You’ll have to act relatively quickly from the date of your “Life Event”. You’ll only have 60 days from the time of your Life Event to enroll into a health insurance plan. This 60 days is your “Special Enrollment Period”.
Some examples of a Life Event are:
A “Subsidy” is where the Government and you share in paying your monthly health insurance payments. The Government helps you pay your health insurance payments monthly, by sending a certain dollar amount of your insurance payment (premium) to the insurance company, and you send in the other portion of your monthly insurance payment to the insurance company. This is called “APTC” (Advance Premium Tax Credit). The factors that affect the percentage or portion of the health insurance premium you pay is your household income and household size (members of your family on your tax return).
Prior to 2014, purchasing individual healthcare with a pre-existing condition, an insurer might have declined covering your condition, or they might have denied you coverage altogether. However, now with the ACA, insurers must provide individual health insurance (with the “10 essential health benefits”) that can no longer exclude, limit, or deny coverage solely because of a pre-existing condition.
Calculating “INCOME”
When you apply for a “Subsidy” you’ll need to estimate your income (before taxes) for the year in which you’re applying for insurance. If you are not sure, you’ll have to make your best estimate. We recommend you speak with your accountant to get your “Modified Adjusted Gross Income” calculation.
Modified Adjusted Income for most folks will be the Adjusted Gross Income on line 37 of your 1040, or 21 of your form 1040A or line 4 of your 1040EZ of your tax return.
Add:
♦ You and your spouse’s income, if you’re married and will file a joint tax return
♦ Any dependents who make enough money to be required to file a tax return
You’ll need to include:
♦ Wages
♦ Salaries
♦ Tips
♦ Alimony – After 1/1/2019 DO NOT include.
♦ Unemployment compensation
♦ Self Employed or business (generally the amount of money you take in from your business minus your business expenses)
♦ Social Security payments, including disability payments – but not Supplemental Security Income (SSI)
♦ Retirement income, Investment income, pension income, rental income, prizes, awards, gambling winnings
♦ Generally withdrawals from an IRA (Not Roth IRA.) See IRS Form 8606
♦ Withdrawals from a 401k plan (less distributions from a Roth Account) See IRS Pub. 575
♦ Excluded (untaxed) foreign income
♦ Capital Gains
Don’t include:
♦ Gifts
♦ Child support
♦ Supplemental Security Income (SSI)
♦ Veterans’ disability payments
♦ Workers’ compensation
♦ Qualified withdrawals from a Roth IRA. See IRS Pub. 590
♦ Proceeds from loans (like student loans, home equity loans, or bank loans)
We suggest you refer to your federal income tax return to get a quick estimate of your AGI. On your tax return, please refer to:
♦ Line 4 if you filed a Form 1040EZ
♦ Line 21 if you filed a Form 1040A
♦ Line 37 if you filed a Form 1040
Keep in mind, the subsidies are based off the “Household Modified Adjusted Income.”
We recommend you speak with your accountant to get your “Modified Adjusted Gross Income” calculation.
Disclaimer: The material in this site is provided for educational purposes only and does not substitute consultation with an Attorney or Accountant. We do not guarantee the accuracy or completeness of the definitions or any information or other items within this website. Any inclusions of incorrect data or omissions of correct data is unintentional. We will make periodic changes to these materials at any time and make no commitment to update the information contained herein, although we will continue to update as often as possible. The Nevada Insurance Enrollment Marketplace shall not assume any responsibility or liability for any such inadvertent errors or inaccuracies, and shall have no obligation to honor transactions or information affected by such inaccuracies.
Depending on your household income, you may or may not qualify for financial assistance in paying for your health insurance plan. If you qualify for a Government subsidy to help pay for your health insurance, you’ll need to shop “On Exchange” – the Government’s Marketplace. We’ll assist you from beginning to end and throughout the year. If you make too much money or don’t want a Government subsidy, we’ll assist you “Off Exchange” – shopping all the insurance companies that offer insurance outside of the Government website.
Insurance companies can decide for themselves if they are going to “participate” on-exchange from year to year. Meaning the Government Exchange.
Nevada Insurance Enrollment is an Insurance Agency. We can assist you with both subsidized plans where the government helps pay for your premiums AND also un-subsidized plans (if you make too much money or don’t want a subsidy).
Call us and we’ll help you determine if you qualify to get financial assistance (subsidy) and help you make a decision on which plan is best for you.
For the first time, many Nevadan’s (those making over 400% of the Federal Poverty Level), may now be eligible for a health insurance subsidy! Plus, for existing members, the rate you are paying will most likely decrease.
For instance, if you were a 60 and 61 year old married couple, and your income was projected to be over $68,960 in 2021 you would not have qualified for a tax credit. Now, since the changes, that same couple making $80K per year would qualify for $1007 per month. This is HUGE!
You can now get a Government subsidy to help you pay for your health insurance premiums. Before these changes, if your income was over $51,040 for a single person in tax year 2021, or $104,800 for a family of 4, you were not eligible for a tax subsidy.
Now there is no income limit to receive these subsidies. The subsidy amount gradually slopes off to be no more than 8.5% of your household income (Modified adjusted gross – for most people, their “Adjusted Gross Income”). So, for many Nevadan’s, they’ll now be eligible for tax credits!
Also in this new law (and this is ONLY for tax year 2020), if you ended up making more than you estimated for tax year 2020, you will not be required to pay back those subsidies.
FREE or NEARLY FREE Health Insurance for any employee who lost their job and collects unemployment any time in 2021. For the tax credit, no matter how much they make on unemployment or otherwise, their income won’t be counted higher than 133% of the federal poverty level. If you are collecting unemployment for 2021, it’s most likely beneficial to apply for Obamacare than Cobra. Why? Free Cobra payments are only good for 5 months, but with Obamacare, the Free to nearly Free health plans are good all year!
These changes do not apply to those Nevadan’s that have jobs that offer insurance to their employees and their families (whether they take their employer, spouses’ employer, parents insurance or not).
Call our office, we can answer your questions, assist you with any changes to your current plan, or help you apply for these new subsidies.
All major medical plans that will be sold from 1/1/2014 and on that sell on or off the “Exchange” (Marketplace) and the “SHOP Exchange” or in the private marketplace must comply with all the rules and regulations in order to be a “Qualified Health Plan”. All health insurance plans for families and individuals MUST cover these 10 items called “Essential Health Benefits.” These 10 benefits must be covered without any lifetime or annual limits on the “Essential Health Benefits.”
From 1/1/2014 and beyond, all new health plans (insured small group and individual health insurance plans) must cover the 10 bulleted benefits below. These are the plans you’ll want to have in order to cover pre-existing conditions, maternity, prescriptions, and much more. They are “qualified health plans”. These “Essential Health Benefits” will be covered.
Dental for “Pediatrics” means anyone under the age of 19. Check the plan “Summary of Benefits” to see if a dental plan for children under the age of 19 is already built into the plan. ON Exchange pediatric dental is offered for purchase separately, OFF Exchange there may be a plan built into the health plan or not. You’ll need to look at the “Summary of Benefits” in your plan.
Vision for children under the age of 19 is covered, 1 visit per year, 1 pair of glasses per year are covered. The pediatric vision has to be covered ON and OFF of the exchange.
Your insurance company must also allow members to request to have a drug covered that they need that the insurance company does not cover.
State or Federal Health Insurance Plans such as Medicare, Medicaid, VA, Tricare, CHIP etc., or part of an Employer Group that provides benefits, or are “Grandfathered,” are all considered Qualified Health Plans.
A drug formulary is a list of the prescription drugs that your health insurance company has agreed to cover so that when you fill your prescription, you don’t pay the full price of the medication. In most cases, formularies are comprised of drugs that are the safest, most effective and most affordable.
The health insurance company determines what these drugs will cost its customers. In most cases, the health insurance company covers a greater portion of the cost of more affordable drugs, such as generics and inexpensive brand name drugs, giving customers an incentive to opt for these over more expensive options.
Drug formularies are comprised of drug tiers. Some health insurance companies only divide their formularies into two tiers while others may have as many as five or six. The tier that your medication is in determines your portion of the drug cost.
In most cases, each tier is associated with a specific co-pay, and the lower the tier, the smaller your co-pay. For example, your health insurance company may cover almost all the cost of a generic medication that is on the first tier, but you may pay a significant portion of the cost of a third- or fourth-tier drug.
Any Ambulatory Surgical Facilities, Dentists, Hospitals, Physicians, Skilled Nursing Facilities, Practitioners, Urgent Care Centers, Surgical or Prescription Fulfillment Service, Medical Supplies or Devices, any other person or licensed entity by the State of Nevada or any entity acting within their medical scope to practice their licensed services.
You or your provider (doctor) get pre-approval from the insurance company before receiving, or planning to receive, any non-emergency healthcare services, in order for those services to be considered covered services. Essentially you are getting permission before the services have happened in order for the services to be covered.
A set dollar amount you pay for a procedure or office visit. (Look at your plan summary very carefully) A copay is helpful because you’ll GENERALLY pay just the copay (unless other procedures are billed by your doctor in addition to the copay). For example, let’s say you see your family doctor for a sore throat. If your plan had a copay of $35 dollars, you’d pay the $35.
But wait, there’s more: Sometimes you can be billed more than just a copay. For example, let’s say you went to a specialist (specialist copays are generally more than a primary care doctor) to have a spot on your skin looked at. The office copay may be $50. You’d pay the $50 for the office visit. But if the doctor wanted to remove the spot, he could charge you/your insurance company for a “procedure”. That charge would be in addition to the copay. So the procedure could be billed to your insurance company and you’d pay whatever your insurance company had negotiated with the doctor for that procedure.
Tiers determine the level of coverage your prescription drug plan offers for a specific type of medication. Many prescription drug plans use a 4-tier system, while some insurers have an additional 5th or even 6th. Your insurer’s formulary and tier system are available on the company website or in the documents you received when you enrolled in your prescription drug plan.
Tier 1 Prescriptions:
This tier is usually the cheapest and generally includes generic medications.
Tier 2 Prescriptions:
This tier includes brand name drugs that are preferred by your health insurance company. Just as your health insurance company provides better coverage for in-network healthcare providers, it provides better coverage for preferred drugs. It can also include more expensive generic medications.
Tier 3 Prescriptions:
This tier includes brand name drugs that are not preferred by your health insurance company. These drugs are still covered, but you will likely pay more out of pocket than you would for a preferred drug.
Tier 4 Prescriptions:
This tier, includes specialty drugs, such as those used for cancer treatment. These drugs have a much higher out-of-pocket cost.
Tier 5 Prescriptions:
This tier, which is not included in all prescription drug plans, includes highest cost specialty drugs.
Tier 6 Prescriptions:
This tier many companies will use and not charge their insureds a copay at all, using a tier-6 medications for “maintenance medication”.
The primary purpose of tier pricing is to help health insurance companies manage their costs. In most cases, the drugs listed on a plan’s formulary are both effective and the most economically priced for treating a condition. To promote the use of generics or more cost-effective brand name drugs, health insurance companies may cover a larger portion of the costs for Tier 1 and Tier 2 drugs.
You must look at your own individual policy.
The amount of money that you pay out of your pocket before the insurance company begins to pay. A prescription deductible is the portion you’d pay first, then after you’ve paid the deductible, you may only have to pay a copay after that when you pick up your medication. If you are single, you would only have to meet your prescription deductible. If you have two or more people in your family, each member may have to meet their own prescription deductible. Usually, the insurance company will have two deductibles per family, but you must read the summary of benefits first to find that out.
A prescription deductible is different and separate from the medical deductible. They are separate deductibles. One deductible is for hospitalization etc., and one for filling your prescriptions.
The prescription deductible may only apply to certain “Tiers” on your insurance company’s “Formulary”, (the list of drugs on your insurance plan the insurance company covers). So based on what “Tier” your prescription drug is, may determine if you start paying for it with just a copay, or if you have to pay the deductible first, then copays. Some health insurance company’s may put a deductible on Tier 3 and Tier 4 medication, but not Tier 1 or Tier 2 medication. Some insurance companies don’t put a prescription deductible on any of their plans.
It’s important to look for your medication in the formulary, find out what Tier it is, then look to see if there is a deductible for that Tier. This is important to do before you buy your health insurance plan. You must look at your own individual policy.