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

    • 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.
    • Annual and lifetime coverage limits have been eliminated.
    • Declining an individual for coverage based on their participation in an approved clinical trial is not allowed.
    • Maternity and mental health are included on all policies.
    • Preventative dental and vision are covered for members up to age 19 on most policies.
    • Whether or not children are students they can stay on their parents’ policy until age 26.
    • The Medical Loss Ratio (MLR)  ensures that 80% of the premium dollars paid to the health insurance companies are spend on providing health care. An insurance company that does not do this must provide rebates to their policyholders.

Understanding the ObamaCare North Carolina Health Insurance Plans

ObamaCare North Carolina - Outline map with transparent pills
Open enrollment for purchasing ACA (Affordable Care Act) compliant health insurance is normally from November 1st through December 15, 2020 with  an effective date of January 1st. Unless one has a qualifying life event,  they are not be allowed to apply for a policy that is compliant with the ACA until the next open enrollment. However, due to concerns about the Corona Virus, President Biden has ordered a second open enrollment which will last from February 15th through May 15th, During this period anyone without health insurance can obtain it and someone who is unhappy with their current health insurance can switch to another policy.

ObamaCare North Carolina termsUnderstanding Insurance and Affordable Care Act Terminology:

ACA-It stands for Affordable Care Act and is often call ObamaCare.

Marketplace– An online marketplace where individuals can compare, shop for and buy qualified health insurance plans. It is also called the “Exchange”.

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 (including 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- State government agency that provides health coverage for low-income people, families, children, the elderly and people with disabilities. You can apply anytime.

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.

MAGI- An acronym for Modified Adjusted Gross Income, which is the total of your adjusted gross income and tax-exempt interest income. These are found on Lines 8b and 37 of the IRS Form 1040 and are used to determine subsidy eligibility.

CMS- An acronym for Centers for Medicare & Medicaid. 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 government Marketplace plan. They are compensated by the insurance companies they represent.

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.

Certified Application Counselors– Individuals who have completed the CMS training and are involved in educating consumers and helping them complete Marketplace applications. Examples of application counselors are staff at community health centers, hospitals or non-profit organizations.

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– 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 quitting your current 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 write a letter to our insurance company explaining why you must continue to take the brand drug.

Short Term Medical Policies (STM) – As the name implies these are health insurance policies are for individuals who need coverage for a short period. Although some will provide coverage for up to 12 months, this is normally not a good choice since they do not cover any pre-existing conditions and are not qualified health plans. STM only covers unexpected illnesses or accidents and since they are not ACA compliant will not prevent one from paying the penalty tax in 2015.

IRS Qualified High Deductible Health Plans (HSA Plans) – With this health insurance plan the policy holder pays for medical expenses 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. If they do set one up, they are not required to use the bank their insurance company recommends. This type of policy is available on the Marketplace.

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.

ObamaCare North Carolina -Health insurance These are the types of plans available through the Marketplace In North Carolina:

Bronze-  Ideal for people that want low premiums and don’t expect to need a lot of medical services.

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 individuals who rarely have any medical expenses. Unless you have a special exemption you must be under age 30 to qualify for this plan unless you get approved for a “hardship” exemption. If you choose this policy you will not be eligible for a subsidy.

These are insurance companies that offer ACA compliant plans in 2021 for North Carolina:

Ambetter

Ambetter has signed a contract with Baptist, Duke, First Moore Regional, Moses Cone and WakeMed hospitals.  As a result many doctors and medical providers working in these hospitals are in network with Ambetter. Ambetter plans are HMO’s (Health Maintenance Organization).  An HMO plan will not cover your medical procedures if you go out of their medical provider network unless it is coded as an emergency, Ambetter plans do allow you to go to an in network specialists without getting a referral from your PCP (Primary Care Physician). For 2021 their sevice area is includes  Alamance,Alexander, Alleghany, Bladen, Caswell, Chatham, Cumberland, Davidson, Davie, Durham, Forsyth, Franklin, Hanett, Hoke, Iredell, Johnston, Granville, Guildford, Lee, Montgomery, Moore, Randolph, Richmond, Robeson, Sampson, Scotland, Stokes, Orange, Person,Vance, Rockingham, Wake, Wilkes, Yadkin and Warren. Policy holders can earn  up to $500 cash rewards for healthy activities like having a flu shot or getting their annual preventative exam as well as doing a health risk assessment.

BlueCross BlueShield of North Carolina

BCBSNC sells ACA compliant plans in all NC counties and has the largest medical networks in the state. However, the medical network available depends on your county. BCBCNC has policies which normally will pay for your medical procedures even if you go out of their network. However, unless it is a procedure that is coded as an emergency the difference in cost might be substantially more.

Bright Health Insurance

Bright Health offers HMO policies in Alamance, Avery, Buncombe. Cabarrus, Cherokee, Chatham,Clay,Davidson, Davie, Durham, Forsythe, Franklin, Gaston, Graham, Guilford, Haywood, Henderson, Jackson, Johnston, Lee, Macon, Madison, McDowell, Mecklenburg, Mitchell, Orange, Person, Polk, Randolph, Rockingham, Rowan, Stokes, Swain, Transylvania, Union Wake, Yadkin, and Yancey. Referrals are not required to visit a specialist. Policy holders can earn  up to $500 cash rewards for healthy activities like having a flu shot or getting their annual preventative exam as well as doing a health risk assessment. After a hospital stay a policy holder can get free meals delivered to their house for several days.

Cigna

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. Their polices require a referral to see a specialist.

The hospitals in their network incude Duke and WakeMed.

Oscar Health Insurance

Oscar offers HMO policies that don’t require a referral from a specialist 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. Policy holders get 24/7 virtual urgent care for $0 a visit and can receive an Amazon gift card for up $100 per year for meeting their step from walking goal.

United Healthcare:

United Healthcare offers 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 the questions you should ask before enrolling in a health insurance policy:

Are my preferred doctors, medical professionals and hospitals in this plan’s provider network?

What is the cost of my prescription drugs?

What is my drug deductible per person?

What is my deductible, co-insurance and maximum out of pocket per person or per family (is there is more than one person on the policy}?

Who is eligible for a Marketplace Plan?
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. Also, individuals who are offered a health insurance plan from their employer that is not considered a Qualified Health Plan or is considered unaffordable for their income level are eligible. The 2021 income subsidies chart for NC below gives  you an income range of who is likely to qualify for a subsidy. Since NC has not expanded Medicaid you will not be eligible for a subsidy if your income is below certain levels unless you are pregnant or are disabled. Even if you do not qualify for Medicaid your children may qualify for Medicaid or CHIP.

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.

If you have access to a  group plan you are usually not eligible for a subsidy. However, the Marketplace will make an exception if they consider the premiums of your group health insurance to be unaffordable based on your family income.

What information is  needed when  applying for a subsidy?

 Applicants  must provide dates of birth and social security numbers of everyone who needs to be covered.

Child support, veteran’s payment 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 should be your expected Modified Adjusted Gross Income (line 37 on a 1040 Form) .

If you are not a US Citizen you will be required to provide your immigration documentation.

Even if you are a citizen if you were not born in the United States you may be required to provide documentation on when you became a citizen.

You will be asked if you plan to file an income tax return for the year you are obtaining a subsidy. If you say no you will be told that you are not eligible for a subsidy.

What are the Premiums?

Premiums are determined by  zip code, type of plan(i.e. Gold, Silver, Bronze or Catastrophic), age of each member on the policy as well as whether or not the policy holders are tobacco users.
 Individuals making up to $51,040 in 2021 may qualify for a subsidy. A family of 4 making up to $104,800 may qualify. Your subsidy can be received in advance or on your tax return. If you choose to receive it in advance it will be sent directly to your insurance company to reduce the amount you have to pay each month. Subsidies are not offered to catastrophic policy holders.

In addition to receiving a subsidy, applicants at lower income levels sometimes receive a reduction in their co pays, deductibles and maximum out of pocket  if they choose one of the Silver Plans.

How do you apply for an North Carolina Obamacare government subsidy?
You can apply for a subsidy by mail, online (healthcare.gov), in person or via a call center, which is 800-318-2596. In person help can be from a Navigator, Certified Application Counselor  insurance agent or insurance broker.

The advantage of receiving help from an insurance agent is they can assist with the subsidy application as well as choosing an insurance plan. Insurance agents now have access to software that allows them to apply for the subsidy on their customers’ behalf and avoid calling the Marketplace.  Most of the healthcare.gov agents are adept at entering information into the web site, but since they are not licensed agents it is difficult for them to help you choose a plan.

Once you have been approved for a subsidy and selected your health insurance plan from the Marketplace, your information must be transmitted electronically to your insurance company. If you have an agent or broker they can follow your application through the enrollment process and make sure it is as fast and problem free as possible. Your agent or broker will continue to be available to address your concerns even after you are enrolled.

 

Contact Wanda Stephens for more information about Obamacare and  Health Insurance Plans in North Carolina.

 

 

 

 

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