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Happy New Year!: Recap of 2015’s Marketplace, Health Insurance, and ACA Topics! Ah, New Year’s. A time to reflect on the changes of the past year and dream about those to come. You’re [...]
CRC Capital Group, Inc. offers some of the best health insurance plans in Sioux Falls, SD.
Whether you’re looking for individual health insurance or group coverage for your business, the Affordable Care Act of 2010 has changed the way America buys health insurance. Inside or outside of the Marketplace let us help you navigate the new rules and go over the details in plain, understandable language. If you want to know more give us a call.
FREQUENTLY ASKED QUESTIONS
Open Enrollment is the period of time in which individuals can enroll into an individual health insurance plan inside or outside of the Marketplace.
For coverage starting in 2016 Open Enrollment begins November 1st, 2015 and end January 31st, 2016.
If a person enrolls November 1st through December 15th their coverage will begin January 1st.
If a person enrolls December 16th through January 15th their coverage will begin February 1st.
If a person enrolls January 16th through January 31st their coverage will begin March 1st.
To be able to enroll into an individual health insurance place other than during this time period a person must qualify for a Special Enrollment Period.
In the Group Benefits market, open enrollment (normally held annually) is the period in which employees may make changes to their current benefit elections. Or, if they did not elect benefits after becoming eligible, they may do so at this time if their benefit provider allows.
This is a period of time outside of Open Enrollment during which a person may be eligible to purchase individual health insurance.
In order to be eligible for a Special Enrollment Period a person must have a Qualifying Life Event and report that event within 60 days.
Though this term is not normally used when talking about Group Benefits there are circumstances when an employee may be able to make changes to their benefit elections.
A Qualifying Life Event is some event that has happened outside of the Open Enrollment Period which qualifies a person for a Special Enrollment Period.
Qualifying Life Events include but aren’t limited to:
Loss of other coverage. An example would be if a person is terminated, changes jobs or no longer qualifies for Medicaid.
Marriage. An example would be if a person marries and wants to add their spouse to their plan.
Divorce. If you become divorced and have lost coverage as a result of that you would qualify for a Special Enrollment Period.
Other examples include, gaining membership into a federally recognized Tribe or moving from another state.
The Affordable Care Act makes available a Tax Credit that can be used to reduce your monthly premium cost. The tax credit is available only for plans that are purchased inside of the Marketplace. If you qualify, the monthly credit amount is sent to the insurance carrier. The insurance carrier subtracts that amount from your monthly premium and bills you the difference.
You will have the option of using all, some or none of your tax credit. If you use less of the tax credit than what you’re due, the remainder is returned to you when you file your annual income tax return. If you use more of the tax credit (in the way of advanced payments) than what you were due, you’ll repay the difference when you file your annual income tax return.
Applying for or renewing your coverage through the Federal Marketplace requires you to provide certain information. The Marketplace asks for the information in order to determine if you’re eligible for a tax credit and in order to enroll you into a plan. The information you’ll need to have is;
A health insurance provider network is all of the doctors, hospitals, clinics, and specialists that a health insurance company contracts with to provide services to its members. The doctors, hospitals, clinics etc. are collectively known as the providers. This means the “network” has come to an agreement with the providers as to what they will pay for any particular procedure. These networks are in important part of the healthcare system we have today. They help insurance companies control costs and the quality of care that its members receive.
Prescription medications have their own network and are managed by a Pharmacy Benefit Managers or PBM. These networks serve the same function as provider networks. Health insurance companies have contracted with a PBM to provide pharmacy services to its members. The health insurance company and the PBM have agreed upon prices for prescriptions and what pharmacies will deliver those prescriptions. The PBM does not control what medications are in the health insurance company’s formulary. The formulary determines what prescriptions will be considered Tiers 1, 2, 3 etc.
A co-pay is a fixed dollar amount that you pay when you receive your medical service or prescription.
The difference between the actual cost and your co-pay amount is paid by your health insurance.
For example; if you have a copay plan and you go to the doctor. After showing the receptionist your ID card she’ll ask you for your co-pay.
After seeing the doctor if he writes you a prescription you go to the pharmacy and the pharmacist will tell you what your co-pay amount is.
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