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Exploring The Unknown

What Are the Enrollment Periods?

Peter Jundt - Saturday, November 08, 2014

This is part 3 in my series on the Affordable Care Act (ObamaCare). This time I want to take a look at the Enrollment Periods.


One of the provisions of the Affordable Care Act that most often confuses my clients are the Enrollment Periods. Prior to the advent of the ACA, anyone could purchase an individual insurance plan (as opposed to a group plan) any time they choose. All of that changed with the advent of the ACA. Now, with a few exceptions everyone must purchase their Qualified Health Plan (QHP) during the Open Enrollment Period.


November 15, 2014 Open Enrollment Starts.

Anyone eligible for the insurance can purchase a new QHP for 2015 (or stay with the one they have if already enrolled).


February 15, 2015 Open Enrollment Ends.

Last day for people to purchase a QHP for calendar year 2015.


February 16, 2015 to October 14, 2015 - Lock-out Period.

Except for special circumstances, no one may purchase a QHP.


October 15 to December 7 every year thereafter - Open Enrollment Period.

Certain “ Qualifying Life Events”can trigger a Special Enrollment Period(SEP). This is a 60 day period during the Lock-out Period where people are allowed to purchase a QHP. These events can include:

  • Marriage or divorce
  • Having a baby,
    • Adopting a child, or
    • Placing a child for adoption or foster care
  • Moving your residence,
    • Gaining citizenship,
    • Leaving incarceration
  • Losing other health coverage
    • Loss of job-based coverage,
    • The end of an individual policy plan year in 2014,
    • COBRA expiration,
    • Aging off a parent’s plan,
    • Losing eligibility for Medicaid or CHIP,
    • Similar circumstances.
  • Change in income or household status that affect eligibility for premium tax credits or cost-sharing reductions


It is important to keep in mind that experiencing a loss of coverage because of one of these life events does not eliminate the Individual Mandate orthe Fee dictated by the law for not having coverage.


So that begs the question: “OK, so what happens if I miss open enrollment and either don’t have or don’t take advantage of an SEP?”In short, you simply cannot purchase a QHP and you will likely be required to pay the fee. That doesn’t mean that you are with out options to protect your family, but they won’t include a QHP.


This is just another reason why it is critical that you seek someone who is capable of guiding you as you Explore the Unknown.


Next time, we will try to clarify another provision of the ACA. As always, Keep Exploring…

What Are The Metal Plans?

Peter Jundt - Saturday, October 18, 2014

This is part 2 in my series on the Affordable Care Act (ObamaCare).  This time I want to take a look at the so called Metal Plans.


QHP’s, or Qualified Health Plans, are set up in 4 basic tiers.  These make up the “Metal Plans”.  They are:


  • Platinum
  • Gold
  • Silver
  • Bronze


When looking at the plans, there are several things that you need to keep in mind: Actuarial Value (AV), Available Subsidies (which can affect both premium, and in the case of Silver level plans, deductible), Deductible Level, Plan Type, Networks, etc.  While at first glance, the Bronze level plans may appear to be the most affordable, but when you take everything into consideration that may not be the case.


The AV reflects, in general terms, the amount that a person can anticipate paying in a given year for medical services.  For example, if you anticipate paying $10,000 in medical expenses, a Platinum plan would cover 90% of those expenses or $9,000.  (This doesn’t include premium expenses).


  • Platinum plans have an AV of 90%
  • Gold plans have an AV of 80%
  • Silver plans have an AV of 70%
  • Bronze plans have an AV of 60%


Subsidies may be available depending on the Federal Poverty Level (FPL).  This scale varies, depending on how many family members there are, but if a family is between 100% (133% in some states) and 400% of the FPL they may be eligible for a subsidy to assist in paying the monthly premium.  There is an additional benefit for families who fall under 250% FPL and purchase a Silver level plan.  These families could be eligible for additional subsidies which decrease the deductible, thereby increasing the AV of the plan.


The three alternative Silver Plans are as follows:

  • 100-150% of FPL = 94% AV, better than average Platinum Plan
  • 150-200% of FPL = 87% AV, better than average Gold Plan
  • 200-250% of FPL = 73% AV, better than average Silver Plan


Other important considerations would be:

  • Plan type: HMO, PPO, POS, HDHP, Etc.
  • Network size and restrictions
  • Formulary (prescription drug list)
  • Co-pay vs. Non Co-pay plans


Each of these variables can have a significant impact on the amour of protection that the plan provides, as well as the out of pocket expenses you could be responsible for.  This is why it is critical that you seek someone who is capable of guiding you as you Explore the Unknown.


Next time, we will look at the enrollment periods.  As always, Keep Exploring…



What is the Affordable Care Act and how does it work?

Peter Jundt - Thursday, July 24, 2014

Healthcare reform.  To some, it engenders feeling of relief and joy.  To others, it causes waves of anger and frustration.  To most, it simply causes confusion.  Whether you love it, hate it, or are confused by it, healthcare reform is the law of the land and it touches each of our lives in a very intimate way.  Understanding how it works and what its requirements are will be vital to ensuring that we have a functional and effective medical plan in place.


The Patient Protection and Affordable Care Act, or as many people call it: ObamaCare, became law on March 23, 2010 with the signature of President Obama.  Major portions of the law went into effect this year; and additional provisions will be phased in over the next several years.  The law and its many regulations are complex, confusing and evolving.  This will be the first in a series of blogs that will explain the law and how it works in a way that I hope will make it clear and understandable.  I don't intend to try and convince anyone to love or hate the law.  That is for you to decide on your own.  I simply want to help you understand how it works.


Lets start at the beginning.  First, it needs to be understood that the insurance is being provided by private insurance companies.  There is no new government insurance.  People often tell me that they want ObamaCare insurance and are quite surprised to learn that it doesnt exist.  The law simply describes what the plans need to look like and how it needs to act.  For example, for a plan to be considered a Qualified Health Plan (QHP) according to the law it needs to cover these 10 Essential Health Benefits:


1.          Ambulatory patient services

2.          Emergency services

3.          Hospitalization

4.          Maternity and newborn care

5.          Mental health and substance abuse services

6.          Prescription drugs

7.          Rehabilitative and habilitative services and devices

8.          Laboratory services

9.          Preventative and wellness services and chronic disease management

10.    Pediatric services (including oral and vision care).


Each of these 10 benefits must be included, no matter what company is providing the insurance, or it isnt considered complaint with the law.  The way in which each of them will be covered may vary somewhat from company to company and plan to plan so it is important to understand how the plan you are reviewing actually works.


Next time Ill take a look at the so called Metal Plans.  Until then, take care and Keep Exploring