FAQ

Groups & Businesses

A group is defined as at least 2 people, at least one of whom is paid on a W-2 basis and who is not related by marriage to any owner of the business. Partner-only businesses are no longer eligible for group plans under the Affordable Care Act.

Generally you need to provide documentation of the legitimacy of your business and sufficient payroll history to show you've been around at least a short while. The types of documents usually include a business license, proof that you are registered with the California Secretary of State's office, a Statement of Information listing business owners and address, and any DBA (Doing Business As) paperwork if applicable.

For payroll purposes, most insurance carriers will insist on a copy of the latest DE-9C Quarterly Contribution Return and Report of Wages form showing that at least one full time employee has been active for at least half of the prior calendar quarter. However, some carriers will accept less payroll, especially if you are a newly incorporated startup. If you have questions as to whether a group plan is a viable option, please contact us.

In some instances, a group plan will not consider an individual or family plan a qualifying reason to waive coverage. We can help you sort out the factors in play and find the right solution.

No, you cannot. This is specifically prohibited under the ACA and carries stiff tax penalties of up to $36,500 per year per employee if you are shown to be reimbursing for open market plans.

If you are a small group between 1-50 employees, you are not required to put a plan in place. However, the plan options available for groups are substantially more comprehensive than those available on the individual and family market.

Not all doctors contract with all plans, it's best to use these provider links and to double check with your doctor before scheduling any visits.

Nothing. A broker's services are always free to the consumer. We are paid by the insurance vendors, and it is a large part of our job to service your account and help resolve any issues that may arise.

It varies depending on the plan. Similar to your insurance, a deductible is the amount you pay in full up front before the insurance company steps in and pays the lion's share of the costs. However, there are some services that you pay for on a strict copayment structure that you do not need to meet the deductible for. These include almost all basic medical visits.

The amount you typically pay for office visits, laboratory tests, X-rays and prescriptions. After you pay the copay for these services, the insurance company typically pays the remainder. There are different copays and limits for out of network care, so try to stay in network whenever possible.

This is the maximum amount you could be required to pay out for claims incurred during any calendar year, provided that you are only using in-network services. The maximum is considerably higher if you use non-network services, so try to stay in the network.

In some plans, these providers are not covered at all. In other plans, they are covered to a much lower level. It is highly recommended not to go out of network if at all possible. If you must see an out of network provider for an emergency issue, this would be paid as an in-network expense.

These claims will often be declined or considered as out of network. Please use our services to help you attempt to get reimbursement on an in-network basis. We have a good track record with helping sort out claims problems, although we cannot guarantee this will always work out.

There is a requirement under the Affordable Care Act, frequently referred to as Obamacare, that all legal residents of the USA have coverage compliant with the new plan requirements. There are tax penalties for deciding not to purchase insurance. For members with coverage starting in 2015, this is 2.0% of your overall income, or $295, whichever is larger. For coverage beginning in 2016, the penalty will be 2.5% of your overall income or $695, whichever is larger.

No. Under the Affordable Care Act, there are no health questions asked and no effect on rates if you have a condition.

If you choose to set up a company plan, you are typically required to contribute at least 50% of the lowest-cost plan you implement. You are free to put in multiple plans (the number of plans will vary depending on the size of your company) and allow staff to customize their plan choice and pay any difference in premium as pre-tax payroll deductions.

We can set up a wide variety of different types of coverage for your firm. For more information, please take a look at our Other Benefits Page.

Individuals & Families

It varies depending on the plan. Similar to your insurance, a deductible is the amount you pay in full up front before the insurance company steps in and pays the lion's share of the costs. However, there are some services that you pay for on a strict copayment structure that you do not need to meet the deductible for. These include almost all basic medical visits.

The amount you typically pay for office visits, laboratory tests, X-rays and prescriptions. After you pay the copay for these services, the insurance company typically pays the remainder. There are different copays and limits for out of network care, so try to stay in network whenever possible.

This is the maximum amount you could be required to pay out for claims incurred during any calendar year, provided that you are only using in-network services. The maximum is considerably higher if you use non-network services, so try to stay in the network.

In some plans, these providers are not covered at all. In other plans, they are covered to a much lower level. It is highly recommended not to go out of network if at all possible. If you must see an out of network provider for an emergency issue, this would be paid as an in-network expense.

These claims will often be declined or considered as out of network. Please use our services to help you attempt to get reimbursement on an in-network basis. We have a good track record with helping sort out claims problems, although we cannot guarantee this will always work out.

There is a requirement under the Affordable Care Act, frequently referred to as Obamacare, that all legal residents of the USA have coverage compliant with the new plan requirements. There are tax penalties for deciding not to purchase insurance. For members with coverage starting in 2015, this is 2.0% of your overall income, or $295, whichever is larger. For coverage beginning in 2016, the penalty will be 2.5% of your overall income or $695, whichever is larger.

To get a quick idea if you qualify for a subsidy, please visit the Covered California Shop and Compare Tool. If you are not eligible for a subsidy, you can actually apply online for many plans available through our quote page, or contact us to walk you through it. If you are eligible for a subsidy and have a qualifying life event, we would be happy to assist you in signing up for a Covered CA plan.

Not all doctors contract with all plans, it's best to check out provider directories and to double check with your doctor before scheduling any visits.

No. Under the Affordable Care Act, there are no health questions asked and no effect on rates if you have a condition.

There are a wide variety of Qualifying Life Events that could permit you to buy coverage on the open market or through Covered California. Generally speaking you may qualify for any involuntary loss of coverage, significant income change, getting too old to stay on a parent's plan, changing residency or marital status, having a child, acquiring citizenship, and many others. Covered California provides a useful reference for the types of qualifying events.

Coverage can be provided by an employer or purchased on the open market. There is a narrow window each year to sign up for coverage, and it is not generally possible to get coverage outside that time frame unless there is a qualifying event. The next open enrollment period for coverage starting in January of 2016 runs from November 1st 2015 to January 31st 2016.

Nothing. A broker's services are always free to the consumer. We are paid by the insurance vendors, and it is a large part of our job to service your account and help resolve any issues that may arise.

Seniors

You are eligible as soon as you turn 65. However, if you are still working and your company provides benefits, you can delay signing up until you are ready to leave the company. If your company has under 20 employees, let us explain.

4 months prior to the month of your birth, you can go to Medicare.gov and apply online for Medicare. If you are already receiving Social Security, a Medicare card will be sent to you automatically. If the card shows Part A and Part B and you don't want Part B yet, you'll need to fix this with the Social Security Department.

Part A is free. Part B for 2015 has a base cost of $104.90 per month. This is based on an adjusted gross income of $85,000 for an individual and $170,000 for a family. If your income is higher, the cost will be higher. Here's the link for higher incomes. Part D is a separate product for prescription drug coverage, and the government cost for Part D is free but it can cost if you are a higher earner.

Medicare definitely does not pay for everything, and it is a good idea to buy a Medicare Supplement (Medigap) or a Medicare Advantage plan to augment Medicare.

Advantage plans are typically HMO-type programs where you select a primary care physician and are referred to specialists and hospitals by that physician. Kaiser Senior Advantage is the primary example of this that most people know about.

A Supplement plan allows you to any provider nationwide as long as they accept Medicare patients. A Plan F is the most comprehensive Supplemental plan and covers 100% of what Medicare Part A and Part B do not cover for any claims that are a Medicare-permitted expense. There are other options to reduce costs.

If you buy an Advantage plan, the cost of the drug plan is included in your premium. If you buy a Supplement plan, you will need to purchase a separate Part D Prescription Drug Plan (PDP). You can find a plan using Medicare.gov, or we can assist you. We can help you find a good prescription plan as a courtesy.

After you and the insurance company have paid $2,960 towards the cost of your drugs, you alone are responsible for the remaining costs before leaving the gap. These vary from carrier to carrier. Sometimes, the insurance company will pay for generic drugs needed during this period, which is referred to as the "gap" or the "donut hole". After you have spent [x] dollars, the plan starts paying for your drugs again and your copayments are greatly reduced.

Many carriers want your business. Please bear in mind that all Supplement plans with a given plan type such as a Plan F are the same, no matter which company you buy them from. Some carriers will have value added features. Let us decipher this for you and find you the plan at the lowest cost that works for you. In California, you can switch this plan every year on your birthday if you wish.

Supplement plans allow you to switch on your birthday to a plan of equal or lesser value. Medicare Advantage and Drug plans share the same open enrollment period each year, usually from October 15th through December 7th. All of those changes are effective January 1st, and the Supplement changes are effective on the first of the month after your birthday.