Navigating the Federal Marketplace
The Marketplace requires we disclose our privacy practices, which you can review on our web page: http://www.danneils.citymax.com/privacy-practices-.html
The Federal Marketplace: What is it for?
The Federal Marketplace is available to provide 2 key functions:
1. A Portal where people sign up for health insurance when they are qualified to do so.
2. A Conduit to receive monthly tax credit to help pay for your insurance premiums. These tax credits are based on your age, projected income for 2020, and 'family size' as defined as as 'who will be on your tax return for 2020'.
EXAMPLE: A 60 year old woman earning $40,000 would qualify for a $552 per month tax credit. A Providence Connect 8150 plan would cost her $83.14 instead of $635 per month applying direct with Providence.
Determine whether you qualify for a tax credit
The Marketplace has an estimator tool to help determine if you qualify for a tax credit, and whether your children qualify for free coverage under CHIP. Before you use the tool, consider these 2 important factors:
1. HOUSEHOLD DEFINITION:
A 'household' is defined by who will be on your tax return for 2020, NOT who lives in your home. If an adult child living with you in on their own tax return, quote them separately. If your spouse is on Medicare, include them.
2. ESTIMATED INCOME:
Your annual income is defined by adding up the total projected income for each person on your tax return for 2020--whether they are applying for coverage or not. This includes projected social security income if you qualify. Line 7 of your 2018 tax return is a good guide to see what your Adjusted Gross income was in 2018.
Tax Credit estimator tool and 2020 plan comparisons
Click on the link below to estimate your tax credit and view plans:
"Seems pretty straight forward, why work with a Broker?"
EVALUATING THE PLAN BENEFITS:
I carefully study all 41 plans and carefully compare all of the plan features and drawbacks. Many important benefits with each company are not clearly seen in the Marketplace presentation. Once you select a plan, I can send you the full plan benefit and inform you of things to know and expect. The trick issues involve provider networks, prescription drugs, and Alternative care.
EVALUATE THE PLAN NETWORKS:
I understand the plan networks for each of the 6 companies offering insurance on the Marketplace. This is near impossible to determine without consulting someone in the know. For example, Providence has 2 separate networks, and you must choose a 'medical home clinic' from the network. This is not shown or explained by the Marketplace. The Marketplace is offering 43 plans for 2020.
NO COST TO WORK WITH A BROKER:
Fortunately, there is no cost to work with me, as my commissions are built into the insurance premium structure. However, I am only compensated if you list me as your broker in your application, which I appreciate your adding me in should you do your Marketplace application or renewal on your own.
If you do the Marketplace application on your own, I would appreciate your adding me as your broker when it asks "Is anyone helping you complete this application?". Check yes and add Dan Neils NPN #757811
This will list me as your broker with the insurance company so that I can serve you when needed throughout the year, and inform you each year of the changes you need to consider each year at renewal. When you complete your enrollment please email me at email@example.com your plan choice for the year and I'll email you back the full plan summary.
What if I have no insurance now or my insurance cancels due to non-pay?
When you discover your plan cancelled, please call me. I can write you a Short Term Medical policy for a month or two. When that coverage ends, I can put you back on a Marketplace plan or another STM plan, if that works better for you. Visit my Short Term Medical tab if you would like to learn more.
I've determined the tax credit issue, and my eligibility to enroll, what now?
SELECT THE PLAN OR PLANS THAT MEET YOUR NEEDS FOR THIS YEAR:
When you go to show for plans, first it asks you how much of the tax credit you want to use, then whether you smoke or not, then whether you want to change 'Groups'. This is asking whether you want everyone on one policy, or whether to choose different policies for each person. Here I will not write too much but to say that it is often to your advantage to put different family members on different plans.
UNDERSTANDING THE HSA ELIGIBLE PLANS:
This gets tricky, unique to HSA plans is the 'Family Deductible' vs the individual deductible. Let me illustrate with the Kaiser HSA6900 plan, the least expensive plan option.
Example: Bob and May both want the KP HSA 6900 plan. If they signed up together on one policy (grou), they would have a $13,200 family deductible to meet before anything is covered. If they signed on 2 separate policies (2 groups), they would each have a $6900 individual deductible instead, which is a far better value in most years.
This ONLY applies to HSA plans. All other plans give each person their own deductible--Confusing? Sure is! This knowledge, among other twists in the system is another reason to have an expert broker helping you.
QUALIFYING EVENTS TO ADD NEW COVERAGE Mid-Year:
- Outside of Open Enrollment, you have a 60-day window (from the date of the event) to buy coverage if you lose employer group health insurance, recent marriage, lose Oregon Health Plan Insurance, move to Oregon, adopt, have a new baby, or if you have a STM plan that ends.
- LIFE CHANGES:
If you have an active Marketplace policy and have a mid-year change to income, address, marital status, add a baby or adopt, you are obligated to notify the Marketplace about these changes. You can process a Life Change by calling the Marketplace at 800-318-2596.
- 'I LOOKED AT THE OPTIONS AND CANNOT AFFORD ANY OF THEM'
I actually do sympathize with this situation as I pay super-high premiums myself. Short Term Medical insurance costs 50-60% of the cost of other plans because the coverage is limited in time. Please ask me about these plans if you would like more information or visit my link below:
Is there a tax penalty for not buying a Marketplace plan in 2020?
NO. The tax penalty for not buying an ACA qualified plan is eliminated for 2019.
However, if you qualify for a tax credit to pay for your premium, you must purchase coverage through the Marketplace.
BROKER HELP TRULY COMES AT NO COST
I like to share at the onset that working with a broker comes at no cost to you. I'm definitely a 'do it yourself'er' on most things, but with your second largest bill, getting it right comes from having the right information and sometimes a little help.
There are a few complicated issues to understand such as specific network limitations, Medical Home requirements, tax credits and income, and other issues that if not understood can be costly. So please, at least have a conversation with me before making application.
I really value your time, and most of my clients prefer to meet with me by scheduling a phone time with a computer screen-share appointment. This is easier than it sounds, and it allows you to see my computer screen while we talk. I have no access to your computer and no software downloads are required. Here's the process:
1. SCHEDULE APPOINTMENT:
Call me at 503-650-4325 to schedule the phone meeting or email me at firstname.lastname@example.org to request an appointment. Plan ahead as I am very busy during this 6-week window, but I make time mornings, evenings, and weekends during this time.
2. SCREEN SHARE WITH OUR PHONE APPOINTMENTS:
If you can, please be in front of your computer during our phone meeting. I will email you a link you can click on that will allow you to see my computer screen while we talk. This aids in our discussion of the coverage, looking up providers, and making application.
Begin your 2020 new application: A few important issues
1. Family member/Household definition:
Your 'Household' includes everyone who will be on your 2020 tax return, whether they are applying for coverage or not, living in your home or not. If your child lives in the house, but will not be on your 2020 tax return, you should do a separate Marketplace application in their own name and create a separate Marketplace account for them.
2. Projected Income to calculate the advanced tax credit
This can be tricky: Your goal here is to project/guesstimate the income you will earn in 2020 and put on your 2020 tax return. Technically, the tax credit is based on your 'Modified Adjusted Gross Income' for every person on your tax return, even if they are not applying for coverage. If you or your spouse have non-taxed Social Security, you also need to include this as a source of income. The tax credit is calculated this way--taking everyone's combined income into account.
If you were unsure of your Adjusted Gross Income last year, look at your last tax return. You will find this on line 37 of a 1040 Federal tax form. It's not a bad idea to estimate a little high.
This can be a tricky guesstimate, particularly for the self-insured as you are trying to project income you have not yet earned yet. You are wise to project your income a little higher than you expect. This way when you do your taxes it will not sting as much if you are incorrect in your projection. Please ask me about this step as it is consequential.
Sometimes understanding the limits to qualify for a tax credit can be critically important.
Case Study: John and Sara are both 60 years old. Their projected income for 2020 to be $70,000. (The cut-off for them to qualify for a tax credit is roughly $67,000). The least expensive Bronze plan would cost them $1148 per month. If their income was $67,000, they would qualify for a $1209 tax credit monthly. If their income was $68,000 they would qualify for $0 tax credit monthly.
HOW MY ADVICE COULD SAVE THEM $13,316:
My advice to John and Sarah was to add $3000 to a Traditional IRA (Not Roth). This reduced their adjusted gross income to $67,000. The lowest cost plan now cost them only $38.33 per month instead of $1209! This is the benefit of having a good Broker.
The Tax credits are based on your 'Modified Adjusted Gross Income', which is close to your Adjusted Gross Income for most people. 2 ways to lower your MAGI is to, 1: Contribute to a Traditional IRA, and 2. Contribute to a Health Savings Account. Under Option 2 you need to purchase an HSA-eligible medical plan.
3. Submit the application and read the Benefit Determination Report:
After completing the Marketplace application, you can view your 'Benefit Determination' report. In it you can see if qualify for a tax credit, and in the 'What Should I do next?' section, it tells you if you need to submit documentation you may need to provide--either to prove your income estimate, or other requested documentation such as social security verification or citizenship claim. Sometimes they ask for nothing.
4. Selecting the right plan or plans for you:
Now that you know have submitted your application, and viewed your benefit determination, it is time to view the plans and select the policy or policies that best fit your family situation for the year. For each of the companies on the Marketplace offering coverage, I have a web page on my website. For example, with Providence, I have a "Providence Page". Here you can view the full brochure, and look up providers so that you can make an informed decision. Be sure to read the limitations and exclusion sections as well.
Before selection of a plan, it would benefit you to have a discussion with me to confirm your understanding of the plan and the plan limitations. I may shine a light on something you haven't considered or missed.
5. Make your initial premium payment
Your premium will be due before the date coverage starts. Be sure to look out both in mail and email for this initial bill. Don't let this slide as the carriers are merciless if there is an error. They are also merciless when it comes to reinstatement should you pay late. PLEASE SET UP BILLING ON AN AUTO-PAY. Each year I have clients that get cancelled and cannot reinstate.
When you pick your plan, then view the final review there is a button that says "Is someone helping you complete this enrollment?". Here I'd appreciate your checking yes and adding broker, Dan Neils, NPN 757811, even if you did it on your own. Thank you! This is how I am compensated.
6. TAKE YOUR TIME DON'T RUSH:
Health insurance is likely one of your largest bills each month. Just a second caution to make sure you understand the plans and networks prior to enrolling and locking in your coverage for the year. It can be very consequential financially. Keep in mind if you want January 1st as your start date, you have until December 15th to select a plan.
COMMON QUESTIONS AND ANSWERS
I've included some of my own Q and A for common areas people mess up. I've included other various Q & A on related topics.
Q: If I'm doing my Marketplace renewal, which Dental plan would you recommend?
A: On the Marketplace, the Kaiser dental plans have no waiting periods, and the Delta Dental Exclusive PPO plan is popular, but you can only use dentists in the Delta Dental PPO Network. I have other direct-written dental plans on my web page.
Q: My son is 23 and is living in my home and will do his own taxes for 2020, should I put him on my application if I intend to pay his premiums?
A: No, to be on your application he has to be a dependent on your tax return for 2020. He is not part of your 'household' for purposes of this process. To get coverage through the Marketplace he can do his own application. You can always pay his premium if that's your goal.
Q: My husband is 66 and on Medicare. Does he need to be on my application?
A: Yes, he needs to be listed as a family member, but check no to the question as to whether he is applying for coverage! If you file taxes jointly, your household income includes everyone on your tax return for that year. When you put him on the application, you say no to when they ask you if he is applying for coverage. You also need to include his income, including Social Security in your income declaration.
Q: When adding up our income projection for 2020, should I put down my husband's untaxed Social Security income?
A: Yes, if you file jointly your taxes, you need to include income from everyone, even if they are not applying for coverage.
Q: How about the $5000 my tax dependent son made at his job?
A. List the projected income for each family member on the application when it asks if you have income.
Q: If my kids are already on Oregon Health Plan, will doing my Marketplace renewal renew their OHP coverage?
A: No, if you child is on OHP, OHP will mail you randomly a renewal packet sometime during the year. However, if they are not on OHP, the Marketplace application may qualify them for initial enrollment. If your child loses OHP coverage, we can do a Life Change and add them onto your coverage. This will increase your tax credit to help you pay for it.
Q: WHAT IF I QUALIFY FOR TAX CREDIT MID-YEAR BECAUSE MY INCOME GOES DOWN OR UP?
A: Anytime you have a change of income substanially you are obligated to report a 'Life Change'. This Life Change may allow you to start getting a tax credit, and you may be allowed mid-year to change your health plan in response. I'm here to help you with this. Be hesitant to use the Marketplace folks to do this, as suffer no consequences if they make a mistake over the phone. They bear no responsibility when they mess up.
Q: If they say I qualify for a $300 tax credit monthly, do I need to take the whole thing every month or can I defer it for later?
A: No, you can choose to not take it up front, then get the money at tax time instead. The purpose of their advancing you the tax credit is to make it more affordable to pay your premium each month. You can also chose to take a percent of what's being offered, like $200 per month, and get the rest at tax time. Most people take the whole credit being offered.
Q: When enrolling, how do I put different family members on different plans?
A: When you start the Enrollment process, it will allow you to chose 'shopping groups'. Creating a new Shopping Group just lets you shop so each person is under their own policy. If you qualify for a tax credit they will divide the credit among you. You could also put 2 people under 1 policy, and 1 person on their own, depending on your needs.
Q: When should I put different family members on different policies?
Let's say Mom has of medications and wants more upfront coverage. You may select a Standard Silver or other plan for her. Dad may rarely go and want a lower cost plan or the HSA option. Put Dad on his own 'shopping group' plan..
WHAT IF OUR SON IS AWAY AT COLLEGE IN ANOTHER STATE PART OF THE YEAR?
Kaiser allows has a Dependent out of state rider to acomodate this. If they spend the bulk of the year in another state you can buy them a policy in that state if they are considered a resident there.
Q: WHEN IS MY FIRST PAYMENT DUE?
Coverage is due by the day the coverage starts. However, let's say your work plan ended on the 29th of March, and I helped you sign up on through the Marketplace for a Kaiser plan on March 30. Coverage would begin April 1, and Kaiser may not bill you until mid-April for the April 1 start date. However, your May 1 payment would be due shortly after.
Q: Why would I want to open an HSA Account anyway?
A: I added a whole page on HSA plans, but basically, if you have an HSA eligible plan, you can make all your eligible medical, dental, vision, alternative care, RX, and more expenses a tax-advantaged situation. If you file a 1040 form, it directly reduces your taxable income.
Q: Why should I list you as my agent if I did the application on my own?
A: Fair question. Listing Dan Neils, , NPN 757811 is much appreciated as this is how I am compensated. I offer all of this info (analysis on this plans) to your each year, I am here to advise you 12 months out of the year, and I'm here to act as your advocate, both with the Marketplace and direct with the Carrier. My services come at no cost to you. A single piece of advice I offer you could save you literally thousands per year.Finally, things will continue to change, and your best source of help when things do is an informed Broker.
If you signed up on your own and want to later add me as your broker, you can do so by signing a 'Broker of Record' request which I can send you if you email me at email@example.com or call me at 503-650-4325.
Q: Are all the plans in HealthCare.gov available if you instead buy direct from the carriers?
A: No. Regence and HealthNet only sells their plans direct with the carrier, not through HealthCare.gov. Other carriers also have some plans that are only available direct. For example Life wise plans are only through the Marketplace for 2016, and HealthNet plans are only direct....another reason to have a Broker.
Q: I've never heard of Bridgespan, tell me more.
A; Regence decide to sell their Individual plans direct-only, then created the company Bridgespan for their plans through the Marketplace. Both companies use a network of providers called the OHSU Plus network.
Q: Why should I use you instead of a slick web-seller like www.esurance.com or healthplans.com rather than work with you?
A: We all offer the same rates, there are no discounts available. That said, they provide you with the data, but I offer you the wisdom on how to interpret and apply it. As you can guess, making a wise decision on health insurance comes down to experience as well as information. I have that experience to help you make an informed decision.
Q: Why are companies raising their rates so high in 2018?
A: Tough one. Many factors. Probably the largest factor is the very sick whose massive claims sink the profitability of the insurance carriers. ObamaCare has built in programs to help compensate the carriers for their losses, but Congress refused to fund these mechanisms, instead leaving the carriers to flounder and carry the losses, to the tune of hundreds of millions of dollars (hoping the program fails). Consequently for 2018 in increasing number of carriers are fleeing the Marketplace. For a private company to succeed, it must be able to make a profit. The cost of custom medications also tanks profitability.
Q: How do I estimate my 2018 income on the Marketplace application if I am self-insured?
A: Super hard! For last year, look at your gross sales, the look to see how much ended up taxable on your tax return after your write-offs. Check mid-year to see if you are on track to the number you estimate. If not do a 'Life Change' to update.
Q: How do I best report a life change?
A: I have seen so many errors from the Marketplace call center, that I plead with you let me show you how to make changes on your own, or I will do it for you. If a Call Center representative messes up your account, he/she is not accountable, and it can cost you literally thousands. Please also do NOT let them do your renewal over the phone. You cannot see what they are doing, and mistakes are consequential.
Q: Last year I signed up, got a nice tax credit, then had it taken away mid year! What did I do wrong?
A; Normally, the FFM request income documentation or other documentation. If they don't like what you sent them they sometimes just take away your credit. If things ever get messed up PLEASE call me, I can help.
Unfortunately, if they mess up, you pay for it. There will not fix it retroactively, but just moving forward.
Q: WHAT IF I HAVE MORE THAN 3 KIDS UNDER AGE 19?
A: If you put your kids on the same policy, you only pay a premium for the first 3, the rest are free. This only works for kids under age of 19.
Q. Dan, I know you are crazy busy the Fall during Open Enrollment, will you have time to help me?
A. Oh yes! I work semi-tirelessly from 8:00 am to 7:00pm helping folks. Just call or email me and we'll get an appointment on the books for you.
Q: You only list 6 or so plans from each type in your recommendations, how do you narrow the plan options to the best 6?
A: Good question! During I go to the provider meetings to learn as a broker what changes they are making in their plans, get rates and plan designs, then start the process of comparing plans. After lots of analysis I narrow the top 6 plans by price and the networks available. For example PacificSource is the most expensive plan, but I include them because they are the only carrier with Legacy providers for 2018.
Q: What do you think about the Christian Health Sharing ministries like Medishare and Liberty?
A: I have taken the time to order materials and read fine-print on both of these plans. Here are a few thoughts: 1. They are not insurance. A Standard Bronze caps your catastropic coverage, including medications at $6350. Sharing ministries are just not prepared to handle that huge cancer or maybe some treatments you may not need. If God's hand is in these plans, I don't want to be against what they are doing. I love the idea of Christians helping to pay each others medical bills and applaud the effort 2. They may not 'share' in some of the stuff you need them to like mental health drugs. 3. If they refuse to 'share in your big bill' you have no recourse. I spoke first-hand with a client who tried one of these 2 ministries, had a delivery that went bad, and refused to share in her $110,000 bill, and had her ask the hospital to write off the bill. That didn't sound right to me. This all said, of the 2 programs I like the Liberty plan better. If you do one of these plan, you may consider adding my MetalGap accident plan which could complement the coverage.
Q: What happened to Lifewise, Oregon's Health Coop and Health Republic?
A. Lifewise will discontinue plans 12/31/16. OHCOOP was shut down July 31due to finances, and Health Republic closed 12/31/15 due to finances. Without reforms this trend is likely to continue. RIP.
Q: What if my income drops mid year? Should I report it?
A: Yes, you can report to the Marketplace by reporting a "Life Change". This will either result in an increase or decrease to your tax credit. Your obligation is to contact the Marketplace if your income changes substantially. I can help you with this. Please don't let the Marketplace folks do the LifeChange for you over the phone if you can at all avoid this. You cannot see what they are doing, and they often make mistakes that can be consequential. A LifeChange reported by the 15th of the month is effective the 1st of the next month.
Q: The Marketplace is requiring I send in proof of my income for 2018, but I haven't earned it yet, this is messed up?
A: The tax credits are giving in advance of what you are likely to earn in 2018. When you file your taxes spring 2019, the IRS reconciles what you said you would earn, say $40,000 with what you really had for a MAGI, say $43,000. If you guessed too low, you may have to pay back some of what you got each month. If you guessed high, you will get extra money in your taxes when they reconcile.
I missed Open enrollment, am I doomed?
So you missed open enrollment, or your coverage cancelled for non-payment mid year. You have a good option in buying Short Term Medical insurance for the rest of the year. Visit my web page at http://www.agapeinsurance.net/short-term-medical-.html
OTHER QUALIFYING EVENTS:
Recent divorce, leaving your parents plan, a move to another state, and a major change of income are all possible qualifying events that may allow you to enroll mid-year.
UNDERSTAND THE TERM 'COST SHARING'
When your income is between 138% - 250% of the Federal Poverty Level, you will benefit by being offered a lower deductible and out of pocket maximum if you select a 'Silver Level' plan. For instance, the Kaiser Standard Silver plan, which has a $2500 deductible, may be offered to you with a $250, or $500, or $750, or $1500 deductible. Be sure to check out the deductible for the Silver plans to see if you qualify.
UNDERSTAND 'DEDUCTIBLE' AND "OUT OF POCKET MAX" ON THE WEBSITE
At www.healthcare.gov, when you view a quote for more than one person, the deductible that shows up is actually double the individual deductible--which is the more important consideration. The website also doubles the out of pocket maximum. Confusing? Yep, sure is! For example when viewing a quote for 2 people, let's say the plan displays as having a $5000 deductible, and $10,000 out of pocket maximum. You should view this as a plan with a $2500 individual and $5000 out of pocket max. Make sense?
Call Dan prior to making a final decision on coverage to make sure you're not overlooking something critical. That's what I'm paid for!
A FEW MORE THINGS TO KEEP IN MIND REGARDING COVERAGE CHANGES FOR 2018: (There are too many to list...)
1. RATES VARY BY PERSON:
There is a different rate for each family member. Don't be afraid to put different family members on different plans, according to your usage needs. There is no advantage to all being on the same plan or company and no cost savings. Kids over age 19 are priced like adults and they get a 40% rate increase when they turn 21.
2. GUARANTEED TO QUALIFY:
Unlike in the past, your approval is guaranteed. No medical questions, denials, or waits for pre-existing conditions. You have full access to every plan--approval guaranteed, which is exciting to anyone who has been denied by a carrier before.
3. ALTERNATIVE CARE:
Many plans will now allow you to use your Naturopathic doctor as your Primary Care Doctor. The Kaiser Silver and Gold plans allow you to go to Alternative Care (Chiropractic, Naturopathic & Acupunture visits, but you need to get a referral from a Kaiser PCP. Most other plans exclude Alternative Care providers for 2018.
4. MAXIMUM OUT OF POCKET:
The term "Maximum out of Pocket" is an important term to understand as it includes your deductible, co-insurance (like the 30%), your copays and your RX costs for services performed 'In Network'. When you reach your out of pocket maximum (in network), the plan pays at 100% for the rest of the year which is great! Understand your coverage. Take the time to read the fine print, read the exclusions and limitations. Try to fight having the 'get it done' mentality. At such a large cost you should understand what you are buying.
5. PLANNING A PREGNANCY OR SURGERY:
When you see a big out of pocket coming, you can select a plan with a low out of pocket maximum. My cart under the link "Individual Medical Plans" show the plans with the lowest out of pocket maximum. We can discuss which company may best meet your needs.
6. PROVIDER NETWORKS:
Each company is reducing their networks for 2018 except Kaiser. With Providence, the important question isn't whether your doctor takes Providence, but whether they are in the Choice or Connect network.
7. HEATH SAVINGS ACCOUNT-ELIGIBLE MEDICAL PLANS (HSA):
I discuss this in depth on my HSA page.
8. HOW MUCH CAN I EARN AN QUALIFY FOR A TAX CREDIT?
This varies by age and family make up. Examples: A couple ages 50, 50, 18, 18 can earn up to about $96,000 per year and qualify for a tax credit. A couple age 60, 60 can earn about $64,000 max and get a large tax credit.
HELPING YOU CONSIDER THESE ISSUES AND PLAN I YOU ARE CLOSE IS PART OF THE BEST SERVICE I PROVIDE TO YOU AS A BROKER. CALL ME TO DISCUSS YOUR SITUATION TODAY. CALL DAN AT 503-650-4325 OR DANNEILS@GMAIL.COM
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