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
In North Carolina Blue Cross Blue Shield of North Carolina (BCBSNC) is selling plans in all 100 counties through the Marketplace. Cigna is selling plans in 5 counties, which are Chatham, Johnston, Nash, Orange and Wake.  Ambetter is new to North Carolina and selling 2019 health insurance policies in Wake and Durham Counties .                                                                                                                                                                                                                                                             Consumers can apply for a government subsidy and after approval enroll in a subsidized health plan of their choice with BCBSNC, Cigna or Ambetter.  Open enrollment for purchasing ACA (Affordable Care Act) compliant health insurance is from November 1st, 2018 through December 15, 2018 with  an effective date of January 1st, 2019 . Unless you have a qualifying event,  you will not be allowed to apply for a ACA compliant policy if you miss this deadline.

Each state was allowed to decide if they wanted a State-based Marketplace (where they did their own training and managed the program), a State Partnership Marketplace (where they managed it in partnership with the Federal government) or a Federally- facilitated Marketplace where a state allows the Federal government to manage all aspects of the program. NC chose the federally facilitated option and also decided not to expand Medicaid. This decision means we are one of the states that forfeited a portion of the 8.4 billion a year from the Federal government for this expansion.

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 the questions you should ask when choosing a plan:

Are your doctors and area hospitals in the network of the plan you choose? Ambetter, BCBSNC and Cigna have websites to answer this question. If you use a broker or agent they can do this for you.                                         BCBS has 4 different networks, Blue Advantage, Blue Select, Blue Local and Blue Value. The Blue Advantage network offers the largest network and these plans have higher premiums. Although Blue Select also has a large network, it has tiers. If your doctor or hospital is tier 2 you pay a higher co-pay or percentage. Blue Value and Blue Local network plans are the least expensive since their network is limited. If your doctors and local hospitals are in this network one these plans is a good option for lowering you premiums.

Ambetter has signed a contract with Duke 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).

Cigna has a contract with the University of NC hospitals. Their policies are HMO’s also. They require that their policy holders have a PCP and get a referral from their PCP before they visit an in network physician.

What is the cost of each of your prescription drugs?

What is your drug deductible per person?

What is your deductible, co-insurance and maximum out of pocket per person?

What is your deductible and maximum out of pocket per family(if there is more than one person on the policy)?

Tip: Dental is offered on the Marketplace  for adults at an extra cost, but since it is not subsidized  you might find it is not price competitive with what you can purchase outside the Marketplace.

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 health insurance plan from their employer that is not considered a Qualified Health Plan are eligible. As you can see from the chart below, if your income is within a certain range you will probably 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.


 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):

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 in 2019. 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.
Older individuals cannot be required to pay more than 3 times what a younger person pays. When consumers apply through the Marketplace they also apply for a government subsidy or other government assistance to ensure their health insurance premium does not exceed approximately 9.5% of their income. Individuals making up to $48,560 may qualify for a subsidy. A family of 4 making up to $100,400 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 (, 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 agent or broker 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 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.

What happens if you do not qualify for a government subsidy?
Although you can still enroll in a plan through the Marketplace normally it is a waste of your time. A broker or agent can still help you find a plan or you can go directly to the insurance company’s website.

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





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