Top 10 List | TN Health Insurance Marketplace

Buying health insurance on the Tennessee Health Insurance Marketplace is not like booking a hotel room online.

Here are 10 tips to better prepare you for your experience.

  1. The Marketplace is not health insurance
  2. Do your homework before buying your first policy
  3. How much your earn will determine how much you pay
  4. Information you will need before applying
  5. Buy a policy now or wait until you need it?
  6. Undocumented Hispanics, rules for getting coverage
  7. How much will it cost to see a doctor?
  8. Prescriptions, Formularies and Generic medicines
  9. Higher premium or higher deductible -- which is better?
  10. I like my current insurance. Can I keep the policy I have?

1. The Marketplace/Exchange is not insurance

The health insurance "Marketplace is an online store, of sorts, created to help you Tennessee Health Exchange Help, insurance broker, SHOPfind the right health insurance policy for the best price. The only reason a person would use the website is if they qualify for a premium or benefit subsidy. If you earn too much money for a subsidy, it's much faster and easier to go straight to the insurance company. It's even easier to use a qualified health insurance agent as they can help you choose the right plan, doctor network and get you enrolled.

The Affordable Care Act set a number of requirements that insurance companies must include in their health insurance policies and grouped the different policies into four categories based on how "high or "low the benefits are. The best and most expensive policies are called Platinum and [health insurance policy]  have nearly 100% coverage for everything from doctor visits and prescriptions to hospitalization. Platinum policies are supposed to cover at least 90% of the costs. Next is gold, then silver (the plan that will be used in most calculations) and bronze, the least expensive plan is supposed to cover 60% of a person's medical expenses.
Requiring each policy cover the same "essential health benefits and putting them into one of four categories makes comparison shopping for similar plans easier. Other key requirements are that the insurance companies cannot ask any medical questions or base your premium (cost) on how healthy or unhealthy a person is. Policies cannot exclude any pre-existing conditions, so a person has full coverage with no waiting periods. The rate you pay is based on your age, where you live and the health plan you choose. There will be a difference in cost with each insurance company and plan design as well as the doctor network you choose. . 
It's very important that you understand the rules of your policy, or the insurance company can make you pay a much higher cost for services or not cover them at all.  There will also be different doctor and hospital networks and prescription benefits. While the "marketplace is designed to make shopping easier, it will be very complicated to compare policies and the rules of each without the help of an Assister/Navigator or insurance Agent/Broker. You can get this help free of charge and have someone who understands the system and how each plan works to make sure you buy the best policy for you and/or your family. Back to top

2. Do your homework before buying your first health insurance policy

how does health insurance work, help, agent, navigator Nashville TnBuying health insurance is not about finding the least expensive rate. You need to find the "right insurance for your situation. For some, that might be the cheapest policy, but for others that could be a catastrophic decision. You are going to have many choices and options when choosing your new health policy on or off your state's Health Insurance Marketplace. The plan you choose does not affect the amount of premium subsidy you may or may not receive. That will be applied to any policy you choose on the Marketplace. After you find out how much your subsidy is, you then can pick the best policy for you and elect to have the subsidy paid directly to that insurance company.


This great resource from authors Wendy Richards and Tracey Baker takes a complicated subject and breaks it down into understandable sections. When you finish reading this book, buying the right policy will be a much easier decision. 

Some of the information is outdated as the rules prior to ObamaCare are gone (with the purchase of a new policy covering EHBs, but the fundamentals are still the same. You are about to make a very important purchase, so you should do your homework. Back to top

3. How much you earn (MAGI) is very important

A new term, MAGI which means Modified Adjusted Gross Income. It  sounds complicated, and it is. MAGI, tax credit, subsidy, Tennessee, Nashville insuranceThis is what will determine how much or little you pay for your health insurance and if you or your children qualify for Medicaid or CHIP. To qualify for subsidies and tax credits, you will have to file a tax return if you have not done so in the past.
For most of us, this is just the total amount of how much we earn in a month or year because we don't have a lot of fancy income or deductions. If your pay changes a lot from month to month, you will want to average it and keep an eye on how close you are during the year. Of course, the less you make the lower your cost for health insurance. It also depends on how many people are in your family. If you and your spouse work, add both incomes together to get the total. Your MAGI will be the number on the bottom of the first page of your 1040 Tax Return. Do you qualify for a subsidy? Find out here  Back to top

4. What information you need when applying for insurance and subsidies

The application process can take up to an hour to complete if you qualify for some type of advanced premium tax credit, benefit reduction subsidy or are eligible for Medicaid or CHIP. You will have to fill out an online or paper application where you give specific details about yourself and all your dependents. You will list anyone who has other insurance or is disabled. Then you must complete financial information for everyone who earns an income in the family to determine your subsidy level. The information you will want to have available when you apply for coverage is: Income verification (like a copy of your most recent tax return), a recent paystub or your hourly earnings. If your income varies, you will determine an average over the year. Have everyones Social Security or State ID cards and their dates of birth. You should also have a list of  prescriptions with the dosage and doctors, clinics or hospitals you want or like to use. This will save a lot of time during the application process and help you accurately determine premiums and your best benefit options. Click here for a complete list of items need to apply for subsidies.  Back to top

5. Why sign up now? Can't I wait until I have a problem?

Waiting is not an option. You can only enroll at certain times during the year. If you don't sign up then, penalty, health insurance, obamacare, exchange, hendersonville, agent, helpyou will have to wait until the next "open enrollment. Once you are enrolled in a health insurance plan, you won't be able to make changes until the next open enrollment period that will take place from November 15 to February 28th each year and the change will take place on the first of the following month if you apply by the 15th.. Most policies will go from January 1 through December 31. If you miss the open enrollment you will have to wait until the next November 15th unless you have a qualifying event. 

There are some exceptions called "qualifying events that allow you to make changes or sign up during the year. These are things like having a baby, getting married or divorced or losing coverage from your job. You only have 60 days after a qualifying event to sign up so don't hesitate. If your income changes dramatically you could become eligible or lose your eligibility for Medicaid. The most important thing to remember is that if you want insurance, you can only sign up during certain times of the year. If you don't, you can't get it until the next year in most cases. There is the "shared responsibility" penalty for not buying health insurance. For 2016 the penalty is $695 per person, or 2.5% of your adjusted gross income. Back to top

6. I am an undocumented Hispanic. Am I am eligible for insurance?

This is one of the greatest challenges to the Hispanic population across the country as rules are hispanic, insurance, subsidy, medicaid, Tenncare, CHIP, confusing and can change from state to state. While the overall goal of the Affordable Care Act is to increase coverage to the uninsured, the five-year eligibility has not changed for undocumented Hispanics, and the benefits and tax subsidies of the health insurance marketplaces will not be available for them.
Medicaid and the Children's Health Insurance Program (CHIP) has long provided benefits to undocumented Hispanic children and the expansion to cover higher incomes allow access to many more families. While this does little to help the adults who are not eligible, it will help many children in these communities. To learn more about the immigration rules visit this site or call 800-880-5305

Many who have eligible family members but who may have been reluctant to apply for coverage for fear of immigration enforcement will be happy to know the process has been streamlined and simplified. There are many community organizations who are trusted sources of assistance and you should ask their assistance. In states who expanded Medicaid and CHIP there are many more children and adults will qualify for benefits. Back to top

7. How much will it cost to go to the doctor?

This sounds like an easy question but the answer can be complicated. When looking at deductible, copay, doctor, hospital, bronze, HSAthe policies you can buy there will be a schedule of co-pays for primary care doctors and/or specialists. That part is easy you pay the co-pay. This will generally cover lab work, x-rays, an EKG or other basic tests. Bigger things are NOT covered under your co-pay and can include expensive tests like an MRI or CAT Scan, stress EKGs and in-office surgeries which are generally applied to your annual deductible. 

Some plans don't have co-pays and all (or most) procedures are applied to the deductible. With these policies you will pay the entire cost of the doctor visit and testing. You do receive the negotiated or "discounted price the insurance company has negotiated with them to be included in their network of "preferred providers. With these policies you generally don't how much it will cost until you receive the bill, and specialists definitely cost more than primary care doctors. For many the additional cost to have a plan with co-pays may not be worth it. Consider how much you save with a basic plan and how often you actually go to the doctor. If you don't have a lot of medical expenses, the less expensive polity without co-pays can save you a lot of money keeping you from paying for an expensive policy you did not use. 
The other thing that can change your cost is a "benefit subsidy where, based on your income, the policy  can have much lower co-pays and deductibles than the schedule shows. If your income is below 250% of the Federal Poverty Level (FPL), you will receive help in paying you're out of pocket costs. The lower your income, the less you pay at the doctor, for prescriptions or hospitalization. This is another reason to get help when signing up for a policy so you know exactly how your plan will work and what options are available to you. Back to top

8. Prescriptions, formularies and generic medicines

Having coverage for your prescriptions should save you a lot of money and give you access to prescriptions, Part D, Rx, pharmacy, help, tennessee, Nashville, Hendersonville, Brentwoodmedicines you may not have been able to afford in the past.  It is very important to know that each insurance company and health plan has different programs to cover prescriptions. The lists and co-pay schedules are called formularies, and it's very important to know if your prescriptions are on these lists. 

Many times you will need to search the insurance company's website to see how much a specific drug will cost. It could be $70 with one plan and $25 with another, so it pays to do this research. There is also "step therapy, you are required to try one or several less expensive prescriptions before getting the new expensive medicine. This saves everyone money because these older, less expensive medicines may work just as well to manage or treat your condition.
You should always ask for samples, try a generic first and look for retailers that offer $4 generics because it's often less expensive than the co-pay through your insurance. Be sure to bring a list of your prescriptions when you meet with the Assister or Broker to help choose your plan. Back to top

9. Higher premium or higher deductible -- what's better?

This is a question each person/family needs to ask and do the math on. Because we will all pay different premiums for our insurance and have different needs, there is no "right answer to this question. If you receive a large premium and benefit subsidy, you are going to have a low-cost, high-benefit plan right from the beginning. If you have an income too high to receive a big subsidy, you will most likely be facing a big premium for your insurance. Depending on what medical expenses you expect in the next year you should compare the out of pocket maximums with your monthly premiums. You will pay the premium each month even if you don't have any claims. 
Many people who have insurance don't have a lot of claims each year. Having a higher deductible or out-of-pocket does not cost you anything unless you have a big claim. If you know you are going to have an expensive procedure, it's easy to see how much you will save with the lower deductible. If you are healthy and rarely go to the doctor, look at how much you save by having a higher deductible. Then, see how long does it take to save enough to pay the difference and cover your increased risk. The same question should be asked about co-pays for doctors and prescriptions: Is it worth the extra cost if you rarely go to the doctor or don't take any prescriptions?
Consider a High Deductible Health Plan (HDHP) and put tax-free money into a Health Savings Account (HSA) as a way to reduce your costs when healthy and use tax advantaged money when/if you have claims. This strategy has saved millions of people a lot of money each year and could work for you as well. Back to top

10. I have an individual insurance policy I like. Can I keep it?

Maybe, but at some point the policy you have may not be available.  The rules vary by carrier but this seems the general consensus. If you have a non-grandfathered plan, you can keep it until the 2014 renewal date, at which point you may be forced to change to a reform compliant plan. If your plan is grandfathered (bought prior to March, 2010) you can keep it until 2016 and then renew to a compliant plan (some carriers are looking out longer). You should call your insurance company today and ask how they are treating the coverage you have. It could make sense to change policies even if they don't force  you to. Many people will receive generous advance premium tax credits to help pay for the policy, and it could actually cost much less to buy a new policy in the marketplace. 

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Marketplace ID - DJCMMOORE
National Producer Number - 2438645