Health Insurance: Frequently Asked Questions

Special Enrollment Period (SEP):

A Special Enrollment Period or SEP is a time outside the yearly Open Enrollment Period when you can sign up for health insurance.  You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married or divorced, having a baby, adopting a child, or if your household income is below a certain amount.

There’s a new Special Enrollment Period (SEP) available to lower income consumers allowing them to enroll in Marketplace coverage any time, if eligible.  Consumers who qualify for this SEP may also qualify for more savings.  Consumers who have an estimated annual household income at or below 150% Federal Poverty Level (FPL) in their state and aren’t eligible for Medicaid/CHIP may be eligible for this SEP.  The annual household income at or below 150% Federal Poverty Level (FPL) varies by state and household size.

Find the 2021 FPL amounts used for 2022 Marketplace applications. This SEP is expected to affect millions of low income individuals and families.

  • Outside Open Enrollment, you can only get individual health insurance 2 ways:
    • With a Special Enrollment Period.  You can qualify if you lose job-based coverage, have a baby, get married or divorced, or have certain other life changes.
    • Through Medicaid or the Children’s Health Insurance Program.  You can apply any time and can enroll immediately if you’re eligible.
  • You qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married or divorced, having a baby, adopting a child, or if your household income is below a certain amount.
  • If you or anyone in your household lost qualifying health coverage in the past 60 days or expects to lose coverage in the next 60 days, you may qualify.
  • If this is the case, then you can appeal the decision.  If you don’t agree with a decision made by the Health Insurance Marketplace, you may be able to file an appeal.  You have 90 days from your Eligibility Notice to ask for an appeal.
  • Here are some instances in where you’re eligible to appeal the decision:
    • Not eligible for advance payments of the premium tax credit (APTC)
    • Eligible for APTC, but the amount is wrong
    • Not eligible for a Special Enrollment Period
    • Not eligible to buy a Marketplace plan
    • Not eligible to choose a Catastrophic plan
    • Not eligible for an exemption from the requirement to have health insurance
    • If you live in Alabama, Alaska, Louisiana, Montana, New Jersey, Virginia, West Virginia or Wyoming, you can also appeal a denial of Medicaid or CHIP eligibility
  • However, you can’t file an appeal until you get an Eligibility Determination Notice that says your eligibility for coverage has ended or your savings have changed.
  • Here’s also a list of things that can’t appeal:
    • You disagree with the date the Marketplace ended your coverage.
    • Your health plan company didn’t apply your premium tax credits correctly.
    • You want to change information on your Marketplace application.
    • You believe your health plan owes you a refund.
    • You want to end your health plan on an earlier date.
    • You disagree with information on your Form 1095-A, or want a corrected form.
    • Your health plan refuses to pay a claim you think should be covered.
    • When you filed your federal income tax return, you owed back some or all of the premium tax credits you used during the year to lower your monthly premiums.

Medicaid and CHIP:

Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities.  Medicaid is administered by states, according to federal requirements.  The program is funded jointly by states and the federal government.

These services are provided by health plans.  If you get Medicaid, you will choose a plan from the ones available in your service area.

  • Regular checkups to the doctor and dentist
  • Medicine and vaccines
  • Hospital care and services
  • X-rays and lab tests
  • Vision and hearing care
  • Access to medical specialists and mental health care
  • Treatment of special health needs and pre-existing conditions

CHIP, also known as Children’s Health Insurance Program, offers low-cost or free health coverage through Children’s Medicaid or the Children’s Health Insurance Program.

Children’s Medicaid is a health care program for children in low-income families.  CHIP is a health care program for children without health insurance whose families earn too much to get Medicaid but cannot afford health insurance.

To get Medicaid or CHIP, a child must be age 18 and younger (in some cases children with disabilities age 19 and 20 can get Medicaid).  They must also be a U.S. citizen or qualified non-citizen.

  • Regular checkups at the doctor and dentist
  • Medicine and vaccines
  • Hospital care and services
  • X-rays and lab tests
  • Vision and hearing care
  • Access to medical specialists and mental health care
  • Treatment of special health needs and pre-existing conditions
  • States aren’t responsible for more than 10 percent of the cost of expansion.  The federal government paid the full cost of expansion from 2014 through 2016.  The federal government’s portion eventually dropped to 90 percent in 2020, and is there permanently.
  • For states that expand Medicaid, the federal funding they receive will be smaller than the amount that the state has to spend.  States must cover 10 percent of the cost of Medicaid expansion.  Their spending is less than this.  Here are a few reasons for that:
    • Medicaid expansion allows some states to shift certain populations from traditional Medicaid eligibility to the Medicaid expansion category.  The federal government pays a much larger portion of the cost.
    • Medicaid expansion reduces the need for state spending on uncompensated care and mental health/substance abuse treatment for low-income residents, since fewer low-income people in the state are uninsured.  It also allows states to use the Medicaid program to cover the cost of inpatient medical care for incarcerated people.
    • The cost of Medicaid expansion can sometimes be offset by increased revenues for the state, including revenue from taxes/fees assessed on hospitals, medical providers, and insurers, increased tax revenue due to economic growth linked to Medicaid expansion, and premiums that some states require some Medicaid expansion enrollees to pay.
  • No.  Each state has its own Medicaid eligibility requirements and you aren’t able to transfer coverage from one state to another.
  • Medicaid offers health coverage to millions of Americans.  In many states, the coverage matches or surpasses private health insurance. Medicaid is funded by the federal government and state governments.  Each state has the option to set its own rules and requirements for eligibility.  This makes transferring your Medicaid coverage from one state to another isn’t always possible.

Income volatility and its impact on eligibility has already been addressed by various provisions of the ACA and IRS regulations.  As of 2021, the rules have become more consumer-friendly for people who would otherwise be caught in the coverage gap in states that have not expanded Medicaid yet.

Customers with income below the poverty level are not eligible for the Affordable Care Act’s premium tax credits. If they’re in a state that has refused to expand Medicaid eligibility under the ACA, they may not be eligible for Medicaid either.

  • Medicaid and CHIP enrollment is year-round.  Don’t take that as you should disregard the end of open enrollment for private health insurance plans.  In most states, open enrollment continues through at least January 15.
  • This is important in states that have expanded Medicaid for people with incomes that hover around the 138% of federal poverty level threshold for Medicaid/QHP subsidy eligibility.  If your income ends up being barely above the Medicaid eligibility limit, you’ll qualify for a significant premium tax credit to help you purchase a private plan in the exchange.

ACA / Obamacare Plans:

The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”).

Yes, the Patient Protection and Affordable Care Act – is also commonly referred to and known as Obamacare.

Not necessarily.  The Affordable Care Act, also known as Obamacare, gives most uninsured people in the U.S. access to health insurance as long as they are U.S. citizens who live in the country, are not incarcerated, and are not covered by Medicare.  Some may qualify for financial assistance or tax credits on the plan’s premium depending on your state and income.

Generally, ACA plans are organized into “metal tiers,” which determine how you and your plan split the cost of care.  Bronze, Silver, Gold and Platinum.

  • Bronze:  Has the lowest monthly premium but also the highest costs when you need care.
  • Silver:  Known as the “benchmark” plan, with moderate monthly premiums and moderate costs when you need care.  You must choose a silver plan to qualify for cost-sharing reductions.  These are also known as “extra savings” on out-of-pocket expenses such as deductibles, co-payments, and coinsurance.
  • Gold:  Has high monthly premiums but low costs when you need care.
  • Platinum:  Has the highest monthly premiums and the lowest costs when you need care.

If you cannot afford Obamacare, see if you can qualify for the state-based insurance program called Medicaid.  Your Obamacare application can help you determine if you qualify for Medicaid.

There are two main types of individual and family health insurance or ACA plans.  These include HMO and PPO plans.  A PPO (Preferred Provider Organization) plan encourages you to use insurance company’s network of preferred doctors and hospitals, but will provide some out of network coverage.  HMO plans (Health Maintenance Organization) usually provide members lower out-of-pocket health care expenses but they provide less physicians and hospital options.

Dental coverage is an essential health benefit for children.  This means if you’re getting health coverage for someone 18 or younger, dental coverage must be available for your child either as part of a health plan or as a stand-alone plan.  Note:  While dental coverage for children must be available to you, you don’t have to buy it.

Nearly all plans cover maternity.  Since January 2014, the ACA has required all newly issued and renewing individual and small group health insurance policies to provide maternity coverage.

The Affordable Care Act requires coverage for pediatric vision care as one of the essential health benefits.  They do not require insurers to provide routine vision care coverage for adults.

All ACA-compliant individual and small group plans include coverage for physical therapy.  Some individual market plans, sold via the health insurance marketplaces and off-exchange, include coverage for chiropractic services, but many do not.  It depends in large part on where you live, as different states have different rules.

Medicare Plans:

Medicare is a health insurance program provided by the federal government for qualifying individuals, including people age 65 and older, those with certain disabilities, and individuals with end-stage renal disease (ESRD).

  • Medicare Part A (Hospital Insurance)
    Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  • Medicare Part B (Medical Insurance)
    Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
  • Medicare Part D (prescription drug coverage)
    Helps cover the cost of prescription drugs (including many recommended shots or vaccines).

Medicare’s Annual Enrollment Period (AEP) is every year from October 15th – December 7th.  The Initial Enrollment Period (IEP) for Medicare is a seven-month period beginning three months before you turn 65, the month in which you turn 65, and three months after you turn 65.  For example, if you turn 65 on June 14, your IEP is from March 1 through September 30.

Medicare Advantage is Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage.  These “bundled” plans include Part A, Part B, and usually Part D.  Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services.

Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You pay for services as you get them. When you get services, you’ll pay a deductible at the start of each year, and you usually pay 20% of the cost of the Medicare-approved service, called coinsurance. If you want drug coverage, you can add a separate drug plan (Part D).

A Medicare Supplement plan, commonly known as Medigap, is an additional coverage option to Original Medicare.  Medicare Part A and Part B only covers 80 percent of services.  Adding a Medigap plan covers the remaining 20 percent, limiting coinsurance or co-payments as well as some additional out-of-pocket costs.

  • You or your spouse had Medicare-covered government employment.
  • You or your spouse has worked long enough (usually 10 years) to qualify for Social Security and paid Medicare taxes.
  • You are receiving retirement benefits from Social Security or the Railroad Retirement board.  Or you are eligible to receive Social Security or Railroad benefits but you have not filed for them.

No they do not qualify for Medicare.  But since your parents are not eligible for Medicare, they can purchase a private plan in the exchange and can receive cost-sharing reductions and premium subsidies if they are eligible based on income.

  • For the purpose of determining subsidy eligibility, the IRS and the health insurance exchanges use an ACA-specific version of modified adjusted gross income (MAGI).  MAGI is based on household income, even if only one spouse is applying for a policy in the exchange.
  • Although your total household income is obviously higher than your wife’s income alone, the poverty level for a household of two is also higher than the poverty level for a household of one.  So while your income is counted when determining whether she’ll qualify for a subsidy, you’re also counted as part of the household when determining how the household’s income compares with the poverty level.

Life Insurance:

  • Life insurance is a promise by an insurance company to pay those who depend on you a sum of money upon your death.  In return, you make periodic payments called premiums.  Premiums can be based on factors such as age, gender, medical history and the dollar amount of the life insurance you purchase.  In the event of your passing, life insurance provides money directly to the individuals you select, your beneficiaries, who can use the money as they see fit, including:
    • Replacing lost income
    • Covering basic living expenses
    • Paying household debts, estate taxes and funeral expenses
    • Funding a child’s education
    • Supplementing retirement savings
  • Life insurance comes in two main types, term and permanent, which may both be available through your workplace.
  • Term life insurance pays a specific lump sum to your loved ones for a specified period of time.  If you stop paying premiums, the insurance stops.  Term policies pay benefits if you die during the period covered by the policy, but they do not build cash value.  They may also give you the option to port.  That is, you can take the coverage with you if you leave your company.
  • Getting life insurance through work can be an easy way to protect your family.  If your employer offers a group plan, consider signing up for advantages that may include:
    • Competitive group rates
    • Guaranteed issue, meaning you can get a certain amount of coverage without answering health questions or taking a medical exam
    • Convenient payroll deductions
    • Easy access to enrollment and educational tools that can help you make the right decisions about the type and amount of insurance that’s right for you
    • The confidence of knowing that your employer has reviewed and selected the plan

You should be able to develop a life insurance plan that, following your death, will allow your family to live comfortably without your economic contribution.  Also consider the effect of inflation over time.  The amount needed for retirement or college 20 years from now is likely to be significantly higher than today.

The period of time you’ll need coverage for should be the main factor.  If you have young children, you may want to consider 20 or 30 years of term life coverage to help your children for college or other future financial endeavors.  On the other hand, if your children are out of college and supporting themselves, a shorter coverage period might suit your needs better.

  • Life insurance through your workplace is more affordable than initially presented.  Many people can get term life insurance coverage from a quality company for a surprisingly low price.
    • Premiums are typically based on factors such as:
    • Age, sex, height and weight
    • Health status, including whether or not you smoke
    • Participation in high-risk occupations
  • Life insurance gets more expensive as you get older, and the type of coverage you choose will also affect your premium.  Rates for term insurance are typically lower, while rates for permanent policies are typically higher.

Buy it now.  Premiums for the same coverage generally increase the older you become.  The longer you wait, the more you risk developing a health condition that could increase your premium further, or make you uninsurable.

Death benefits are generally received income tax-free by your beneficiaries.  In the case of permanent life insurance policies, cash values accumulate on an income tax-deferred basis.  That means you would not have to pay income tax on any of the policy’s earnings as long as the policy remains in effect.

  •  It’s a good idea to review your coverage every few years to make sure it still meets your financial needs. Check to make sure that all information is current.  It might be time to re-evaluate your coverage if you:
    • Recently married or divorced
    • Received an inheritance
    • Purchased a new home
    • Refinanced your home mortgage in the past six months
    • Have a child or grandchild who was recently born, adopted or about to enter college
    • Provide care or financial help to a child or parent
    • Want to ensure that financial resources are available for a loved one’s assistance or long-term care
  • To make sure your benefits are distributed to those you intend, you must select a beneficiary.  Without a validly named beneficiary, the life insurance proceeds will be distributed according to the terms of the insurance contract.  This may result in proceeds going to family members such as spouse, children, parents or siblings, or it may go to your estate.
  • In addition to being financially secure, the life insurance company you choose should have a good claims payment history, good customer service, and competitive pricing.  You can find insurance company ratings online.

Travel Medical Insurance:

Getting travel insurance quotes with Healthedly Insurance Services is easy.  Visit our page and we will help you find the right travel insurance meant for you.

Enter the total amount of your non-refundable and pre-paid travel arrangements to be insured.  If you would like to see plans that exclude trip cancellation coverage, then enter $0 for your Trip Cost.  Frequent flier miles and their dollar equivalents cannot be insured.

Select your destination country from the list.  If you are visiting multiple countries, choose the destination where you will be spending the most time during your trip or one of the countries.  If you are spending equal time in each, you will still be covered when visiting other countries from your specified departure date through your return date.

Click on the calendar icon to select the date that you are leaving for your trip as well as the date that you return.

Select the number of travelers that you would like to insure on this policy.  Only add travelers that share the same trip dates/itineraries.  Quote and buy separately if you have travelers with differing itineraries and/or states of residence.

Enter the age of each traveler with one traveler’s age per box.  Make sure not to enter the age of the person during the trip dates.  Enter the age of additional travelers in separate boxes.  If a child is under one year old, enter 1.

Select the initial date that you made a partial or whole payment for your trip.  If you booked with rewards points and no actual payment, use the date that you booked your trip.  If you have not purchased your travel yet, select today’s date to see quotes.

Small Group / Small Business:

  • It’s a type of insurance plan is a type of group health plan that provides actual health insurance coverage for a business’s employees.  Many group health insurance plans will also offer cover to family members and dependents of the employees.
  • A group health insurance policy is purchased by an employer (or employee organization) and is offered to eligible participants and eligible dependents of participants.
  • With group health insurance, the costs are spread over the company and the number of participants covered.  There are several types of group health insurance plans available, including HMO, PPO, etc.
  • Group health insurance is sometimes known as employer-sponsored health insurance or job-based health insurance.
  • Health insurance that is provided to employees by an employer is known as group coverage.
  • Health insurance that a person buys on their own (i.e. meaning not through an employer or association) is individual coverage.
  • If a person has employer-sponsored health insurance coverage, there are several benefits:
    • They are offered a choice of health insurance plans
    • An employer will often pay for a portion of the monthly health insurance premium
    • Any employee can have their insurance premium deducted from their paycheck
  • If a person can’t get coverage through an employer (or they are self-employed), they will often buy individual health insurance.
  • Unlike traditional employer-sponsored insurance, purchasing health coverage through an individual plan means:
    • Shopping for and choosing a plan
    • Purchasing a individual plan
    • Contributing all monthly premium payments
    • Managing all health insurance coverage and benefits
  • Depending on how many employees there are, benefits covered by group insurance and individual insurance may be different.
  • The short answer is that it depends on the specific health insurance group plan.  Some companies will offer these additional types of health care coverage as an employee benefit.
  • Vision and dental insurance can come from varying sources:
    • 1) There are health insurance plans that include vision and dental benefits.  These can be offered by an employer or purchased on your own through the insurer.
    • 2) There are separate, standalone plans for vision or dental benefits that can be used on top of a health insurance plan as a form of supplemental insurance. There are even dental and vision insurance “packages” that offer benefits for both.
  • The premiums for group policies typically increase every year based on the previous year’s healthcare costs of the employee group.  This cost varies considerably for small employers versus those on a large group plan.  Medical expenses can be exorbitant and that is something the affordable care act aimed to mitigate.
  • With group health insurance, the risk of someone making a claim is only spread over the individual company, which means rates can increase dramatically depending on the number of employees being covered.
  • Generally, to be eligible for group health coverage, a company must fulfill two main requirements:
    • The business must have at least one qualified full-time or full-time equivalent employee other than the business owner or a spouse.
    • The company must be considered a legal business entity according to its state’s regulations.
    • The definition of a group or employee varies by state. A qualified full-time or full-time equivalent eligible employee is usually considered someone who works at least 30 hours per week.
  • To get group insurance coverage, your employees must follow these IRS guidelines: Full-time employees are employees who work for you at least 30 hours per week.
  • Full-time equivalent employees are non-full-time employees but who, in combination, are the equivalent of a full-time employee.
  • Once you have decided to enroll, the best method is to work with a group health insurance agent.  They will guide you through the application steps and the specific application forms to complete for the company and employees.
  • The process of enrolling for Group Health Insurance can be smooth and easy when working with an agent who has experience.