Health Insurance

Healthcare Reform - Making an Informed Decision

Beginning in 2014, we transitioned into a new era of healthcare and individual health insurance with the advent of the Affordable Care Act (ACA). If you need health insurance because you aren’t covered through your job or your spouse’s plan, or you’ve retired but are younger than 65 and not yet eligible for Medicare, you may want to consider signing up for an individual plan under the Affordable Care Act.  Our goal is to inform you of your options regarding the Affordable Care Act and help you navigate the process of obtaining coverage and determining eligibility for premium tax credits when purchasing an ACA compliant plan.

What is an ACA compliant plan?

ACA compliant plans are plans that meet certain “Essential Health Benefit” requirements.  Three significant mandates included in compliant plans are maternity care, coverage for mental health benefits and coverage for pre-existing health conditions. 
          There are only 4 factors used to rate policies in ACA compliant plans:  

·         Family matrix

·         Age

·         Smoking

·         Geographic area

 

How do I obtain coverage for an ACA compliant plan?

Coverage can be obtained through any carrier that offers ACA compliant plans but there is a limited open-enrollment period in which to apply for coverage.  Open enrollment is from November 1, 2023 - December 15, 2023 for coverage effective January 1, 2024. Applications received and December 16, 2023 – January 15, 2024 will have an effective February 1, 2024.  Outside of the open enrollment period you may enroll for coverage if you have a qualifying life event and are eligible for a Special Enrollment Period (SEP).

 

What Is a Qualifying Life Event?

·         You move to a new area that offers different plans, or isn't covered by your HMO network

·         You get married

·         You have or adopt a child

·         You lose other health coverage due to job loss, a decrease in work hours, end of COBRA coverage or other reasons

·         You become a U.S. citizen

·         Your income changes or some other event changes your income or household status

·         You can prove that your health insurance company violated its contract with you

·         You are no longer covered on a family member's policy because you turned 26, you have legally separated from or divorced your spouse,
          or the policy holder has passed away

·         You become a member of an American Indian and Alaska Native tribe

 

How do I select and apply for a plan?

All ACA compliant plans are available through private health insurance companies.  If you qualify for a premium tax credit, you will need to apply through the Health Insurance Exchange available through our website, www.statewidehealthinsurance.com .  The health insurance exchange, otherwise known as the Health Insurance Marketplace, is a comparison-shopping site for health insurance. Private health insurance companies list their health plans with the Exchange, and you can comparison shop from among the available health plan listings. Plans on the Exchange fall within the following categories to make it easier for consumers to compare plan premiums and coverage options:  Catastrophic, Bronze, Silver, Gold and Platinum plans. When applying through the Exchange, your premium will be calculated based on the amount of tax credit you are eligible for. 

If you do not qualify for a premium tax credit, you can go still go to www.statewidehealthinsurance.com and easily obtain and compare current rates from carriers offering coverage in your county. 

ON-EXCHANGE: You are registering to obtain the Advance Premium Tax Credit. You can get this as an advance to assist with paying your monthly premiums or you can receive a lump sum credit when you file your tax return.

OFF-EXCHANGE: You are going straight to the carrier and not registering through the Exchange.

Things to know:

Individual health plans utilize separate provider networks than group plans!  The key to selecting an individual plan is verifying that providers you are wanting to see are participating providers within that carrier’s individual network.   Individual plan options are HMO / EPO plans.  There are NO out of network benefits.

Blue Cross Blue Shield of Texas along with Community Health Choice currently have the most favorable participating provider networks. Additional carrier options include:

AmBetter    Aetna/CVS     United       Oscar        Molina

(Brightway and Friday Health exited the Texas Market in 2023)

 

Remember, the government is not in the health insurance business! They are in the “helping you pay your premium business” if you qualify for tax credits based on your income and family size. If you register through the Exchange, your coverage is still provided through one of the private carriers that participate in the Exchange. Plan designs are the same on or off the Exchange.  

How do I determine if I qualify for an Advanced Premium Tax Credit (APTC)? 

 

The APTC or Subsidies are based on eligibility, your family size and projected Modified Adjusted Gross Income (MAGI) for 2023. Qualifying for subsidies can lower your net premiums on an ACA compliant health plan purchased through the Health Insurance Marketplace. For most applicants this will be your Adjusted Gross Income reflected on Line 11 on Form 1040.

 

There is no cost to the applicant when working with an agent!

A licensed health insurance agent can assist you with making an informed decision and

guide you through the application process. For more information visit our website (www.statewidehealthinsurance.com) or call us at 281-485-0088.