Brokers Should Have Answers to These Five Questions

Whether renewing coverage or purchasing a plan for the first time, selecting the coverage that best meets your client’s needs can often become a complicated process.

With the open enrollment season in full swing, consumers are asking more insurance-related questions. For many benefit brokers, this means an influx of questions – ranging from general plan selection, to the type of benefits that they can expect to receive.

To ease your clients’ journeys, here are answers to five of the top questions asked each year:

  1. How do I help them choose the right health insurance plan?
    Choosing the right plan can be complicated. With an abundant amount of options available, there are many factors that must be considered and evaluated. It’s important to remind your clients that when shopping for health insurance, plans should be compared by monthly premium, out-of-pocket costs, benefits, and provider networks [1]. Knowing how to explain each of these aspects to help simplify the enrollment process, is always helpful (See also:  Key Terms for the Open Enrollment Season).
  1. What happens if my customer has a pre-existing condition?
    Historically, pre-existing conditions meant the possibility of being denied coverage. But, since the passage of the health law in 2010 a lot has changed. Pre-existing conditions or health histories are no longer a barrier to enrollment and plans offered through state and federal health insurance marketplaces must cover treatment for pre-existing medical conditions. For consumers, this means that:
  • No insurance plan can reject, charge more for, or refuse to pay essential health benefits for any condition [2] 
  • Once a consumer is enrolled, the plan cannot deny coverage or raise their rates based on your health conditions [2]
  • Medicaid and the Children’s Health Insurance Program (CHIP) cannot refuse to cover you or charge you more because of your pre-existing condition [2]
  1. How do I find out if I qualify for tax credits?
    Premium tax credits are designed to help eligible individuals and families with low or moderate incomes afford health insurance through the Marketplace [3]. To qualify for this financial assistance, consumers must meet all of the requirements set by the Internal Revenue Service (IRS) [3]:
  • Have household income that falls within a certain range.
  • Do not file a Married Filing Separately tax return
    • Unless you meet the criteria in the regulations, which allows certain victims of domestic abuse and spousal abandonment to claim the premium tax credit using Married Filing Separately
  • Cannot be claimed as a dependent by another person.
  • In the same month – a coverage month – you, or a family member:
    • Enroll in coverage through a Health Insurance Marketplace
    • Are not able to get affordable coverage through an eligible employer-sponsored plan that provides minimum value
    • Are not eligible for coverage through a government program, like Medicaid, Medicare, CHIP or TRICARE
    • Pay the share of premiums not covered by advance credit payments.
  1. What is my plan’s deductible?
    The deductible is how much you must pay for health care services before the health insurance carrier starts to pay. After the deductible, consumers usually pay a copayment or coinsurance for their covered services. Many plans will pay for certain services, including checkups or disease management even before you have met your deductible [5].Here are some helpful reminders [5]:
  • All marketplace plans pay the full cost of preventive benefits before a consumer meets their deductible
  • Some plans have separate deductibles for certain services
  • Family plans can have an individual deducible in addition to a family deductible
  • Generally speaking, plans with lower monthly premiums have higher deductible and plans with higher monthly premiums usually have lower deductibles
  1. Can you explain the summary of benefits and coverage for my plan?
    The summary of benefits and coverage for each plan can be accessed throughout the shopping experience – whether it’s when comparing plans or when completing your application. Insurance companies are also required to distribute the SBC upon request, during the time of application, and when renewing coverage.The health law requires that insurance companies provide all consumers with the details of their health insurance benefits in a simple, consistent format. Using plain language, this document serves as an easy-to-understand summary with examples of various medical scenarios to help consumers understand the benefits they are entitled to.

Having the Answers

In recognizing the significance of these questions, benefit brokers can proactively prepare. Familiarizing yourself with key terms and principles can also help you to better advocate for your clients and guide them throughout the process.

You may also be interested in some of our other resources available:

[1] https://www.healthcare.gov/blog/how-to-find-the-health-insurance-plan-that-s-right-for-you/
[2] https://www.healthcare.gov/coverage/pre-existing-conditions/
[3] https://www.irs.gov/affordable-care-act/individuals-and-families/the-premium-tax-credit
[4] http://familiesusa.org/product/7-questions-ask-when-buying-or-renewing-health-insurance-marketplace
[5] https://www.healthcare.gov/glossary/deductible/

The views and opinions expressed by the authors on this blog website and those providing comments are theirs alone, and do not reflect the opinions of Softheon, Inc. (dba Welltheos).

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Yvonne Villante
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Yvonne Villante

Senior Research Manager, Healthcare Reform at Welltheos
As our Senior Research Manager, I work closely with our Solution Architect, Product Management, and Sales teams. My role centers around competitive and market analyses, constructing premium content (whitepapers, research briefs, infographics), curating stories for our newsletters, and blogging.

I earned my BAA from the State University of New York at Stony Brook and MBA in Healthcare Administration from the University of Ohio (Athens). I was born and raised on Long Island, NY and enjoy capturing what the island has to offer through photography.
Yvonne Villante
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