Recently we added a form to our blog so that you can ask your most important individual insurance questions regarding the Affordable Care Act, or frankly any healthcare insurance question you may have. We know during times of great change, it is important to reach out to anexperienced health insurance broker in order to receive good advice.  We are pleased to provide answers to many of those questions today. Let’s get started!

Will hospitals and/or providers accept the plan?

The Individual Insurance Exchange is just like any other insurance plan in that it has a network of doctors and hospitals that will accept the insurance. The levels will provide different access, again like many other insurance plans we have seen. Think of it this way – if you purchase an automobile, then you expect to receive more amenities and upgrades the more you pay. This is a simple analogy, but it is somewhat the same with the individual insurance exchange plans.

The best advice we can give is to check with local physicians and hospitals. If you already have physicians you see, ask them if they intend to participate in the Exchange. Contact your local hospitals to find out the same. If you do not already have doctors, then at a minimum contact your local hospitals to ensure they will accept the Exchange plans.

Will I qualify for subsidy?

The short answer is it depends. There are specific calculations to determine if you qualify for a subsidy and if so, how much. The basic calculation is as follows:

If your employer does not have a plan that meets the minimum value standard, meaning it pays, on average, less than 60% of the overall cost of essential health benefits to plan members OR does not meet government standards for an affordable plan (9.5% of your W-2 pay), then you can use the following as a guide to determine if you can get assistance:

      • Income is less than $45,960 as an individual.
      • Income is less than $94,200 for a family of four.


      • Your Employer does not have a plan that meets the minimum value standard, meaning on average, it pays less than 60% of the overall cost of essential health benefits. If this is the case, then plan value is below the lowest level of plans, called Bronze.


      • The employer’s plan does not meet the government’s affordability standard, meaning employee-only coverage is more than 9.5% of your W-2 income.

To be eligible for a subsidy, you must be enrolled at a minimum in the second-to-lowest cost Silver plan.  The amount of the subsidy will be dependent on your household income and the region of the country in which you live.

There is a great calculator on the Kaiser Family Foundation website that can assist you with your specific situation. You simply fill in the form and it will tell you if you are qualified and if so, an estimate based on your specific details.

Why are the rates so high?

Rates are based on a number of factors, such as geography. It is also important to remember that the carriers are now assuming a higher risk. In the past, carriers were able to ask questions regarding medical history in order to ascertain the most appropriate plan for that person and the carrier.

Unfortunately, without that information carriers have to assume the worst case scenario for everyone, resulting in rate increases across the board.

Should I stay grandfathered?

If you have an individual healthcare plan that is grandfathered and can stay with it, then we would recommend doing so. However, there are certain scenarios that may warrant a look at the Individual Exchanges. For example, in 2014 pre-existing conditions can no longer be considered. If you have a plan that has a rider on the policy for a pre-existing condition, it’s probably worth your time to take a look at the Exchange or other individual healthcare policies to see what is now available.

Grandfathered plans will remain in effect until 2018, at which time everyone will be required to evaluate their plans and select new ones. In the meantime, if your plan works well and provides the coverage need, we recommend keeping it.

How do I get onto the Exchange if the website does not work?

If you have done your due diligence, including speaking to one of our experienced health insurance specialists,then feel free to contact our office to receive a paper application.

The reality is that the Individual Insurance Exchange plans should be analyzed the same as any individual healthcare plan. Make sure to ask questions and ensure that your doctors are going to accept the plans. As always, we are here for you so feel free to either submit your question via our form here on the blog or give us a call.

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