How do you get paid?

  • Workplace Benefits is contracted as an insurance broker. We are paid by the various carriers that we represent once a policy is sold.

When is Open Enrollment this year?

  • The 2016 plans and prices will be released on November 1, 2016. If you purchase a policy between November 1, 2016 and December 15, 2016, you will have an effective date of January 1, 2017.
  • If you purchase a plan between December 15, 2016 and January 15, 2017, you will have an effective date of February 1, 2017.
  • If you purchase a plan between January 15, 2017 and January 31, 2017, you will have an effective date of February 1, 2017.

What about dental, vision, life and disability?

  • Workplace Benefits represents several carriers for dental, vision, life and disability.
  • We are able to offer this to you as a group or individual basis.

What is a PPO, HMO and an EPO?

  • These acronyms refer to types of networks.
  • Here is a great article that explains the differences between the types of networks as well as other helpful information.

What is the difference between a deductible, coinsurance & out of pocket maximum?

  • For example: Let’s say that you have a $100,000 claim. You have a $1000 deductible, 80/20 coinsurance, and $3000 out of pocket maximum. You are going to pay $1000 upfront, kind of like a down payment. Now, you have $99,000 left. The insurance company will pay 80% and you will pay 20%. Until your 20%s adds up to $2000, you have then met your out of pocket maximum.
  • Basically, it’s all a fancy way of saying that you would owe the out of pocket maximum in the worst-case scenario. We feel as though this is the number that you should focus on.

What is a copay?

  • This is the shared cost that you will owe the provider after you have been seen.
  • For example, if you go to a Primary Care Physician (PCP), you will owe $15 for the visit. If you go to a specialist, you will owe $30 for the visit. The reminder of the cost for your visit will be charged to your insurance company. (unless otherwise indicated by your specific carrier)

If I’m subsidy eligible, how does that work?

  • First of all, your eligibility is determined by your projected overall household income for 2016.
  • You do not get a check for this money. The amount of your subsidy will be paid to the insurance company of your choice. Then, you will owe the remainder to the insurance company.
  • If you have “under” bet your income for this year, but made MORE, you will have received MORE subsidy than you should have for this year. You will likely owe this back when you file your taxes in April of 2017.
  • If you have “over” bet your income for this year, but made LESS, you will have received LESS subsidy than you should have this year. You will likely receive this back in a refund when file your taxes in April of 2017.
  • Either way, if you know you will have a drastic change in your income during 2016, you will need to call HealthCare.Gov to have your subsidy adjusted. (1-800-318-2596)
  • Ultimately, it will all become clear when you file your taxes in 2017. You can either wait until your file your taxes in 2017 or call HealthCare.Gov mid-year. This is your choice.
  • Also, if you are subsidy eligible, you will be asked by HealthCare.Gov to submit proof of your income very soon after you sign up. You can mail this in or upload it to your online account. If you do not submit it, you will lose your subsidy. Honestly, we recommend that you do this online as it will create a paper trail, which will help you if anything should ever be questioned.

What if I miss a premium payment during the year?

  • You DO NOT want to go longer than 30 days without making a payment.
  • If you miss a payment, you WILL BE cancelled. And, it’s near impossible to get you reinstated outside the Open Enrollment period.
  • We encourage you to make a note to yourself each month to make sure that this payment has been made.

What if I have a baby mid-year? What do I do?

  • Once the baby arrives, you will have to wait 4-6 weeks to get their birth
    certificate and social security card.
  • When you have it, let us know. We will submit the application & birth
    certificate and social security card to the insurance company that you have chosen.
    (NOTE: You have 60 days to do this)
  • Once it’s submitted, the coverage will go back to their birthday.
  • I know it doesn’t feel like he/she has coverage during those 4-6 weeks, but
    he/she actually does.
  • All claims that have been incurred since birth will be covered retroactively. Also, these claims may have to be reprocessed, but we can help you out with it.

I never go to the doctor, so why do I need to buy health insurance?

  • Well, because it’s the law. If you do not purchase health insurance, YOU WILL BE FINED when you file your taxes.
  • If you don’t have health insurance in 2016, you’ll pay the higherof these two amounts:
    • 5% of your yearly household income(Only the amount of income above the tax filing threshold, about $10,150 for an individual in 2014, is used to calculate the penalty.) The maximum penalty is the national average premium for a Bronze plan.
    • $695 per person ($347.50 per child under 18)The maximum penalty per family using this method is $2,085.

What’s covered under preventative services?

  • With your plan, these services are covered at 100%. AKA: FREE!
  • You can go to your carrier’s website to find out what services are included
  • PLEASE take advantage of these services as they are available to you at no cost.
  • Plus, we want to keep you as healthy as can be!

When does the deductible start over?

  • For ALL Marketplace plans regardless of when they are purchased, the deductibles will start over January 1 of EVERY YEAR.

What if ObamaCare/the Affordable Care Act is repealed, what happens then?

  • Well, this is a great question and unfortunately, it’s pretty impossible to answer.
  • Keep in mind that regardless of what you hear politicians say on TV, the ultimate decision is made by the Supreme Court. And, it has been upheld twice now.
  • However, as your agent, please know that we are constantly monitoring the current landscape.
  • If anything is officially decided, we will communicate with you and let you know how it specifically is interpreted for you.

With the Marketplace plans, networks are limited. How do I find out if my hospital/doctor is in the network? Also, how will I know if my drug is covered?

  • Each carrier has a network provider directory available online. You can plug in your doctor/hospital, and hopefully, they will pop up.
  • Also, because these websites are being updated all of the time, you can also call your doctor/hospital directly to ask if they are in your carrier’s network.
  • There are also formularies available online to check prescription drugs.

I have a pre-existing condition. Will it be covered?

  • Under the Affordable Care Act, which went into effect January 1, 2014, pre-existing conditions are no longer allowed to be denied.
  • You will also not be rated up due to medical conditions either.

Is a High Deductible Health Plan (HDHP) and an Health Savings Account (H.S.A.) right for me?

  • Well, it really depends. Here are a couple of blog posts that might help better explain it for you.