Frankly, health insurance is what I do all day long. I specialize in it, and have for 10+ years. I’m licensed in FL, E&O insured, and been a student of the ACA health care law since it passed.  My clients get my advice and year round responsive service for free.  I get paid commissions from the insurance companies, which comes out of your insurance premiums. BUT, you pay the same premium whether you use an agent or not (required by law).  I assist clients with navigating a complicated government website,  and assist with any follow up documentation that might be required by the government. I have an incentive that your policies never lapse, and practice best methods to avoid future headaches for both of us. I read a LOT on all the changes occurring, so you don’t have to. Whether it’s industry articles, carrier webinars, or the constant government updates……I’m prepared for your questions.  Believe me, there is a right way and a wrong way to buy health insurance in today’s complex market, and you get one chance a year to do it correctly.

In short, if your income is low enough to qualify for financial assistance in the form of premium and deductible subsidies. If you qualify, you must buy your health plan “ON the Marketplace” in order to get these subsidies or advanced premium tax credits (APTC)  to lower your monthly health insurance premiums.  APTC is determined by your modified adjusted gross income (MAGI), your household size, and how that relates to the Federal Poverty Level (FPL) guidelines.  In Florida, if you’re between 100% – 400% of FPL, then you may be eligible for APTC.

In addition, if between 100% and 250% of FPL, you’re also eligible to buy a Cost Sharing Reduction (CSR) plan with reduced deductibles and out of pocket maximums.  In order to receive these additional benefits, you must buy a Silver Level plan.  More information on these topics is located on the ON Marketplace website page.

OEP will be from November 1st through December 15th. 

If you need a January 1st effective date, you need to apply by December 15th.

An Open Enrollment Period (OEP) for ACA Health Plans occurs once a year and will last only 45 days this year. It’s the period of time where consumers are free to purchase or move to a new plan, for any reason, from any approved insurance carrier ON or OFF the Marketplace.

Outside of Open Enrollment (OEP), you may be eligible for a Special Enrollment Period (SEP) if you have a Qualifying Life Event (QLE).  This allows the consumer to buy a health plan outside of the OEP period with effective dates of March through December.  Examples of QLE’s include:  Loss of group health plan, loss of Cobra or Medicaid, marriage, divorce, birth, or if you move to a different county or state. 

A full QLE list can be found here at healthcare.gov

The Marketplace requires that you now send in proof of your loss of coverage or other proof to support your special enrollment reason.

Whether you buy “ON” or “OFF” the Marketplace, all Affordable Care Act (ACA) compliant plans include:

• Guarantee Issue – no medical questions allowed (except tobacco), and you cannot be declined.
• Pre-existing Conditions – are covered with no waiting period, but subject to policy benefits.
• Free Preventative Care – before any deductibles and with a $0 copay.  A list can be found here.
• The 10 Essential Health Benefits – are based on federal guidelines, and the state benchmark plan.
• Maximum Out of Pocket Limitations – adjusts higher each year.

Supplemental plans (Gap Plans) are used by consumers to “fill the gaps” of the high deductible ACA compliant plans. They can come in the form of an “accident” only plan (broken bones, stitches, etc), or a combination of an accident and critical illness policy (heart attack, cancer and stroke).  A young family with active kids would be a prime example of someone who should consider an accident policy to help cover the high deductible of an ACA plan.

They are NOT to be used as a substitute for a Major Medical ACA compliant health plan.

You can find a list of supplemental plans and links on the Florida Supplemental Plans page.

A major hole in the law was exposed to consumers with household income under 100% of Federal Poverty Level (FPL) in Florida, after the Supreme Court ruled that individual states can not be forced into expanding Medicaid to childless adult residents between 0% and 138% FPL.   Florida was among about 20 states that elected NOT to expand Medicaid creating a void or Medicaid “hole” for many residents in this income range of 0% – 138% FPL.

BUT, the ACA law also contained verbiage that allows subsidies for those with income between 100% to 400% of FPL, sparing those between 100-138% of FPL, with massive financial assistance to buy private health insurance in Florida through the Health Insurance Marketplace.

Unfortunately, if the combined income for your household size is below 100% of FPL, then you are NOT eligible for financial assistance / subsidies, reduced deductible plans or Medicaid.  You are eligible to buy a health plan, but would have to pay the entire premium amount.  Not to worry, your income should be low enough to allow you to get an exemption from having to buy coverage or pay any penalties.