Aca/marketplace Break Down I Find Works for Clients to Gain Clarity and Feel Comfortable with Me As

Mar 16, 2015

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  1. sorellana
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    sorellana New Member

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    Yes I'm new, but in being new my learning on the the topic of health care reform as it pertains to the aca/ federally run market places has its helpful perks.

    Most clients we as agents run into are confused and frustrated. Change is evil to them. However if they understood the way we do why would they need us? That is why our jobs as agents are secured.

    And I ran into a post where the particular poster is concerned or was which ever it is that we are replaced by online entities. I can assure this poster that it is not the case at all.

    Look these individual go online answer questions worded in a way that sometimes frustrates them and they ultimately either give up or go to ...you ready for this? an agent.

    As it stands I am only trained for under 65 individuals, but here is how I explain it to them trust me 9 times out of 10 they get it and feel comfortable with me.

    The affordable care act did away with a lot of referral business to see a doctor and annual life time limits. It also requires that all plans have a set of core benefits. They include:
    1.hospitalization
    2. ambulatory services
    3. Maternity
    4. Prescription coverage
    5. Rehabilitation/ habilitation services
    6. Preventative care
    7. Office visits
    8. Emergency
    9. Pediatric care (ie vision/dental)
    10. Mental health/ substance abuse services.

    any plan you look at will have these core benefits. The difference in the plan will be how you pay for those benefits. The plans are now known by metal levels.
    you have:
    bronze - plan covers 60% individual covers 40%
    silver- plan covers 70% individual covers 30%
    Gold- plan covers 80% individual covers 20%
    platinum- plan covers 90% individual covers 10%

    The plans are set on a sliding scale. Bronze and silver is going to have the lower premiums on the scale but higher out of pocket cost. While the gold and platinum are going to have the higher premiums but lower out of pocket cost.

    In terms of premiums that's based upon location of the individual, weather or not that individual is a smoker and the individuals on the plan.

    The issue of plans being unaffordable has many factors.

    Here's where the federal market places step in.

    There are two subsidies offered on the market place.
    premium tax credit- which depending on household size an income can help apply a certain amount towards an individual's premium in two ways.
    1. You apply it monthly and when you do your taxes so long as your income matches what you estimated you either owe, are owed, or you break even.
    2. You pay the full premium every month and get a large lump some at the end of the year.

    cost share subsidy- a subsidy that can only be used on silver metal level plans. It reduces what an individual pays in terms of deductibles and Copays. Basically lowers the out of pocket cost of the benefits.

    Side note - the premium tax credit can be used on any metal level. Honestly if I find a client qualifies for both I tend to gear them toward a silver level plan. But that's just me.

    Now for those who qualify for medicaid.
    If they opt out of taking it they can still get an exchange plan but no subsidies. The reason is that medicaid is technically like a subsidy if you think about it. No premium, very very very low cost share if any. In terms of an individual's stigma towards the program, well if they understood their tax dollars go into funding the program they might not be so against it, and call it a hand out. They should be looking at it like they do medicare but eh we as agents can only do so much.

    explaining the deductible :
    some plans have a certain amount that an individual has to pay before their benefits kick in. Generally they are the high deductible plans. Basic definition to give would be its a set amount that has to be paid out of pocket first by the individual before cost share kicks in.

    explaining a maximum out of pocket amount to the clients:
    it is a safety net feature built into the aca plans to help cap what an individual spends on their benefits in a benefit year and includes the annual deductible in it. After that amount is paid out by the individual the carrier then incurs 100% of the cost for the remainder of the benefit year. The only expense still carried on by the individual is the monthly premium to keep the plan enforced as it is not included in the annual deductible or the max out of pocket.

    side note- the annual life time limits that were done away with were not the same and some clients may think they are. Annual lifetime limits from what I understand were the max amount the carrier would pay on an individual. Although I have to admit my training really didn't cover much on the topic.

    And yes explaining all of this before reviewing the plans to a client is what I do and it helps they understand what I am talking about when they hear me review the plan options for them and I find it cuts through a lot of confusion. I have more to share but let's see how this goes and take it from there.
     
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