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Health Insurance 2018 – An Overview

A massive change in how health insurance is marketed started January 1, 2014 as mandated by the Affordable Care Act (ACA).

Open Enrollment

Last chance to buy individual health insurance for 2018 is December 15, 2017. This will be for a plan effective January 1, 2018. Sign up today !

Important: Health insurance plans are not be available for purchase outside of “Open Enrollment” except for special circumstances.

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Special Enrollment

Besides the “Open Enrollment” period each year, enrollment in individual health insurance plans is only available due in special situations. You can also switch plans if you have a one of these “triggering events.” Here’s partial a list:

  • Getting Married (becoming a dependent spouse)
  • Getting Divorced and losing health insurance coverage
  • A new child (including birth, child of your new spouse, adoption & placement for adoption)
  • Permanent move outside of your current plan’s territory
  • Losing your current health insurance coverage such due to changing employers (does not include non-payment cancellation or voluntarily quitting a current policy)
  • Change in eligibility for premium tax credits or cost-sharing assistance
  • New citizenship or lawful resident
  • Current plan does not provide “Essential Benefits”
  • An American Indian (can change enrolled plans once a month)
  • Your COBRA coverage eligibility expires

You have to exercise your “Special Enrollment” rights within 60 days to enroll in your new health plan or to change health plans from the date of the “triggering event.”

Marketplace (Health Insurance Exchanges)

Texas is a Federal Government run exchange since. Plans will be available outside of the “Marketplace” but the only place to receive a financial subsidy (an advance on your Federal income tax based on your predicted tax credit) will be via applications submitted via the Marketplace program. While there is considerable political conversation, the Affordable Care Act Marketplace and Advanced Income Tax Credit (subsidy) are the law of the land.

Health Insurance Subsidy (Advanced Tax Credits)

To obtain a subsidy, you must apply via Healthcare.gov, you need to meet the eligible requirements including not having employer based health insurance available and have an income level between 133% and 400% of the Federal Poverty Level. Here are the income levels for 2017:

  • Individual – minimum $15,800 to maximum $47,520
  • Family of 2 – min. $21,306 to max. $64,080
  • Family of 3 – min. $26,812 to max. $80,640
  • Family of 4 – min. $32,319 to max. $97,200

The Ten “Essential Benefits”:

  1. Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care (care before and after your baby is born)
  5. Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  6. Prescription drugs
  7. Rehabilitative and habitability services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services

Color-Coded Plan Levels

Each plan offered will be categorized by the relative benefit level into four different color-coded levels: Bronze, Silver, Gold and Platinum.

The “color-code” Metal Levels are based on the actuarial values of each plan. A plan that is expected to have a consumer be responsible for 40% of the healthcare costs is rated as a Bronze Plan (highest consumer contribution), 30% for a Silver Plan, 20% for a Gold Plan and 10% for a Platinum Plan (least consumer contribution).

There also is a “Catastrophic Plan” of limited benefits and lower insurance cost for adults under age 30 and for individuals that have financial hardships and can’t meet the affordable insurance cost rule.

Healthcare Plan Designs / Features

Each health insurance companies will create different selections of plan features such as Doctor Co-pays, Deductible, etc. What cost-sharing features will be an important consideration on which plan to select along with the Metallic Benefit Level, Network and Price. The lower priced “Bronze” plans will typically have little besides catastrophic protection while the higher priced “Gold” & “Platinum” will typically have attractive co-pay features and lower deductibles.

It is important to look beyond the monthly premium cost of a plan and buy what you need based on your expectation of healthcare use. For example: a person with substantial and regular medical costs should consider a higher priced “Platinum” or “Gold” plan with it’s lower out-of-pocket costs because they likely would spend less total money for the combination of healthcare & health insurance. On the other hand, a person that expects very modest healthcare use should consider a lower priced “Bronze” or “Silver” plan to reduce the cost of health insurance because they likely would spend less total money (combination of healthcare & health insurance).

Another consideration is looking for a plan that is compliant with making Health Savings Account contributions. See more information on High-Deductible health insurance plans that are H.S.A. compliant. The combination of a Health Savings Account and a High-Deductible Health Insurance plan can provide financial protection form the potentially huge costs of a major illness or injury and a lower insurance premium plus a tax advantage.

Network Type: HMO

HMO (Health Maintenance Organization): Healthcare cost are only covered “in-network” except in a medical emergency. To received treatment from a specialist, a referral is required from your assigned Primary Care Physician. All the Blue Cross Blue Shield plans we offer are HMO network plans.

Access / Pre-Existing Conditions / Rating Rules

One of the major changes in the health insurance marketing is the availability of insurance regardless of current health conditions and with no exclusions on treatments for pre-existing conditions. Insurance policy prices will be community based and not increased for people due to medical conditions. Health plans can be rated for age, tobacco use and family size (number of family members covered). The rate differential for age and tobacco use is limited by law.

Individual / Employer Mandate

Individuals: Nearly all U.S. Citizens and legal residents will be required to have a qualifying health insurance plan, qualify for an exemption or pay a penalty via their income tax filing. The “Shared Responsibility Payment” increases for the 2018 tax year to 2.5% of household income above a threshold determined by the national average Bronze Plan insurance cost.

Dependent Coverage

The new market rules require insurers to offer coverage to dependent children until age 26 on a parent’s health plan.

Maximum Out-of-Pocket Limits for 2018

Health plans will have Federally mandated maximum out-of-pocket costs which is adjusted each year. Maximum out-of-pocket costs for 2017 plans including co-pays, deductibles and other cost sharing will be limited to $7350 for an individual and $14,700 for a family. A new rule for 2016 for a family health insurance policy is that the individual deductible is “embedded”. This means that an individual will reach their maximum out-of-pocket regardless of the family maximum level.