What is a QHP? A QHP or Qualified Health Plan is a health insurance policy that you can purchase through the Marketplace. It is sometimes referred to as Obamacare. In order to be considered a Qualified Health Plan, it must consist of 10 Essential Health Benefits. Those benefits are Ambulatory Services, Emergency Services, Hospitalization, Maternity and Newborn Care, Mental Health and Substance Abuse, Prescription Drugs, Rehabilitative and Habilitative Services, Laboratory Services, Preventive and Wellness Services and Pediatric Services. If the health plan is missing at least 1 of these essential health benefits, it is not considered to be a Qualified Health Plan. Qualified Health Plans are typically your best option for coverage because they must cover pre-existing conditions, they provide comprehensive coverage and they are affordable because they provide subsidies for those who qualify in most cases.

When can I purchase a Qualified Health Plan?  There are 2 ways that you can purchase a Qualified Health Plan. The most accessible way is during Open Enrollment which is from November 1^st through December 15^th. The Open Enrollment period has changed over the years since 2013 so it may be different for the upcoming year. During that time, you can purchase a Qualified Health Plan without the requirement of a life changing event or special circumstance. The alternative way to purchase a QHP is called Special Enrollment. In order to qualify for Special Enrollment, you need to have a life changing event or qualifying life event that occurred in the last 60 days. There are specific life changing events, so you need to make sure that your life event qualifies you. Some of the most common QLE’s are Voluntary or Involuntary loss of Employer Coverage, Exhaustion of COBRA, Ineligibility for Medicaid due to income change or household size, Aging off Parent’s plan, losing coverage due to a move, Marriage, losing coverage due to a divorce, Birth of a Child, Release from Incarceration and gaining citizenship.  If you have documentation that supports any of these QLE’s, then you will qualify for Special Enrollment. It is important to understand that if you can’t provide proper documentation that the insurance carrier you applied with will deny you coverage.

Types of Documents for SEP:      Letter from Employer stating your loss of coverage

                                                                Letter from Insurance Company stating your loss of coverage

                                                                Letter from Medicaid or CHIP stating your loss of coverage

                                                                Letter from COBRA showing your exhaustion of coverage

                                                                Marriage Certificate

                                                                Loss of Coverage due to the Divorce

                                                                Letter of Release from Incarceration

                                                                Birth Certificate

                                                                Citizenship Paperwork

What is a Tax Credit?    

A tax credit or subsidy is a set amount that the government will pay towards the cost of your qualified health plan premium every month. That amount will vary based on your household size, household income and age. In order to qualify for a tax credit, your gross household income cannot exceed 400% the Federal Poverty Guidelines. Please reference our FPL Chart for more information on that. Believe it or now, it is also possible to make too little of an income as well. That amount varies by state.

How to Qualify for a Tax Credit?

 In order to qualify for a tax credit, you must meet certain criteria.

                Your income must fall within the Federal Poverty Guideline ranges

                If Married, you must file Married Jointly

                Are not eligible for coverage through an Employer

                Are not eligible for a government program such as Medicaid, Medicare, CHIP or Tricare

                Must file taxes

What are Cost Sharing Reductions (CSR)?

If you qualify for Cost Sharing Reductions, not only will you receive a tax credit, you will qualify for a qualified health plan that has lower co-pays, lower deductibles and lower max out of pockets. In order to take advantage of these savings, your income must be between 138% and 250% the Federal Poverty Lines and you must choose a Silver Plan. In some cases, choosing a Silver plan with “csr” will provide more coverage than a Gold or Platinum plan. It is important to understand the benefit to choosing a Silver plan with csr whenever possible.

Types of Qualified Health Plans

Catastrophic Plan: Meets all the requirement to be defined as a Qualified Health Plan and it provides 3 Primary doctor visits at a copay before your deductible, co-insurance and max out of pocket are met. In order to qualify, you must be under the age of 30. Another important fact to note is that Catastrophic plans do not qualify for tax credits.

Bronze Plans: Cover 60 % of the Actuarial Value

Silver Plans: Cover 70% of the Actuarial Value

Gold Plans:Cover 80% of the Actuarial Value

Platinum Plans: Cover 90% of the Actuarial Value

Actuarial Value: The percentage of medical expenses the plan will pay based on a given area. This does not mean that a plan that has a 70% Actuarial Value has a 70/30 coinsurance. It just implies that the plan will pay 70% of the overall medical costs.

Different Types of Networks: Each insurance company has different types of networks they provide for doctors and facilities. The type of network available varies from one demographic to another. Below you will find the different type of networks you will see through the Marketplace.

HMO: Health Maintenance Organization. An HMO requires the insured to choose a Primary Care Physician when they initially get enrolled. You must get a referral to see a specialist from your PCP. An HMO does not provide out of network coverage unless it is deemed to be a medical emergency.

POS: Point of Service. A POS also requires the insured to choose a PCP and get a referral to see a Specialist. A POS does provide out of network coverage.

EPO: Exclusive Provider Organization. With an EPO network, you don’t have to choose a PCP and you do not need a referral to see a specialist. Some EPO networks will also provide out of network coverage.

PPO: Preferred Provider Organization.  A PPO allows you to choose any doctor to be your PCP and you can see any specialist without getting a referral. A PPO also has out of network coverage.

Ease of Use (Best to Worst):  PPO, EPO, POS, HMO

Cost (High to Low): PPO, EPO, POS, HMO

Medicaid Expansion: Medicaid Expansion is available in certain states and allows adults to qualify for Medicaid without having to be pregnant or have children. If you make below 138% the fpl, you can qualify for Medicaid. As opposed to those states who didn’t expand Medicaid, you must be pregnant or have children and make under a certain income. The threshold for qualifying for Medicaid is 100% the fpl. There are 36 states that have expanded Medicaid and 14 that have not. Below you will find an updated list of the states that have expanded and those that have not.

Alaska	Expanded	Kentucky	Expanded	North Carolina	No-Expansion
Alabama	No-Expansion	Louisiana	Expanded	North Dakota	Expanded
Arkansas	Expanded	Maine	Expanded	Ohio	Expanded
Arizona	Expanded	Maryland	Expanded	Oklahoma	No-Expansion
California	Expanded	Massachusetts	Expanded	Oregon	Expanded
Colorado	Expanded	Michigan	Expanded	Pennsylvania	Expanded
Connecticut	Expanded	Minnesota	Expanded	Rhode Island	Expanded
Delaware	Expanded	Mississippi	No-Expansion	South Carolina	No-Expansion
Florida	No-Expansion	Missouri	No-Expansion	South Dakota	No-Expansion
Georgia	No-Expansion	Montana	Expanded	Tennessee	No-Expansion
Hawaii	Expanded	Nebraska	Expanded	Texas	No-Expansion
Idaho	Expanded	Nevada	Expanded	Utah	Expansion
Illinois	Expanded	New Hampshire	Expanded	Vermont	Expanded
Indiana	Expanded	New Jersey	Expanded	Washington	Expanded
Iowa	Expanded	New Mexico	Expanded	West Virginia	Expanded
Kansas	No-Expansion	New York	Expanded	Wisconsin	No-Expansion
Wyoming	No-Expansion