Obamacare – Individual

Government Releases Proposed Rule on Marketplace Re-enrollment 2015
Cost Estimates
Open Enrollment for 2015 will begin on November 15th and run until Feb 15th.
What is changing about plans?
How can I enroll? What information will I need?
What income and household information do I provide when I apply for Marketplace coverage?
Modified adjusted gross income and household income

Government Releases Proposed Rule on Marketplace Re-enrollment 2015

The proposed rule:

  • Allows state-based exchanges to choose one of three methods for conducting annual redetermination of eligibility for the federal premium tax credit and cost-sharing assistance;
  • Allows for re-enrollment for an individual, if that person remains eligible for a Qualified Health Plan (QHP) that is still available for renewal, unless the person terminates coverage or selects a different QHP;
  • Creates a framework for automatically renewing individuals whose plans are no longer available on the Marketplace; and
  • Makes changes to the process for individuals to report eligibility changes to the Marketplace.

CMS also released sub-regulatory guidance describing an alternative redetermination procedure that will apply to federally facilitated Marketplaces for the 2015 enrollment year (and may also be used by state-based Marketplaces) if the proposed rule is adopted as written. The guidance outlines three notices that will be sent to eligible individuals based on tax return data received from the Internal Revenue Service. The guidance would require individuals to go to the federally facilitated Marketplace to obtain their updated 2015 federal premium tax credit and cost-sharing subsidy amounts. Individuals enrolled in QHPs who do not go to healthcare.gov for subsidy redetermination could see their subsidies reduced or eliminated.

Finally, a CMS bulletin contains revised model notices for health plans to send on renewals and discontinuations.

  • In the large group market, issuers may use any form and manner permitted by law in sending renewal and discontinuations.
  • In the individual and small group markets, the bulletin requires issuers to provide information on the difference between the 2015 monthly premium and the most recent monthly amount of the 2014 subsidy paid, if applicable.

We are currently reviewing the proposed rule and will provide more information once it is available.

Cost Estimates

Costs for plans next year will be factored differently than health insurance has been factored before.  On going rates will be determined by Age, Zip Code, Smoking Status (suspended for one year) and income.  Yearly income will be the biggest factor for what you will actually pay for your plan.  Consumers will have two costs that they see; the first cost will be the actual cost of the plans, the second cost will be their actual cost after an advanced tax credit.  The lower your income the more of an advanced tax credit you will get.  Those making over 400% of the Federal Poverty Level (FPL) are highly encouraged to talk to a broker about their options because you may have access to plans with expanded physician and hospital networks on non subsidized plans.

The best cost estimator currently online is www.healthsherpa.com.  This estimator only takes into account the “On Exchange” plans.  If you are over 400% of FPL or do not plan on using a federal subsidy then you will have additional options “Off Exchange” through the carriers.


Open Enrollment for 2015 will begin on November 15th and run until Feb 15th.

Starting November 15th you will be able to view and enroll in new health insurance options starting on Jan 1st, 2015.  If the rules remain constant you can start your new plan on January 1st if you enroll between November 15th and December 15th.  February 1st starts dates will be for those enrolling between December 16th and January 15th.  March 1st start dates for those enrolling between January 16th and February 15th.
The enrollment period this year has decreased from the 6 month window from last year to a 3 month window for the 2015 plan year.
We are certified with the Federal Facilitated Marketplace to assist you in researching  your needs and applying for subsidies.

The federal government just endorsed the use of brokers to navigate all your options with you when they stated “use a health insurance agent or broker, they’ll be able to help you figure out your options. Brokers sell many different insurance products and are usually paid by insurance companies.” on the www.healthcare.gov website.

If you have questions of how to prepare or how to move forward I encourage you to send us an email at Ron@NemetzInsurance.com or call 800-401-5695 so that I can help guide you through the process.

What is changing about plans?

There will be no more medical underwriting for plans, that means a few things; first you can not be denied coverage for a pre-existing condition nor can you be rated up (charged more) or ridered (coverage excluded) for a condition.  This is a big positive for the consumer, but will more than likely increase cost when compared to current individual plan prices.  The only “medical” condition that will be evaluated is smoking status.  Initially that law stated that you can be charged up to 50% extra premium for being a smoker, but as of the last report we’ve read they have waived this for the first year due to other factors in the law.

Plans will have Minimum Essential Health Benefits that the government has mandated.  The biggest changes, when compared to current individual plans, is that plans must contain coverage for maternity and labor as well as mental health benefits.  Many current providers do not include this as standard coverage, but will have to do for new plans as of Jan 1st, 2014.  A complete list of the Minimum Essential Health Benefits can be found at here: Essential Health Benefits

All plans must include Free Wellness and Preventative Services, this has been part of the law that was established in 2010.  Many common things must be covered under this, such as Pap Smear, mammograms, routine physicals, routine blood testing a physical, children’s immunizations, age recommended cholonoscopy, etc.  The biggest thing to remember is if you have all ready had a condition, such as high cholesterol, then a test for cholesterol would be diagnostic and not preventative, so it would not fall under the free provision.

How can I enroll? What information will I need?

As a broker, we are certified in the exchange to help consumer enroll (at no cost to the consumer).  This training/certification process was completed in the summer of 2013.  We were trained to walk you through the process of figuring out your advanced tax credits and assist you in applying for the plan of your choosing.

Brokers are an essential element of the enrollment process.  We will still be needed to help explain plan options to you, explain your tax credits, how  your max out of pockets work, and the specific aspects of your plan.  We are licensed an trained to provide this for consumers at no cost to them.

You can prepare to have this conversation with the broker of your choice, but they will need some information from you to get you the most accurate comparisons: your anticipated 2014 income (mainly for modified adjusted gross income), names, dates of birth, citizenship status, smoking status, and if you have workplace insurance options.

If you would like for us here at Nemetz Insurance Services to assist you then please call us at 512-351-8855 and we would be glad to speak to you now and schedule a time at a future date when the exchange is up an running to go over your options with you.


What income and household information do I provide when I apply for Marketplace coverage?

If you want to find out if you qualify for lower costs on Marketplace coverage, you’ll need to provide information about your household members and income.

The Marketplace application includes detailed instructions. It makes calculations using the information you provide to determine whether you’re eligible for lower costs.

The information on this page can help you prepare before you apply.

Reporting on your household

When filling out your application, DO include:

  • Yourself
  • Your spouse
  • Your children who live with you, even if they make enough money to file a tax return themselves
  • Your unmarried partner who needs health coverage
  • Anyone you include on your tax return as a dependent, even if they don’t live with you
  • Anyone else under 21 who you take care of and lives with you

DON’T include:

  • Your unmarried partner who doesn’t need health coverage and is not your dependent
  • Your unmarried partner’s children, if they are not your dependents
  • Your parents who live with you, but file their own tax return and are not your dependents
  • Other relatives who file their own tax return and are not your dependents

To learn about who qualifies as a dependent, refer to IRS Publication 501.

Estimating your income

When you apply for lower costs in the Marketplace, you’ll need to estimate your income for 2014.

You can start by adding up the following items for:

  • You and your spouse, if you are married and will file a joint tax return
  • Any dependents who make enough money to be required to file a tax return

For each of the following sources, estimate what your income will be in 2014:

  • Wages
  • Salaries
  • Tips
  • Net income from any self-employment or business (generally the amount of money you take in from your business minus your business expenses)
  • Unemployment compensation
  • Social Security payments, including disability payments–but not Supplemental Security Income (SSI)
  • Alimony

Other items to include when estimating your 2014 income are: retirement income, investment income, pension income, rental income, and other taxable income such as prizes, awards, and gambling winnings.

DON’T include the following:

  • Child support
  • Gifts
  • Supplemental Security Income (SSI)
  • Veterans’ disability payments
  • Workers’ compensation
  • Proceeds from loans (like student loans, home equity loans, or bank loans)


Modified adjusted gross income and household income

When you fill out the Marketplace application, your estimated household income will be calculated using the information you provide. Your household income determines your eligibility for lower costs on Marketplace coverage.

Your household income is your modified adjusted gross income (MAGI) (joint MAGI if you’re married), plus the MAGI of your dependents who make enough money to have to file a tax return.

MAGI is generally your adjusted gross income plus any tax-exempt Social Security benefits (except for Supplemental Security Income (SSI), which is not counted), tax-exempt interest, and tax-exempt foreign income.

You don’t have to figure out your household income or MAGI yourself when you fill out your application. It will be done for you with the income information you include on the application.