We have been a certified agent for Covered California since the first open enrollment began in 2013. Correctly completing the online Covered California application is crucial to obtaining the proper amount of advanced premium tax credits to offset the cost of coverage. We’ve helped hundreds of families complete the application and choose the best health insurance plans for their particular needs. We are paid by the insurance companies to provide this service. There is no cost to you for our assistance, so call us today!
Aetna is entering the individual marketplace with an HMO product. It is competitively priced, but in our service area their provider network is not robust. The biggest impact of Aetna’s entry will be in eastern El Dorado County, where there will now be three carriers instead of two. Since the Affordable Care Act bases premium tax credits on the cost of the second cheapest silver plan in a given zip code, and because there is a wide gap between Aetna and Anthem’s prices, which are similar, and Blue Shield’s PPO, which is much higher, Blue Shield PPO subscribers in eastern El Dorado County are going to see significant cost increases in 2023. Switching to Aetna or Anthem will alleviate the price increase, but you may need to travel west for your medical care, except in an emergency situation where you are allowed to use out of network providers.
This table shows some of the substantial increases in deductible and copayments for silver plans in 2023. Costs shown are per-person, per visit, and in-network.
| 2022 | 2023 | |
|---|---|---|
| Hospital Deductible | $3,700 | $4,750 |
| Out of Pocket Maximum | $8,200 | $8,750 |
| Primary Care Visit | $35 | $45 |
| Specialist Visit | $70 | $85 |
family glitch: Dependents will now be eligible for premium tax credits if your employer doesn’t subsidize the cost of their insurance, making it unaffordable
Prior to 2023, if an employer offered health coverage to an employee, the additional cost to cover the employee’s dependents was not considered when determining whether or not the employer’s coverage was affordable. This family glitch prevented many families from getting subsidies for dependent coverage from Covered California. For example, if an employer paid for an employee’s health insurance but charged $1,000/month to cover the spouse, the spouse’s coverage was considered affordable.
In 2023, the cost of covering the entire family is considered; if the family cost (employee plus dependents) exceeds 9.12% of the household’s income, then the dependents are eligible to receive premium tax credits for coverage through Covered California. Note that the cost of an employee’s coverage is still considered separately from the family cost; employees whose employee-only coverage costs less than 9.12% of household income cannot get premium tax credits for themselves, even if their dependents can. This means that the family glitch isn’t completely fixed. For example, if a married couple both work and each spouse’s cost for coverage through their respective employer costs 9% of the household’s income (total cost: 18% of household income), neither spouse would be eligible for premium tax credits.
The reason the glitch wasn’t fully fixed is because the wording of the Affordable Care Act as to whether or not an employee’s coverage is affordable is flawed, testing each employee’s affordability of coverage as a percentage of the entire household’s income. The Internal Revenue Service was able to add a regulation as to the affordability of coverage for dependents who aren’t employed by an employer who offers them health coverage, but it couldn’t work around the wording of the law with respect to a family member whose employer does offer them coverage. Completely fixing the family glitch will require Congress to amend the law, which has so far been impossible due to partisan politics.
Note that Covered California does not perform any of these tests; it is up to the applicant to correctly answer the is this coverage affordable
question in the Covered California application. Let us sign you up and we’ll do the math for you!
Medicare is a federal healthcare benefit for seniors and the disabled. Eligibility begins the earlier of:
OriginalMedicare
Covers inpatient hospitalization, care in a skilled nursing facility, and hospice care. Drugs received while a hospital inpatient are also covered. A deductible applies, as well as coverage limits after 60 consecutive days of care. There is no charge for Part A if you or your spouse paid Medicare taxes for ten or more years; otherwise you have to pay a monthly premium for it.
Most medically-necessary treatments and supplies that aren’t covered by Part A are covered by Part B, such as physician fees, durable medical equipment, home health care, lab tests, and preventative care. The notable exception is prescription drugs, which are covered separately under Medicare Part D. Part B has limited coverage for accupuncture and chiropractic services.
Part B generally covers 80% of the allowed costs, but preventative care is free. You must pay a monthly premium for Part B. The amount changes every January and is set at 25% of Medicare’s estimate of the average cost to provide Part B services. In addition to the base monthly premium, you may have to pay a late enrollment penalty of 10% for every year you were eligible for part B but didn’t sign up. Individuals with higher incomes may also pay an IRMAA (income-related monthly adjustment amount) which increases the premium from the standard 25% of the expected cost of Part B services to as much as 85%. The IRMAA for a given year is based on your income tax return from two years prior (for example, the 2023 IRMAA would be based on your 2021 tax return).
If you are receiving social security benefits, you’ll be automaticaly enrolled in Medicare parts A and B upon your eligibility date; otherwise, you can sign up starting three months prior to your initial eligibility month. If you don’t sign up after three months following your eligibility month, you will pay a late enrollment penalty when you do sign up, although the penalty doesn’t apply if you had health coverage through you or your spouse’s employer and signed up within eight months of losing that coverage (note that electing COBRA coverage does not extend the eight month period).
While most health insurance policies have an out of pocket maximum that caps your medical costs for a calendar year, original Medicare has no out of pocket maximum, potentially saddling Medicare recipients with large medical and hosptial bills to pay. Most Medicare recipients purchase insurance to cover these gaps in Medicare, either in the form of a Medicare supplement or a Medicare Advantage policy.
Medicare supplement policies are intended to cover the gaps in original Medicare, which is why they are also known as Medigap policies. There are several types of medigap policy sold; each type is assigned a letter, and every policy with the same letter offers the same set of benefits. The most popular plans with the greatest benefits are plans F and G, which are identical except that plan F covers the annual Medicare Part B deductible, which changes each year and is $226 for 2023. Plan F is available only to people who were initially eligible for Medicare prior to 2020. If you have a plan F policy and its annual cost exceeds the cost of plan G by more than the Part B deductible, you should consider switching to plan G. Here is a list of plan G benefits:
Your enrollment in a Medicare supplement is guaranteed during your initial eligibility period for Medicare. After then, the insurance company can ask questions about your health and decline you based on your responses. Once accepted for coverage, you cannot be dropped as long as you pay your premiums on time.
Medicare Advantage plans, also known as Medicare Part C, were first offerred in 1999. They are sold by private insurance companies and resemble individual health insurance plans, with deductibles, copayments for most services, and out of pocket maximums. Prescription drug benefits are usually included. The monthly premium for Advantage plans is less than for a Medicare supplement plus prescription drug plan, especially for older seniors, as Advantage plan rates are flat while medicare supplement rates increase as you age. The premium is in addition to the Medicare Part B premium and any Part B and Part D late enrollment penalties and income-related monthly adjustment amounts.
Like individual plans, you can only sign up for an Advantage plan during an annual open enrollment period (October 15th to December 7th), or right after a qualifying life event like becoming eligible for Medicare or moving (see full list) Once enrolled, you generally cannot be dropped as long as you pay your premiums on time.
Like individual health plans, Most Medicare Advantage plans have a network of doctors, with reduced or no coverage if you obtain care outside of the network except in an emergency. If you travel extensively or don’t want to be bothered with having to choose in-network providers, or if you are a frequent user of medical services where the copayments would start adding up, then Original Medicare plus a Medicare supplement with prescription drug plan is likely preferable to an Advantage plan for you.
Prescription drug coverage, or Medicare Part D, is an optional coverage that began in 2006. Prior to then, prescription drug coverage could be purchased as part of a Medicare supplement plan. Now it is purchased as a standalone policy or bundled with medical coverage as part of a Medicare Advantage plan. All prescription drug plans have the same basic structure, with four stages of coverage:
TrOOP) reaches the catastrophic threshold, you move to the catastrophic coverage phase.
Like Part B, Part D has a late enrollment penalty if you don’t sign up during your initial eligibility period for Medicare. The penalty is waived if you have creditable coverage (prescription drug coverage through another source, such as an employer or grandfathered Medicare supplement policy). If subject to a late enrollment penalty, you pay an additional 1% in premium for each month you were without coverage. An income-related monthly adjustment amount (IRMAA) may also apply; for 2023 the Part D IRMAA varies from $12.20 to $76.40 per month, depending on your income in 2021.
REQUIRED MEDICARE ADVANTAGE AND PRESCRIPTION DRUG PLAN DISCLOSURE: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
According to the U.S. Census Bureau, as of 2019, 56.4% of Americans received health insurance coverage through their (or their spouse’s or their parent or guardian’s) employer. Employer-sponsored coverage is still the backbone of the U.S. healthcare system. Employers with 50 or more full-time equivalent employees are required to provide health insurance to their employees who work thirty or more hours per week. The coverage must meet certain affordability and minimum value standards. Call us if your business is reaching the threshold of the employer mandate for health insurance or if you are interested in changing your current group health insurance offering or want to switch health insurance brokers to our firm.
Small employers with less than 50 full-time equivalent employees can choose to offer health insurance for their employees, but typically it is more cost-effective for both the employer and employees for the employees to instead receive federally-subsidized individual coverage through Covered California. Instead of group medical coverage, consider offering your employees benefits for which they don’t get tax credits under the Affordable Care Act, such as dental, vision, and group life insurance.
Dental and vision plans can be purchased year-round without waiting for open enrollment. Some medical plans provide limited dental and/or vision benefits; call us to discuss your needs.