Frequently asked questions

96 questions people actually ask me

These are the doubts that come up over and over on my calls, with the same answer I give on the phone. Search for yours or browse by topic.

Before you start

I compare the plans available in your area, explain what each one covers, and handle the enrollment paperwork. Afterwards I stay your point of contact if something goes wrong during the year.
Nothing. Agents are paid by the insurer a client enrolls with, not by the client. The plan costs the same whether you go through me, on your own, or through another agent.
From a commission paid by the insurer, set in advance and the same regardless of which plan you choose. That is why I do not earn more by selling you something more expensive.
No. Plenty of calls end with me explaining that you already have what you need, or that waiting is the better move. That is also doing my job.
You can check it yourself before telling me anything. At NIPR.com you search by NPN and it shows the agent name and the states they are authorized in. Mine is 18106026.
ZIP code, the ages of everyone going on the plan, and an estimate of household income. That is enough for real options. A Social Security number is only needed to enroll, not before.
Because plans are built by county. Two cities in the same state can have different insurers, networks and prices, so without the ZIP code I cannot tell you anything concrete.
It depends on the state. An agent needs a license in the state where the client lives. The states I am authorized in are publicly visible by my NPN at NIPR.com, and if yours is not among them I will tell you on the first call.
Spanish, English and Portuguese. You can have the call in whichever language you feel comfortable in, and I go over the paperwork with you in that same language.
No. The following year plans change prices and networks, and that has to be reviewed. Also, if a prescription gets denied or an odd bill shows up, that is when having someone to call actually matters.
Yes. It is a simple change and it does not affect your plan or your coverage: what changes is who advises you, not what you are enrolled in.
No, and nobody does. I work with the companies I am contracted with in each area. That is why you should know other options exist and where to look them up.

Obamacare and the Marketplace

It is the popular name for the law that created the Marketplace, where someone without job-based coverage can buy a health plan and, depending on income, get government help paying for it.
The federal open enrollment period runs from November 1 to January 15. Outside those dates you need a life event that opens a special enrollment period.
If you enroll by December 15, it usually starts January 1. Between December 16 and January 15, it starts February 1.
A window that opens when something important changes in your life: moving, losing job coverage, getting married, having a child. It usually lasts sixty days from that change.
No. Marketplace plans cannot deny you coverage or charge you more for a pre-existing condition, and they cannot exclude it from the plan either.
It is not quality, it is cost sharing. On average bronze covers about 60 percent of costs, silver 70, gold 80 and platinum 90. The less you pay monthly, the more you pay when you use it.
Because they are the only ones that can carry cost-sharing reductions. If your income falls in a certain range, a silver plan lowers your deductible and copays, and that help is lost with any other metal level.
They are the categories every Marketplace plan must cover: outpatient care, emergency care, hospitalization, maternity, mental health, prescriptions, rehabilitation, lab work, preventive care and pediatric services.
Only if they are in the network of the plan you choose. It is the first thing I check, by name and not by area, because networks change from year to year even when the plan keeps its name.
They have to be checked one by one against the plan drug list. Two plans at the same price can cover a medication very differently, or not at all.
You pay everything yourself and have to wait for the next open enrollment, unless you have a life event. Getting sick does not open a special enrollment period.
You can, but it usually is not worth it: if your job offers coverage considered affordable, you lose the right to Marketplace financial help and would pay the full plan price.

Medicare

Medicare goes by age or disability, regardless of income. Medicaid goes by income, at any age. You can have both at once, and that confusion is what wastes people the most time.
You have a seven-month window around your 65th birthday: the three months before, the month itself, and the three months after.
A is hospital, B is doctor and outpatient care, C is Medicare Advantage, which bundles A and B into a private plan, and D is prescription drugs.
For most people yes, if you or your spouse worked and paid in enough, roughly ten years. Those who did not pay a monthly premium for it.
A permanent penalty can apply: a ten percent surcharge for each full twelve-month period you could have had it and did not. You pay it for as long as you have Part B.
There is a penalty for that too, and it grows over time. It is calculated per month without drug coverage, so saving today costs more when you actually need them.
It is a private plan that replaces Original Medicare: you stay in Medicare, but your coverage is run by an insurer, almost always with a doctor network and often with drugs and extras included.
Because Medicare pays the insurer to cover you. Zero per month does not mean zero when you use it: there are still copays, a doctor network and an annual out-of-pocket limit worth checking.
From October 15 to December 7 for the following year. And if you are already in a Medicare Advantage plan, January 1 to March 31 gives you one more window to switch.
The ones that surprise people most: routine dental, glasses, hearing aids and long-term care. Some Advantage plans add part of that, with their own limits.
It depends on the size of the employer and your current coverage. In some cases you can delay it without penalty and in others you cannot, so it is one of the decisions most worth asking about before you turn 65.
No. They are incompatible paths: either Original Medicare with a Medigap, or an Advantage plan. Anyone offering you both at once is not explaining it properly.

Medicaid, CHIP and immigration status

It is public coverage based on income, not age. Each state sets its own limits, so the same family can qualify in one state and not in the next one over.
It is the coverage program for children in families that earn too much for Medicaid but not enough to afford a private plan. Many families qualify for CHIP without knowing it.
Yes. Medicaid and CHIP have no open enrollment period: you apply whenever you need to, and if you qualify coverage can start right away.
In states that did not expand Medicaid there are people who earn too little for Marketplace help and too much for Medicaid. They fall in between, with nothing.
No. The Marketplace requires lawfully present status. That does not mean there is nothing: there are community clinics, private plans outside the Marketplace, and state programs depending on where you live.
In many cases yes. A child can qualify for Medicaid or CHIP based on their own status and household income, even when the parents do not. It is always worth asking.
The public charge rule does not count Marketplace subsidies, and does not count Medicaid either except for long-term institutional care. Even so, if your immigration case is in progress, check with an immigration attorney first.
A hospital with an emergency room has to stabilize you regardless of your status or ability to pay. There is also Emergency Medicaid, which can cover that specific care.
Many residents have to wait five years for Medicaid, with exceptions for children, pregnant women, refugees and asylees depending on the state. In the meantime the Marketplace is usually available.
Generally yes, and that opens the door to the Marketplace and financial help. Each immigration category has its own rule, so we confirm it with your document in hand before applying.
You have to cancel the Marketplace plan. If you keep both, you will have to pay back the financial help you received during those months when you file taxes.
Losing Medicaid opens a special enrollment period in the Marketplace. You get a window to enroll without waiting until November, and at that income there is usually financial help.

Supplemental plans and Medigap

Two very different things are sold under that name: a Medigap, which covers what Original Medicare leaves you paying, and an indemnity plan, which pays you a fixed amount when something happens. The first thing I do is find out which one you are being offered.
It is a policy that pays the deductibles and coinsurance Original Medicare does not cover. It is not a separate health plan: it sits on top of Medicare and works with any doctor who accepts Medicare.
Because they are standardized by law. A Plan G covers the same thing no matter who sells it; what changes between companies is the price and the service, not the coverage.
The six months that begin when you are 65 and your Part B takes effect. In that window they cannot turn you down or charge you more because of your health. It is the window most people let pass.
Outside it the insurer can usually review your health and decide whether to accept you and at what price. That is why the path is best decided before you turn 65, not after.
No. Current Medigap policies do not include drugs: you need a separate Part D plan for that. It is the most common first-year surprise.
A plan that pays an agreed amount when something specific happens, like a night in hospital or a diagnosis. That money goes to you, not the hospital, and you use it for whatever you need.
No, and it matters to be clear on that. It does not cover essential benefits and has no doctor network: it is a complement, never a household main coverage.
Not a Medigap, since they are incompatible. An indemnity plan can coexist with an Advantage plan, and sometimes makes sense because of the annual out-of-pocket limit.
No. It works with any provider that accepts Medicare anywhere in the country, and that is exactly what people value when they travel or live between two states.
You can try, but outside the protected window the new company can usually review your health. Switching is not automatic the way it is with Medicare Advantage.
Ask one thing: does it cover a percentage of the bill, or pay me a fixed amount? If it covers no percentage and has no network, it is not primary coverage, whatever it is called.

Dental and vision

Because in the United States they are sold as different products. Except for children, an adult health plan usually does not include dental, and it has to be bought separately.
Almost always at any time of year. Unlike medical plans, dental does not depend on open enrollment, which gives you room to get it before you need it.
That is the waiting period. Cleanings are usually available right away, but crowns, root canals and dentures can take six to twelve months depending on the plan.
Honestly, rarely for that treatment. What I can do is look for plans with short waits and tell you exactly how long you would have to hold out before using it.
It is the most the plan pays in the whole year. It is the opposite of a health plan out-of-pocket limit: once it runs out, you pay the rest in full.
A PPO has a wide network and shares costs by percentage. A DHMO is cheaper, with set fees and no deductible, but ties you to a specific network and a main dentist.
No. You pay a fee to access reduced prices and then pay the full treatment at that price. Nobody covers a percentage for you, and many people find out at the front desk.
Many plans do not cover replacing a tooth that was already missing before you enrolled. It is a common exclusion that rarely appears in the brochure, so I always ask about it.
Yes, there are family plans. The same plan is not always better for everyone, so sometimes it is worth comparing individual against family before deciding.
In some plans yes. When it is, it usually covers an annual exam and an allowance toward lenses or frames, with its own limits separate from dental.
It may be, since most plans cover preventive care in full from day one. You compare the annual premium against what those cleanings would cost paid out of pocket.
With a PPO usually yes, if they are in the wide network. With a DHMO you have to pick one from its specific network, so I check them by name before you sign.

Life insurance

So the money coming into the household does not vanish overnight. It replaces an income, covers debts that would fall to someone else, and pays for the funeral, which in the United States is not cheap.
Term covers a set number of years and is much cheaper. Permanent lasts your whole life and builds cash value, but costs considerably more for the same amount.
A small policy, usually five to twenty-five thousand dollars, meant only for the funeral and immediate costs. It is usually available at older ages with simple health questions.
It depends on your income, how many years you want to cover, and the debts you would leave behind. The life insurance page has a calculator that gives you a starting figure in thirty seconds.
Not always. There are policies with no exam, with health questions, or even with no questions at all. The fewer the questions, the more expensive it usually is and the more limits it has in the early years.
Because age weighs more than anything else, more than weight or tobacco. The same policy bought five years later costs considerably more, and that difference stays forever.
In policies that accept anyone with no questions, if you die of illness in the first two years they usually return the premiums plus a percentage instead of paying the full amount.
During the contestability period, usually two years, the insurer can review whether the application contained false information. That is why every answer should be exact, even when it seems to work against you.
Almost anyone you name, and you can list several with percentages. The important thing is to review it after a divorce, a death or a birth, which is when it goes out of date.
As a general rule the death benefit is not taxable income for the beneficiary. There are particular situations, so with large estates it is worth checking with an accountant.
It is usually small, often one or two times salary, and it disappears if you leave the company. It is a good extra, but fragile as a family only protection.
Yes. Every policy has a free look period in which you can return it and get your money back. The exact length is set by each state, so I tell you yours before you sign.

Money, paperwork and dates

It is calculated from your estimated annual income and household size, compared against the Federal Poverty Level. The Obamacare page has a calculator that gives you that percentage.
Household income for the full year, not last month. If you are self-employed or your hours vary, you estimate the whole year, and that estimate can be corrected if it changes.
It is settled at tax time: if you received more help than you were entitled to, you pay the difference back. That is why it is best to report income changes during the year.
Then at filing time you get back the help you missed out on. Many families do not know this and leave that money unclaimed.
Yes. If you receive Marketplace help and then do not file, you can lose the right to that help the following year. It is one of the costliest mistakes and almost nobody warns you.
The deductible is what you pay before the plan starts covering. The copay is the fixed amount for each visit or prescription. A plan can have both.
The cap on what you can end up paying in a year for covered services. Past that the plan covers one hundred percent, and it is the number that actually protects you from disaster.
Because the monthly premium is only one part. A cheap plan usually comes with a high deductible and high copays: if you go to the doctor, you end up paying more than with a higher premium.
Identification, a Social Security number or immigration document if applicable, and proof of income such as pay stubs or last year tax return. Sometimes proof of address is requested.
It depends on when you enroll and the type of coverage. In the Marketplace it starts on the first of the following month depending on the cutoff, and with Medicaid it can be much faster.
It can be appealed, and there are specific deadlines. Tell me as soon as it happens: many denials are resolved with the right paperwork and a timely call.
Once a year, without fail. Plans change prices, networks and drug lists every January, and the one that was perfect this year can stop being so without anyone telling you.

These answers explain how coverage works in general, not the terms of any specific plan nor a recommendation for your case. The rules and figures are set each year by the federal government, your state and each insurer, and should be confirmed before you decide. I am not affiliated with the U.S. government, HealthCare.gov or the Medicare program. I do not offer every plan available in your area: to learn about all your options you can contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP).

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