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Our Mission
About
How to Read an Insurance Quote
A - Insurance Carrier
B - Plan Name
C - Annual Deductible
D - Highlight Plan Features
Blue = Yes; Feature included.
Gray = No; Not included.
E - Plan Details
Click to view additional plan details.
F - Find a Doctor
Click to find a list of available providers.
G - Plan Brochure
Click to view the carrier's plan brochure.
H - RX Lookup
Click to lookup Carriers RX directory.
I - Plan Overview
Overview of basic plan attributes.
J - Apply Now
Link to carrier application through specific agent's carrier portal.
K - Plan Number
Number assigned to each plan within the Nexben database.
L - Monthly Premium
Rating variation is based on applicant's age, geographic area, family composition, and tobacco use.
M - Compare Checkbox
Click the checkbox to compare the plan alongside up the three others.
Glossary of Insurance Terms
A
ACO: Accountable Care Organization
A group of coordinated health care providers which delivers care to a group of patients. The ACO is structured to be accountable to the patients and the third-party payer for the quality, appropriateness and efficiency of the heath care provided.
Annual Limit
A dollar limit placed upon the claims an insurer will pay over the course of a plan year. The Patient Protection and Affordable Care Act (PPACA) prohibits annual limits for essential benefits for plan years after September 23, 2010.
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C
Co-Insurance
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Co-Payment
A fixed amount you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
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Deductible
The amount of expenses that must be paid out of pocket for health care services before an insurer will pay any expenses. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
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E
Essential Health Benefits
A set of health care service categories that must be covered by certain plans, starting January 1, 2014. The Affordable Care Act ensures that ALL health plans offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Exchange Qualified
Identifies plans that are found in a public exchange; these plans include all mandatory essential benefits.
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G
Guaranteed Issue
A tax advantage medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit and they can roll over into the next year if they are not spent.
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H
Health Maintenance Organization (HMO)
Prepaid health plans in which you pay a monthly premium and the HMO covers your doctor's visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan's network.
HSA: Health Savings Account
Prepaid health plans in which you pay a monthly premium and the HMO covers your doctor's visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan's network.
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I
Individual Mandate
A component to the Patient Protection and Affordable Care Act, signed into law March 2010, and effective January 1, 2014. It states that all United States citizens and legal residents are required to buy health insurance or pay a penalty.
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M
Medicaid/Medical Assistance
A joint federal-state health insurance program that is run by the states and covers certain low-income people (especially children and pregnant women), and disabled people.
Metal Level Plans
Bronze: 60% Co-Insurance
Silver: 70% Co-Insurance
Gold: 80% Co-Insurance
Platinum: 90% Co-Insurance
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N
Network
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
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O
Out-of-Pocket Limit
The maximum amount you can pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your plan doesn’t cover. Some plans do not count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
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P
POS: Point-of-Service Plan
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which individuals decide whether to go to a network provider and pay a flat dollar copayment (say $10 for a doctor's visit), or to an out-of-network provider and pay a deductible and/or coinsurance charge.
Preferred Provider
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
PPO: Preferred Provider Organization or Participating Provider Organization
A managed care organization of providers - medical doctors, hospitals, and other health care entities - who have negotiated contracts with an insurer or a third-party administrator to provide health care at reduced rates to the insurer’s or administrator’s clients. Patients have financial incentives to select providers within the PPO network.
Premium
The estimated monthly cost of an insurance policy. The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
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Q
QHP: Qualified Health Plan
Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the public exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.
Qualifying Life Event
A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby).
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Third-Party Payer
Any payer of health care services other than you. This can be an insurance company, an HMO, a PPO, or the federal government.
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Qualifying for A Premium Tax Credit
Premium Tax Credit Eligibility Criteria Overview:
Must be a U.S. citizen or a lawfully present immigrant
Have a household income between 100% and 400% of the Federal Poverty Limit
Must NOT be eligible for public coverage – including Medicaid, the Children’s Health Insurance Program, Medicare, or Military Coverage
Must NOT have access to health insurance through an employer
Must purchase coverage through a public Marketplace
Qualifying for Premium Tax Credits
The Affordable Care Act (ACA) establishes a system of tax credits to help consumers pay for the health coverage plans they are required to purchase by law. This tax credit helps contribute to the monthly cost or premium for the health plan coverage.
Premium tax credits are ONLY available for coverage purchased in a public Marketplace.
Premium tax credits will be available to U.S. citizens and lawfully present immigrants who purchase coverage in the Marketplace and who have income between 100% and 400% of the federal poverty level. Premium tax credits are also available to lawfully residing immigrants with incomes below 100 percent of the poverty line that are not eligible for Medicaid because of their immigration status.
In addition, to be eligible for the premium tax credits, individuals must not be eligible for public coverage—including Medicaid, the Children's Health Insurance Program, Medicare, or military coverage—and must not have access to health insurance through an employer.
However, there are exceptions in cases when the employer plan is unaffordable, if the plan fails to provide a minimum level of coverage, or if a plan does not meet the standards for minimum value. If you are required to pay for than 9.5% of your income for coverage for a single person under your employer’s health plan, you could qualify for premium tax credits. You could also qualify for premium tax credits, if your annual deductible is higher than $6,350 per person.
Applying for Premium Tax Credits
When you apply for a premium tax credit during Open Enrollment, you will not necessarily know exactly what your 2014 income will be, so you will apply based on your best estimate of your 2014 income. When you file your 2014 tax return, due April 15, 2015, the IRS will compare you actual 2014 income to the amount of premium tax credit you claimed in advance. If your actual income is greater than your estimated income, you may be required to pay back some or all of the difference. If you did not receive all of the premium tax credit you are entitled to during the year, you can claim the difference when you file your 2014 tax return.
If your income changes during the year, you can modify the amount of premium tax credit accordingly. You can report any changes to a public Marketplace to raise or reduce the amount of premium tax credit you receive.
Calculating Your Premium Tax Credit
Your premium tax credit is calculated based on geographic location, household income, number of adults and children in the household, and the second lowest costing Silver plan available in your area.
To calculate your estimated premium tax credit, use our Premium Tax Credit Calculator located on the right-hand side of this page.
If you have questions or require further explanation, please contact your Agent for assistance.
A Quick Guide to Healthcare Reform: The Affordable Care Act
The Patient Protection and Affordable Care Act (ACA or PPACA)
Signed into law March 23, 2010 by President Obama
Commonly referred to as Obamacare
Focuses on provisions to:
Expand coverage,
Control healthcare costs, and
Improve health care delivery system
Establishes Public Health Insurance Exchanges (Run by State or Federal governments)
Creates an Open Enrollment period for purchasing coverage
In summary, the Affordable Care Act…
Guarantees issue and renewability from insurance carriers
Extends dependent coverage for children up to age 26
Prohibits exclusions or denial based on pre-existing conditions
Limits waiting period for coverage to 90 days
Prohibits annual and lifetime limits on coverage
Creates an Essential Health Benefits Package for all plans in the Individual and Small Group markets
Requires most U.S. Citizens and legal residents to have qualifying health coverage or pay a penalty
Requires some employers to offer coverage to employees or pay a penalty
Individual Mandate
Beginning January 1, 2014
Requires U.S. Citizens and legal residents to have qualifying health coverage or pay a penalty
Penalty Structure:
In 2014 – 1% of income or $95, whichever is greatest
In 2015 – 2% of income or $325, whichever is greatest
In 2016 – 2.5% of income or $695, whichever is greatest
For a family, the penalty is capped at three times the individual amount
Employer Requirements
Employers with 50 or more full-time employees (FTE) must offer coverage to at least 95% of employees or pay a penalty
Employers with more than 200 employees must automatically enroll employees into employer provided health insurance plans
Small Business Tax Credit
Available to small employers with up to 25 employees and average annual wages of less than $50,000
Individual Premium Tax Credit & Cost-Sharing Subsidies
Beginning January 1, 2014
Premium Tax Credit Assistance
Available to U.S citizens and legal immigrants with household income between 100% and 400% of the Federal Poverty Level
Individuals must not be eligible for public coverage (Medicaid, Medicare, etc.)
Must not have access to employer sponsored health insurance
Cost-Sharing Subsidies
Reduce the cost-sharing amounts and annual cost-sharing limits
Public Health Insurance Exchanges
Establishes State and Federal Marketplaces and Small Business Health Options Program (SHOP) Exchanges
Only available to U.S. citizens and legal immigrants
4 Metal Benefit Categories of Plans & Catastrophic Plans
Bronze – covers 60% of the benefit costs of the plan
Silver – covers 70% of the benefit costs of the plan
Gold – covers 80% of the benefit costs of the plan
Platinum – covers 90% of the benefit costs of the plan
Catastrophic – only available to individuals up to age 30
Reduces the out-of-pocket limits for those with incomes up to 400% FPL
Guaranteed issue and renewability from insurance carriers
Rating variation based only on age, geographic location, family composition, and tobacco use
Private Insurance Carriers
Dependent coverage for children up to age 26
Cannot deny or exclude applicants based on pre-existing conditions
Waiting period of 90 days of less for coverage
No annual and lifetime limits on coverage
The 10 Essential Benefits of ACA
Ambulatory patient services
Emergency services
Maternity and newborn care
Pediatric services, including dental and vision care
Rehabilitative/habilitative services and devices
Mental health and substance use disorder services, including behavioral health treatment
Preventive and wellness services and chronic disease management
Hospitalization
Prescription drugs
Laboratory services
Medical Marketplace
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Dental Marketplace
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Vision Marketplace
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Proposal for Coverage
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