Major Medical

There is no charge to discuss your specific situation, our agency is paid a commission if you decide to enroll through us. However, we do not pressure. We are independent agents representing many carriers in Georgia and South Carolina, your needs determine the plan/carrier.

Enrollment Information

You can enroll into an individual/family medical plan only during the Open enrollment period is typically from November 1st to December 15th. 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 You apply for a subsidy based on projected income for the next year. Income includes but is not limited to: Social Security, retirement distributions, income from employer, or self-employed. Since it is an estimate the marketplace may require evidence of income/loss of income. When you file taxes the following year you may have to return a portion of the subsidy (if you earned more than estimated), or receive a greater subsidy (earned less than estimated). Under the resources tab there is a Federal Poverty level income chart.

2. You must make a minimum income You MUST make the minimum income amount for yourself/family to receive a subsidy. GA and SC did NOT expand Medicaid so if under 100% of the FPL you pay the total cost of coverage. Under the Resources tab there is a Federal Poverty level income chart.

3. Changes must be reported to the marketplace Any changes which can affect your subsidy must be reported to the marketplace. 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 Not all carriers offer plans through the marketplace and the carriers who offer plans may have different plans for on and off market enrollments.

5. Plans are identified by Medals Bronze, Silver, Gold, Platinum. Typically, Bronze is the lower premium but higher cost sharing. Platinum- higher premium, lower cost sharing.

6. Under 30 and Hardship Under 30 years old may enroll into a Catastrophic plan (lowest premium plan offered), anyone over 30 cannot enroll into the Catastrophic plan unless they are approved for a hardship. Hardships are approved annually through the marketplace and include as a minimum but not limited to 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. The network can vary between carriers. Example: HMO if you go out of the network you pay 100% of the costs. This plan may require a referral to see a specialists or to receive other services. Some carriers allow you access to a nationwide list of providers some are simply local facilities/providers, and yet others allow you to use any provider in the statewide network. Additionally, all carriers have a different formulary (list of covered medicines). Expect to pay 100% of costs for a medicine not on the formulary.

8. There is a tax penalty (individual shared responsibility payment) if you do not have qualifying health coverage you and any family member is subject to the penalty. Use this link for more information on the penalty: https://www.healthcare.gov/fees/  

On Marketplace enrollments

If you want to apply for 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 is below 250% of the FPL and meet eligibility requirements you may also qualify for Cost Share Reduction (CSR). This is when your costs (deductible, co-pay, coinsurance) are reduced. The amount of reduction is based on eligibility. The CSR is only applied 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 On market plans.    We represent BCBS of GA and SC, Aetna, Coventry, Humana.