All of the answers to your insurance related questions
Frequently Asked Questions
While Employer Benefits, Inc. offers complete free consultations and services, we do have some questions here to get you a quick answer. If there is anything not listed here, please call us at 775-786-6381 and we’d be more than happy to get you answers to all of your questions!
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Group Insurance FAQ
Individual Insurance FAQ
Commonly Asked Questions About
The Affordable Care Act
Are my doctors in the provider network?
Each insurance carrier has their own provider network. It is important that you check the provider directory before selecting an insurance plan.
Can I apply with a pre-existing condition?
Insurance companies are no longer allowed to deny you medical coverage based on pre-existing health conditions.
Do I have to buy insurance?
On March 23, 2010, the Affordable Care Act as sometimes referred to as “Obamacare” was signed into law. Most people are required to have continuous health coverage as of January 1, 2014.
Do I have to buy through the Nevada Health Exchange?
No, if you believe you qualify for a subsidy you would use the exchange to utilize the subsidy.
How much will my insurance plan cost? How are rates calculated?
Insurance costs are determined by your age, zip code, and if you are a tobacco user. If you would like to know how much insurance would cost for you or your family, please call our office for a free quote.
What is a deductible?
It is the amount you owe to your providers and for services that the plan covers, before the insurance plan begins to pay.
What is a max-out-of-pocket?
It is the most an individual will pay during the policy period which usually is one year before the insurance plan begins to pay 100% of the covered health benefits. The Affordable Care Act for 2016 did not allow any plan be more than $7,350 for an individual and $14,700 for a family. The 2017 limits are $7,900 for an individual and $15,800 for a family.
What is a PPO?
A Preferred Provider Organization does not require you to select a primary care provider and you do not need to obtain a referral to see a specialist.
What is an HMO?
An HMO or otherwise called a Health Maintenance Organization requires you to select a primary care physician (PCP) who will be required to manage all of your healthcare. In order to use a physician specialist or diagnostic service inside the provider network you will be required to get a referral from your PCP.
What is Obamacare? What is the Affordable Care Act?
The Affordable Care Act otherwise known as ‘Obamacare’ was enacted in March of 2010.
What is the Nevada Healthlink?
Under the directive of the Affordable Care Act the individual states were allowed to create their own website resource that allows individuals, families and small business to compare insurance plans and enroll in them. The site is also where an individual can enroll for health insurance if they qualify for tax credit which lowers their month premiums and out-of-pocket maximums.
When is the deadline to buy insurance?
Individuals must enroll by December 15, 2018 to receive coverage effective January 1, 2019 and avoid having to pay the penalty for that year.
Will it cost me more if I smoke?
Under the Affordable Care Act insurance companies are allowed to charge smokers and other tobacco users as much as 50 percent on their premiums. Not all insurance companies have chosen to do this.
Commonly Asked Questions About
Do I have to offer health coverage to my employees?
No employer has to offer coverage. However, some large businesses that do not offer coverage may have to make a shared responsibility payment in 2017.
- If you have fewer than 50 full-time equivalent (FTE) employees, you are not subject to the Employer Shared Responsibility parts of the law. You may use SHOP to offer coverage for your employees.
- If you have 50 or more FTEs you may have to make an Employer Shared Responsibility Payment if at least 1 of your full-time employees gets lower costs on their monthly premiums when buying insurance in the Marketplace.
Learn more about the Employer Shared Responsibility Payment
How do I know whether the coverage that I provide is affordable?
If an employee’s share of the premium for employer-provided coverage would cost the employee more than 9.5 percent of that employee’s annual household modified adjusted gross income, then the coverage is considered “unaffordable” for that employee. If you offer multiple healthcare coverage options, the affordability test applies to the lowest-cost option available to the employee that also meets the minimum value requirement.
Because employers generally will not know their employee’s household incomes, employers can take advantage of one of the “affordability safe harbors” set forth in the federal regulations. Under the safe harbors, an employer can avoid a payment if the cost of the coverage to the employee would not exceed 9.5 percent of the wages the employer pays the employee that year, as reported in Box 1 of Form W-2, or if the coverage satisfies either of two other design-based affordability safe harbors.
How the Affordable Care Act Affects your Business
On March 23, 2010, President Obama signed the Affordable Care Act (health care reform) into law. The law puts in place a significant number of health insurance reforms; many rolled out between 2011 and 2013 while some of the final, and most significant, changes of the law took effect on January 1, 2014. There are still changes taking place in the current year.
It is likely that some of these new laws and regulations will affect your business in some way. This guide is intended to help you navigate these challenges and opportunities so that you can make the best decisions for your business as the health insurance landscape continues to change in 2017 and beyond.
I have 50 or more employees; can I supplement my employees' income instead of offering insurance?
There is no provision for a monetary payment to the employee to avoid the assessment. According to Section 4980H of the Internal Revenue Code, an employer with 50 or more employees could be subject to assessment if any full-time employee is certified to receive an advance premium tax credit or cost-sharing reduction. Generally this may occur where either: (1) the employer does not offer to its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan; or (2) the employer offers its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an employer-sponsored plan that is either unaffordable relative to the employee’s household income or does not provide minimum value.
Other changes that affect Employers
Health Care Reform will affect Small Employers and Large Employers differently. Therefore it is important to know how your business will be classified when considering how you will be impacted.
An employer with anywhere from one to 50 full-time and full-time equivalent employees is considered a Small Employer.
An employer with 51 or more full-time and full-time equivalent employees is defined as a Large Employer.
A sole proprietor with no employees must purchase insurance as an individual.
Health Insurance Rates
How health insurers rate individuals and small businesses: They are only able to use age, composition of family, geographic area and tobacco as rating factors. Nevada has also expanded its review of health insurance rates. Nevada now reviews all health insurance rate changes in the individual and small group insurance markets.
The law also requires insurance companies to spend the majority of your premium dollars on health care. This means that insurers selling policies to individuals or small groups must spend at least 80 percent of premiums on direct medical care and efforts to improve the quality of care or provide a premium rebate to their customers.
What if I'm self-employed?
If you’re self-employed with no employees, you’re not considered an employer. You can use the individual Marketplace to find coverage that fits your needs.
How to know if you’re “self-employed”
If you run an income-generating business with no employees, then you’re considered self-employed (not an employer) and can get coverage through the Marketplace. You’re not considered an employer even if you hire independent contractors to do some work.
If you have employees (generally, workers whose income you report on a W-2 at the end of the year) you’re considered an employer. Then you could get coverage for yourself and your employees through the SHOP Marketplace. Learn more about how to determine if you have employees.
If you’re self-employed, you’ll have health coverage options in 2018.
Starting November 1, 2017, you can use the Marketplace to find health coverage that fits your budget and meets your needs. You can compare important features of several plans side-by-side, all of them offering a full package of essential health benefits. You can see what your premium, deductibles, and out-of-pocket costs will be before you decide to enroll.
You can’t be denied coverage or charged more because you have a pre-existing health condition.
If you currently have individual insurance–a plan you bought yourself, not the kind you get through an employer–you may be able to change to a Marketplace plan. Learn more about changing individual insurance plans.
What is a full-time employee?
For the sake of your employee count, your full-time employees and the number of full-time equivalent employees is used. This includes:
- Employees who work an average of 30 hours or more a week.
- Employees who worked 130 hours or more per month.
- The number of hours worked by all part-time employees divided by 120 (rounded down to the nearest whole number). This is your full-time equivalent employee count.
- Seasonal employees are included in your count, for more information please see the “Questions for Large Employers” section.
Calculating Your Annual Average Employee Count
To calculate your annual average, add the monthly totals of full-time and full-time equivalent employees from the last calendar year, and divide the total by 12. Round down to the nearest whole number.
It is important to note that this calculation takes into account all employees employed by the same person, entity, or group. For example, one individual owning two unrelated businesses, each with 40 full-time employees and equivalents, may be considered a large employer with 80 employees. If you have questions specific to your situation or use an employee leasing or temp company, please consult an attorney.
What is considered a small business?
If you have 50 or fewer full-time equivalent (FTE) employees, you’re considered a small business under the health care law.
As a small business, you may get employee insurance through the SHOP Marketplace. This applies to non-profit organizations too.
If you have fewer than 25 employees, you may qualify for the Small Business Tax Credit. Non-profit organizations can get a smaller tax credit.
The Small Business Health Options Programs (SHOP) are open to employers with 100 or fewer FTEs.
If you’re self-employed and have no employees, you can buy insurance through the individual Health Insurance Marketplace. You would not use the SHOP.
If you have more than 50 employees
Many important parts of the health care law apply to businesses with more than 50 FTEs. Under the health care law, these are considered “large businesses.”
Find out how the health care law could affect you if you’re considered a large business.
What is minimum essential coverage?
In order to qualify as minimum essential coverage, a plan must be an employer-sponsored plan defined as, with respect to an employee, a group health plan (including both fully insured and self-insured plans) or group health plan insurance coverage offered by an employer to an employee that is (1) any plan or coverage offered in the small or large group market within Nevada; or (2) a health plan treated as being grandfathered under the Affordable Care Act that is offered in the group market.
What is minimum value?
Minimum value is defined by the U.S. Department of Health and Human Services as coverage of at least 60 percent of the total allowed cost of benefits provided under the plan—it is a measure of benefits, not a measure of premium.
A minimum value calculator will be made available to employers by the IRS and Department of Health and Human Services. Employers can input certain information about the plan, such as deductibles and copay, into the calculator and get a determination as to whether the plan provides minimum value. If the plan covers at least 60 percent of the estimated total allowed cost, the plan will meet the “minimum value” test.
What is the Health Insurance Marketplace?
The Marketplace is a new way to find quality health coverage. It can help if you don’t have coverage now or if you have it but want to look at other options.
With one Marketplace application, you can learn if you can get lower costs based on your income, compare your coverage options side-by-side, and enroll.
Learn more about Nevada Health Link Here.
Will I have to provide coverage to my employees?
The law does not require you to provide health insurance. However, if you employ 50 or more full-time employees or full-time equivalent employees, and you do not provide affordable minimum essential coverage for your full-time employees (and their dependents), you will be required to pay an assessment to the Internal Revenue Service (IRS).
The law specifically exempts all businesses that have fewer than 50 full-time employees or full-time equivalent employees from this assessment.
For employers who have 50 or more full-time or full-time equivalent employees and who do not offer affordable minimum essential coverage, the assessment will be calculated in one of these ways:
- If you do not provide insurance at all or offers coverage to less than 95% of your full-time employees (and dependents), and if at least one full-time employee receives an advance premium tax credit, the assessment for calendar year 2017 is $2,260 for each full-time employee you employ after the first 30 employees.
- If you do provide insurance to at least 95% of your full-time employees (and dependents), but have at least one full-time employee who receives an advance premium tax credit, the assessment for calendar year 2017 is a monthly charge calculated at: the number of full-time employees receiving a premium tax credit for that month multiplied by 1/12 of $3,390.
The amount of the payment for any calendar month is capped at the number of full-time employees (up to 30 per month) multiplied by 1/12 of 2000. Part time and certain full time employees are not counted for this calculation.
Will my part time and seasonal employees be counted for the purpose of the assessment?
To be subject to the assessment, you must employ at least 50 full-time employees or a combination of full-time and part-time employees that equals at least 50.
For example, 40 full-time employees employed at least 30 hours per week on average plus 20 half-time employees working 15 hours per week on average would be the equivalent of 50 full-time employees. As an employer, you must determine each year, based on your current number of employees, whether or not you will be required to pay an assessment.
For example, if you have at least 50 full-time employees (including full-time equivalents) in the prior calendar year, then you will be required to pay an assessment.
If you have seasonal employees, then you must average the number of employees across the months in the year to see whether you have 50 or more employees. The averaging can take into account fluctuations throughout the year. If you are close to the 50 full-time employees (including equivalents) and want to know what to do, a special transition relief program as been proposed. The regulations issued by the IRS provide additional information about determining the average number of employees for a year and information about how to take account of salaried employees who may not clock their hours and additional information on seasonal workers. Additional information is available at: http://www.healthcare.gov
Employers will not have to pay an assessment if two conditions are met: The employer averages 50 or more full-time employees (including equivalents) for 120 days or less, and the employees who bring the employer over the 50-employee threshold are seasonal workers. If these two conditions are met, the employer is not subject to the assessments that would apply for failing to provide coverage to full-time employees.
Commonly Asked Questions About
How can I get lower costs on Marketplace coverage?
You can save money in the Health Insurance Marketplace 3 ways. All of them depend on your income and family size.
- You may be able to lower costs on your monthly premiums when you enroll in a private health insurance plan. These plans all cover essential health benefits and pre-existing conditions.
- You may qualify for lower out-of-pocket costs for copayments, coinsurance, and deductibles.
- You or your child may get free or low-cost coverage through Medicaid or the Children’s Health Insurance Program CHIP. Some states have expanded Medicaid eligibility, so you may qualify even if you have been turned down for Medicaid in the past.
When you fill out your Health Insurance Marketplace application as soon as November 1, you’ll find out what plans and premiums are available to you and see how much you will save. Most people who apply will qualify for lower costs of some kind. Coverage can begin as soon as January 1, 2018.
How can I get ready to enroll in the Marketplace?
To prepare to enroll, you can learn about types of health coverage, research your questions, and figure out what you need to know before open enrollment begins.
The Health Insurance Marketplace will help you get coverage that meets your needs and fits your budget. Open enrollment starts November 1, 2017. Coverage can start as soon as January 1, 2018.
Pete Gilbert is a Licensed Resident Producer, and has been certified by the state of Nevada to enroll plans in the Nevada HealthLink and HealthCare.gov. Call our office today 775-786-6381 for more information and to enroll.
How do I get help enrolling in the Marketplace?
Pete Gilbert is a Licensed Resident Producer, and has been certified by the state of Nevada to enroll in the Nevada HealthLink and HealthCare.gov. Call our office today 775-786-6381 for more information and to enroll.
How Healthcare Reform Affects You and Your Family
Guaranteed coverage and benefits
You can no longer be declined coverage or charged extra for health insurance because of a health issue you have now or in the past.
One of the biggest ways that Health Care Reform will affect you is through the benefits that will be available to you through the health insurance policies that you may now purchase.
No annual or lifetime dollar limits on Essential Health Benefits
The Health Care Reform Law sets as a standard for all plans in the individual and small group market a minimum level of benefits that must be provided. These benefits are referred to as Essential Health Benefits.
Essential Health Benefits are a set of health care services that must be covered with no “annual or lifetime dollar limits.” These benefits may still have other limitations, such as a visit limit. These benefits include:
- Ambulatory patient services;
- Emergency services;
- 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 dental and vision care.
Read more about Essential Health Benefits in Nevada.
Preventive Care Services
Preventive care services must be provided without any cost-sharing to you long as the service is provided by a network provider. This means that a network provider cannot charge copays, deductibles or coinsurance to you or your family. These services include, but are not limited to:
- Blood pressure, diabetes and cholesterol tests;
- Many cancer screenings, including mammograms and colonoscopies;
- Counseling on such topics as smoking cessation, weight loss, eating healthy, treating depression, and reducing alcohol use;
- Regular well-baby and well-child visits from birth to age 21;
- Routine vaccinations against diseases such as measles, polio and meningitis;
- Counseling, screening and vaccines to ensure healthy pregnancies; and
- Flu and Pneumonia shots.
Read more about Preventive Care Services.
How to get ready for the Health Insurance Marketplace?
Gather basic information about your household income. Most people using the Marketplace will qualify for lower costs on monthly premiums or lower out-of-pocket costs. To find out how much savings you’re eligible for, you’ll need to provide income information, like the kind you get on your W-2, current pay stubs, or your tax return. You can use this checklist to get started.
•Set your budget. There will be different types of health plans to meet a variety of needs and budgets. You’ll need to figure out how much you want to spend on premiums each month. You can use this quick calculator to get an estimate of costs and savings on Marketplace health insurance.
•Make sure you understand how coverage works, including things like premiums, deductibles, out-of-pocket maximums, copayments, and coinsurance. You’ll want to consider these details while you’re looking for health insurance.
•Learn about different types of health coverage. Through the Marketplace, you’ll be able to choose a health plan that gives you the right balance of costs and coverage. You can be better prepared if you understand the types of coverage you’ll choose from.
•Make a list of questions you have before it’s time to choose your health plan.
•Explore current options. You may be able to get coverage that starts before January 1 through existing programs. Learn more about health insurance for adults up to age 26, and programs for people and children in families with limited incomes including Medicaid and the Children’s Health Insurance Program (CHIP). Medicare covers people who are 65 and older or who have certain disabilities.
•Ask your employer if it plans to offer health insurance in 2018. If not, you may need to get insurance through the Marketplace or from other sources in 2018. If you don’t have coverage, you may have to pay a fee.
Pete Gilbert is a Licensed Resident Producer, and has been certified by the state of Nevada to enroll in the Nevada HealthLink and HeathCare.cov. Call our office today 775-786-6381 for more information and to enroll.
What if I have a pre-existing health condition?
Health insurance plans can no longer refuse to cover you or charge you more just because you have a pre-existing health condition.
Being sick doesn’t keep you from getting coverage.
Once you have insurance, the plan can’t refuse to cover treatment for pre-existing conditions. Coverage for your pre-existing conditions begins immediately.
This is true even if you have been turned down or refused coverage due to a pre-existing condition in the past.
What if someone doesn’t have health coverage?
If someone who can afford health insurance doesn’t have coverage, they may have to pay a fee. They also have to pay for all of their health care.
When the uninsured need care:
When someone without health coverage gets urgent—often expensive—medical care but doesn’t pay the bill, everyone else ends up paying the price.
That’s why the health care law requires all people who can afford it to take responsibility for their own health insurance by getting coverage or paying a penalty.
People without health coverage will also have to pay the entire cost of all their medical care. They won’t be protected from the kind of very high medical bills that can sometimes lead to bankruptcy.
In 2016 it was 2.5% of your yearly income or $695 per person (347.50 per child under 18,) whichever is higher. The fee did not increase in 2017.
It’s important to remember that someone who pays the fee won’t get any health insurance coverage. They still will be responsible for 100% of the cost of their medical care.
After open enrollment ends on December 15, 2017, they won’t be able to get health coverage through the Marketplace until the next annual enrollment period, unless they have a qualifying life event.
Minimum essential coverage
To avoid the fees, you need insurance that qualifies as minimum essential coverage. If you’re covered by any of the following plans, you’re considered covered and don’t have to pay a penalty:
- Any Marketplace plan, or any individual insurance plan you already have
- Any employer plan (including COBRA), with or without “grandfathered” status. This includes retiree plans
- The Children’s Health Insurance Program (CHIP)
- TRICARE (for current service members and military retirees, their families, and survivors)
- Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA), and Spina Bifida Health Care Benefits Program)
- Peace Corps Volunteer plans
Other plans may also qualify. Ask your health coverage provider.
What kinds of health insurance don’t qualify as coverage?
Health plans that don’t meet minimum essential coverage don’t qualify as health coverage. If you have only these types of plans, you may have to pay the fee. Examples include:
- coverage only for vision care or dental care
- workers’ compensation
- coverage only for a specific disease or condition
- plans that offer only discounts on medical services
What plans in the Marketplace (Nevada HealthLink and SHOP) cover?
Insurance plans in the Marketplace are offered by private companies. They cover the same core set of benefits called essential health benefits. No plan can turn you away or charge you more because you have an illness or medical condition. They must cover treatments for these conditions. Plans can’t charge women more than men for the same plan. Many preventive services are covered at no cost to you.
What you’ll learn when you apply in the Health Insurance Marketplace (Nevada HealthLink and SHOP)?
When you use the Health Insurance Marketplace, you’ll fill out an application and see all the health plans available in your area. You’ll provide some information about your household size and income to find out if you can get lower costs on your monthly premiums for private insurance plans. You’ll learn if you qualify for lower out-of-pocket costs.
The Marketplace will also tell you if you qualify for free or low-cost coverage available through Medicaid or the Children’s Health Insurance Program (CHIP).
Most Americans will be eligible to use the Marketplace.
Who doesn’t have to pay the fee?
Uninsured people won’t have to pay a fee if they:
- are uninsured for less than 3 months of the year
- are determined to have very low income and coverage is considered unaffordable
- are not required to file a tax return because their income is too low
- would qualify under the new income limits for Medicaid, but their state has chosen not to expand Medicaid eligibility
- are a member of a federally recognized Indian tribe
- participate in a health care sharing ministry
- are a member of a recognized religious sect with religious objections to health insurance
If you don’t qualify for these situations, you can apply for an exemption asking not to pay a fee. You do this in the Marketplace.
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