Health and Dental Insurance

This section of the website contains information on the following:

Affordable Care Act (AKA “Obamacare”)

: These plans apply to individuals under age 65. As an exception, individuals over 65 who are not enrolled in Medicare Parts A and B can also apply for these plans. Please call us at 786-970-0740 (Cell) to learn more concerning eligibility requirements of individuals over age 65 for enrolling in ACA plans.

These plans are sold on what is called the “marketplace” or “exchange,” which is the only place where individuals who qualify for tax subsidies (called “advance premium tax credits”) can purchase insurance. The following 29 states, including Florida, participate on www.healthcare.gov:

Federally facilitated Marketplace (27 states): Alabama, Alaska, Arizona, Delaware, Florida, Hawaii, Indiana, Iowa, Kansas, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, and Wyoming.

State-based Marketplaces on the federal platform (2 states): Arkansas and Oklahoma. These states run some marketplace functions themselves, but residents still apply and enroll through HealthCare.gov.

All other states and D.C. run their own exchanges. See https://www.healthcare.gov/marketplace-in-your-state/ for more information.

Individuals who do not qualify for subsidies can buy EITHER on the marketplace or directly from insurance carriers. Buying directly from an insurance carrier is referred as to buying “off the exchange.” Note that any plan that complies with the Affordable Care Act (either on or off the marketplace) must comply with the law and must include what are called the ten “Essential Health Benefits.”

Open Enrollment is the ONLY time individuals can buy an Affordable Care Act plan without having what is called a “qualifying life event” (examples are moving to a different plan service area, getting married or divorced, birth of a child, losing Medicaid eligibility, etc.).

NOTE: Until January 1, 2019 there was a federal tax penalty for individuals who did not purchase an Affordable Care Act plan or who qualified for another type of plan (such as Medicaid or healthcare/medical cost sharing) that was either recognized as meeting Affordable Care Act requirements or was exempted under the Act. CA, DC, MA, NJ, and RI have state tax penalties. VT statute requires state residents to enroll in Affordable Care Act-compliant plans, but there is presently no penalty for non-compliance.

The following are alternatives to Affordable Care Act coverage:

Short-Term Health Insurance

: These plans do not provide all the essential health benefits required for ACA plans (e.g., preventive care, prescription drug coverage, and maternity benefits) but are considerably less expensive than non-subsidized or lowly-subsidized Affordable Care Act plans. These plans are regulated by State Insurance Commissions, and provisions vary between states. Florida permits these plans to be bought for up to three years (with three one-year plans). However, states are permitted to mandate shorter durations, make these plans available only at certain times of the year, or, like California, not offer these plans at all.

Limited Benefits Plans

: In today's market where health insurance is often unavailable or not affordable, a limited benefit plan can help families budget and pay for health care expenditures. By providing a choice between different levels of hospital, medical and outpatient coverage, individuals, and families can choose a plan according to their health care needs.

Note: these are not major medical plans and do not comply with the Affordable Care Act (for example they do not include all the minimum essential benefits).

Eligibility for these plans is based on medical underwriting and not all those who apply will be eligible for coverage. Some of these plans have pre-existing condition limitations where pre-existing conditions are not covered until the policy has been in effect for a stated period.

Private Plans (Alternatives To ACA Plans)

: These plans use the structure of a group insurance contract but are issued to individuals and families who qualify and are regulated under the Employee Retirement Income Retirement Act (ERISA) rather than the Affordable Care Act. They often include:

• Access to large national preferred provider organization networks such as Cigna, PHCS, or First Health (owned by Aetna)
• Lower monthly premiums compared with Affordable Care Act plans
• Predictable copay-based benefits rather than high deductibles
• Requirement to pass medical questions to qualify for plan eligibility. Medical questions differ between each set of plans. There are no pre-existing condition limitations if a person passes these questions and qualifies to enroll in the plan. Because these plans enroll only healthier individuals, premiums are significantly lower than for unsubsidized Affordable Care Act plans, and premiums are kept much more stable.

For healthy individuals and families who do not qualify for large Affordable Care Act subsidies, these plans can deliver strong value and broad provider access.

Guaranteed Issue Plans

: We offer one product that is issued on a guaranteed acceptance basis with no health questions. This plan provides copay benefits for certain medical services through the Multiplan (PHCS) Practitioner and Ancillary network but hospital and certain other benefits are based on a reference-based pricing model.

Medical Cost Sharing

: We also offer medical cost sharing programs in most states. Program availability and programs differ between states. These programs aren’t regulated by state departments of insurance but some states don’t permit offering these programs in their jurisdiction. These are not insurance programs but, instead, members participate in a community of like-minded people that share medical expenses. These programs can be up to 50% or more less expensive than traditional health insurance.

Supplemental Plans

: These plans do not include all the ten Essential Health Benefits and do not otherwise comply with the Affordable Care Act. They include supplemental benefit plans like critical illness; cancer; accident medical expense, hospital illness indemnity plans, gap plans, and hospital sickness plans. Plans can be bought up to age 65 in almost every state, and some can be bought after age 65 depending on the carrier and the state. Except for accident medical expense most of these types of plans require answering health questions to qualify.

Dental, Vision, and Hearing Plans

: Dental, vision, and/or hearing plans can be bought on either an insured basis or as discount plans. They can be purchased any time during the year, and in most cases are available to persons of all ages.

Please contact us on 786-970-0740 (Cell) if you’d like more information or for help enrolling in any of these options.