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ESSENTIALS:

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ESSENTIALS: THE “NEED-TO-KNOWS” ABOUT THE NEW INDIVIDUAL HEALTH INSURANCE MARKETPLACE


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With the onset of healthcare reform, the landscape in the individual health insurance marketplace has changed dramatically. There are LOTS of questions.


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We’ll describe what you need to know in order to navigate the NEW individual segment of the health insurance industry. Get. Ready.


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Let’s share a very short background about the differences between individual health insurance and employer health insurance. They’re not Differences? the same.


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You’ll know that individual versus employer health insurance are two completely different ballgames when it comes to plan design. There are different rules. There are different tax incentives. There are different eligibility criteria. The list goes on. And THAT’S a whole different article. IF YOU KNOW MUCH ABOUT THE HEALTH INSURANCE INDUSTRY AT ALL…


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As an individual or BUSINESS OWNER you’ll want to know the “ins and outs” of both: employer plans AND the new individual marketplace.


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BECAUSE FOR CERTAIN BUSINESS OWNERS: THE INDIVIDUAL SEGMENT WILL BE MOST IMPORTANT NOW ANYWAYS.


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HERE ARE THE “ESSENTIALS” OF THE NEW INDIVIDUAL HEALTH INSURANCE MARKETPLACE. THIS IS WHAT YOU NEED TO KNOW.


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THIS IS PROBABLY THE BIGGEST GAME-CHANGER OF THEM ALL: “Guaranteed Issue.” One of those big insurance words. ESSENTIAL #1: “GUARANTEED ISSUE” MANDATE


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For years-upon-years, if you were going to apply for an individual health insurance plan…. You had to go through a series of health-related questions in order to apply for coverage. There were 50, 60, and sometimes even 70 or more questions. If you’ve applied for coverage before 2014, you know what this is all about. YES. MISERY.


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You heard that right: OUTA’ HERE. It’s still difficult for many to comprehend. There are NO MORE health-related questions on individual health insurance applications anymore. THIS is what is called “Guaranteed Issue” in the insurance world. LOVE. That. Starting in 2014: these health related questions are all GONE.


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ALL GUARANTEED ISSUE MEANS, IS THAT IF YOU APPLY FOR COVERAGE, YOU HAVE GOT TO BE ACCEPTED. You’re in.


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Q: How does this change the ballgame? Game changer. A: You don’t need access to an employer health insurance plan to apply for coverage anymore. This is huge. Especially for those with preexisting conditions.


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It can’t be emphasized enough how much this has freed up individual choice in health insurance plans. We like options. You can literally pick any plan from any company, and apply for coverage now.


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And to boot: if you’re eligible for subsides at the new health insurance marketplaces… Game changing. Again. You could end up receiving quite a bit of money in the form of subsidies that will help you pay for your premiums.


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This all sounds fine and dandy, right? It is. But there are some important concepts that need to be understood. Movin’ on.


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In the past (before 2014), you could apply for an individual health insurance plan at any time during the year. You could go out, pick a plan, and apply for coverage… but you might be denied. ESSENTIAL #2: OPEN ENROLLMENT PERIODS WELL THAT’S ALL HISTORY NOW.


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BECAUSE TODAY (in 2014 and Beyond): There’s now an “individual open enrollment period.” Save the date. Q: What’s an open enrollment period? A: It’s a time-frame at the end of the year when you can enroll for individual health insurance. OPEN ENROLLMENT PERIOD


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THIS is that exact same concept. Except it’s in the new individual health insurance marketplace now. AND IT’S A BIG ENROLLMENT: IT’S THE ENTIRE USA. If you’ve ever worked for an employer that has a company health insurance plan, you’ll know that you’ve usually got to apply for coverage during yearly enrollment.


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Need an appendectomy in the middle of June? It’s too late. Open enrollment is over. Get covered. You’ve now got to enroll during open enrollment each year. This can be very important, because if you miss open enrollment, you don’t get an opportunity to apply again until the end of the next year.


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BUT. WHAT IF I LOSE MY COVERAGE IN THE MIDDLE OF THE YEAR? LIKE CHANGE JOBS. OR GET DIVORCED. BECAUSE: You’re special. IMPORTANT QUESTION. Which leads us right into our next individual marketplace essential: SPECIAL ENROLLMENT.


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ESSENTIAL #3: Special Enrollment Period Q: What is a special enrollment period? A: It’s a time to enroll in the middle of the year (outside of the open enrollment we just described), under special circumstances. THIS IS SPECIAL.


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WHAT ARE THESE SPECIAL ENROLLMENT CIRCUMSTANCES? They’re events. It’s life. They’re “life events” that can take place in the middle of the year. If you incur one, you can “special enroll.” Here are examples: You get married. You get divorced. You have a child. You lose your coverage. You move. Plus others… LIFE EVENTS


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In the KNOW. Most events give you 60 days to enroll in a plan from the time the “life event” takes place. HOWEVER: A Few of these events only give you 30 days. Be sure you know which event applies to you, and how much time you have to enroll. YOU’LL WANT TO MAKE SURE TO UNDERSTAND THESE LIFE EVENTS IF YOU EVER NEED TO UTILIZE THE SPECIAL ENROLLMENT PERIOD.


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Rolling. CONGRATULATIONS: MOVING RIGHT ALONG. THERE ARE ONLY A COUPLE OF “ESSENTIALS” LEFT. We’re going to briefly go over these terms: ESSENTIAL #4: SHARED RESPONSIBILITY ESSENTIAL #5: MINIMUM ESSENTIAL COVERAGE


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ESSENTIAL #4: “Shared Responsibility” “Shared responsibility” is a term that has been coined in the healthcare reform law. It means everybody has got to be “in” in order to make these reforms work: Individuals. Employers. The Government. EVERYONE has got to have a health insurance plan.


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ESSENTIAL #5: Minimum Essential Coverage “Minimum essential coverage” is the type of coverage you need to have in order to satisfy the requirements of the Affordable Care Act (ACA). There is a standard of coverage that has to be met. THE BAR HAS BEEN RAISED.


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Effectively: “Minimum Essential Coverage” has standardized health insurance. There are now only FOUR metallic levels of coverage when it comes to ALL health plans: PLATINUM. GOLD. SILVER. BRONZE. (For those under 30yo, there’s also a “Catastrophic” plan) It’s minimum. It’s essential.


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Roger that. IN ORDER TO AVOID PAYING A TAX PENALTY, YOU MUST BE ENROLLED IN A “MINIMIUM ESSENTIAL COVERAGE” HEALTH PLAN. There’s no doubt about it. There are tax penalties that start in 2014 if you don’t have a health insurance plan. You’ll need to participate in a bronze, silver, gold, or platinum level plan in order to avoid it.


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THIS is where the bar was raised. AND: THAT PLAN WILL NEED TO CONTAIN NEW MANDATED “ESSENTIAL BENEFITS.” Count ‘Em:


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NO “ifs, ands, or buts.” #1) Outpatient Care. #2) Trips to the Emergency Room. #3) Inpatient Hospital Care. #4) Well Baby Care. #5) Mental Health Coverage. #6) Prescription Drug Coverage. #7) Services if you’re Disabled. #8) Lab Testing. #9) Preventive Services. #10) Pediatric, Including Dental. EVERY HEALTH PLAN MUST HAVE:


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AND THAT’S IT. THOSE ARE THE ESSENTIALS OF THE NEW INDIVIDUAL HEALTH INSURANCE MARKETPLACE. THEY’RE THE “NEED-TO-KNOWS” SO THAT YOU CAN BEGIN TO NAVIGATE THE INDIVIDUAL HEALTH INSURANCE SEGMENT MORE EASILY.


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TYSON J LESTER, RHU, REBC President, Policy Advantage Insurance Services Toll Free: (800) 617-0089 Los Angeles Area: (424) 442-0170 Email: info@policyadvantage.com www.policyadvantage.com | CA Insurance License #0F22799 ARTICLE WRITTEN BY


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We help individuals and businesses sort out all of the aspects of employer health plans, and the NEW individual health insurance marketplace. Please contact us if you have questions. We share high-value information and look forward to working with you. Thanks for stopping by. Toll Free: (800) 617-0089 Los Angeles Area: (424) 442-0170 Email: info@policyadvantage.com www.policyadvantage.com | CA Insurance License #0F22799 WE HELP INDIVIDUALS AND BUSINESSES


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