes! One of the essential health benefits that all plans must cover, is prescription drugs.
To find out which prescriptions are covered through your Marketplace plan:
- Visit your insurer’s website to review a list of prescriptions your plan covers
- See your Summary of Benefits and Coverage
- Call your insurer directly
- Review any coverage materials that your plan mailed to you
- Ask your health insurance broker
No, you will pay the same amount to work with an agent as you would if you were researching and dealing with the application process all on your own.
FHK Insurance is one of the oldest and largest insurance agencies in Wisconsin. We currently have agents with over 30+ years of experience, who can help you determine what you are eligible for and when. Unlike the federal Marketplace call center and Marketplace Navigators, FHK agents are licensed and certified to make Affordable Care Act plan recommendations. We are devoted to providing a personalized touch, that only an independent broker can offer. We represent most major health insurance companies; our entire focus is on working with our clients and finding the most efficient plan for them.
To find out how we can help you today, click here for no-pressure information from our seasoned agents.