Major Medical
Major medical coverage for the individual and family summarized in one word: confusing. We offer advise for on/off health insurance coverage in Georgia and South Carolina.
Enrollment Information
For health coverage effective January 1st, you can enroll only from November 1st through December 15. Furthermore outside this time period you cannot enroll in coverage unless you have an acceptable Special Election Period(SEP). SEP includes but is not limited to: moving out of your current plans coverage area, loss of group medical coverage, new born.
Here’s a few key need to know thoughts:
1. Subsidy is based on estimated income Take note, you apply for a subsidy based on projected income for the next year. Consequently it’s important to know sources of Income. Consider: Social Security, retirement distributions, income from employer. Since it is an estimate the marketplace may require evidence of income. When you file taxes the following year subsidy adjustments are made. If you earned more than estimated, you may have to return a portion of the subsidy. file less income you may receive a greater subsidy. Under the resources tab there is a Federal Poverty level income chart.
2. You must make a minimum income Due to the fact GA and SC did NOT expand Medicaid, you MUST make the minimum income amount to receive a subsidy. Under the Resources tab there is a Federal Poverty level income chart.
3. Changes must be reported to the marketplace Almost all life events change your subsidy and must be reported to the marketplace immediately. This includes but is not limited to: income increase/decrease, change in family- newborn, divorce, marriage, now offered group coverage.
4. Plans may be different for On and Off market Carriers who do offer on market health coverage may have different plan design for on and off market enrollments.
5. Plans are identified by Medals Plans are labled either Bronze, Silver, Gold, Platinum. While Bronze premiums are lower your out of pocket cost increase. In contrast the Gold/Platinum plans include higher premium but lower out of pocket costs.
6. Under 30 and Hardship Under 30 years old may enroll into a Catastrophic plan (lowest premium plan offered). Typically anyone over 30 cannot enroll into the Catastrophic plan unless they are approved for a hardship. Hardships are approved annually through the marketplace. One example for hardship- income under 100% of the Federal Poverty Level (FPL). Under the Resources tab there is a Federal Poverty level income chart.
7. Network/formulary All carriers have a network of providers. Make sure you understand the plans restrictions concerning out of network providers. Example: EPO/HMO- if you go out of the network you pay 100% of the costs. The plan may require a referral to see a specialists or to receive other services. All carriers use a formulary (list of covered medicines). Expect to pay 100% of costs for a medicine not on the formulary.
On Marketplace enrollments
To receiver a subsidy (assistance paying for medical coverage) you must be eligible based on your income and specific criteria established by the Federal Government. Under the forms tab there is a Federal Poverty level income chart. You must: fall within the income levels, not be offered group coverage through your or a spouses’ employer, and file a tax return (if married it a joint return). Additionally, if your income falls below 250% of the FPL you may also qualify for Cost Share Reduction (CSR). CSR reduces your costs (deductible, co-pay, coinsurance) . Amount of CSR vary based on eligibility. The CSR applies ONLY to the Silver plans. Enrolling through or with the assistance of an agent does NOT increase your premium. Raborn Insurance Associates is certified to offer assistance for On market plans.
Off Marketplace enrollments
Subsidies are NOT offered for off market enrollments. You still are required to enroll during the approved enrollment period. Enrolling through an agent does NOT increase the premium. Raborn Insurance associates is certified to offer assistance for Off market plans.
We represent Anthem, Blue Cross and Blue Shield and Ambetter in Georgia and South Carolina.