ACA – Errors People Make and a direction for help

Again this week, the Marketplace and insurance agents are receiving phone calls with people stating “I want to change my health insurance”. Many are also stating they “want health insurance, not an Obamacare (ACA) Plan”. Health insurance is not what it was 7 years ago. First error: Although it’s not uncommon for people to think they can change health insurance outside of the Open Enrollment Period (11/1-12/1 every year); in most cases they cannot. In addition, for most people there are not permanent health insurance options other than ACA.

The only alternatives are employer coverage, as of Fall 2018 Association Group Coverage and temporary plans. Of course you must work for an employer offering an Employee Health Plan (EHP) or be a qualified dependent of one who is. Association Group Plans are only available to members of an association that is offering health coverage. i.e. a professional organization such as the bar association. Temporary plans insure a person for only a short period of time 3 -12 months, ask health questions and do not cover pre-existing conditions.

Second error: people buy the cheapest plan available. This plan is most likely an HMO were you can only use network doctors. These plans can work very well if your doctor is in network, but do not work well if you do not use the HMO network. You would pay all costs out of pocket if you use out of network providers and the reason is not an emergancy. Even if this is your preferred network, but your primary care doctor (PCP) is not in the plan; this plan probably will not work well for you.

Third error: people think they can make an appointment directly with a specialist. In most HMOs, you must have your primary care doctor direct all care. That includes setting up appointments with specialists. So, if your idea was to change primary care doctors when you changed plans, you should set up an appointment with a network PCP today. Otherwise your ability to see a specialist, and have it covered, may be delayed. You would need to set an appointment with your new PCP (may take several weeks to get in as a new patient) and then another time period for the appointment with the specialist. It’s critical to become established with your new PCP today!

PPOs and HMO POS Plans will allow you to see a specialist in the network without a referral. It is always best to contact your insurance company if you have any questions. The phone number is on the back of your ID card.

Fourth error: Most people do not consider their medical usage. Simply, if most of your expenses are for seeing your PCP, enroll in a plan that covers your PCP. Weigh any premium increase for this plan against a paying your own PCP and having that expense applied toward your deductible.

Fifth error: Some people get parts of the application wrong. Two common misunderstandings here are:
“Do you have employer health coverage or access to an employer health plan EHP as a dependent?” Some people answer this question “no” when they do have access to an EHP. If that person is given an advanced premium tax credit (subsidy); they will, most likely, need to pay the money back to the government if it is found that a person has EHP availability.

Simply, if you are eligible for EHP you will not be eligible for a subsidy in most situations. Thus your premiums could be much higher than originally shown. That being said, it is always best to complete an ACA application and read your “Eligibility Results” to see what you are eligible for.

Your household adjusted modified gross income MAGI affects your premium. Projecting a too high or too low income could change the amount of subsidy that you may receive to help with your premiums. Payback comes when you file your taxes. It is important to advise the marketplace of any changes in income during the year.
Did you know that all family members do not need to enroll in the same plan? As always, feel free to contact our office if you have questions.

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