Topics Covered and Questions Answered:

  • Explanation of the ACA (Affordable Care Act) provisions
  • Update on the plans available in Raleigh, Durham and Chapel Hill area
  • ACA Terminology
  • How to choose a plan?
  • Who is eligible for a government subsidy?
  • How to apply for a government subsidy and what questions to expect?
  • When you can apply for health insurance?
  • What alternatives are available to ACA compliant policies?
  • Who to call when you have health insurance complaints or to report fraud.

As a result of the Affordable Care Act (a.k.a. ObamaCare) the following provisions are now in place for health insurance policies with an effective date January 1, 2014 or after:

  • Individuals cannot be declined for health insurance or charged more due to their health status or gender.
  • Insurance premiums are based on age, your zip code and tobacco usage.
  • Coverage limitations or exclusions based on pre-existing conditions are not allowed.
  • Elimination of annual and lifetime coverage limits.
  • Prohibition of declining an individual for coverage based on their participation in an approved clinical trial.
  • Maternity and mental health are included on all policies.
  • Preventative dental is covered for members up to age 19. There is also some vision coverage available for this age group.
  • Whether or not your children are students they can stay on your policy until age 26.
  • Introduction of the Medical Loss Ratio, which ensures that 80% of the premium dollars paid to the health insurance issuer are spent on providing health care. An insurance company that does not do this must provide rebates to their policyholders.

Note: Dental and Vision are not covered for adults but both can be purchased as standalone policies.

 When can you apply for Health Insurance?

Whether or not you qualify for financial assistance paying your health insurance premiums, you can only apply during Open Enrollment, which is between November 1st, 2018 and December 15, 2018. The effective date for these policies is January 1, 2019.  The only exception is if you have a Qualifying Life Event that triggers a 60 day Special Election Period to apply for insurance.

In addition to applying for health insurance during Open Enrollment, you can also change policies, change insurance companies, buy a more expensive, benefit rich policy or buy a less expensive policy with less benefits.

Who is eligible for a Marketplace Subsidy?

Individuals or families who are not eligible for employer health insurance and whose household income is between 100% and 400% of the Federal Poverty Level are usually eligible. Sometimes individuals who are offered health insurance from their employer are approved for a subsidy if their employer’s plan is not ACA compliant or the employer’s plan is not considered “affordable”. Since NC has not expanded Medicaid you will not be eligible for a subsidy if your income is below a certain level. This is the Federal Poverty Level Guidelines chart which can help you determine if you are eligible for a government subsidy:

 in Household 100% FPL 138% FPL 150% FPL 200% FPL 250% FPL 300% FPL 400% FPL
1 $12,140 $16,753 $18,210 $24,280 $30,350 $36,420 $48,560
2 $16,460 $22,715 $24,690 $32,920 $41,150 $49,380 $65,840
3 $20,780 $28,676 $31,170 $41,560 $51,950 $62,340 $83,120
4 $25,100 $34,638 $37,650 $50,200 $62,750 $75,300 $100,400
5 $29,420 $40,600 $44,130 $58,840 $73,550 $88,260 $117,680
6 $33,740 $46,561 $50,610 $67,480 $84,350 $101,220 $134,960
7 $38,060 $52,523 $57,090 $76,120 $95,150 $114,180 $152,240
8 $42,380 $58,484 $63,570 $84,760 $105,950 $127,140 $169,520
For households with more than 8, add $4,320 for each additional person.

Note: Eligibility for premium tax credits in coverage year 2019 is based on poverty guidelines for 2018. FPL = federal poverty line.

Source (plus Hawai’i and Alaska guidelines):

Even if you do not qualify for Medicaid your children may qualify for Medicaid or CHIP. The Federal Poverty Level Guidelines are also on page 13 of the BCBS 2019 Health Plans Brochure.

How your subsidy and health insurance premiums are determined?

The amount of a government subsidy is based on the age of each family member, family size, and your estimated Modified Adjusted Gross Income (MAGI) of the entire family for 2018.  MAGI is your adjusted gross income (line 37 on IRS 1040) added to your tax-exempt interest income (line 8b on IRS 1040 Tax Return Form).

Health insurance premiums are based on age of each family member, zip code, the plan design (i.e. size of deductible, co-pays and provider network), tobacco usage and the claims experience of the plan and insurance company. If you qualify for a subsidy you can take it as a tax credit when you file your taxes, take part of it or do as the majority of policy holders do, take the entire amount each month. Unless you choose to wait until you file your taxes, the government sends your subsidy to your insurance company each month and you pay the difference.

 Understanding Insurance and Affordable Care Act Terminology:

ACA-It stands for Affordable Care Act which went into effect January 1, 2014 and is also known as heath care reform, Patient Protection Affordable Care Act, PPACA or ObamaCare.

Health Insurance Marketplace– An online marketplace where individuals can compare, shop for and buy qualified health insurance plans. It is also called the “Exchange” or A policy purchased through the Marketplace is called an “On-Exchange” policy. One purchased directly from the insurance company is called an “Off-Exchange” policy.


EHB- An acronym for the 10 Essential Health Benefits that the Affordable Care Act requires for all policies that are effective January 1, 2014 or later. These are ambulatory patient services, emergency services, maternity, pediatric dental & vision, rehabilitative services & devices, mental health & substance use disorder, preventive (including chronic disease management), hospitalization, prescription drugs and laboratory services.

QHP– An acronym for Qualified Health Plan which is a health plan that has the 10 essential benefits.

Medicaid- A program run jointly by the Federal and State Governments that provides health coverage for low-income people, families, children, the elderly and people with disabilities. You can apply anytime. To apply for Medicaid or CHIP call 919-212-7000 or visit

CHIP– An acronym for Children’s Health Insurance Program. This is administered by the state and provides no-cost or low-cost health insurance for children in families who earn too much to qualify for Medicaid, but cannot afford to purchase private insurance. In NC this is known as Health Choice. You can apply anytime.

CMS- An acronym for Centers for Medicare & Medicaid Services. This agency, which is under the U.S. Department of Health and Human Services, is responsible for Medicare, Medicaid and the implementation of the Affordable Care Act.

Broker– This is an insurance agent who represents multiple insurance companies. Agents and brokers who have completed and passed the CMS Marketplace training can assist individuals with enrolling in a Marketplace plan over the phone. Most, like me, have access to software which allows them to enroll their clients in a subsidized plan without the client touching their computer.

 Navigators– Individuals who have completed the CMS training so they can assist consumers with applying for Marketplace Plans. They also provide outreach and education to raise awareness about the Marketplace Plans. Their activities and pay are funded through state and federal grant programs. To find the location of a navigator or set up an appointment, call 1-855-733-3711 or visit

SEP- Special Enrollment Period– This is a period outside of open enrollment when individuals can enroll in or change a plan purchased on the Marketplace within 60 days due to a qualifying event.  

Qualifying Life Event– An event in your life that provides for a Special Election Period when you can purchase health insurance. Examples are getting married, birth or adoption of a child, permanently moving to a new area that offers different health plan options, losing health coverage due to job loss, divorce, loss of Medicaid or CHIP eligibility, expiration of COBRA, or a health plan being decertified. Note: Voluntarily dropping your health insurance or being terminated for not paying premiums is not a qualifying event.     

Step Therapy- Policy holders taking an expensive brand drug are often required by their insurance company to try a generic equivalent. If your doctor thinks this would be a threat to your health he can request an exception from your insurance company.

Short Term Medical Policies (STM) – As the name implies, these are health insurance policies for individuals who need coverage for a short period. Although some will provide coverage for up to 12 months, they do not cover any pre-existing conditions or preventive. Due to the fact that consumers can purchased these plans for longer periods they sometimes assume they will cover preventative and are surprised they do not cover the drugs they need due to a pre-existing condition.

IRS Qualified High Deductible Health Plans (HSA Plans) – With this health insurance plan the policy holder pays for all medical expenses except preventative until he reaches his deductible. These plans can be paired with a Health Savings Account (HSA) which can reduce the policy holder’s taxable income. The policy holder can withdraw money from his Health Savings Account to pay his medical expenses without a penalty. Individuals who purchase these plans are not required to set up an HSA. My website,, has more details about Health Savings Accounts.


COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) allows workers and their dependents to purchase group coverage for 18 months (or sometimes longer) when the worker is voluntarily or involuntarily terminated. Workers can pay up to 102 % of the cost of the premium the employer pays for coverage. The former employee can purchase COBRA for a dependent even if he does not purchase it for himself. Also, normally one can accept the dental and vision COBRA even if they don’t accept the medical.


Metallic levels of the Health Insurance Plans

Health care reform established these levels to help consumers compare the value of various plans. They are used by for plans on and off the exchange.

 Bronze- Ideal for people that want low premiums and don’t expect to need a lot of medical services. Policy that are compatible with Health Savings Accounts are in this category.

Silver– Designed for those who want monthly premiums and out-of-pocket medical costs more balanced. Applicants with very low incomes are eligible for silver enhanced plans with lower copays, deductibles and maximum out of pockets.

Gold– These plans are designed for individuals who receive medical attention on a regular basis and are willing to pay a higher premium.

Catastrophic– These are the least expensive plans designed for individual who rarely have any medical expenses. Unless you have a “hardship” exemption you must be under age 30 to qualify for this plan.  To get a “hardship” exemption you must submit an application, which is on the Marketplace web site, and be approved. Examples of hardships that would qualify you for the exemption are being homeless, an eviction from your home during the past 6 months, recent shut-off from a utility company, domestic violence, damage to your property due to natural or human caused disaster, bankruptcy, death of a close family member or having an income too low to qualify for government financial assistance for health insurance.  If you choose this policy you will not be eligible for a subsidy.

2019 update of Health Insurance Companies Serving Durham, Raleigh & Chapel Hill:

BlueCross BlueShield of North Carolina ( The large Blue Advantage and its tiered cousin Blue Select medical networks are available in all but 19 NC counties.

Chatham, Durham, Franklin, Orange and Wake Counties are among these 19 counties. Policy holders in these counties only have the Blue Value network which includes Rex and UNC Hospitals. The policies in these counties are POS’s (Point of Service). With this type of policy you can go out of their medical network, but unless it is coded as an emergency you will pay a higher amount for medical services. Also, specialists in a POS type network sometimes require a referral from your Primary Care Physician.

BCBS offers plans in all 100 NC counties and is the only insurance company that is participating in the Marketplace in all 100 counties.  The term “participating in the Marketplace” means the CMS (Centers for Medicare and Medicaid Services) has approved a health insurance company to sell subsidized policies on the Marketplace. CMS is the government agency responsible for administering the Affordable Care Act.

Ambetter Health Insurance (, created from Celtic Health Insurance in 2014, Parent company is Centene) will be offering HMO (Health Maintenance Organization) plans in Durham and Wake County in 2019. This means if you go to an out of network provider the insurance company will not pay for your medical services unless it is coded as an emergency. Ambetter does not require you have a referral from your PCP (Primary Care Physician) before you visit a specialist. Duke and WakeMed hospitals are in-network with Ambetter.

Their plans include:

  • Myhealthpays Rewards which allows policyholders to earn up to $125 for health activities like getting a flu shot, having a wellness exam and completing an Ambetter Wellness survey. The rewards are given in the form of a prepaid Visa card and can be used to pay premiums, co-pays or buy food at Walmart.
  • Telehealth, which is a 24 hour phone or video access to in-network providers for non-emergency health issues.

Cigna: Cigna is offering HMO (Health Maintenance Organization) plans in NC in five counties, which are Chatham, Johnston, Nash, Orange and Wake. The UNC (University of North Carolina) and Rex Hospitals are in-network with Cigna.

Their HMO plans require the policy holder to have a PCP (Primary Care Physician). Unless it’s an emergency these plans do not pay your medical expenses if you go outside their medical provider network. Also, they will not pay for specialist visits if you do not have a referral from your PCP.

For more information about the Cigna plans you can call Cigna Direct to Customer at 1-866-438-2446, visit or call the Marketplace at 1-800-318-2596.

Make sure you know the answers to the following 8 questions before you enroll in a new plan:

  1. Are all your medical providers (i.e. doctors, pharmacies and hospitals) in the network of this plan?
  2. Can you go out of the medical provider network?
  3. What is the deductible (dollar amount you must pay before your insurance pays) for medical procedures and pharmaceuticals?
  4. Are my prescriptions drugs in the formulary of this plan?
  5. What are the co-pays (fixed dollar amount) for medical services and my prescription drugs?
  6. Is a referral required from my Primary Care Provider to visit a Specialist?
  7. What is the Maximum out of pocket? This is the maximum you pay from your own funds and includes deductibles, co-pays and co-insurance for covered medical and drug expenses. Once you reach this amount the insurance must pay 100% of your medical expenses until the end of the year.
  8. Is this plan compliant with the ACA (Affordable Care Act)?

What information will you need and questions to expect when you are applying for a subsidy?

  • You must provide dates of birth and social security numbers of all the members of your household.
  • You’re required to provide all sources of income such as the company you work for, type of work you do as a self-employed person, rental income or dividend producing stock.
  • Child support and Supplemental Security Income are not considered part of your income.
  • Income information must be provided for everyone you claim on your 1040 tax form even if they are not applying for coverage. Your income used to calculate your subsidy can be from your tax return from 2017 as well as your expected income for 2018.
  • Normally your children’s income is included as part of your income if you claim them as a dependent on your income tax return.
  • If you are not a US Citizen you will be required to provide your immigration documentation.
  • You will be asked if you plan to file an income tax return in 2019. If you say no you will be told that you are not eligible for a subsidy.

How do you apply?

You can do it yourself on-line at or by calling for assistance at 800-318-2596.  However, these are professionals who can assist you at no cost:

  • Although there are exceptions, most health insurance brokers and agents do not charge for their services if you select an Ambetter or BCBSNC plan. They can help you look up your medical providers to determine what network they are in and make sure you choose the plan that best fits the needs of you and your family.  Our access to HealthSherpa software means you do not have to meet with us in person, log into the Marketplace or touch your computer.
  • You can meet with a navigator in person. Go to to find a planned public navigator event in your area or make an appointment. You can also call 1-855-733-3711.

Once you have been approved for a subsidy and selected your health insurance plan from the Marketplace, your information will be transmitted electronically to your insurance company. If you have a broker or agent they receive a report which allows them to follow your application through the enrollment process making sure you make your first payment on time, supply the Marketplace with additional information if they request it and make the process as problem free as possible. Your broker will continue to be available to address your concerns even after you are enrolled.

What alternatives do you have to purchasing an individual ACA health insurance policy?

Short Term Medical plans

Association Medical plans through organizations like Shop Local Raleigh or National Association of Realtors


Small Group Plans

Health Sharing Ministries (not health insurance)


Veteran’s benefits

Who you can call with health insurance consumer complaints or to report fraud?

Call the NC Department of Insurance at 1-855-408-1212 or visit their website at

This presentation was given to Colonial Job Seekers on December 3rd, 2018.


Wanda Stephens, NPN (National Producer Number): 8504772

Health Insurance Solutions of NC   Website:

Email: Office: 919 845 6001 Cell: 919 740 6534

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