Frequently Asked Questions About Health Insurance
Medicare & Supplement Plan FAQs
Part A: Hospital Coverage - no cost for most people.
Part B: Medical Coverage (80%) - cost is $164.90 per month for most people in 2023.
Part C: Medicare Advantage - cost varies by plan (as low as $0).
Part D: Prescription Drug Coverage - cost varies by plan.
If you are already receiving Social Security benefits, you will automatically be enrolled in Parts A & B. You can decline this enrollment if you wish to.
If you are not receiving Social Security benefits, you can enroll in Parts A & B 3 months before your 65th birthday, and they would be effective for the first day of your birth month. Example: If your 65th birthday is August 12th, you would be able to apply as early as May 1st, and your Parts A & B would be effective on August 1st.
If you have enrolled in Parts A & B, you can also enroll in a Medicare Advantage (Part C) plan OR a Medigap (Supplement) plan, which can start as early as the first day of the month you turn 65.
If you qualify for Social Security Disability and you have been on it for 24 months or more, you may qualify for Medicare coverage even if you are younger than 65.
- In most cases, you can stay on your employer plan if you wish to.
- You can be enrolled in an employer plan AND Medicare Parts A & B. They will work together to provide more coverage.
- It is also an option to disenroll from your employer plan and enroll in Medicare.
If you qualify for Medicare and your income is below 150% of the federal poverty level, you may qualify for a Low Income Subsidy (LIS) from the government to help pay for your prescription drugs.
There are also many other assistance programs available to help with the cost of prescription drugs. Visit our Health & Prescription Discount Programs page for more information on some of these programs.
Original Medicare (A & B) covers medically necessary dental; it does NOT cover routine or comprehensive dental services. Medically necessary dental includes dental reconstruction needed as a result of surgery (i.e. facial tumor removal), stabilization of teeth for reduction of jaw fracture, and tooth extractions to prepare the jaw for cancer treatment.
Medicare Advantage plans MAY cover routine and comprehensive dental services.
Most individuals will pay the standard amount for Part B and the assigned plan premium for their Part D coverage. However, those who have higher incomes may have an adjusted, higher monthly premium amount for Part B and an additional amount added to their Part D premium.
The income amount used to determine IRMAA is the modified adjusted gross income, as reported on your IRS tax return from 2 years ago.
Individual & Family Health Insurance & Marketplace FAQs
Individuals and families can purchase health insurance from the “Marketplace,” and the government will provide an Advanced Premium Tax Credit (APTC) to assist with the monthly premium for your health insurance plan. The amount of this tax credit is based upon your projected income for the year, your age and where you live. Other names for the Marketplace include the Affordable Care Act (ACA), Obamacare, and the Health Insurance Exchange.
The deductible is the dollar amount you pay for covered healthcare services before your plan benefits begin covering costs. Often, a plan will have both an individual deductible and a family deductible. Many companies offer plans with no medical deductible.
The max out-of-pocket is the maximum amount that you will pay for covered medical services in a calendar year. If your plan has copayments and/or coinsurance, these amounts will be put towards your max out-of-pocket.
For some plan types, the deductible and max out-of-pocket are the same amount. This means that you pay full price for covered medical services, and once you have met the amount of the deductible and max out-of-pocket, you pay nothing for covered services for the remainder of the calendar year.
In most cases, no, you will not qualify for an Advanced Premium Tax Credit (APTC) if you are offered coverage by your employer. However, you can still enroll in a Marketplace plan at full cost during an enrollment period, even if you don’t qualify for APTC.
If you have a low household income, it is likely that you will qualify for a tax credit that will cover most or all of your monthly health insurance premium, or you may qualify for Medicaid/Badgercare.
Anyone who is eligible can enroll in Marketplace coverage during the Open Enrollment Period from November 1st to December 15th into a plan that will be effective for January 1st. You can also enroll in a plan from December 15th to January 15th that will be effective for February 1st.
You may also qualify for a Special Enrollment Period during the year if you have a qualifying event. Some of these events may include: retirement, marriage, divorce, birth, adoption, loss of employer coverage, loss of Medicaid / Badgercare coverage, or you move out of your plan's service area.
A Health Savings Account is savings account that allows you to deposit money tax-free and use it to pay for medical expenses including deductibles, copayments, and coinsurance. These accounts are offered by banks, credit unions, and other financial institutions. Any interest or other earnings from your HSA plan are not taxable.
You must have an HSA-eligible plan in order to contribute to an HSA account. These plans are sometimes referred to as HDHPs (High Deductible Health Plans). Most HDHPs only cover preventive services prior to paying the deductible amount.
If you did not receive your 1095a form from the Marketplace, we can help you access it! CONTACT US for assistance.
Employer Group Health Plan FAQs
In most cases, you will need at least two of your employees to participate in the plan to offer group coverage.
ICHRAs are an employer-funded, tax-advantaged health benefit where business owners determine a set budget to reimburse their employees for health insurance, and workers buy the plan that works best for them. They allow businesses the ability to offer employees a monthly allowance of tax-free money and choose which medical expenses to cover, set eligibility criteria, and offer different reimbursement levels. This allows flexibility, which allows businesses to customize a plan that fits their needs, control costs, and address ACA compliance for applicable large employers.
Dental Insurance Plan FAQs
For most dental insurance plans, wait periods are waived if you have had prior dental coverage that ended less than 63 days before enrollment in the new dental plan.
If you did not have prior dental coverage, there are some dental plans that do not have wait periods.
Routine dental benefits typically include 2 exams and cleanings per year and bitewing x-rays once per year. Comprehensive dental benefits encompass services like extractions, fillings, root canals, etc.
In most cases, you can enroll in a dental plan at any time during the year, and it will be effective as early as the first of the following month.
Original Medicare only covers limited services that are done in conjunction with medical procedures.
If you have a Medicare Advantage plan, your policy MAY include built-in routine and/or comprehensive dental and vision benefits or it may have a program that helps pay for dental and vision services.
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