Frequently Asked Questions
Will it cost me anything to use your services?
There is no cost to you for using any of our services. We do not make a commission, we receive a small policy fee from the company, which does not affect your premiums. This means your monthly premium is the same whether you do all of the work and research, or we do it for you.
How does my broker (Davies Insurance Services) help me?
We at Davies Insurance have worked diligently to understand how the new health care laws will impact you. We undergo annual training with all of the carriers in Idaho, with the Idaho Marketplace Exchange a.k.a. Your Health Idaho, and many of the larger nationwide carriers. We are prepared and ready to answer any questions that you may have and to provide guidance as you need to make important decision about your health coverage.
What do I need to know about health care reform?
There are several changes that have taken effect for every new policy that is sold. These changes include:
• The removal of the lifetime caps
• The removal of annual limits for covered essential health benefits
• Wellness services are now covered at 100% with no benefit limit (In-network covered services)
• Dependents can be covered on their parents policies through age 25
• No pre-existing condition limitations
• To apply for coverage outside of the annual open enrollment period, you must have a qualified Life Change Event that will authorize you a Special Enrollment Period (SEP). Without an SEP, you cannot enroll for coverage until open enrollment.
What are Insurance Exchanges? aka Marketplace?
An exchange is a public marketplace that allows you to compare insurance products, their pricing, and plan details from multiple insurance carriers in one place. Exchanges also provide enrollment options and subsidy verification.
How do subsidies work?
If your household income is between 100% and 400% of the federal poverty level, you may qualify for a subsidy to help offset the cost of buying an individual health insurance policy. The subsidy is paid by the federal government directly to the insurance carrier, if you choose this option. The premium you pay each month to the insurance carrier is the subsidized premium (the amount remaining after all tax credits and discounts have been applied). You will NOT need to pay the full premium and be reimbursed later (unless you choose that option).
The amount you are eligible for depends on your family size and how much money your family earns. The Dept. of Health & Welfare (DHW) will determine how much you or your family qualifies for and also the effective date that the subsidy will have. Please note that when you apply for the subsidy, the application will be processed to see if anyone is eligible for Medicaid first. This is because if anyone is eligible for Medicaid, they are not eligible for any subsidies. For more details, you will want to call the DHW directly. In general, the lower your income, the higher your tax credit will be.
If your family income is too high for Medicaid, DHW will determine if the household is eligible for any other programs, such as Cost Sharing Reduction (CSR). CSR immediately reduces your out of pocket expenses like your deductible, copays, and annual out of pocket limits. There are several levels and the amount it is reduced by is dictated by what level you qualify for.
What if I'm on a "Grandmothered" or "Transitional" plan?
***UPDATE: April 27, 2018
The latest CMS guidance released on April 9, 2018, allows states the option of extending the transitional plans for an additional year, through December 31, 2019. The Idaho Department of Insurance (DOI) has issued Bulletin No. 18-03, permitting the extension of non-grandfathered transitional plans (also known as "Grandmothered" plans) through December 31, 2019. This applies to the Idaho individual and small group markets. Based on the requirements of Bulletin No. 16-03 and Bulletin No. 17-01, all transitional plans must now be on a calendar year renewal schedule. Carriers offering these plans must offer policyholders a renewal for the 12 month period beginning January 1, 2019. Your carrier will provide a notice at renewal which informs the individual or small employer of the option to renew the existing coverage or to enroll in a new plan on or off the Exchange (Your Health Idaho). In will also include important information about specific market reforms that were NOT originally included with grandmothered plans, but must now be included to ensure compliance with ACA provisions. These provisions include:
So what happens if you receive a subsidy and then your family’s income increases or decreases?
Any changes to income whether it be an increase or a decrease needs to be reported to Dept. of Health and Welfare (DHW) as soon as possible. That way your tax credit amount can be adjusted accordingly, so it stays in line with the income change. If you fail to do so, you could end up with a smaller refund, or even owing money back as a result of the reconciliation process upon filing your taxes. Conversely, you could end up with a larger refund. The amount you have to pay back or be credited will be based on how much your income has changed.
Can I get free Health Insurance?
It’s possible. There are a lot of myths in regards to the new health care laws and plans that are offered. You may qualify for a subsidy to assist you with the cost of health insurance premiums, which may bring premiums of some plans to zero. There are several factors which determine the amount of the subsidy you qualify for including your income, age and family size.
Do I have to buy health insurance through the Exchange?
No. However, the only way to qualify for the subsidy is if you purchase insurance through the exchange. Using the exchange enables you to compare plans and rates, including subsidies side by side, choose a plan, and even purchase the insurance plan, all in the same visit. Literally one stop shopping.
What happens if I choose not to buy health insurance?
Beginning January 1, 2014, the Affordable Care Act required most Americans to have health insurance. To aid in this process, the law mandates that all health plans must guarantee policies to any individual or employer applicant regardless of health status. This includes those with preexisting medical conditions. Individuals who are not covered by an insurance policy will be charged an annual penalty. For 2016 and 2017, the fee is calculated 2 different ways: as a percentage of income or per person. You will pay whichever is higher. The per person penalty is $695/adult, $347.50/child (with a maximum of $2,085 for families) or 2.5 percent of income above the filing threshold. It will be reconciled when you file your taxes. This penalty will be reduced to $0 beginning on January 1, 2019. See our home page for more details.
What is open enrollment?
Open enrollment is a specified timeframe in which you can purchase health insurance plans and make changes to an existing plan without the need for a qualifying Life Change Event (LCE). Examples of LCE that qualify you for an SEP include but are not limited to: your current plan is expiring and will not continue, involuntary loss of group coverage, marriage, divorce, newborn child and adoption. For policies to be effective by January 1st, the plan must be purchased and paid for by December 15th. Any applications received after December 15th will be processed as an SEP application, and NOT open enrollment. This means that without a qualifying event, you will have to wait until next year's open enrollment to apply for coverage.
What are navigators, certified application counselors, and assisters?
These are individuals that are intended to provide assistance to individuals applying for medical premium assistance and/or enrolling on the exchange. They will primarily be regulated by the Idaho exchange. They are NOT licensed brokers and they cannot make product recommendations.
Will health insurance cost more?
In general yes, however, the premiums you personally pay, may be more or less, as there are a number of factors including; subsidy eligibility, plan selection, tobacco use, age(s), family size, and geographic location that can greatly affect the amount of premium you pay. Because all new plans must adhere to new lower out-of-pocket limits and essential health benefit guidelines, the overall effect is higher premiums.
What are the metal plans?
All plans are separated into 4 different categories: Bronze, Silver, Gold and Platinum. Platinum plans are the richest in benefits; Gold plans are the second richest and so on. The metal designation is used to help when comparing plans. As a general guideline, Platinum plans cover approximately 90% of actuarial value, Gold plans 80%, Silver plans 70% and Bronze 60%. Bronze plans are designed with the lowest monthly premium and highest out of pocket – such as deductibles, coinsurance and or copayments – when health care services are utilized. Platinum plans generally have the highest monthly premium and lowest out of pocket responsibility for the member.
What is Cost Sharing Reduction?
A discount that lowers the amount you have to pay out-of-pocket for deductibles, coinsurance, and copayments. You can get this reduction if you get health insurance through the Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category. If you’re a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits. When the Affordable Care Act was first implemented, this discount was funded by the federal government in the form of reimbursement to the insurance carriers. As of 2018, carriers are no longer being reimbursed yet are still required to have the discounts available. This is one of the reasons why premiums in Idaho jumped substantially in 2018.
What are Essential Health Benefits?
Health plans offered both inside and outside of the Health Insurance Marketplace must offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within 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; chronic disease management; and pediatric services, including oral and vision care.
Insurance policies must cover these benefits in order to be certified or "ACA-compliant" and offered in the Health Insurance Marketplace.
If I am on a group plan, can my spouse and child be covered on an individual plan?
Yes, but you might not qualify for any type of subsidy. You will want to contact your agent or Dept. of Health and Welfare for more detailed information on how access to group coverage affects your eligibility for subsidies. Generally speaking, if you have access to a health plan through your employer, you will not be eligible for any subsidies. Circumstances vary greatly though, and the only way to find out for sure is to contact the Marketplace, who will coordinate any subsidy eligibility through the Dept. of Health & Welfare. For more details, search online for "Family Glitch".
What is the difference between group and individual insurance?
Group health insurance is insurance that is provided through an employer. Individual health insurance is personal health insurance that you purchase by yourself without the help of an employer. The rules are very different between these two types of health insurance programs, and we highly recommend contacting your insurance agent or your employer's HR person (if applicable) with any questions.
Can an insurance carrier cancel my coverage?
Yes, but only for fraud, deliberate misrepresentation, nonpayment of premiums or discontinuation of current product. No insurance carrier can cancel coverage for health insurance claims of any kind.
What is the best health insurance plan for me?
This is a very complicated question. In part because the answer varies so much depending upon your personal circumstances, how long you need coverage, your preferences and other relevant factors.
The professionally trained and licensed brokers at Davies Insurance will work closely with you, on a one on one basis, to ensure that we place you with the best health insurance company and plan that suits your needs.
What is a deductible?
A “deductible” is a specific dollar amount that an insured member is responsible for before your health insurance plan begins to make payments for covered services. Most insurance plans offer what are called “pre-deductible”, “up front” or “first dollar” benefits. These are benefits that are available without the deductible being met. These benefits always include wellness services and may also include; doctor office co-pays, Rx, accident benefits, chiropractic, vision, lab and x-ray.
What is a co-pay?
A “co-pay” is a specific dollar amount or percentage, separate from the co-insurance amount, that your health insurance plan might require you pay for covered services. For example, your health insurance plan may require a $30 co-payment for the physician charge or prescription drug, after which the insurance company pays the remainder of the charges.
How do you protect my private information?
At Davies Insurance Services, we take very seriously our responsibility to safeguard your personal information. We are continuously updating and doing all that we can to safeguard personal information.
Davies Insurance Services will NOT sell, trade, or give your personal information to anyone, anywhere, at any time for any reason, with insurance carriers for quoting or enrolling being the only exception.
Davies Insurance Services, Inc., 450 W. State Street, Suite 125, Eagle, Idaho 83616
Phone: 208-345-3900 Fax: 208-321-4141