Frequently Asked Questions

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Medical (Health), Dental, Vision, Life, Supplemental, Critical Illness, Short term disability, AD&D, Hospital, & catastrophic. I have access to many different regular health and supplemental plans through a wide variety of carriers, as well as a group option that most brokers don’t have access to. The group plan is a great cost-effective option for those who do not qualify for the ACA subsidies.

Health insurance plans typically include HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), EPOs (Exclusive Provider Organizations), and POS (Point of Service) plans. Each has its own network of providers and coverage options, so it's important to assess individual needs and preferences.

Consider factors like premium costs, deductibles, co-pays, network coverage, prescription drug coverage, and specific health needs. Evaluating these elements alongside individual circumstances and budget can help identify the most suitable plan.

No fee, I am your personal dedicated advisor that will come with the plan.

ACA (Marketplace/Exchange Plans)

Pros:

• Guaranteed issue: Can’t be denied for pre-existing conditions
• Subsidies available: Premium tax credits and cost-sharing reductions
• Covers all 10 essential health benefits
• Free preventive services
• Annual out-of-pocket maximum limits

Cons:

• Limited to Open Enrollment Period (unless you qualify for a Special Enrollment Period)
• Network may be narrower depending on the plan (e.g., HMO vs. PPO)
   

Employer-Sponsored Insurance (Group Plans)

Pros:

• Often includes employer contribution to premium costs
• Wide provider networks (especially large employers)
• Usually includes dental and vision options
• No need to shop on the Marketplace

Cons:

• Limited choice (usually 1–2 plan options)
• May lose coverage if you change jobs
• Not eligible for ACA subsidies if employer plan is considered “affordable” and “minimum value”
   

Short-Term Health Plans

Pros:

• Lower monthly premiums
• Flexible enrollment — can enroll year-round
• Good for temporary gaps in coverage

Cons:

• Not ACA-compliant — may exclude pre-existing conditions
• Often do not cover essential health benefits
• Can have caps on benefits and no preventive care
• May be denied coverage based on health history

 Choosing an Affordable Care Act (ACA) plan offers several important benefits, especially for individuals and families who need comprehensive, affordable health coverage. Here are the key advantages:

Comprehensive Coverage.  ACA plans are required to cover 10 essential health benefits, including:

• Doctor visits and outpatient care
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative services
• Laboratory services
• Preventive and wellness services
• Pediatric services (including dental and vision)
   

Guaranteed Coverage.  You cannot be denied coverage or charged more based on pre-existing conditions, health status, or gender.

Subsidies to Lower Costs.  Many people qualify for:

• Premium tax credits to reduce monthly premiums
• Cost-sharing reductions (CSRs) to lower out-of-pocket costs (like deductibles and copays) if enrolled in a Silver plan and income is within the eligible range
   

No Annual or Lifetime Limits.  ACA plans do not have annual or lifetime caps on essential health benefits, so your coverage won’t run out if you have extensive medical needs.

Free Preventive Services.  Plans cover many preventive services at no cost, such as:

• Annual checkups
• Vaccinations
• Cancer screenings
• Birth control
• Diabetes screenings
   

Standardized Coverage Levels.  Plans are grouped into metal tiers (Bronze, Silver, Gold, Platinum), making it easier to compare based on the value of coverage:

• Bronze: lower premiums, higher out-of-pocket costs
• Silver: moderate premiums and costs (and eligibility for CSRs)
• Gold/Platinum: higher premiums, lower out-of-pocket costs
   

Network Access.  ACA plans usually offer access to a broad network of doctors, hospitals, and specialists, depending on the insurer and plan type (HMO, PPO, etc.).

 You may qualify for help paying for your health insurance — called a subsidy — based on your:

• Household income
• Family size
• ZIP code
• Eligibility for other coverage (like Medicaid or employer insurance)

There are two main types of subsidies available through the Marketplace:

Premium Tax Credit

• Helps lower your monthly premium.
• Available if your household income is between 100% and 400% of the Federal Poverty Level (FPL) — and in many states, even above 400% due to expanded rules under the American Rescue Plan.
• You must not be eligible for Medicaid, Medicare, or affordable employer coverage.
   

Income Example (2024 Guidelines)

For a single person, you may qualify if your income is between $14,580 and around $58,320.

For a family of 4, the range is roughly $30,000 to $120,000, depending on the state.

Cost-Sharing Reductions (CSRs)

• Help lower out-of-pocket costs like deductibles, copays, and coinsurance.
• Only available if:
  • You enroll in a Silver plan, and
  • Your income is between 100% and 250% of the FPL
     

How to Check Your Eligibility:

The fastest way is to:

• Use a Marketplace website:  getcovered.nextgenhia.com
• Enter basic info: income, household size, ZIP code 

You’ll get an instant estimate of your monthly premium and any savings you qualify for.

Tips for Accurate Estimates:

• Income: Use your expected Modified Adjusted Gross Income (MAGI) for the coverage year. This includes wages, self-employment income, unemployment benefits, and other taxable income.
• Household Size: Include yourself, your spouse, and any dependents you claim on your tax return.
• Employer Coverage: If you have access to affordable employer-sponsored insurance, you may not be eligible for Marketplace subsidies. 

Yes!  All of our plans are fully ACA-compliant and cover all 10 essential health benefits.  ACA Plans may be the least expensive option if you qualify for subsidies or have a major health condition.  If not, you may qualify for our Group Plan, which is also fully ACA-compliant.

ACA health plans do not require a long-term contract like some other types of insurance or services. When you enroll in an ACA plan:

• You’re covered for the calendar year (usually January 1 through December 31).
• You can cancel at any time—there’s no penalty or fee to drop your coverage early.
• However, once you’re enrolled, you typically can’t switch plans until the next Open Enrollment Period, unless you qualify for a Special Enrollment Period due to a life change (like losing other coverage, moving, or having a baby).

So, while you’re enrolling for a year of coverage, there’s no binding contract, and you have the flexibility to cancel if needed.

Open Enrollment is the one time each year when you can sign up for a health insurance plan through the Marketplace. During this period, you can:

• Enroll in a new plan
• Renew your current plan
• Make changes to your existing coverage

For most states, Open Enrollment runs from November 1 to January 15 each year. If you miss this window, you can only sign up or make changes if you qualify for a Special Enrollment Period (like losing other coverage, having a baby, getting married, etc.).

It’s important to review your options during Open Enrollment to make sure you’re getting the best coverage and savings available for the coming year.

Other Health Insurance options like Dental/Vision/Accident or our Group Plan are not limited by Open Enrollment and are available throughout the year.

 If You Stop Paying Your Premiums:

Grace Period
If you receive subsidies (like a premium tax credit), you get a 90-day grace period to catch up on missed payments.

• Your plan won’t be canceled right away.
• Claims may be held during this time and processed if you catch up.

If You Don’t Pay Within 90 Days

• Your coverage will be terminated. 
• You may owe money for care you received during the unpaid period.
• You likely won’t be able to re-enroll until the next Open Enrollment Period, unless you qualify for a Special Enrollment Period (SEP).
   

If You Want to Change Plans Mid-Year:

You can’t change ACA plans mid-year unless you qualify for a Special Enrollment Period (SEP). Common reasons for a SEP include:

• Losing other coverage (like employer or Medicaid)
• Moving to a new ZIP code or county
• Having a baby, adopting a child, or getting married
• Changes in income that newly qualify you for subsidies or Medicaid
• Gaining eligible immigration status

Most SEPs give you 60 days from the event date to enroll in a new plan.

You may qualify for a Special Enrollment Period if you’ve experienced any of the following in the last 60 days:

Loss of Coverage

• Lost employer-sponsored health insurance (fired, quit, reduced hours)
• COBRA expired (not due to non-payment)
• Aged off a parent’s plan (turned 26)
• Lost Medicaid or CHIP
• Lost individual or Marketplace coverage (non-payment does not qualify)
   

Household Changes

• Got married 
• Had a baby, adopted a child, or placed a child for foster care
• Got divorced or legally separated and lost coverage
   

Change in Residence

• Moved to a new ZIP code or county
• Moved to the U.S. from abroad or a U.S. territory
• Moved from a shelter or transitional housing
   

Change in Immigration or Citizenship Status

• Gained eligible immigration status or became a U.S. citizen
   

Change in Income

• Now qualifies for help paying for coverage (tax credits or cost-sharing reductions)
• Became newly ineligible for Medicaid
   

Other

• Released from incarceration
• Gained status as a member of a federally recognized tribe

It depends on the specific plan and provider network. Some plans allow you to keep your current doctor if they are in-network, while others may require you to switch providers. It's crucial to review the plan's network to ensure your preferred doctors are included.

It depends on your plan type:

HMO (Health Maintenance Organication)

• Yes, a referral is usually required.
• You’ll need to see your primary care doctor (PCP) first, who will refer you to a specialist within the plan’s network.
• HMO plans tend to be lower in cost but have more rules about how care is accessed.
   

PPO (Preferred Provider Organization)

• No referral is needed.
• You can see a specialist directly, even out-of-network (but you’ll pay more if the provider isn’t in the plan’s network).
   

EPO (Exclusive Provider Organization)

• No referral needed, but you must use in-network specialists (except in emergencies).
• Out-of-network services are usually not covered at all.
   

POS (Point of Service)

• Referral is usually needed to see a specialist.
• You can go out-of-network but will pay more, and referrals are still required for most services.

To avoid surprise costs, it’s always best to:

1. Check if the specialist is in-network. 
2. Confirm whether your plan type requires a referral before making an appointment.

The out-of-pocket maximum is the highest amount you'll pay for covered services within a policy year. Once you reach this limit through deductibles, co-pays, and coinsurance, the insurance company covers 100% of the costs for covered services.

Public Marketplace (aka ACA/Obamacare plans) are based on income and age, not health.

Our Group Plan prices are based on age, not health, but you do need to be relatively healthy to qualify.

Private plans are based on health and age – the lower risk you are the cheaper your premium, but you must be healthy, with no pre-existing conditions to qualify.

 There’s no fixed amount, but ACA plan premiums tend to increase slightly each year—typically by 2% to 10%, depending on:

Medical Cost Trends

• As the cost of healthcare services, prescription drugs, and hospital care rises, premiums may increase.
   

Plan Changes

• If you switch to a different plan or metal tier, that can affect your cost regardless of annual increases.

Age

• Premiums increase with age (this is built into ACA pricing), so even if the plan doesn’t change, you might see a modest rise as you get older.
   

Area/Zip Code

• Premium changes also depend on local market rates, including hospital costs, provider competition, and available insurers in the area.
   

But - Many people don't feel the increase

If you qualify for premium tax credits:

• Your subsidy usually increases as plan premiums go up.
• So even if the full plan price rises, your actual monthly payment may stay the same or change very little.
   

Example:

If a Silver plan premium rises from $500 to $530/month, but the benchmark plan also increases, the tax credit adjusts — often keeping the net cost steady.

Employers with fewer than 50 full-time employees are not required to offer health insurance under the ACA, but they can choose to offer it voluntarily.

SHOP Marketplace Plans (Small Business Health Options Program)

• Designed for small businesses with 1–50 full-time employees
• Offers group health and dental plans
• Businesses may qualify for the Small Business Health Care Tax Credit if:
  • They have fewer than 25 full-time equivalent (FTE) employees 
  • Pay average wages below $62,000/year (adjusted yearly)
  • Pay at least 50% of employee premium costs
     

Employers can enroll in SHOP coverage any time — there’s no set Open Enrollment Period.

QSEHRA (Qualified Small Employer HRA)

• Allows small employers to reimburse employees tax-free for individual health insurance premiums and medical expenses
• Great option if
  • You don’t want to manage a group plan
  • You want to give employees flexibility to choose their own ACA plan
     

You must not offer a group health plan if you offer a QSEHRA.

Even One Employee?

Yes — an employer with just 1 full-time W-2 employee (who is not the owner or a spouse/family member of the owner) may be eligible for a small group plan.

Generally, no. To comply with federal rules and avoid discrimination:

• If you offer a group plan, it must be offered to all eligible employees (usually full-time).
• You can set reasonable eligibility requirements, like a waiting period or minimum hours (e.g., 30+ hours/week).

You’re not required to, but yes, you can.
 

If you choose to offer it, you must follow the same terms for all similarly situated part-time employees.

For SHOP plans, you must pay at least 50% of the employee’s premium for the lowest-cost plan.

For other group plans, contribution requirements depend on the insurer, but 50% is a common minimum.

Yes! Premium contributions are tax-deductible as a business expense.
 

If using the SHOP Marketplace, you may also qualify for the Small Business Health Care Tax Credit.

Group plan: Employer picks a plan and pays part of the premium.
 

QSEHRA: Employer sets a budget and reimburses employees for their own individual ACA plans.