Open Enrollment Has Begun for Individual Plans

Open enrollment for individual plans for 2019 runs from 10/15/2018 to 1/15/2019. To guarantee an effective date of 1/1/2019, applications must be submitted by 12/15/2018.

Open enrollment means that anyone who is eligible for individual coverage may apply and will be accepted regardless of prior coverage or pre-existing medical conditions. Acceptance is guaranteed and pre-existing medical conditions are covered.

In our area, there are essentially two carriers, Anthem Blue Cross and Blue Shield of CA (BSCA). The main differences between the carriers is the provider network. Anthem’s product is an EPO (Exclusive Provider Organization). This means you must use a network provider or NO benefits are payable. This product uses the Pathway network which is much smaller than the full network.

In fact, the network is limited to only participating providers in our area, plus UC Davis and UCSF. Fortunately, many of our local providers refer to these two systems. Stanford and Sutter are not a part of the network.

Blue Shield’s product is a PPO (Preferred Provider Organization). Insureds received the highest level of benefits when using network providers, but are allowed to go out of the network. The penalties are quite steep for out of network coverage.

Anthem’s product allows access to the “Blue Card”. This grants reciprocity to other Blue Cross/Blue Shield providers when needing care out of the state. BSCA allows use of this feature only for emergencies. They are encouraging the use of Teledoc instead.

It is very important to understand that products in the individual market are the same , whether or not coverage is purchased through Covered CA, also known as the “Exchange”. Some providers continue to be confused and think there is a difference.

Covered California is our local “Exchange” where an eligible individual may purchase coverage and obtain premium subsidies to help pay for the coverage. This is due to the Affordable Care Act (ACA also known as Obamacare). It’s important to note that the subsidies are only available if the coverage is purchased through the website at www.coveredca.com.

These subsides can be substantial and should be considered. To be eligible, the individual or family’s income must be between 138% and 400% of Federal Poverty Level. For a family of four that may be as high as $100,000! A single person can earn up to $48,500 and qualify.

One way to estimate the subsidies is to go to www.coveredca.com and click on “shop and compare”. Be careful to avoid the “sponsored” sites that are not the actual site. You will get caught up in marketing and advertising. If you need assistance you may contact certified enrollers at Shasta Community Health Center or click “find an agent near you”. However, some agents may not be taking new Covered CA accounts.

The enrollment process is much more complicated than simply applying for health insurance. The enroller must understand the tax consequences of your income and how to report it accurately to assist you. The process can easily take an hour or more.

Beginning with the 2019 tax year, there is no penalty if you choose to be without health insurance. However Applicable Large Employers with 50 or more full time employees continue to be required to offer health insurance plans that qualify with the law and must offer “minimum essential benefits”.

Short Term health plans are not available in California. They were outlawed this year as they do not provide the Essential Health Benefits required by the ACA. They were always what I called “run over by a truck” coverage, anyway. They did not cover pre-existing conditions and often did not provide coverage for prescription drugs. They only lasted 1-12 months, depending on the carrier.

Individuals who do not qualify for a subsidy are going to see rate increases this year. Out of pocket maximums will also increase. This means the most an individual will pay “out of pocket” for covered expenses in a calendar year. In most cases it will be over $6500 for an individual. However that total will likely include deductibles.

With the holidays in the middle of open enrollment, time can get away from us. So it’s important to start looking at options now.

Margaret R. Beck

Margaret Beck CLU, ChFC, CEBS started her insurance practice in Redding in 1978. She founded Affiliated Benefit Services.

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