Topics Covered and Questions Answered:

  • Explanation of the ACA (Affordable Care Act) provisions
  • 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 that is compliant with the Affordable Care Act?
  • What alternatives are available to ACA compliant policies?
  • Who to call when you have health insurance complaints or to report fraud.

To be in compliance with the Affordable Care Act (a.k.a. ObamaCare) a health insurance policy much conform to the following provisions:

  • 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.
  • 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. There are exceptions.  Ambetter offers policies in NC which include dental and vision. BCBSNC has policies that cover dental and vision for children up to 19.

 When can you apply for Health Insurance that is compliant with the ACA?

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 and December 15th. The effective date for these policies is the following January 1st.  Normally, the only exception is if you have a Qualifying Life Event that triggers a Special Election Period (SEP), which is normally 60 days.  Examples of a Qualifying Life Event 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.  

Due to the large numbers of people who have died or become sick due to the Corona Virus, President Biden has ordered a second open enrollment for 2021. This Open Enrollment will last from February 15th through May 15th. During this period a person without health insurance can obtain health insurance that is compliant with the Affordable Care Act. Also someone who is unhappy with their current insurance can change to a different policy.

What is a Marketplace Subsidy and who is eligible?

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 probably not be eligible for government assistance if your income is below a certain level. Even if you do not qualify for Medicaid, your children may qualify for Medicaid or CHIP. The Federal Poverty Level Guidelines chart below will help you determine if you are eligible for a subsidy.

Household Size Minimum Income –
100% Federal Poverty Level
Maximum Income –
400% Federal Poverty Level
One individual $12,760 $51,040
Family of 2 $17,240 $68,960
Family of 3 $21,720 $86,880
Family of 4 $26,200 $104,800
Family of 5 $30,680 $122,720
Family of 6 $35,160 $140,640
Family of 7 $39,640 $158,560
Family of 8 $44,120 $176,480

For families/households with more than eight people, add $4,480 for each additional person.

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 2020.  Normally this is income before state and federal taxes are subtracted.

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.

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 without meeting with them in person.

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.

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.

Deductible – The amount you or your family owe for certain covered medical procedures or services before your health insurance begins to pay.

Coinsurance – When you pay a percentage of the cost of a covered medical procedure or service after the deductible is met.

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.

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 healthcare.gov. 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.

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, www.hisonc.com, has more details about Health Savings Accounts.

Maximum out of pocket limit – This is the maximum a policy holder has to pay from their own funds for covered medical procedures during the calendar year. This includes the amount spent on deductibles. copayments, coinsurance and prescription drugs. It does not include the amount spent on premiums, non covered  services and out of medical network charges.

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 https://dma.ncdhhs.gov/medicaid.

 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 NCNavigator.net.

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

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 and can be renewed for several years, they normally do not cover any pre-existing conditions or preventive. Due to the fact that consumers can now purchase these plans for longer periods they sometimes assume they will cover preventative and are surprised when they discover they much pay out of pocket for their preventative exam.

 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.

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 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. Policies 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.

 These are the insurance companies that in 2021 will offer insurance plans compliant with the Affordable Care Act in NC:  

                                                                  

BlueCross BlueShield of North Carolina, a.k.a BCBSNC (www.bcbsnc.com)

For residents of Alamance, Caswell, Chatham, Durham, Franklin, Johnston, Lee, Orange Person and Wake Counties the medical provider network is Blue Home with UNC. Blue Home’s network is UNC Health Alliance (which includes Rex Hospital) and its affiliated doctors and hospitals. The policies in these counties are POS (Point of Service). With this type of policy you can go out of the medical network, but unless it is coded as an emergency you will pay a higher amount for medical services. No referrals are needed to see at specialist.

In addition to Blue Home with UNC, in 2021 they have the Blue Home with Novant, Blue Local with Atrium and it’s affiliates, Blue Local using only Wake Forest Baptist and it’s affiliates, Blue Value and Blue Advantage. The Blue Advantage network has the largest number of doctors, medical providers and hospitals in its network, but it is not available in all counties. BCBSNC offers plans that are compliant with the Affordable Care Act (ACA) in all 100 NC counties.

For 2021 BCBSNC will offer 24/7 Telehealth care options for physical and behavioral health.

Ambetter Health Insurance (www.ambetterofnorthcarolina.com, created from Celtic Health Insurance in 2014, Parent company is Centene) offers HMO (Health Maintenance Organization) plans in Alamance, Alexander, Allegany, Bladen, Caswell, Cumberland, Chatham, Davidson, Davie, Durham, Forsythe, Franklin, Granville, Guilford, Harnett, Hoke, Iredell, Johnston, Lee, Montgomery, Moore, Orange, Person, Randolph, Richmond, Robesson, Rockingham, Sampson, Scotland, Stokes, Vance, Wake, Warren, Wilkes and Yadkin Counties. 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. Baptist, First Health Moore Regional, Duke, Moses Cone and WakeMed hospitals are in-network with Ambetter.

Their plans include:

  • Myhealthpays Rewards which allows policyholders to earn up to $500 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 over the counter items at some retail stores.
  • Telehealth, which is a 24 hour phone or video access to in-network providers for non-emergency health issues.
  • Some plans include dental and vision for adults.

Bright Health Insurance: In 2021 Bright Health offers HMO plans in these counties Alamance, Avery, Buncombe, Cabarrus, Cherokee, Chatham, Clay, Davidson, Davie, Durham, Forsyth, Franklin, Gaston, Graham, Guilford, Haywood, Henderson, Jackson, Johnston, Lee, Macon, Mecklenburg, Mitchell, Orange, Person, Polk, Randolph, Rockingham, Rowan, Stokes, Swain,Transylvania, Union, Wake, Yadkin and Yancey. Referrals are not required to visit a specialist. Alamance Regional, Annie Penn, Caromont, Central Carolina, Duke, Frye Regional, Maria Parham, Mose H. Cone, Novant, Person Memorial, Mission, Rutherford Regional,  WakeMed and Wesley Long hospitals are in network with Bright Health.

Their plans include:

  • Bright Health Rewards which allow policy holders can earn cash rewards for healthy activities like having a flu shot or getting their annual preventative exam, completing a Health Risk Assessment or selecting a Primary Care Provider.  One can earn up to $500 on a Visa card card that can be used to pay premiums, copays and some over the counter retail items like over the counter drugs.
  • After a hospital stay a policy holder can get free meals delivered to their house for several days.

Cigna: Cigna offers HMO (Health Maintenance Organization):   Cigna offers HMO plans in the Raleigh/Durham area in Alamance, Durham, Franklin, Granville, Johnston, Lee, Orange, Person, Vance,Warren and Wake counties. With their rural expansion they also offer plans in Montegumery, Moore, Richmond, Scotland, Hoke, Robeson, Cumberland, Harnett, Bladen, Sampson, Duplin, Onslow, Wayne, Greene, Wilson, Pitt, Edgecomb, Nash, Halifax, Northamption, Hertford, Gates, Chowan, Perquimans, Pasquotank, Camden, Currituck, Bertie, Martin, Cateret. Jones, Pamilico, Craven, Lenoir, Beaufort, Hyde, Dare, Tyrell, Washington, Cherokee, Graham, Clay, Macon, Swain, Jackson, Translyvania, Haywood, Madison, Buncombe, Henderson, Polk, Rutherford, McDowell, Yancey Mitchell, and Avery.   

In network hospitals include Advent Health,Betsy Johnson, Bladen County, Cape Fear Valley, Central Harnett, Duke, First Health Regional, Highsmith Rainey,Sampson Regional, Southeastern Regional, Vidant, WakeMed and Wilson Regional.

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.

Oscar Health Insurance: offers HMO policies in the Asheville area. Their service area includes Buncombe, Haywood, Henderson, Madison, Transylvania, Macon, McDowell, Jackson, Polk and Yancey counties. In network hospitals include Mission, Angel, Highlands-Cashiers and Transylvania. Referrals are not required to visit a specialist, but some specials may require a referral from a PCP.

Their plans include:

  • 24/7 Virtual Urgent Care for $0 a visit
  • Get paid to Walk where you can earn up to $100 per year Amazon Gift Card

United Healthcare: offer HMO policies in the following counties Alexander, Bladen, Brunswick, Buncombe, Burke, Caldwell, Columbus, Cumberland, Durham, Franklin, Guilford, Harnett, Haywood,Henderson, Hoke, Iredell, Jackson, Johnston, McDowell, New Hanover, Orange,Pender, Randolph, Richamond, Robeson, Rutherford, Sampson, Scottland, Transyvania and Wake Counties. These plans do require you to obtain a referral from your Primary Care Physician before you visit a specialist.

In network hospitals include Advent Health Hendersonville, Angel Medical, Annie Penn, Betsy Johnson,DLP Rutherford Regional, Haywood Regional Memorial, Harris Regional, Highlands Cashiers, Highpoint Regional, Johnston Memorial,Margaret R.Pardee Memorial, MH Mission, Moses Cone, Randolph Health, Rex, Translyvania Regional and UNC.

These are examples of questions to ask before you enroll in a new plan:

  1. Are my medical providers (i.e. doctors, pharmacies and hospitals) in the network of this plan?
  2. If I see a medical provider out of network when it’s not emergency will I have to pay the full cost myself?
  3. What is the deductible (dollar amount you must pay before your insurance pays) for medical procedures and pharmaceuticals?
  4. Are my prescription 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)?

 

Required information 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. For example, if you work for a company but also have rental income or dividend producing stock, you must provide information and dollar amounts about each type of income. If you are self-employed you must provide information about your type of work, expected income as well as name and address of your company.
  • Child support, Veteran’s payments and Supplemental Security Income are not considered part of your income.
  • Income information must be provided for everyone you claim or claims you on your 1040 tax form even if they are not applying for coverage.
  • 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 2021. If you say no you will be told that you are not eligible for a subsidy.
  • Once you are approved for a Marketplace subsidy you may be asked to provide proof of income or other information. They will give you an exact date that they must receive this information. If you don’t have this information to them by the specified date they will terminate your subsidy.

How do you apply?

You can do it yourself on-line at www.healthcare.gov 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, BCBSNC or Bright Health plan. They can look up your medical providers to determine what insurance plans they accept. Their services include explaining your policy choices so you can make an informed decision. Our access to Health Sherpa software means you do not have to meet with us in person or log into the Marketplace. After you are enrolled in a policy we continue to be available to answers your questions and address your concerns.
  • You can meet with a navigator in person. Go to NCNavigator.net 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.

 

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

Short Term Medical plans

Association Medical plans through organizations

COBRA

Small Group Plans

Health Sharing Ministries (not health insurance)

Tricare

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 www.ncdoi.com.

Wanda Stephens, NPN (National Producer Number): 8504772

Health Insurance Solutions of NC   Website: www.hisonc.com

Email: wanda@hisonc.com Office: 919 845 6001 Cell: 919 740 653

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